Limit of Safe Practice Assessment

Limits of Safe Practice Assessment
This assessment should be done in any circumstance where in the professional judgement of the nurse, or nursing team, there is an inability to provide appropriate care for one or more health consumer/s. This includes but is not limited by the presence of one or more factors affecting safe practice in the Limits of Safe Practice Assessment.

Privacy Act 2020

The personal and health and safety information collected on this form may be used to facilitate safer staffing in the workplace.

This statement does not replace, and should be read in conjunction with, the privacy statements on the NZNO online joining form.

You are protected when raising a health and safety matter

It is illegal for the PCBU (i.e. your employer or their representative) to take discriminatory action against you or other workers for completing this assessment. Under the Health and Safety at Work Act 2015 you have protections from such conduct.

Please complete both Sections of this form
- Section 1 captures the formal assessment of the situation. On completion you will be sent a PDF file and an Edit link so you can return to complete Section 2.
- Section 2 captures what happens after your senior RN/MW is informed of the situation. On completion you will be sent a PDF link for the full report and an Edit link for any further updating.
Your NZNO Delegate and your Health and Safety Representative can review these Assessments and follow up with your senior RN/MW. You can also liaise with your local NZNO Organiser if further assistance and/or escalation is required.

If you have any questions or concerns, please contact us at nurses@nzno.org.nz.
Section 1
Health NZ Region and Hospital/Facility*
Name of other facility*
Department*
Other Department details*
Ward/Service/Unit*
Date of assessment*

DayMonthYear
Date
Time assessment started*

Hour Minutes
Name of this shift*
Shift day name*
Your name*

First nameLast name
Submitter authority (select items which apply)*

Shift Coordinator/Leader of the affected work teamHealth and Safety Representative of the affected work groupLocal Union DelegateIndividual worker/Lone worker situationOther
Email address for you*
Will be sent a copy of Sections 1 AND 2 of this Assessment
Email address for copy to senior RN/MW
Will be sent a copy of Section 1 ONLY of this Assessment
Email address for copy to Other e.g. Delegate/HSR/Organiser
On completion of Section 2, will be sent a copy of Sections 1 AND 2 of this Assessment
Do you use TrendCare in your work area?*

YesNo
Local actions taken before informing senior RN/MW

Team huddleWorkload/Caseload review to ensure optimal and/or equitable distribution of workHealth consumer acuity review to confirm care requirementsReview of timing and/or number of scheduled transfers in and outReview of timing and/or number of scheduled admissions/new clientsNumber and anticipated timing of scheduled dischargesUse of senior nurses to provide careAssistance already requested but insufficient/none suppliedTrendCare data validation - All Predictions completed and align with known acuityTrendCare data validation - All on-duty staff in Allocate Staff with correct hours in Clinical-in-DepartmentVariance Indicator System re-scored to confirm adverse statusAny other actions taken - please enter details
Local actions taken before informing senior RN/MW

Team huddleWorkload/Caseload review to ensure optimal and/or equitable distribution of workHealth consumer acuity review to confirm care requirementsReview of timing and/or number of scheduled transfers in and outReview of timing and/or number of scheduled admissions/new clientsNumber and anticipated timing of scheduled dischargesUse of senior nurses to provide careAssistance already requested but insufficient/none suppliedAny other actions taken - please enter details
Factors affecting safe practice (may include)
DO NOT include information which identifies an individual health consumer e.g. Name or NHI
1. Variance Indicator System (VIS) level is in an adverse colour status*

YesNoN/A
Record details here
2. Care is reduced to provision of life preserving services*

YesNoN/A
Record details here
3. Clinical emergency not manageable with existing workers/support*

YesNoN/A
Record details here
4. Inability to provide time-critical cares and assessments*

YesNoN/A
Record details here
5. Absence of appropriate cultural support is significantly impacting upon wellbeing of the health consumer and/or whanau*

YesNoN/A
Record details here
6. Worker and/or other person at risk of physical/mental harm due to unsafe behaviour of a health consumer; the control measures in place are inadequate*

YesNoN/A
Record details here
7. Inability to monitor a health consumer with behaviour of concern who requires constant close supervision*

YesNoN/A
Record details here
8. Physical/mental harm has occurred or is occurring to a worker, health consumer or other person*

YesNoN/A
Record details here
9. Worker and/or other person at risk of physical/mental harm due to unsafe behaviour of the health consumer’s whanau or other visitor; the control measures in place are inadequate*

YesNoN/A
Record details here
10. Care rationing is occurring*

YesNoN/A
Record details here
11. Cares and assessments are unduly delayed*

YesNoN/A
Record details here
12. The worker skill mix is unsuitable*

YesNoN/A
Record details here
13. There is insufficient essential equipment or supplies*

YesNoN/A
Record details here
14. Health consumer dignity is compromised, e.g. personal and hygiene cares not attended to in a timely manner*

YesNoN/A
Record details here
15. Worker/s have been unable to take meal and/or rest breaks, affecting their ability to provide care safely*

YesNoN/A
Record details here
16. The workplace environment being used is not fit-for-purpose for the delivery of safe and competent care e.g. a health consumer being treated on a stretcher in a corridor*

YesNoN/A
Record details here
17. Other roles that work with and support the nursing team are reduced to care rationing or unavailable e.g. Medical, Allied Health, other non-clinical support*

YesNoN/A
Record details here
18. Record details of any other factor/s affecting safe practice here, e.g. unsafe deployment or directives to workers
Senior RN/MW informed that worker/s are at the Limits of Safe Practice
Time informed*

Hour Minutes
Role informed*
Feedback received from senior RN/MW at time of notification*
Declaration
This report is completed on behalf of the work team in the identified Ward/Service/Unit.

I declare that this Limits of Safe Practice assessment has been completed in good faith using professional judgement, and that to the best of my knowledge and ability, the information provided is as true and correct as was possible to determine under the circumstances of an acute staffing shortage situation.
Please tick to confirm your declaration*

I confirm
Click Submit to receive an email which contains:
1. A printable PDF of this Assessment (includes Section 1 only) which you can give to the senior RN/MW who reviews the situation.
2. An edit link to come back and complete Section 2 of this Assessment.
It is important that you return to complete Section 2. This Assessment can only be followed up by NZNO if both sections are completed.

Please remember to come back and complete Section 2.

Limits of Safe Practice Assessment

Privacy Act 2020

You are protected when raising a health and safety matter

Please complete both Sections of this form

Section 1

Factors affecting safe practice (may include)

Senior RN/MW informed that worker/s are at the Limits of Safe Practice

Declaration

Section 2

Senior RN/MW review to validate whether Acute Staffing Shortage situation exists

Outcome after senior RN/MW notified that an Acute Staffing Shortage situation exists

Mandatory reporting