Currently Approved Nurse Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

HEALTHCARE FACILITY WORKPLACE VIOLENCE PREVENTION PROGRAMS  OPT OUT

Nurse Survey

BACKGROUND

1. What is your job title?  RN  LPN  Other (Specify: ____________________)

2. How long have you been in your current position? _________________(years)

3. In the past 12 months, what type of facility did you work the most time in? (check only one)

 Acute care >300 beds  Acute care <300 beds

 Trauma I or II  Trauma III or IV

 Psychiatric  Nursing Home

 Other (Specify: ____________________)

4. In the past 12 months, what type of department/unit/area did you work the most time in? (check only one)  Medical/Surgical  Obstetric/Gynecologic

 Operating/Recovery Room  Emergency

 Intensive Care  Occupational Health

 Psychiatric/Behavioral  Education/Research

 Other (Specify: ____________________)

5. How long have you worked in the health care field? _________________(years)

6. In the past 12 months, how many months did you work in patient care? _________________(months)

7. In the past 12 months, what was the primary shift you worked? (check only one)

 Day  Evening  Night  Rotating  12-hour days 7a-7p  12-hr nights 7p-7a

8. What is your gender?  Female  Male

Public reporting burden of this collection of information is estimated to average 20minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

VIOLENCE-BASED SAFETY PROGRAMS IN HEALTH CARE

1. H

   ____________________________________________________________________________

   ave you heard about the New Jersey Violence Prevention in Health Care Facilities Act?

 Yes- If Yes, how did you hear about it?

 No

2. Do you participate in your health care facility’s safety or workplace violence prevention committees?

 Yes- If Yes, how often does the committee meet? _________________________________

 No

3. Do you feel secure in your department / unit / area:

 Always  Most of the time  Sometimes  Rarely  Never

4. Did you receive training about violence-based safety in your workplace?

 Yes- Please answer questions 4a-4e

 No- Please continue to question 5

 Unknown- Please continue to question 5

IF YES:

4a. Do you receive violence-based safety training:

 As a New Hire  Recurring  Both at New Hire and Recurring

4b. How long is the violence-based safety training?

New Hire: ____________ (minutes) Recurring: ____________ (minutes)

4c. Which of the following components are included in the violence-based safety training either at new

hire or on a recurring basis?

Review of the facility’s violence-based safety policies	 Yes  No  Unknown
Identification of predicting factors for aggression and violence	 Yes  No  Unknown
Verbal methods to diffuse aggressive behavior	 Yes  No  Unknown
Physical methods to diffuse or avoid aggressive behavior	 Yes  No  Unknown
Obtaining a history on a patient with violent behavior	 Yes  No  Unknown
Techniques for restraining violent patients	 Yes  No  Unknown
Self-defense if preventive action does not work	 Yes  No  Unknown
Appropriate use of medications to subdue aggressive patients	 Yes  No  Unknown
Requirements and procedures for reporting a violent event	 Yes  No  Unknown
Location and operation of safety devices	 Yes  No  Unknown
Resources for employee victims of violence	 Yes  No  Unknown
Worksite-specific summary of risk factors for violence and preventive actions taken in response	 Yes  No  Unknown
Information on multicultural diversity to increase sensitivity to racial and ethnic issues and differences	 Yes  No  Unknown

4d. What, if anything, do you feel should be changed about the training? ________________________________________________________________________________________________________________________________________________________

4e. How good would you say your violence-based safety training program is:

 Excellent  Very Good  Adequate  Not very good

5. Do you consistently employ your facility’s violence-based safety policies and procedures:

 Always  Most of the Time  Rarely  Never

EXPERIENCES WITH VIOLENCE

In the past 12 months, have you ever experienced work-related:
Threats A threat occurs when someone uses words, gestures, or actions with the intent of intimidating, frightening, or causing harm to you (physically or otherwise). Threats may also include theft or property damage.	 Yes  No	If yes, how frequently did this occur?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more
Sexual harassment Sexual harassment occurs when you experience any type of unwelcome sexual behavior (words or actions) that create a hostile work environment.	 Yes  No	If yes, how frequently did this occur?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more
Verbal Abuse Verbal abuse occurs when someone yells or swears at you, calls you names, or uses other words intended to control or hurt you.	 Yes  No	If yes, how frequently did this occur?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more
Bullying Bullying occurs when one or more people tease, threaten, spread rumors about, hit, shove, or hurt you over and over again.	 Yes  No	If yes, how frequently did this occur?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more

1. Did you miss at least one day of work as a result of a violent event?

 Yes- How many days total: ____________

 No

 Did not experience any of the above events

2. Did you fill out an incident form to report the violent event?

 Yes  No  Did not experience any of the above events

3. In your opinion, what percentage of the following violent events goes unreported?

Threats: _______ % Sexual Harassment: _______ %

Verbal Abuse: _______ % Bullying: _______ %