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
    • Provide real life examples of the impacts of unsafe staffing on patients. Any examples selected from CFSS forms will have names, facilities, PHI and any other identifiable information removed.

    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.

  • List the name(s) of any other MNA member(s) who assisted you.
  • 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.
  • Select date YYYY dash MM dash DD
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • 0 of 6000 max characters
  • Please enter a number from 0 to 50.
  • Please enter a number from 0 to 50.
  • Please enter a number from 0 to 50.
  • Please enter a number from 0 to 50.
  • Please enter a number from 0 to 50.
  • Please enter a number from 0 to 50.
  • Please enter a number from 0 to 50.
    (unlicensed assistive personnel)
  • Please enter a number from 0 to 50.
    (unlicensed assistive personnel)
  • Please enter a number from 0 to 50.
    (unlicensed assistive personnel)
  • Choose all that apply
  • Choose all that apply
  • Choose all that apply
  • Choose all that apply
  • If you did not receive help what action(s) did you take or will you take to continue to advocate for your patients? (choose all that apply)
  • Additional action taken to advocate for patient safety and assist others in doing the same: (choose all that apply)

  • NOTE: For HIPAA purposes the detailed explanation/narrative you write in the "others" fields will NOT be included on the hard copy of the form that you can print off and share with your supervisor after you hit "Submit." However, the detailed explanation/narrative you write in the "others" fields WILL be included in the electronic copy of this submission that is e-mailed to MNA and to yourself if you included your e-mail address on the form.

  • This field is for validation purposes and should be left unchanged.