Safe Staffing Next Shift Assessment

Safe Staffing Next Shift Assessment
To the senior RN/MW responsible for staffing:

This safe staffing assessment is to inform you that due to an identified potential Acute Staffing Shortage on the next shift, an unsafe work situation may occur if effective control measures are not implemented.

These measures will need to address the predicted negative shift variance and/or other factors which reflect the workload, health consumer acuity, skill mix and the workers available.

If the staffing shortfall is not adequately addressed, a worker or workers may breach their Limits of Safe Practice.

The measures taken or not taken may also affect provision of safe and competent care to health consumers.
To the worker completing this form:

Privacy Act 2020

The personal and health and safety information collected on this form may be used to facilitate safer staffing in the workplace.

This statement does not replace, and should be read in conjunction with, the privacy statements on the NZNO online joining form.

You are protected when raising a health and safety matter

It is illegal for the PCBU (i.e. your employer or their representative) to take discriminatory action against you or other workers for completing this assessment. Under the Health and Safety at Work Act 2015 you have protections from such conduct.
Health NZ Region and Hospital/Facility*
Name of other facillity
Department*
Ward/Service/Unit*
First name*
Last name*
Submitter authority (select items which apply)

Shift Coordinator/Leader of the affected work teamHealth and Safety Representative of the affected work groupLocal Union DelegateIndividual worker/Lone worker situationOther
Email address for you*
Email address for copy to senior RN/MW
Email address for copy to Other e.g. Delegate/HSR/Organiser
A copy of this form will be emailed to safestaffing@nzno.org.nz.
THIS shift: Staffing situation
Shift date*

DayMonthYear
Shift name*
Shift day name
Time assessment started*

Hour Minutes
THIS shift: Variance situation
Do you use TrendCare in your work area?*

YesNo
TrendCare variance per FTE: + or -
TrendCare variance per FTE: Hours
TrendCare variance per FTE: Minutes
TrendCare Variance Indicator System (VIS) Colour
Based on the roster and workload of THIS shift, is there a deficit of 8 hours or more?

YesNo
Is THIS shift in an "Acute Staffing Shortage" situation?*

YesNo
If you have not already done so, please complete a Limits of Safe Practice Assessment.
NEXT shift: Staffing situation
Shift date*

DayMonthYear
Shift name*
Shift day name*
Care hours available*
Care hours required*
Health consumers in*
Admissions, new referrals
Health consumers out*
Transfers, discharges
NEXT shift: Known staffing shortfalls
Administration Support*
Health Care Assistant/Hospital Aide*
Enrolled Nurse*
Registered Midwife*
Registered Nurse*
NEXT shift: Anticipated shortfall of other support roles
Select the other support roles where shortfalls exist*

NoneMedicalAllied HealthOther
Please explain the Medical staff shortfall
Please explain the Allied Health staff shortfall
Please explain the Other staff shortfall
NEXT shift: Expected conditions
"Shift Below Target"?*

YesNo
Assessed workload will significantly exceed assessed staffing resource available*

YesNo
Clinical area or service at 100% capacity or over?*

YesNo
Unable to transfer, admit or discharge due to bed-block?*

YesNo
Time-stamp and declaration
Today's date*

DayMonthYear
Time of submitting this assessment*

Hour Minutes
I declare that I have completed this Safe Staffing Next Shift assessment in good faith, and that to the best of my knowledge and ability, the forecast information provided is accurate as was possible to determine at the time of completion.
Please tick to confirm your declaration*

I confirm
Once you have submitted this form it cannot be amended.

When you are ready, click the Submit button to receive an email which contains a printable PDF of this Assessment for your records

Then print out the PDF and provide a copy to:
- Senior RN/MW or other manager as necessary
- The NEXT shift coming on-duty so are aware of the safety concerns raised.
A copy of this form will be emailed to safestaffing@nzno.org.nz. The information will be reviewed by your local NZNO Organiser and stored for use as needed with the escalation pathway process.

Thank you very much for taking the time to complete this Assessment. You're helping to make your workplace safer for yourself and your colleagues.
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Safe Staffing Next Shift Assessment

To the senior RN/MW responsible for staffing:

To the worker completing this form:

Privacy Act 2020

You are protected when raising a health and safety matter

THIS shift: Staffing situation

THIS shift: Variance situation

NEXT shift: Staffing situation

NEXT shift: Known staffing shortfalls

NEXT shift: Anticipated shortfall of other support roles

NEXT shift: Expected conditions

Time-stamp and declaration