1 Attachment B: Draft Workplace Safety Cognitive Interview

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

Attachment B: Draft Nursing Home Workplace Safety Cognitive Interview Guide

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

Draft Nursing Home Workplace Safety Supplemental Item Set

Cognitive Interview Guide

1/27/2022

Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the interview. 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.

Survey on Workplace Safety in Nursing Homes: Cognitive Interview Guide

Respondent ID#:	Interviewer:
Respondent Job Title:	Note Taker:
Date & Time of Interview:	Recorded?

Introduction and Oral Consent

Introduction

Hello, thank you for taking the time to talk with me today. My name is _____________________________, and I also have [a/two] colleague(s) with me here [NAME(S)]. They will just be observing in the background while we talk.

We work for Westat, a private research company in Rockville, Maryland. For this project, Westat is under contract with Agency for Healthcare Research and Quality, which is part of the U.S. Department of Health and Human Services, to create a survey that asks about the culture in nursing homes.

At this stage, we’re still developing the survey questions, and we’re trying to make them as easy as possible for people to understand and answer. That is what we’re asking you to help us with today. I’m going to ask you to read and answer some draft questions for the survey, then we will discuss your thoughts and reactions. For example, I may ask you if the questions were easy to understand and answer? Were any of the words vague or confusing? What does the question mean to you? There are no right or wrong comments.

Informed Consent

We’ll be talking about the survey topics, including workplace violence, stress, and reporting incidents. If this discussion is upsetting to you, I can give you the contact information for the Occupational Safety and Health Administration office (also known as OSHA) which can help you find local resources on workplace safety issues. Would you like me to share that phone number? (IF YES: You may call 1-800-321-6742.)

We take many steps to keep your comments and survey responses private. The information we discuss will not be shared with your employer, or anyone else outside of our research team. I will discuss your responses only with other project team members. We will not include your name or the name of your facility in any written findings or reports. We may include quotes in our internal notes to help us better understand the phrasing you and others use to describe your experiences.

This is a research project and your participation is voluntary. There are minimal risks and no direct benefits to participating in this study. You may skip any question that you do not want to answer, and you may stop the interview at any point. I expect the interview to take about 1 hour, and you will receive [Admin or CNA: $150/ Nurse: $200 / Physician: $300] in appreciation of your time.

I am happy to answer any questions you may have about this task. If you have any questions about your rights as a research participant, you may contact Westat’s Human Subjects Protections office. Would you like that phone number? (IF YES: Please call 1-888-920-7631 and leave a message with your first name, the name of this research study “Workforce Safety Survey Items”, and a phone number beginning with the area code. Someone will return your call as soon as possible).

Task Description

Next, I’m going to have you go through the survey; and as best you can, I’d like you to read aloud as you go along – just read the question, and whatever your answer is. As much as possible, try to read and respond to the survey the way you normally would if you were doing this on your own. Some people might read every word they see, while others might skim or skip stuff here and there – please do whatever feels most natural to you.

Please share whatever reactions come to mind while you’re answering. We’re especially interested in knowing about things that are confusing, such as when you’re not quite sure what a question is asking you – just let me know when that happens. I didn’t write the questions so you won’t be hurting my feelings if you have something negative to say.

Finally, I’ll stop you now and then as you’re going through the survey and ask to discuss certain questions. I might ask you things like how you decided on your answers, or ask in your own words what a question is asking. Your answers and comments will help us to understand how the survey is working and to identify possible problems. Please don’t hesitate to share any thoughts, bring up problems, suggest wording changes, or say which items you prefer – the purpose of this interview is to improve the survey items and make sure they make sense.

Because I want to pay close attention to what you say, I would like to record our interview so that I can listen to it later to see if I missed anything. Is that okay?

Okay great, I’ll start recording [START ZOOM RECORDING], and I need to ask your permission one more time so that it is recorded: Today is [mo/day/year at [time]. Do you agree to participate in this interview and to have it audio recorded?

Great, Thank you. Before we start, do you have any questions?

Okay, let’s begin. I’m going to start by sharing my screen so we can both see the survey questions you’ll be answering. [CONFIRM PARTICIPANT CAN SEE SCREEN].

GENERAL INTERVIEWER INSTRUCTIONS:

-HAVE PARTICIPANT READ AND ANSWER ALL QUESTIONS IN A SECTION, THEN GO BACK TO ADMINISTER PROBES

-AS PARTICIPANTS READ ALOUD, MARK THE RESPONSE THEY CHOSE IN THE PDF DOCUMENT ON THE SHARED SCREEN

-FOR EACH QUESTION< BEGIN WITH GENERAL PROBE ABOUT THE PARTICIPANTS ANSWER (e.g. – Can you tell me how you chose your answer for…). CONTINUE WITH SCRIPTED PROBES OR UNSCRIPTED PROBES AS NECESSARY TO EVALUATE THE PARTICIPANT’S COMPREHENSION & RESPONSE

-MAKE A NOTE AND PROBE ON ANY CUE THE PARTICIPANT GIVES WHILE ANSWERING A QUESTION. (FOR EXAMPLE, DID THEY PAUSE OR STUMBLE WHILE READING A WORD? DID THEY GO BACK TO RE-READ ANYTHING? DID THEY SWITCH RESPONSES? DID THEY SHOW ANY OTHER SIGNS OF CONFUSION?)

-PAY PARTICULAR ATTENTION TO ATYPICAL RESPONSES SUCH AS DNA/DK, NEITHER…, OR DISAGREE (OR AGREE FOR NEG. WORDED ITEMS)

-IF YOU THINK A RESPONDENT EXPERIENCED A PROBLEM ANSWERING THE QUESTION (OR THE QUESTION HAS A PROBLEM IN NEED OF ATTENTION), MARK THAT QUESTION AND WRITE UP THE PROBLEM IMMEDIATELY FOLLOWING THE INTERVIEW

Section A: Exposure to Workplace Hazards (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	(if R did not read instructions aloud) First, did you see these first couple lines of instructions, or did you not notice them? (all) What do you think of these instructions?
There are good processes to protect staff from infectious diseases, body fluids, or other workplace hazards.	Can you tell me how you chose your answer for the first question? Can you say more about the processes in your facility to protect staff… ? Are there set process that everyone uses? Can you say more about why you [AGREE/NEITHER/DISAGREE] that the processes in your facility are good? Can you tell me in your own words what “infectious diseases” means? Is this a term you’ve heard at your nursing home? What do you think about of the phrase “infectious diseases, bodily fluids, or other workplace hazards”? Do you hear the term “hazards” in your workplace? Is there another term you use to describe risks like these? Are there any other workplace risks you experience that aren’t covered here?
Staff are provided with the appropriate personal protective equipment (PPE)	Can you tell me how you chose your answer for the next question? What PPE does your nursing home provide to staff? Do they provide all of the PPE you need, or are you responsible for getting any of it yourself? [if self] What PPE are you getting yourself? What do you think think this question means when is asks about “appropriate” PPE? What is appropriate?
Staff are trained to put on, use, and remove PPE	Can you tell me how you chose your answer for this question? (if agree) Tell me more about how were you trained to use PPE. (if needed) Was there official training, or were you just told about it? Was it verbally or in writing? (if neither or disagree) What would it look like to be trained to use PPE?
Staff use the appropriate PPE when needed	Can you tell me how you chose your answer for the next question? In your own words, what does “the approriate PPE” mean? How do you know if PPE is appropriate? How do you know when PPE is needed?
Staff clean their hands before and after helping residents with personal care	Can you tell me more about your answer for this? How or where do staff at your nursing home usually clean their hands? (if needed) Do you think that “clean their hands” includes using hand sanitizer? When you were answering this question, were you thinking just about yourself, or were you thinking about other staff as well? (if others) Can you tell me more about how you know whether other staff are cleaning their hands? In your own words, what do you think “personal care” means in this question? What types of intereactions with residents require you to clean your hands?

Section B: Moving, Transferring, or Lifting Residents (scale: Never – Always)

Draft Items	Interviewer Script, Probes, and Notes
	Okay let’s discuss the questions about Moving, Transferring, or Lifting Residents.
Equipment or assistive devices are available when needed to help move, transfer, or lift residents	Can you tell me about your answer for question 1? Is it ever the case that equipment is not available when needed? [IF YES] How often is that the case? What types of equipment or assistive devices were you thinking about while answering this section? [IF NEEDED] Were you just thinking about more complex equipment like lifts, or did you also include things like a gait belt, walkers, canes, etc.? In your opinion, how are “assistive devices” different than “equipment”?
Equipment and assistive devices are in good working condition	Can you tell me how you chose your answer for the next one? How can you tell whether or not equipment and devices are in good working condition?
Staff are trained on how to use equipment and assistive devices	(if Rarely, Sometimes, Most) You said that staff are trained (rarely/somteimes/most of the time). Can you give me more detail about when staff receive training, and when they don’t? (if sometimes or more) Tell me more about how staff are trained to use equipment and assistive devices. (if needed) Was there official training, or were you just told about it? Was it verbally or in writing? (if < sometimes) What do you think would be included in a training on using equipment and assistive devices?
Staff use equipment or assistive devices when needed to help move, transfer, or lift residents	In your own words, what is this question asking about? (if sometimes or more) How do staff know whether equipment or assistive devices are needed? (if < sometimes) Tell me more about why staff might not use equipment or devices when needed?
Enough staff are available when needed to help move, transfer, or lift residents	Can you tell me about how you chose your answer for this last question? How do you know when other staff are needed to move, transfer, or lift residents?
Section question	Are there any other issues associated with moving, transferring, or lifting residents that we haven’t talked about so far? Has anyone in your facility ever been injured while moving, transfering, or lifting a resident? (if yes) Can you tell me more about what happened?

