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 situationsProvide MNA the information to identify and address these trends with hospital managementDocument the actions you took to advocate on the behalf of your patientsProvide 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.Name* First Last Assisted ByList 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. Date* YYYY dash MM dash DD Facility*Select your FacilityAbbott Northwestern HospitalAllina Health Faribault Medical CenterAlomere HealthAvera Marshall Regional Medical CenterBuffalo HospitalCambridge Medical CenterCentraCare - MonticelloCentraCare - Redwood HospitalChildren's Hospital - MinneapolisChildren's Hospital - St. PaulChippewa County-Montevideo HospitalClearwater County Home Care and HospiceColonial Manor Nursing HomeCommunity Memorial HospitalCook County North Shore HospitalCook HospitalDakota County Public HealthEly-Bloomenson Community HospitalEssentia Health - BrainerdEssentia Health - Deer RiverEssentia Health - Duluth Miller-DwanEssentia Health - Moose LakeEssentia Health - SandstoneEssentia Health - St. Mary's DuluthEssentia Health - St. Mary's Hospice Unit BEssentia Health - St. Mary's Superior RNsEssentia Health - VirginiaFairview Lakes Medical CenterFairview Northland Medical CenterFairview Range Regional Health ServicesFairview Southdale HospitalFairview UMMC Riverside CampusGrand Itasca Hospital and ClinicHealthEast - Bethesda LTAC (St. Joe's)HealthEast - St. John's HospitalHennepin County Medical CenterHorizon - Douglas County PHHorizon - Granite Falls PHHorizon - Grant County PHHorizon - Pope County PHHorizon - Stevens County PHHorizon - Traverse County PHHudson HospitalKinnic Health and RehabLake Region HealthcareLake View HospitalLakeshore - Ecumen Nursing HomeLakeWood Health Center - BaudetteMayo - Albert LeaMayo - AustinMayo - FairmontMayo - Lake CityMayo - Red WingMcLeod Public HealthMercy HospitalMethodist HospitalMethodist Jennie Edmundson HospitalMille Lacs CountyMurray County Medical CenterNew Ulm Medical CenterNorth Memorial Care Access TriageNorth Memorial Health CareOwatonna HospitalPerham Health SanfordPhillips Eye InstitutePipestone County Medical CenterRainy Lake Medical CenterRefusing an Unsafe Assignment TrainingRegina HospitalRice County Public HealthRice Memorial HospitalRiver Falls Area HospitalRiverwood Healthcare CenterSanford Bagley Medical CenterSanford Bemidji Medical CenterSanford Thief River Falls Medical CenterSanford Worthington Medical CenterSleepy Eye Medical CenterSpencer HospitalSt. AlexiusSt. Francis Regional Medical CenterSt. Gabriel's HospitalSt. Joseph's - Park RapidsSt. Luke's HospitalState - Health DepartmentState - Human ServicesState - Veteran's HomeState of MNStearns CountyStevens Community Medical CenterUnited HospitalUnity HospitalUnityPoint - MarshalltownWelia HealthWestHealthWinona HealthHiddenUnit*HiddenFacility*Select your FacilityAbbott Northwestern HospitalAllina Health Faribault Medical CenterAlomere HealthAvera Marshall Regional Medical CenterBuffalo HospitalCambridge Medical CenterCentraCare - MonticelloCentraCare - Redwood HospitalChildren's Hospital - MinneapolisChildren's Hospital - St. PaulChippewa County-Montevideo HospitalClearwater County Home Care and HospiceColonial Manor Nursing HomeCommunity Memorial HospitalCook County North Shore HospitalCook HospitalDakota County Public HealthEly-Bloomenson Community HospitalEssentia Health - BrainerdEssentia Health - Deer RiverEssentia Health - Duluth Miller-DwanEssentia Health - Moose LakeEssentia Health - SandstoneEssentia Health - St. Mary's DuluthEssentia Health - St. Mary's Hospice Unit BEssentia Health - St. Mary's Superior RNsEssentia Health - VirginiaFairview Lakes Medical CenterFairview Northland Medical CenterFairview Range Regional Health ServicesFairview Southdale HospitalFairview UMMC Riverside CampusGrand Itasca Hospital and ClinicHealthEast - Bethesda LTAC (St. Joe's)HealthEast - St. John's HospitalHennepin County Medical CenterHorizon - Douglas County PHHorizon - Granite Falls PHHorizon - Grant County PHHorizon - Pope County PHHorizon - Stevens County PHHorizon - Traverse County PHHudson HospitalKinnic Health and RehabLake Region HealthcareLake View HospitalLakeshore - Ecumen Nursing HomeLakeWood Health Center - BaudetteMayo - Albert LeaMayo - AustinMayo - FairmontMayo - Lake CityMayo - Red WingMcLeod Public HealthMercy HospitalMethodist HospitalMethodist Jennie Edmundson HospitalMille Lacs CountyMurray County Medical CenterNew Ulm Medical CenterNorth Memorial Care Access TriageNorth Memorial Health CareOwatonna HospitalPerham Health SanfordPhillips Eye InstitutePipestone County Medical CenterRainy Lake Medical CenterRefusing an Unsafe Assignment TrainingRegina HospitalRice County Public HealthRice Memorial HospitalRiver Falls Area HospitalRiverwood Healthcare CenterSanford Bagley Medical CenterSanford Bemidji Medical CenterSanford Thief River Falls Medical CenterSanford Worthington Medical CenterSleepy Eye Medical CenterSpencer HospitalSt. AlexiusSt. Francis Regional Medical CenterSt. Gabriel's HospitalSt. Joseph's - Park RapidsSt. Luke's HospitalState - Health DepartmentState - Human ServicesState - Veteran's HomeState of MNStearns CountyStevens Community Medical CenterUnited HospitalUnity HospitalUnityPoint - MarshalltownWelia HealthWestHealthWinona HealthHiddenFacility LabelDepartmentSelect your Unit– Fill Out Other Fields –Other Department Not ListedShift*Select your shiftDaysEveningsNightsOther (please specify)Shift, Other*Are you staffed via an electronic staffing program that predicts the staff necessary for your unit? Yes NoWas more staff was requested due to a risk of workplace violence? Yes NoPerson(s) Notified*Please selectManagerSupervisorName of Person(s) Notified*What Response did the supervisor/manager give you?*Did anyone attempt to discourage you from filling out this form? Yes NoWere you bullied regarding your concern for short /unsafe staffing? Yes NoRNs on dutyPlease enter a number from 0 to 50.RNs scheduledPlease enter a number from 0 to 50.RNs neededPlease enter a number from 0 to 50.LPNs on dutyPlease enter a number from 0 to 50.LPNs scheduledPlease enter a number from 0 to 50.LPNs neededPlease enter a number from 0 to 50.UAPs on dutyPlease enter a number from 0 to 50.(unlicensed assistive personnel)UAPs scheduledPlease enter a number from 0 to 50.(unlicensed assistive personnel)UAPs neededPlease 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 Not enough qualified staff Charge nurse took patients over and above what staffing grid provides Other (explanation)Explanation OtherHow 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 Closed the unit to admissions I was provided the necessary training or preceptor I was reassigned Other (resolution)Resolution OtherWhat impact did this have on patient care?Choose all that apply Increased the number of home visits required Increased length of stay for patients Inability to answer call lights Patients left without being seen Patients not seen on scheduled day Incomplete admissions Incomplete discharge planning/teaching Incomplete assessments Inability to provide face to face hand off Delay in treatment or cares Delay in medications Inadequate patient pain management Patient injury Assault or injury to another patient visitor Other (impact)Impacts OtherWhat impact did this have on the nurse/s and other support staff?Choose all that apply Nurse experienced increased stress Nurse experienced increased anxiety Nurse experienced fatigue Missed meal break Overtime Staff Injury (work related injury, like back injury from moving a patient) Staff Injury from assault Staff sexually harassed Staff sexually assaultedAction TakenIf 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) Repeated phone calls Move up the chain of command with phone calls Refused the assignment Refused additional clients/visits Other (action)Action OtherAdditional Action TakenAdditional action taken to advocate for patient safety and assist others in doing the same: (choose all that apply) Notify nurses on the next shift Start a petition demanding safe staffing be addressed Deliver the petition to the manager (i.e. "march on the boss") Contact MNA Nursing Practice Staff to further pursue additional actions Other (addl action)Addl OtherNOTE: 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.CommentsThis field is for validation purposes and should be left unchanged.Δ 2019-01-09