Kuakini Safe Staffing Form

  • Kuakini Safe Staffing Form

  • Staffing Concern Form Instructions

  • Purpose: 
     
    Document staffing concerns, actions taken, and the response of the manager.  The RN must verbally protest assignment to the Supervisor or Charge Nurse during the time it occurs. 
     
    Ethical Considerations:
     
    A Registered Nurse who receives an assignment, that in his or her professional judgement is unsafe, has an obligation to take action.  Nurses share the responsibility and accountability with the employer to ensure the safe nursing care is provided.  This accountability is both an ethical and legal responsibility as outlined in the Nurse Practice Act and the American Nurses’ Association’s Code for Nurses.  The Code states the nurse exercises informed judgement and uses individual competence and qualifications as criteria in seeing consultation, accepting responsibilities, and delegating nursing activities to others.
     
    Directions:
    1.  Verbally address your staffing concern to the Charge Nurse or Supervisor immediately.
    2. Attempt to resolve the staffing concern using your best professional judgement.
    3.  After the assignment is complete or shift is over, fill out the Staffing Concern form, best to your ability within 5 working days (excluding weekends and holidays).
    4.  Send the form online.  Then print 3 copies, give one to your Union Representative or Safe Staffing Committee member, one to your manager and keep one copy for yourself. 
     
    Follow up:
    Management is obligated to respond, in writing to this form within 5 working days (excluding weekends and holidays).
     Any employee who submits a Concern for Safe Staffing form may, upon receipt of the nurse manager’s written response, present the issue to the Safe Staffing Committee to review. 
     
    No Retaliation:
    You have a right to communicate your concerns about patient care.  Please contact HNA representative if you feel this right has been violated. 
     
     

  • Format: (000) 000-0000.

  • Documentation of Concern for Safe Staffing for Patient Care

     This form is to document a staffing concern and the response of the Supervisor.  It is a tool to avoid similar situations in the future.
  • Date of Incident
     - -

  • I have notified at the time of the incident to:

  • that in my professional opinion, I am unable to assure the delivery of safe or adequate nursing care because of the following conditions. (check all that apply)

  • Orientation/Experience:
  • Patient Acuity:
  • Staffing:
  • Check all that apply:

  • I indicate my acceptance of the assignment despite any objections, and attempt to carry out the assignment to the best of my ability.  I hereby give notice to my employer to the above facts.

  • Should be Empty: