Have you witnessed acts of workplace violence? Have you, personally, experienced verbal or physical abuse while on the job? Do you ever fear for your safety while at work? Please help us explore these serious issues by completing the questionnaire here or online. We'll publish the results in a future issue.
Internet: http://nursingcenter.com/NM/workplace/survey
Mail: Nursing Management Workplace Violence Survey 2008, 323 Norristown Road, Suite 200, Ambler, PA 19002
Fax: 215-367-2147
1. Gender:
[white square] female
[white square] male
2. What's your age?
[white square] <25
[white square] 36-40
[white square] 51-55
[white square] 25-30
[white square] 41-45
[white square] 56-60
[white square] 31-35
[white square] 46-50
>60
3. What's your current title?
[white square] CEO/COO
[white square] Asst. Nurse Manager
[white square] Administrator
[white square] Case Manager
[white square] Vice President
[white square] Supervisor
[white square] Director
[white square] Educator
[white square] Nurse Manager
[white square] Consultant
[white square] Other (specify) _____________________________
4. How long have you been in nursing?
[white square] <5 years
[white square] 16-20 years
[white square] 5-10 years
[white square] 21-25 years
[white square] 11-15 years
[white square] >25 years
5. What's your level of education?
[white square] doctoral degree _________________________
[white square] MSN
[white square] master's degree, other (specify) _______
[white square] BSN
[white square] bachelor's degree, other (specify) _____
[white square] ADN
[white square] diploma in nursing
[white square] other (specify) ___________________________
6. In what locale do you work?
[white square] urban
[white square] rural
[white square] suburban
[white square] remote area
7. In what setting do you work?
[white square] hospital/health system
[white square] outpatient services/clinic
[white square] community/home healthcare
[white square] long-term care
[white square] rehabilitative care
[white square] subacute care
[white square] academic/university setting
[white square] other (specify) ___________________________
8. What's your area of clinical practice?
[white square] medical/surgical
[white square] critical care
[white square] emergency department
[white square] operating room
[white square] maternal/child health
[white square] psychiatric
[white square] other (specify) _____________
9. How many beds does your facility have?
[white square] < 100
[white square] 301-500
[white square] 701-1,000
[white square] 101-300
[white square] 501-700
[white square] >1,000
10. Where do you live?
[white square] New England: CT, ME, MA, NH, RI, VT
[white square] Middle Atlantic: NJ, NY, PA
[white square] East North Central: IL, IN, MI, OH, WI
[white square] West North Central: IA, KS, MN, MO, NE, ND, SD
[white square] South Atlantic: DE, DC, FL, GA, MD, NC, SC, VA, WV
[white square] East South Central: AL, KY, MS, TN
[white square] West South Central: AR, LA, OK, TX
[white square] Mountain: AZ, CO, ID, MT, NV, NM, UT, WY
[white square] Pacific: AK, CA, HI, OR, WA
[white square] Canada
[white square] Other (specify) ______________
11. Check any of the following that you've witnessed when working with a colleague.
[white square] increasing belligerence
[white square] apparent obsession with a supervisor or coworker
[white square] ominous or specific threats
[white square] recent acquisition or fascination with weapons
[white square] hypersensitivity to criticism
[white square] preoccupation with violent themes or recently publicized violent events
[white square] outbursts of anger
12. Check any of the following that you've experienced in the work setting.
[white square] physical violence
[white square] threats of physical violence
[white square] harassment
[white square] intimidation
[white square] threatening, disruptive behavior
[white square] bullying
[white square] intentional property damage
[white square] carrying or storing of weapons
13. How frequently have these episodes occurred?
[white square] never
[white square] occasionally
[white square] frequently
[white square] always
14. Who's been the victim of workplace violence?
[white square] yourself
[white square] nursing colleague
[white square] physician
[white square] other healthcare worker
[white square] patient
[white square] visitor
15. Who's demonstrated workplace violence?
[white square] nursing colleague
[white square] physician
[white square] other healthcare worker
[white square] patient
[white square] visitor
16. Check any of the following measures that your organization has implemented.
[white square] zero tolerance policies and procedures for workplace violence
[white square] education/training on: harassment and workplace violence, conflict prevention, sexual harassment, workplace security, and a drug-free workplace (Circle all that apply.)
[white square] conflict management programs
[white square] employee assistance programs
[white square] preemployment screening
[white square] photo identification badges
[white square] security guard services
[white square] individually coded key cards for access to buildings and grounds
[white square] controlled facility access
[white square] alternative dispute resolution
[white square] threat assessment team
[white square] emergency response team
[white square] reporting procedures for workplace violence
[white square] incident response team
[white square] visible security
[white square] mock drills
[white square] metal detectors
[white square] sign-in procedure for visitors
[white square] other (specify) _______________
17. Please provide any additional comments you might have regarding workplace violence.
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