STRAUB-HNA Staffing Concern Form
For Registered Nurses to document unresolved safe staffing concerns at Straub Medical Center. Do not include any patient identifying information.
Instructions
The purpose of this form is for Registered Nurses to document unresolved safe staffing concerns with their Manager, who shall review, address and take action as appropriate. Please complete this form at the end of your shift if the staffing concern remains unresolved. Do NOT include any patient identifying information. For further details, refer to Section 32.6 of the CBA. If you have questions or feel your rights have been violated, contact HNA or your steward. Phone: (808) 531-1628. May 2023.
Unit/Department
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Date of Assignment
*
-
Month
-
Day
Year
Date
Start Time of Assignment
*
Hour Minutes
AM
PM
AM/PM Option
End Time of Assignment
*
Hour Minutes
AM
PM
AM/PM Option
Your Role During Assignment
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Charge Nurse
Staff Nurse
Float Nurse
I/we under protest carried out the assignment to the best of my/our ability and believe this situation carries a potential safety issue. I/we have given the appropriate notification to management.
Unit Composition at Time of Objection
Please provide the following details about unit staffing and capacity during the shift.
Unit Capacity
*
Unit Census
*
Number of RNs Needed
*
Number of RNs Provided
*
Number of CAs Needed
*
Number of CAs Provided
*
Number of WCs Needed
*
Number of WCs Provided
*
Number of Patients Assigned to Charge Nurse
Notification Details
You must notify the supervisor or manager at the time of concern.
Name of Person Notified
*
Position of Person Notified
*
Date & Time Notified
*
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Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Factors Impacting Ability to Provide Safe Nursing Care (Check all that apply)
*
Patient characteristics and census
Staffing inadequate for acuity level of patients
Staffing inadequate due to high patient census
Staffing inadequate for number of Admits
Staffing inadequate for number of Discharges
Staffing inadequate for number of Transfers
Staffing inadequate for number of Post-Ops
Staffing inadequate for number of Triage
Staffing inadequate for number of Walk-Ins
Staffing inadequate for number of Scheduled Appointments
Patient(s) placed/stayed inappropriately on unit who required higher-level care or specialization
Unplanned events (behavior, code, fall, etc.)
Insufficient number of staff (RN/CA/WC/Other)
Missing or broken equipment not replaced or repaired
Unit geography/layout is not conducive to safe care
Staff not adequately oriented to unit
Insufficient or no training on equipment or technology
Insufficient or no training on patient care procedure
Skill mix of staff inadequate to deliver safe care
Other (please specify below)
If applicable, please provide additional details for checked items above (e.g., Acuity System used, number of Admits/Discharges/Transfers, specify equipment, specify procedure, etc.):
Description of Objection Not Already Covered Above
Did the outcome of this assignment also require an incident form?
*
Yes
No
As a result of this incident, I/we (check all that apply)
Missed a break
Missed a meal
Late meal
Worked overtime involuntarily
Worked overtime voluntarily
Other (please specify below)
Suggestions to improve or prevent this situation from occurring in the future
By initialing, I attest that the stated RNs do agree to this submission and designate me as point person for written follow up with manager.
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Submitted By (Add all submitting nurses below)
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Submit Staffing Concern
Should be Empty: