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BFN Outpatient CFSS/ADO Form

Your Name(s) *

Clinic Setting *

Date *

Day of the Week *

Cost Center *

Length of scheduled shift: *

Number of actual hours worked: *

Manager's Name *

As a patient advocate, in accordance with the Nurse Practices Act, this is to confirm that I/we notified you that in my/our professional judgment, my/our workload is unsafe and places my/our patients at risk. I have been mandated to provide care and do not want to abandon my patients. As a result, the facility is responsible for any errors or incidents that take place.

NOTIFICATION GIVEN (You must notify your manager / supervisor at the time of need or concern) Manager / Supervisor *

Time: *

Response: *

FACTORS AFFECTING ABILITY TO PROVIDE SAFE NURSING CARE (Check all that apply) 1. Lack of experience / training

Float Nurse
Orienting Nurse

2. Scheduled staff not replaced

Unfilled position
Sick Time
Vacation
Emergency Responder
Wellness RN
Weekend clinic coverage

3. Lack of ancillary help

Reception
MA

4. Staffing situation posed an actual or potential threat

Injury
Stress
Violence

5. Unable to delegate / perform / supervise safely due to needs greater than staff available

Injury
Stress
Violence

6. MORE FACTORS AFFECTING ABILITY TO PROVIDE SAFE NURSING CARE

Missed breaks and/or meals
Skill mix of staff inappropriate
Required to stay beyond shift

7. OTHER FACTORS NOT COVERED ABOVE:

STAFFING PROVIDED WAS NOT ADEQUATE TO ADDRESS PATIENT NEEDS RELATED TO (check all that apply)

High patient volume
High patient acuity

DELAYS + COMPROMISES IN PATIENT CARE NECESSITATED BY STAFFING SITUATION (Check all that apply):

Timely triage
Delay in care / rooming / HPI
Medication reconciliation
Patient assessment
Patient education
Prescription refill orders
Care coordination
Team communication delays
Procedures: dressings / staple removal / lab-based med adjustments / foot care (...)
Documentation

Other Delays + Compromises Not Covered Above:

Brief Statement of the Problem: *

Number of staff you actually had:

RN, LPN, MA...

Number of staff you needed in your judgment

RN, LPN, MA...

Number of Ambulatory Resource Nurses requested:

Number of Ambulatory Resource Nurses deployed:

Who determines staffing?

Manager/Practice supervisor
Staffing office
Director of Nursing

Please Provide Additional Information Here:

AFT Vermont, an affiliate of the American Federation of Teachers, represents over 8,000 healthcare and higher education professionals in Vermont and New Hampshire.