Section C: Addressing Inappropriate Resident Behavior Toward Staff (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	Let’s talk about this section on inappropriate Resident Behavior Toward Staff
Inappropriate resident behavior toward staff includes: Inappropriate physical contact toward staff, such as residents biting, scratching, hitting, kicking staff or other physically aggressive behavior Inappropriate verbal communication toward staff, such as residents yelling, using offensive language, bullying, harassing, or threatening staff.	Did you read the description of “Inappropriate resident behavior” at the beginning of the section, did you just skim it, or did you not notice it? (if noticed) What did you think about it? What did you think about the term ‘Inappropriate physical contact’ used here? What other terms do staff at your nursing home use to refer to these types of behaviors? What are some other examples of inappropriate physical contact toward staff? What about the term of ‘Inappropriate verbal communication’? What words do staff at your nursing homes usually use to refer to these types of behaviors? What are some other examples of inappropriate verbal communication toward staff? When answering these questions, were you thinking about inappropriate behavior toward staff specifically, or were you also thinking about inappropriate behavior between residents? Are there any other types of inappropriate resident behavior toward staff that aren’t covered by this description?
Staff are trained on how to identify triggers or situations that lead to inappropriate resident behavior toward staff	Can you tell me in your own words what this first question is asking? (if needed) How did you decide on your answer? What’s an example of a trigger or situation that can lead to inappropriate resident behavior? Is “trigger” a term that you hear in your nursing home? (if no) what other words do staff at your nursing home use to describe situations that lead to inappropriate resident behavior? [IF AGREE] Tell me more about how staff are trained to identify resident triggers or situations that lead to inappropriate behavior toward staff? (if needed) Was there official training, or were you just told about it? Was it verbally or in writing?
Staff are trained on how to respond or calm down residents who are agitated or upset	Can you tell me about your answer for question 3? (if agree) Tell me more about how you were trained to respond or calm down residents who are agitated or upset? (if needed) Was there official training, or were you just told about it? Was it verbally or in writing? (for all) What types of behaviors were you thinking about when it asks about “residents who are agitated”? Do you think that “agitated” means something different than different from “upset”? What do you think this question means when it asks about “respond or calm down”? Can you give me an example?
Staff work as a team to address inappropriate resident behavior toward staff	Can you tell me about your answer for question 3? Which staff were you thinking about when you answered this question? What does this question mean when it asks if staff “work as a team” to address inappropriate resident behavior?
There are effective policies and procedures to keep staff safe from inappropriate resident behavior	How did you arrive at your answer for number 4? (if agree) Tell me more about the policies and procedures to keep staff safe from inappropriate resident behavior. Can you give me an example? How do you know that these policies and procedures are effective?
There is a problem with the way this nursing home deals with inappropriate resident behavior toward staff.	How did you choose your answer for this question? What do you think this question means when it asks if there’s “a problem” with how a nursing home deals with innapropriate resident behavior? (if agree) tell me more about why it’s a problem, (if neither or disagree) how would you know if it was “a problem”? (for all) Can you give me an example of how your nursing home deals with innapropriate resident behavior?
Inappropriate resident behavior toward staff happens so often or is so severe that it makes staff feel unsafe.	Tell me in your own words what this question is asking. What do you think the word “severe” means in this question? (if agree) Can you give me an example of how innapropriate resident behavior has made staff feel unsafe?
Section level questions	Is there anything else that we haven’t discussed that staff at your nursing home do to reduce inappropriate resident behavior toward staff? Is there anything else you think that staff could or should do to reduce inappropriate resident behavior toward staff?

