3 Attachment A: Draft Workplace Safety Supplemental Item S

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

Attachment A: Draft Nursing Home Workplace Safety Supplemental Item Set

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

Draft Workforce Safety Supplemental Item Set

1/27/22

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Your participation is voluntary and all of your answers will be kept confidential to the extent permitted by law. 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.

Workplace Safety

The following questions ask about workplace safety for staff in your nursing home.

If a question does not apply to you or you don’t know the answer, please select “Does Not Apply or Don’t Know.”

Section A: Protection From Workplace Hazards

How much do you agree or disagree with the following statements about your nursing home?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 		Strongly Agree 		Does Not Apply or Don’t Know 
There are good processes to protect staff from infectious diseases, body fluids, or other workplace hazards.	☐ 1	☐ 2	☐ 3	☐ 4		☐ 5		☐ 9
Staff are provided with the appropriate personal protective equipment (PPE)	☐ 1	☐ 2	☐ 3	☐ 4		☐ 5		☐ 9
Staff are trained to put on, use, and remove PPE	☐ 1	☐ 2	☐ 3		☐ 4		☐ 5	☐ 9
Staff use the appropriate PPE when needed	☐ 1	☐ 2	☐ 3		☐ 4		☐ 5	☐ 9
Staff clean their hands before and after helping residents with personal care	☐ 1	☐ 2	☐ 3		☐ 4		☐ 5	☐ 9

Section B: Moving, Transferring, or Lifting Residents

How often do the following things happen in your nursing home?

	Never 	Rarely 	Sometimes 	Most of the time 	Always 	Does Not Apply or Don’t Know 
Equipment or assistive devices are available when needed to help move, transfer, or lift residents	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Equipment and assistive devices are in good working condition	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Staff are trained on how to use equipment and assistive devices	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Staff use equipment or assistive devices when needed to help move, transfer, or lift residents	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Enough staff are available when needed to help move, transfer, or lift residents	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9

Section C: Addressing Inappropriate Resident Behavior Toward Staff

Inappropriate resident behavior toward staff includes:

• Inappropriate physical contact toward staff, such as residents biting, scratching, hitting, or kicking staff.

• Inappropriate verbal communication toward staff, such as residents yelling, using offensive language, bullying, harassing, or threatening staff.

How much do you agree or disagree with the following statements about your nursing home?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Staff are trained on how to identify triggers or situations that lead to inappropriate resident behavior toward staff	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Staff are trained on how to respond or calm down residents who are agitated or upset	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Staff work as a team to address inappropriate resident behavior toward staff	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
There are effective policies and procedures to keep staff safe from inappropriate resident behavior	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
There is a problem with the way this nursing home deals with inappropriate resident behavior toward staff.	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Inappropriate resident behavior toward staff happens so often or is so severe that it makes staff feel unsafe	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9

Section D: Interactions Among Staff

How much do you agree or disagree with the following statements about your nursing home?

Strongly Disagree 

Disagree 

Neither Agree nor Disagree 

Agree 

Strongly Agree 

Does Not Apply or Don’t Know 

Staff interact with each other in a professional manner.

☐ 1

☐ 2

☐ 3

☐ 4

☐ 5

☐ 9

There is a problem with staff being rude or disrespectful to one another

☐ 1

☐ 2

☐ 3

☐ 4

☐ 5

☐ 9

Section E: Supervisor Support for Workplace Safety

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

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
My supervisor regularly monitors the workplace to identify unsafe working conditions for staff	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
My supervisor encourages staff to report their concerns about workplace safety	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
My supervisor asks staff for their ideas and suggestions to improve workplace safety	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
My supervisor listens to staff ideas and suggestions about workplace safety	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
My supervisor can be trusted to do the right thing to keep staff safe	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9

Section F: Management Support for Workplace Safety

How much do you agree or disagree with the following statements about management in your nursing home?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
The actions of management show that the safety of staff is a top priority	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Management provides adequate resources to ensure the safety of staff	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Management takes action to address staff concerns about workplace safety	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9

Section G: Workplace Safety Reporting

How much do you agree or disagree with the following statement about your nursing home?

	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Staff are afraid to report their concerns about workplace safety.	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9
Staff can report their concerns about workplace safety without fear of negative consequences	☐ 1	☐ 2	☐ 3	☐ 4	☐ 5	☐ 9

Section H: Work Stress/Burnout

1. Using your own definition of “burnout,” please select one of the answers below:

☐ 1 I have no symptoms of burnout.

☐ 2 I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.

☐ 3 I am beginning to burn out and have one or more symptoms of burnout, e.g., emotional exhaustion.

☐ 4 The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot.*

☐ 5 I feel completely burned out. I am at the point where I may need to seek help.*

* If you indicated you have symptoms of burnout or feel completely burned out, please consider seeking assistance [e.g., from your insurance provider or employee assistance plan (EAP)].

Section I: Overall Rating on Workplace Safety for Staff

1. How would you rate your nursing home on workplace safety for staff?

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

Background Questions

1. Overall, how satisfied are you with your job?

☐ a Very Dissatisfied

☐ b Dissatisfied

☐ c Neither Satisfied or Dissatisfied

☐ d Satisfied

☐ e Very Satisfied

2. Are you considering leaving your nursing home within the next 12 months, and if so why?

☐ a No

☐ b Yes, to retire

☐ c Yes, to take another job in another nursing home

☐ d Yes, to take another job within healthcare

☐ e Yes, to take another job outside of healthcare

☐ f Yes, other

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