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Workplace Situation Reports
Hospital Work Situation Report 2025
Section 1: General Information
Name(s) of Employee(s):
Are you an:
RN
LPN
Employer:
Unit/Area/Program:
Date of Situation:
MM slash DD slash YYYY
Time:
:
Hours
Minutes
AM
PM
AM/PM
Shift:
7.5 Hours
11.25 Hours
# Regular Staff:
RN
LPN
PCA
Clerical Support
# Actual Regular Staff:
RN
LPN
PCA
Clerical Support
Staff Shortage Due to:
Sick Call
ELOA
Vacancies
Did This Cause You to Miss Your:
Meal Break:
Yes
No
Rest Period/Break:
Yes
No
Nurse Overtime:
Yes
No
Name of Nurse Manager or Supervisor Reported to:
Section 2: Details of Situation
Provide a detailed summary of the situation and how it impacted patient care:
(what, when, where, why)
Was the safety of the patient or nursing professional compromised?
Yes
No
How?
Workload not completed:
(e.g. Insulin or heparin was not double checked; patient rounds not done on an hourly basis, other)
Is this an isolated incident?
Yes
No
Ongoing problem?
Yes
No
Section 3: Patient Care Factors Contributing to the Occurrence
Please check off the factor(s) you believe contributes to the workload issue and provide details
# of Admissions:
Number of Admissions, discharges and transfers
# of Admissions:
# of Admissions:
# of discharges:
# of transfers:
Change in patient acuity
Change in patient acuity
Lack of equipment/malfunctioning equipment/supplies.
Lack of equipment/malfunctioning equipment/supplies.
Lack of equipment/malfunctioning equipment/supplies. Please specify:
Number of patients on infections precaution:
Number of patients on infections precaution:
Number of patients on infections precaution:
Over capacity protocol in effect?
Over capacity protocol in effect?
Over capacity protocol in effect?
Patient Census at time of situation:
Patient Census at time of situation:
Patient Census at time of situation:
Visitors/Family Members
Visitors/Family Members
Visitors/Family Members
Other:
Other: (non-nursing duties, student supervision, mentorship, etc)
Other:
Section 4: Recommendations
Please check-off one or all of the areas below you believe should be addressed in order to prevent similar situations:
Recommendations
In-service
Orientation
Change unit layout
Review Workload Measurement Statistics
RN Staffing
LPN Staffing
PCA Staffing
Clerical Support
Float/casual pool
Review policies and procedures
Replace sick calls, vacation, paid holidays, other absences
Other:
Other:
Section 5: Employee Signatures and Contact Information
Signature:
Contact Information:
Signature:
Contact Information:
Signature:
Contact Information:
Signature:
Contact Information:
Section 6: Management Comments
Please provide any information in response to this report, including any actions taken to remedy the situation where applicable.
Management Signature:
Date
MM slash DD slash YYYY
Section 7: Recommendations of Professional Practice Committee
The Professional Practice Committee recommends the following in order to prevent similar situations:
Is this issue resolved?
Yes
No
Manager Email:
*
NBNU Local President Email:
*
Member Email:
*
Dated:
MM slash DD slash YYYY