If you find yourself in a situation that you believe creates unsafe conditions for patients or for you,
complete the Nurse Staffing Concern Form. #

By completing the staffing Concern Form, you are helping to make the problem known to manage­ment, which creates an oppor­tu­nity for the problem to be addressed. Addition­ally, you are documenting the facts, which may be helpful to you later if there is a negative outcome due to the concerns that you identify.

Types of Situa­tions Where You Should Complete a Staffing Concern Form:

  • Charge nurse is unable to perform charge nurse duties, secondary to increased patient care assignment
  • Inade­quate nurse to patient ratios for patient acuity based on your clinical judgment
  • Insuf­fi­cient support staff requires you to assume additional duties
  • You are not trained or experi­enced in the area assigned
  • You have not been oriented to this unit / case load
  • Patient care equip­ment missing or unusable
  • Neces­sary equip­ment is not avail­able (e.g.: supplies, IVs, medica­tion availability)
  • You are not trained or experi­enced to use equip­ment in assigned area
  • System failure (e.g.: computer, phone, pyxis, call system)
  • An assign­ment poses a serious threat to your health and safety
  • An assign­ment poses a serious threat to the health and safety of a patient under your direct care
  • Forced / Manda­tory Overtime
  • Missed breaks

Learn More — Guide­lines for the Regis­tered Nurse in Giving, Accepting or Rejecting an Assignment

Download this free WSNA Handbook (PDF)

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