NURSES
Notice of unsafe/unacceptable conditions for practice

[Please print] TO: FROM: WORKPLACE: DATE:

POSITION: JOB TITLE: EMPLOYER: TIME:

In accordance with my responsibilities as a Registered Nurse/Midwife/Health Visitor, it is my duty to draw your attention to what I consider to be unsafe/unacceptable standards of care, for the patients/clients in my care due to staff shortages. While accepting responsibility for aspects of care within my control, I must inform you that I will not be held responsible for untoward incidents or substandard levels of care whcih are caused or exacerbated by inadequate levels of staff or too few qualified members of staff.

I would refer you to the following UKCC documents as a reminder of my professional accountability:
1) Code of Professional Conduct specifically Paragraphs 1,2,11,12 and 13.
2) A Midwife's Code of Practice
3) Guidelines for Professional Practice (Making concerns known)
I regret having to take this serious action. However, I feel I have no alternative. The circumstances that lead me to take this course of action are outlined below.

Area of Practice affected: Period of time concerned: Number of patients/clients affected: Number, grade and experience of staff on duty:   Special notes, eg. medical emergencies/high dependency/violent patients:   Name and status of manager informed and action taken:
Date and time informed:	Witnessed by:

I am sending a copy of this to my local UNISON representative.
[Where more than one individual is affected, each one should sign this form]

NAME: NAME: NAME:

SIGNATURE: SIGNATURE: SIGNATURE:

I/we would appreciate an early written reply.

UNISON Nurses - delivering quality care, dignity and accountability

Designed, printed and published by UNISON Scotland, 14 West Campbell St, Glasgow G2 6RX. 0141-332 0006 60, Belford Rd, Edinburgh EH4 3UQ, 0131-226 2662.