3 Attachment A: Draft Workforce Safety Supplemental Item

Pilot Test of the Proposed Workforce Safety Supplemental Item Set for the Surveys on Patient Safety Culture™, Supporting Statement A

Attachment A: Draft Workforce Safety Supplemental Item Set

Form Approved
OMB No. XXXX-XXXX
Exp. Date XX/XX/20XX

Draft Workforce Safety Supplemental Item Set

8/3/2020

Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Section A: Safe Patient Handling

How much do you agree or disagree with the following statements?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
In this [unit/nursing home/facility], equipment needed to help lift or move patients is readily available	1	2	3	4	5	9
In this [unit/nursing home/facility], staff use equipment for moving patients when necessary	1	2	3	4	5	9
In this [unit/nursing home/facility], staff are encouraged to use available patient lifting and transfer equipment even if it means taking more time	1	2	3	4	5	9
Staff appropriately use safe patient handling and mobility technology (including patient lifts and transfer devices) to transfer, lift, or reposition patients	1	2	3	4	5	9
In this [unit/nursing home/facility], staff understand how to use safe patient handling equipment (including patient lifts and transfer devices)	1	2	3	4	5	9

Section B: Slips, Trips, and Falls

How much do you agree or disagree with the following statements?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
In this [unit/nursing home/facility], regular assessments are conducted to identify hazards that could lead to slips, trips, and falls	1	2	3	4	5	9
In this [unit/nursing home/facility], unsafe conditions and other hazards regularly cause staff to slip, trip, or fall.	1	2	3	4	5	9

Section C: Personal Protective Equipment (PPE)/Exposure

How much do you agree or disagree with the following statements?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Providers and staff feel comfortable asking for personal protective equipment (PPE) if it is not available	1	2	3	4	5	9
Providers and staff properly use personal protective equipment (PPE) when it is needed	1	2	3	4	5	9
This [hospital/nursing home/facility] has effective procedures to limit provider and staff exposure to harm from blood borne pathogens and infectious diseases	1	2	3	4	5	9
Management is responsive when providers and staff need additional personal protective equipment	1	2	3	4	5	9
Management is responsive when providers and staff report concerns about personal protective equipment	1	2	3	4	5	9

Section D: Sharps

How much do you agree or disagree with the following statements?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Providers and staff in this [unit/nursing home/facility] carefully follow procedures to prevent injuries from contaminated sharp objects such as used needles and scalpels	1	2	3	4	5	9
This [unit/nursing home/facility] has an effective sharps injury prevention program.	1	2	3	4	5	9
In the event of a sharps injury, providers and staff know the steps to take to reduce their risk of contracting blood borne pathogens/infectious diseases	1	2	3	4	5	9

Section E: Workplace Violence

Psychological or verbal aggression includes abusive, intimidating or harassing behavior and threats.

How much do you agree or disagree with the following statements?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
There is a problem with psychological or verbal aggression by those working in this [unit/nursing home/facility]	1	2	3	4	5	9
There is a problem with disruptive/disrespectful behavior by those working in this [unit/nursing home/facility]	1	2	3	4	5	9
There is a problem with unwanted physical contact from patients/visitors in this [unit/nursing home/facility]	1	2	3	4	5	9
This [unit/nursing home/facility] has measures/systems in place to properly/effectively respond to situations involving physically violent patients/visitors	1	2	3	4	5	9

Section F: Stress/Burnout

How much do you agree or disagree with the following statements?

I Statements

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
I feel a great deal of stress on the job/during my workday	1	2	3	4	5	9
I feel emotionally drained from my work	1	2	3	4	5	9
I am often assigned a higher workload than I am comfortable with	1	2	3	4	5	9
I don’t have time to take enough rest breaks at work	1	2	3	4	5	9
I feel burned out from my work	1	2	3	4	5	9

Section F: Stress/Burnout (continued)

Collective Statements

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Providers and staff in this [unit/nursing home/facility] feel a great deal of stress on the job	1	2	3	4	5	9
Providers and staff feel emotionally drained from their work	1	2	3	4	5	9
We often have such a heavy workload that we are constantly rushing	1	2	3	4	5	9
We don’t have time to take enough rest breaks at work	1	2	3	4	5	9
Providers and staff in this [unit/nursing home/facility] feel burned out from work	1	2	3	4	5	9

