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Workplace Situation Reports
Nurse Manager / Nurse Supervisor / Work Situation Report 2025
"
*
" indicates required fields
Section 1: General Information
Name(s) of Employee(s):
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
Other
# 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
Required Overtime:
Yes
No
Name of Program Director of immediate 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
N/A
How?
Workload not completed:
(e.g. unable to attend meetings, performance appraisal delayed, supervisor’s rounds not done…)
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
Change in patient acuity
Change in patient acuity
Coverage of other sectors
Coverage of other sectors
Number of complex cases
Number of complex cases:
Number of complex cases:
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:
Staffing:
Staffing,
Staffing,
Visitors/Family Members/complaints follow-up:
Visitors/Family Members/complaints follow-up.
Visitors/Family Members/complaints follow-up.
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
Change unit layout
Consultation/communication
Create Float Nurse manager position
Float/casual pool
In House support staffing
In-service
Orientation
Replace sick calls, vacation, paid holidays, other absences by a Nurse Manager/Nurse Supervisor
Review policies and procedures
Review Workload Measurement Statistics/Care Model recommendations/core staffing recommendations
RN Staffing
Other:
Other:
Section 5: Employee Signatures and 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
Immediate Supervisor Email
*
NBNU Local President Email
*
Member Email
*
Dated:
MM slash DD slash YYYY
