Staffing Complaint / ADO Form

If you find yourself in a situa­tion that you believe creates unsafe condi­tions for patients or for you, complete the Staffing Complaint / ADO (Assign­ment Despite Objec­tion) form as soon as possible.

By completing the form, you are helping to make the problem known to manage­ment, which creates an oppor­tu­nity for the problem to be addressed. Addition­ally, you are documenting the facts, which may be helpful to you later if there is a negative outcome.

Types of situa­tions where you should complete a Staffing Complaint / ADO form:

  • Charge nurse is unable to perform charge nurse duties, secondary to increased patient care assignment
  • Inade­quate nurse to patient ratios for patient acuity based on your clinical judgment
  • Insuf­fi­cient support staff requires you to assume additional duties
  • You are not trained or experi­enced in the area assigned
  • You have not been oriented to this unit / case load
  • Patient care equip­ment missing or unusable
  • Neces­sary equip­ment is not avail­able (e.g.: supplies, IVs, medica­tion availability)
  • You are not trained or experi­enced to use equip­ment in assigned area
  • System failure (e.g.: computer, phone, pyxis, call system)
  • An assign­ment poses a serious threat to your health and safety
  • An assign­ment poses a serious threat to the health and safety of a patient under your direct care
  • Forced / manda­tory overtime
  • Missed breaks

Online form

Complete the online form and your WSNA Nurse Rep, Staffing Committee, and Local Unit Chair / Co-Chair will be notified immediately.

Offline access

If you need offline-access to the form, you can download and print this form.