cfss.mnnurses.orgConcern for Safe Staffing – Minnesota Nurses Association
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Skip to content You are using an outdated browser (IE 8 or before). For a better user experience, we recommend upgrading your browser today or installing Google Chrome Frame Safe Staffing Form MNA Blog Member Center Contact Search A union dedicated to advocating for nurses, patients, and quality care in Minnesota, Wisconsin, North Dakota, and Iowa Minnesota Nurses Association Primary Navigation Menu Menu About MNA MNA Structure MNA President MNA Executive Director MNA Board of Directors Represented Facilities Staff List Affiliations Careers at MNA History Contact MNA Issues & Advocacy Issues Get Involved How the Legislature Works Elections Get Involved How Elections Work Endorsement Process MNA Candidate Endorsements MyBallot – Endorsed Candidate Lookup Take Action Events Action Center Get Involved MNA Student Nurse Day on the Hill News 2020 Negotiations MNA Blog Press Releases Nursing Accent Online Stay Connected Events Calendar Resources Nursing Practice My License Report Unsafe Staffing Education Education Calendar Twin Cities Pension MNA Foundation Member Benefits Members-Only Discounts and Services Council of Active Retired Nurses Rainy Day Fund Calculator Join MNA I Want a Union Why Unions Membership Categories Application for Membership Concern for Safe Staffing Concern for Safe Staffing According to the MN Nurse Practice Act, you are obligated to advocate for your patients in situations that may threaten their safety. If you have a situation where you feel that unsafe staffing is a concern in your facility, please report it to the appropriate manager/supervisor/administrator at the time that it occurs. MNA also provides you an opportunity to fill out Concern for Safe Staffing forms. These forms are used to: Track Short Staffing which includes numbers of nurses, number of support staff, skill mix and training of staff. Track and identify trends in threats to patient safety that Registered Nurses have reported as a result of unsafe staffing situations Provide MNA the information to identify and address these trends with hospital management Document the actions you took to advocate on the behalf of your patients You may choose to provide this form to your manager/supervisor/administrator or not. No one can tell you that you cannot file this form with MNA. The important thing is that you must always notify the immediate supervisor/manager/director when staffing is short and vigorously advocate for safe staffing by reporting unsafe situations at the time it occurs. When filling out this form, please be sure to maintain the privacy of your patients by leaving out specific identifying data and specific patient diagnoses and actions. Thank you for taking the time to document your nursing advocacy. It is important to be as accurate as possible and collect as much information as you can but do not let a lack of specifics deter you from completing the form. Name * First Last Assisted By List the name(s) of any other MNA member(s) who assisted you. Personal Email * A copy of the completed form will automatically be sent to the e-mail address you enter. Please do not use your work provided email addresses. Facility * Select your Facility Abbott Northwestern Hospital Allina District One Hospital Alomere Health Avera Marshall Regional Medical Center Buffalo Hospital Cambridge Medical Center CentraCare Health - Monticello Children's Hospital - Minneapolis Children's Hospital - St. Paul Chippewa County-Montevideo Hospital Clearwater County Home Care and Hospice Colonial Manor Nursing Home Community Memorial Hospital Cook County North Shore Hospital Cook Hospital Dakota County Public Health Ely-Bloomenson Community Hospital Essentia - Duluth Miller-Dwan Medical Center Essentia - St. Mary's Hospice Unit B Essentia Health - Brainerd Essentia Health - Deer River Essentia Health - Duluth St. Mary's Medical Center Essentia Health - Sandstone Essentia Health - Superior St. Mary's Hospital Essentia Health - Virginia Fairview Lakes Health Services Fairview Northland Medical Center Fairview Range Regional Health Services Fairview Riverside Campus Fairview Southdale FirstLight Health System Grand Itasca Hospital and Clinic HealthEast - Bethesda Hospital HealthEast - St. John's Hospital HealthEast - St. Joseph's Hospital Hennepin County Medical Center Horizon - Douglas County PH Horizon - Grant County PH Horizon - Pope County PH Horizon - Stevens County PH Horizon - Traverse County PH Hudson Hospital Kinnic Health and Rehab Lake Region Health Care Lake View Hospital Lakeshore - Ecumen Nursing Home LakeWood Health Center - Baudette Mayo Clinic Health System - Albert Lea Mayo Clinic Health System - Austin Mayo Clinic Health System - Fairmont Mayo Clinic Health System - Lake City Mayo Clinic Health System - Mankato Mayo Clinic Health System - Red Wing Mayo Clinic Health System - Waseca Mercy Hospital Mercy Hospital - Moose Lake Methodist Hospital Methodist Jennie Edmundson Hospital Mille Lacs County Murray County Medical Center New Ulm Medical Center North Memorial Health Care Owatonna Hospital Perham Health Sanford Phillips Eye Institute Pipestone County Medical Center Rainy Lake Medical Center Refusing an Unsafe Assignment Training Regina Hospital Rice County Public Health Rice Memorial Hospital River Falls Area Hospital Riverwood Healthcare Center Sanford Bagley Medical Center Sanford Bemidji Medical Center Sanford Thief River Falls Medical Center Sanford Worthington Medical Center Sleepy Eye Medical Center Spencer Hospital St. Alexius St. Francis Regional Medical Center St. Gabriel's Hospital St. Joseph's Area Health Services - Park Rapids St. Luke's Hospital State - Health Department State - Human Services State - Veteran's Home State of MN Stearns County Stevens Community Medical Center United Hospital Unity Hospital UnityPoint - Marshalltown WestHealth Winona Health Date * Date Format: MM slash DD slash YYYY Unit * Shift * Select your shift Days Evenings Nights Other (please specify) Shift, Other * Are you staffed via an electronic staffing program that predicts the staff necessary for your unit? Yes No Person(s) Notified * Please select Manager Supervisor Name of Person(s) Notified * What Response did the supervisor/manager give you? * Did anyone attempt to discourage you from filling out this form? Yes No Were you bullied regarding your concern for short /unsafe staffing? Yes No RNs on duty Please enter a number from 0 to 50 . RNs scheduled Please enter a number from 0 to 50 . RNs needed Please enter a number from 0 to 50 . LPNs on duty Please enter a number from 0 to 50 . LPNs scheduled Please enter a number from 0 to 50 . LPNs needed Please enter a number from 0 to 50 . UAPs on duty Please enter a number from 0 to 50 . (unlicensed assistive personnel) UAPs scheduled Please enter a number from 0 to 50 . (unlicensed assistive personnel) UAPs needed Please enter a number from 0 to 50 . (unlicensed assistive personnel) What made your shift unsafe? Choose all that apply Too many patients/clients High acuity Wrong skill mix (e.g. need RN, LPN or 1:1) 1:1 Not filled UAP pulled to fill 1:1 leaving unit short UAPs Inadequate orientation or training to unit/equipment Nurse fatigue due to missed breaks or O.T. Not enough qualified staff Charge nurse took patients over and above what staffing grid provides Other (explanation) Explanation Other How was the unsafe staffing situation rectified? Choose all that apply It was not rectified Extreme overtime (greater than 16h/24h or multiple consecutive doubles) New nurse pulled off orientation early to fill short staffing need Obtained correct # of staff Obtained correct skill mix of staff Refused assignment / I was reassigned / Refused additional clients / Refused additional visits Closed the unit to admissions I was provided the necessary training or preceptor Other (resolution) Resolution Other What impact did this have on patient care? Choose all that apply Increased length of stay for patients Increased the number of vis...
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