Section D: Interactions Among Staff (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	Let’s move on to the next section
Staff interact with each other in a professional manner.	Can you tell me about your answer this item? What do you think this question is asking about when it says “professional manner”? Can you give me an example?
There is a problem with staff being rude or disrespectful to one another	Can you tell me about your answer this item? What do you think this question is asking about when it asks about staff being “rude or disrespectful”? What types of behavior were you thinking about? In your opinion, does “rude” mean the same thing as “disrespectful”? (if no) how are they different? What do you think this question means when it asks if there’s “a problem” with staff being rude or disrespectful to one another? (if agree) tell me more about why it’s a problem, (if neither or disagree) how would you know if it was “a problem”? What are some other issues with interactions among staff that we haven’t covered yet?

Section E: Supervisor Support for Workplace Safety (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	Let’s move on to the next section titled: Supevisor Support for Workplace Safety This section asks questions about “your supervisor”, did you know right away who we meant when we said “your supervisor”, or did you have to think about it? (if thought about it) Tell me more about that
My supervisor regularly monitors the workplace to identify unsafe working conditions for staff	Can you tell me about your answer for the first item? [IF AGREE]: In your own words, what does it mean to ‘regularly monitor the workplace to identify unsafe working conditions’? How exactly does your supervisor monitor the workplace to identify unsafe working conditions? How regularly do they monitor…? Is somebody else responsible for monitoring,besides your supervisor? Is the workplace monitored in a different way to evaluate the safety of staff, than for the safety of residents/visitors? [IF NEITHER OR DISAGREE]: What would it mean to regularly monitor the workplace to indentify unsafe working conditions? Does your supervisor ever monitor…? Is somebody else responsible for monitoring…besides your supervisor? Can you give me an example of “unsafe working conditions”?
My supervisor encourages staff to report their concerns about workplace safety	Can you tell me about your answer for item 2? How do staff report concerns about workplace safety at your nursing home? [IF AGREE]: How exactly does your supervisor encourage staff to report concerns about workplace safety’? Is somebody else responsible for addressing concerns about staff safety…? [IF NEITHER OR DISAGREE]: What would it mean for a supervisor to ‘encourage staff to report concerns about workplace safety’ Is somebody else responsible for addressing concerns about staff safety…?
My supervisor asks staff for their ideas and suggestions to improve workplace safety	How did you decide on your answer for this question? (if agree) can you give me an example of a time when this happened? how often does your supervisor ask staff for ideas to improve workplace safety?
My supervisor listens to staff ideas and suggestions about workplace safety	Can you tell me about your answer for the next item? (if agree) Can you give me an example of a time this happened? Were any changes made as a result? (if neither or disagree) Do staff ever talk to your supervisor about workplace safety? (if yes) What does your supervisor do when this happens?
My supervisor can be trusted to do the right thing to keep staff safe	Can you tell me about your answer for the last item? What do you think it means to “trust” your supervisor to do the right thing? (if needed) How do you know whether your supervisor can be trusted? What does it mean for your supervisor to “do the right thing” to keep staff safe? Can you give me an example of what you think this is talking about? Are there any other ways your supervisor may support safety for staff that we haven’t talked about yet?

Section F: Management Support for Workplace Safety (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	Let’s move on to the next section entitled: Management Support for Workplace Safety This section asks about…“Management” … in your nursing home, is this term the same or something different from your “Supervisor” who we asked about in the previous section? Can you say more about that? Were you thinking about the same or different people as the last section? …in your nursing home, is there a difference between managmeent and top management?
The actions of management show that the safety of staff is a top priority	Can you tell me about your answer for the first question? Can you say more about what actions the nursing home management takes, or doesn’t take? What makes you [AGREE/NEITHER/DISAGREE] that the safety of staff is a top priority for nursing home management?
Management provides adequate resources to ensure the safety of staff	Can you tell me about your answer for the next item? [IF AGREE]: What does it mean that management provides adequate resources to ensure the safety of staff? [IF NEITHER/DISAGREE]: What would it mean that nursing home management provides adequate resources to ensure the safety of staff?
Management takes action to address staff concerns about workplace safety	Can you tell me about your answer for the next item? [IF AGREE]: What does it mean that management takes action to address staff concerns about workplace safety? Can you give me an example of what they do to address staff concerns about safety? [IF NEITHER/DISAGREE]: What would it mean that management takes action to address staff concerns about workplace safety? Can you think of an example of what they could to address staff concerns about safety?