Section G: Management Support for Workplace Health and Safety

How much do you agree or disagree with the following statements?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Management in this [unit/nursing home/facility] responds to provider and staff concerns about work-related stress/burnout	1	2	3	4	5	9
Management is genuinely concerned about the well-being of everyone who works here.	1	2	3	4	5	9
Unsafe working conditions/workplace safety hazards are quickly corrected when they are brought to management’s attention	1	2	3	4	5	9
Management in this [unit/nursing home/facility] takes action to address workforce safety concerns that are brought to their attention	1	2	3	4	5	9
Management is quick to respond to workplace safety concerns	1	2	3	4	5	9

Section G: Management Support for Workplace Health and Safety (continued)

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Management regularly monitors the workplace to identify and correct unsafe working conditions.	1	2	3	4	5	9
Management in this [unit/nursing home/facility] encourages staff to voice their concerns about workplace safety	1	2	3	4	5	9
Management in this [unit/nursing home/facility] takes staff concerns about workplace safety seriously	1	2	3	4	5	9
Providers and staff trust that management will do the right thing to keep workers safe	1	2	3	4	5	9

Section H: Speaking Up

How much do you agree or disagree with the following statements?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Staff in this [unit/nursing home/facility] inform their supervisor as soon as possible when they notice a workplace safety hazard	1	2	3	4	5	9
In this [unit/nursing home/facility], staff speak up if they see something that may negatively affect workplace safety.	1	2	3	4	5	9
In this [unit/nursing home/facility], staff are afraid to voice their concerns about workplace safety	1	2	3	4	5	9
Staff in this [unit/nursing home/facility] tell other staff who are doing something unsafe to stop	1	2	3	4	5	9

Section I: Reporting of Workplace Safety Incidents

1. In the past 12 months, have you experienced one or more workplace physical injuries or harm from any of the following?

   1. Lifting patients or equipment

   2. A slip, trip, or fall

   3. A used sharp object like a needle or scalpel

   4. Hazardous materials, pathogens, and/or contagious diseases

   5. Physical violence from others

1 Yes, and I reported ALL incidents

2 Yes, and I reported SOME incidents

3 Yes, but I DID NOT report any of these incidents

4 No, I did not experience any injuries or harm from these types of incidents

2. In the past 12 months, have you experienced one or more incidents involving workplace disruptive behavior or psychological or verbal aggression?

1 Yes, and I reported ALL incidents

2 Yes, and I reported SOME incidents

3 Yes, but I DID NOT report any of these incidents

4 No, I did not experience any incidents involving workplace disruptive behavior or psychological or verbal aggression

How much do you agree or disagree with the following statement?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
In this [unit/nursing home/facility], reporting of worker injuries and health concerns is encouraged	1	2	3	4	5	9

Section J: Training on Workplace Health and Safety

How much do you agree or disagree with the following statements?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
In this [unit/nursing home/facility], providers and staff lack proper training in workforce/workplace safety practices and policies	1	2	3	4	5	9

Section J: Training on Workplace Health and Safety (continued)

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
In this [unit/nursing home/facility] providers and staff are adequately trained in workplace safety practices and policies	1	2	3	4	5	9
This [unit/nursing home/facility] has effective training programs to prevent workplace injuries	1	2	3	4	5	9
In this [unit/nursing home/facility] providers and staff receive enough/ adequate training on:
the use of safe patient handling equipment and practices	1	2	3	4	5	9
the proper use of personal protective equipment (PPE)	1	2	3	4	5	9
sharps safety protocols and policies	1	2	3	4	5	9
bullying and violence prevention protocols and policies	1	2	3	4	5	9

Section K: Overall Ratings on Workplace Safety

1. Please give your [unit/nursing home/facility] an overall rating on patient safety.

	Poor ▼	Fair ▼	Good ▼	Very Good ▼	Excellent ▼
	1	2	3	4	5

2. How effective is your organization at preventing injuries and managing the safety of providers and staff?

	Not at all effective ▼	Slightly effective ▼	Somewhat effective ▼	Very effective ▼	Extremely effective ▼
	1	2	3	4	5

THANK YOU FOR COMPLETING THIS SURVEY.

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