Nurse Survey

H

Form Approved

OMB No. 0920-0914

Exp. Date 01/31/2015

EALTHCARE FACILITY WORKPLACE VIOLENCE PREVENTION PROGRAMS  OPT OUT

BACKGROUND

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

2. Do you have an advanced certification or degree?  Yes (Specify:_____________________)  No

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

4. 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  Other (Specify: ____________________)

5. 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: ____________________)

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

7. In the past 12 months, how many months did you work in direct patient care? _________(months)

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

 Day  Evening  Night  Rotating  12-hour (starting am)  12-hour (starting pm)

9. What is your gender?  Female  Male

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



Public reporting burden of this collection of information is estimated to average 20 minutes 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 (0920-0914).

Facility does not have a workplace violence prevention committee

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 whether formal or informal?

 Yes- Please answer questions 4a-4e

 No- Please continue to question 5

 Unknown- Please continue to question 5

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

 As a New Hire  Regularly (e.g. every year)  Both at New Hire and Regularly

 Other (Specify: ____________________________________________________________)

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

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

Other (Specify: _____________________________________________________________)

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?  No changes should be made

__________________________________________________________________________________

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 procedure?

 Always  Most of the Time  Rarely  Never  Facility does not have policies

EXPERIENCES WITH VIOLENCE

In the past 12 months, have you ever experienced work-related violence events (includes any activities associated with your job or events that occur in your work environment):

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). For patient perpetrators, this is regardless of their state of being, such as dementia or substance use. Threats may also include theft or property damage.	Perpetrator is a Patient or Family Member  Yes  No If Yes, how frequently?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more	Perpetrator is a Coworker or Administrator  Yes  No If Yes, how frequently?  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). For patient perpetrators, this is regardless of their state of being such as dementia or substance abuse.	Perpetrator is a Patient or Family Member  Yes  No If Yes, how frequently?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more	Perpetrator is a Coworker or Administrator  Yes  No If Yes, how frequently?  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. For patient perpetrators, this is regardless of their state of being such as dementia or substance abuse.	Perpetrator is a Patient or Family Member  Yes  No If Yes, how frequently?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more	Perpetrator is a Coworker or Administrator  Yes  No If Yes, how frequently?  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, hurt you over and over again, or unfair/unsafe work assignments/schedules. For patient perpetrators, this is regardless of their state of being such as dementia or substance abuse.	Perpetrator is a Patient or Family Member  Yes  No If Yes, how frequently?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more	Perpetrator is a Coworker or Administrator  Yes  No If Yes, how frequently?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more
Physical Assault Physical assault occurs when you are hit, slapped, kicked, pushed, choked, grabbed, sexually assaulted, or otherwise subjected to physical contact intended to injure or harm you. For patient perpetrators, this is regardless of their state of being such as dementia or substance abuse.	Perpetrator is a Patient or Family Member  Yes  No If Yes, how frequently?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more	Perpetrator is a Coworker or Administrator  Yes  No If Yes, how frequently?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more
Electronic Aggression Electronic aggression can occur through words, pictures, or videos and includes someone telling lies, making fun of you through words, pictures or videos, making rude or mean comments, spreading rumors, or making threatening or aggressive comments through email, a cell phone, text messaging, a chat room, instant messaging, or a website (e.g., MySpace, Facebook, YouTube).	Perpetrator is a Patient or Family Member  Yes  No If Yes, how frequently?  1 to 4 times  5 to 9 times  10 to 19 times  20 times or more	Perpetrator is a Coworker or Administrator  Yes  No If Yes, how frequently?  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 any violent event?

 Yes- How many days total: ____________

 No

 Did not experience any of the above events

2. In the past 12 months, how often did you fill out an incident form to report any violent events (use definitions from the table above)?

Threats: Always Sometimes Never N/A- Did not experience

Sexual Harassment: Always Sometimes Never N/A- Did not experience

Verbal Abuse: Always Sometimes Never N/A- Did not experience

Bullying: Always Sometimes Never N/A- Did not experience

Physical Attack: Always Sometimes Never N/A- Did not experience

Electronic Aggression: Always Sometimes Never N/A- Did not experience

3. In the past 12 months, how would you characterize the frequency of any violent events at your workplace?

Threats: Many (>10 events) Some (5-9 events) Few (1-4 events) None (0 events)

Sexual Harassment: Many (>10 events) Some (5-9 events) Few (1-4 events) None (0 events)

Verbal Abuse: Many (>10 events) Some (5-9 events) Few (1-4 events) None (0 events)

Bullying: Many (>10 events) Some (5-9 events) Few (1-4 events) None (0 events)

Physical Attack: Many (>10 events) Some (5-9 events) Few (1-4 events) None (0 events)

Electronic Aggression: Many (>10 events) Some (5-9 events) Few (1-4 events) None (0 events)

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