Section G: Workplace Safety and Reporting (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
Staff are afraid to report their concerns about workplace safety	What do you think this question is talking about when is says “concerns about workplace safety”? (if needed) what types of concerns is this asking about Do staff ever report concerns about workplace safety at your nursing home? (if yes) Can you give me an example of a time when this happened? (if needed) Who did they report to? What was the response? (if no) Why don’t staff report concerns about workplace safety?
Staff can report their concerns about workplace safety without fear of negative consequences	How did you decide on your answer to this question? What do you think this question is asking when it says “negative consequences”? Can you give me an example of what you think it means?

Section H: WORK STRESS/BURNOUT

Draft Items	Interviewer Script, Probes, and Notes
	The question in this next section asks about work stress and burnout…can you say in your own words what the term burnout means to you? Is this a term you’re familiar with? Is it used in your facility ? Overall – how would you describe the level of stress in your nursing home? Would you say all of your co-workers feel the same, or do they differ in how much stress they experience at work? How easy or difficult was it to answer the question in this section? [PROBE CAREFULLY AS THIS QUESTION COULD BE SENSITIVE]
Using your own definition of “burnout,” please select one of the answers below: a. I have no symptoms of burnout. b. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out. c. I am beginning to burn out and have one or more symptoms of burnout, e.g., emotional exhaustion. d. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot.* e. 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)].	How easy or difficult was it to choose a response for this item? Can you say more about your answer? How easy or difficult was it to choose your response? Did you think that the response you chose does a good job of describing your experience? Did you see this footnote here at the bottom, or did you not notice it? What do you think it’s talking about when it says “consider seeking assistance”? (if needed) What type of assistance is it talking about? The footnote says to “consider seeking assistance from an insurance provider or employee assistance plan (EAP)”. Do you have an insurance provider or EAP? (if no EAP) Have you heard of employee assistance plans before, or have you not heard of them?

Section I: Overall Rating on Workplace Safety for Staff

Draft Items	Interviewer Script, Probes, and Notes
How would you rate your nursing home on workplace safety for staff?	The next question is in the overall rating section. Can you tell me how you chose your answer for this question? What types of specific things were you thinking about when you chose your answer?

Background Questions

Draft Items	Interviewer Script, Probes, and Notes
Overall, how satisfied are you with your job?	Can you tell me how you chose your answer for this question?
Are you considering leaving your nursing home within the next 12 months, and if so why?	Can you tell me how you chose your answer for this question?

SUMMARY AND BACKGROUND PROBES

Instruction and Definition	Interviewer Script, Probes, and Notes
COVID FOLLOW-UP QUESTIONS	Before we finish up, can you tell me about how your nursing home is adjusting to the COVID-19 pandemic? How has your workflow changed, if at all, due to the pandemic? Have these changes affected the type of care that you provide? how so? Is your [facility] providing COVID testing? Do they provide testing for staff, residents, or both? When you were answering the questions in this survey, how did your experience with COVID affect your answers? Do you think you would have responded differently before COVID?

CLOSING QUESTIONS:

The questions we went over cover a number of different topics related to the safety of staff in your workplace. Are there any aspects of workplace safety at your nursing home that you think are missing from the survey?

[FOR Rs WHO DID NOT SELECT DK/DNA]: Now I have a general question about the survey. I noticed you didn’t select Does Not Apply or Don’t Know - the response option in the last column. Did you notice it?

Do you have any additional comments or feedback about the survey?

Thank you very much for participating in this interview. Your comments have been helpful.

TURN OFF RECORDER

As you know, we discussed some topics that could be stressfull for some people. If it was upsetting to you, I can give you the contact information for the Occupational Safety and Health Administration office (also known as OSHA) which can help you find local resources on workplace safety issues. Would you like me to share that phone number? (IF YES: You may call 1-800-321-6742.)

To show our appreciation for your time and help, we will send you a check for [Admin or CNA: $150/ Nurse: $200 / Physician: $300]

Please [confirm/tell me] your mailing address:

Mailing address – Enter Address into tracking spreadsheet. Do not save PII in this document.

We will send the check by FedEx and it should arrive within 10 business days – you do not have to be there to sign for it.

[NOTE: WE HAVE TO SUBMIT INFO TO ACCOUNTING BY COB MONDAY OR THURSDAY FOR TUESDAY AND FRIDAY PROCESSING - LET RESPONDENT KNOW APPROXIMATELY WHEN TO EXPECT CHECK.]

IMMEDIATELY AFTER THE INTERVIEW, ADD THE PARTICIPANT’S ADDRESS TO THE TRACKING SPREADSHEET.