• This assessment is to inform the senior nurse/midwife-in-charge 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 reach their Limit of Safe Practice.

    The measures taken or not taken may also affect provision of appropriate care to health consumers.

    Your privacy

    The purpose of the collection of this health and safety information is to facilitate safer staffing in the workplace.

    The NZNO Escalation Pathway operational guideline requires that the Safe Staffing Next Shift information be provided to a senior nurse/midwife prior to the end of your shift.

    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.

  • The information in this form is submitted by the above person on behalf of workers on the NEXT shift.

  • A copy of this form will be emailed to escalationpathway@nzno.org.nz.

  • Staffing situation THIS shift

  • Date of this shift

  • :
  • Variance per FTE and shift assessment

  • Outcomes

  • Staffing situation NEXT shift

  • Date of next shift

  • Expected conditions

  • Known staffing shortfalls

  • Thanks for completing this form. You're helping to make your workplace safer for yourself and your colleagues.