Nurse Survey

Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

Appendix C4

Nurse (RN and LPN) Survey

OMB: 0920-0914

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Appendix C4:

Healthcare Facility Workplace Violence Prevention Programs Home 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: ____________________)

  1. 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: ____________________)

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

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

  3. 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)

  1. 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

  1. 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



  1. 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?

  1. Review of the facility’s violence-based safety policies

Yes No Unknown

  1. Identification of predicting factors for aggression and

violence

Yes No Unknown

  1. Verbal methods to diffuse aggressive behavior

Yes No Unknown

  1. Physical methods to diffuse or avoid aggressive behavior

Yes No Unknown

  1. Obtaining a history on a patient with violent behavior

Yes No Unknown

  1. Techniques for restraining violent patients

Yes No Unknown

  1. Self-defense if preventive action does not work

Yes No Unknown

  1. Appropriate use of medications to subdue aggressive

patients

Yes No Unknown

  1. Requirements and procedures for reporting a violent event

Yes No Unknown

  1. Location and operation of safety devices

Yes No Unknown

  1. Resources for employee victims of violence

Yes No Unknown

  1. Worksite-specific summary of risk factors for violence and

preventive actions taken in response

Yes No Unknown

  1. 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):

  1. 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

  1. 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

  1. 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

  1. 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

  1. 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

  1. 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

  1. 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

  1. 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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File Typeapplication/msword
File TitleNIOSH Project Form – Project Proposal Information
AuthorAnn Berry
Last Modified BySawyer, Tamela (CDC/NIOSH/OD)
File Modified2012-10-04
File Created2012-10-04

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