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Professionals
COVER LETTER TEMPLATE (Date)_____________ Dear ____________________________ (Patient, Family Member, Professional) ___________________ Health System is a member of a group of Catholic health care organizations across the United States. The goal of this Coalition is to improve care for persons who may be affected by a life-threatening illness. We are inviting you to take part in a project to pilot test a new questionnaire. In the future, this questionnaire (form) will help Health Systems and health services collect information about how well they are providing care. Your answers on the forms will help us refine them for future use. It will also help us know if there is a need for more focused change in health care or services for people affected by life-threatening illnesses. The questionnaire that follows is designed to have health care professionals provide feedback on the following: Perception and report of personal and professional experiences and outcomes You will not directly benefit from filling out the forms. Your information will be kept confidential. Your answers will be combined with those from other people. Your name will not be used in any written project report or presentation. However, you may receive follow-up contact from ____________________ Health System or __________________ health service project staff. Completing and returning these forms is voluntary and will qualify as your consent to take part in this project. You will not be paid to take part in this project.
If you have questions about this project, you may call _________________________ Health System or ___________ health service. The contact person is: (Name and title) (address) (phone number) (e-mail address) If you have questions or want additional information, about the Coalition, contact: Karin Dufault, Ph.D., RN, Executive Director Supportive Care Coalition c/o Providence Health System 4805 N.E. Glisan St., RM 2E07 Portland, OR 97213 (503) 215 - 5053 e-mail: karin.dufault@providence.org Sincerely, Note: This project received approval by Providence Health System IRB on 1/20/99
**Modified City of Hope Professional Questionnaire June 1999 PERSONAL /PROFESSIONAL EXPERIENCES Please answer the following questions based on your perception at this time. Rate the following items from your personal perspective 1.Feel satisfied with my work Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 2.Work schedule is unrealistic and high stress Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 3.Have adequate budget and staffing to perform my job Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 4.Feel I work as a member of a strong care team Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 5.Can influence system to improve care Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 6.Receive appropriate recognition for my work Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 7.Have an opportunity to grieve the loss of patients Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 8.Feel not enough time to meet needs Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal
Place of Care Environment (Health Care Experience) Work place structures, procedures, and policies can influence our care. To what extent are the following an issue as you provide care in your workplace. Please mark NA if you have no information about the item. 1. Effective and timely pain management support is present NA No problem 0 1 2 3 4 5 6 7 8 9 10 Severe problem 2.Effective and timely symptom relief, e.g. difficulty breathing, nausea, constipation, support is present NA No problem 0 1 2 3 4 5 6 7 8 9 10 Severe problem 3.Resources adequate for obtaining help to meet physical needs at home NA No problem 0 1 2 3 4 5 6 7 8 9 10 Severe problem 4.When a conflict over care occurs, adequate support for patient/family in resolving issues and carrying out their care wishes NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 5.Providing appropriate control and freedom to refuse care or treatments NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Completely 6.Making family feel welcomed 24 hours a day and with each appointment NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Completely 7.Accessibility to support groups or others who have similar experiences NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 8.Access to and opportunity to talk with professional counselors NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 9. Availability of chaplains or others to pray with and for patients NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Completely 10.Understanding of illness, treatment, and care wishes by all of the health care team NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 11.Getting enough help finding needed resources and support, e.g. transportation or homemaker assistance NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 12.Extent to which communication with healthcare personnel has assisted to maintain hope NA None 0 1 2 3 4 5 6 7 8 9 10 A great deal 13.Doctors listen and convey caring, respect, and genuine presence NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 14.Doctors' communication easy to understand and conveys a consistent message NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 15.Doctors supportive of seeking second opinions and other care choices NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 16.If "alternative therapies" desired as part of care, doctors answer questions to the satisfaction of patient and families NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 17.Doctors provide opportunity to discuss possible death NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 18.Nurses and other health care providers listen, and convey caring, respect, and genuine presence NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 19.Nurses and other health care providers' communication is easy to understand and conveys a consistent message NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 20.Nurses / other health care providers provide the opportunity to discuss possible death NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 21.DNR orders written in a timely manner NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 22."Being with" patient/family in addition to "doing for" patient is valued NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 23.Professional education in providing excellent end-of-life care is supported NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 24.Bereavement and follow-up services are accessible and sufficient NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 25.Appropriate patients are referred to hospice in a timely manner NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 26.There is support for ethical discussions and consultations NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal Please comment on very low or very high scores: EFFECTIVENESS OF CARE Please answer the following questions based on your perception at this time. Circle the number from 0 - 10 that best describes your perception and experience. If the item is not applicable for your practice, circle NA. Physical Area How effective do you think you are as a provider in addressing patient and family concerns regarding or treating physical symptoms of: 1.Fatigue NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely effective 2.Sleep changes NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely effective 3.Problems with dry mouth, change in food tastes, drooling or appetite changes NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely effective 4.Intestinal problems of constipation or diarrhea NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely effective 5.Nausea NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely effective 6.Shortness of breath or difficulty breathing NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely effective 7.Aches or pain NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely effective List by number the items where you feel that you do NOT have sufficient knowledge and skills to counsel or treat patients and families:
Please comment on very low or very high scores:
Emotional / Relationship Area
How effective do you think you are as a provider in addressing patient and family concerns regarding or treating symptoms of:
8.Finding sources of satisfaction / meaning in life NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 9.Anxiety NA None at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 10.Expressing feelings of sadness, grief, and anger NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 11.Finding opportunity to talk about illness, experiences, and possible death NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 12.Feeling like a burden for the family NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 13.Worry about family and friends not being there NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 14.Worry about physicians and other professionals not being there NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 15.Having family / friends give specific support without asking NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 16.Amount of support required to meet needs NA Not at all 0 1 2 3 4 5 6 7 8 9 10 Completely 17.Isolation from others felt to be caused by illness or treatment NA None at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 18.How much of treatment wishes and goals family / friends know NA None at all 0 1 2 3 4 5 6 7 8 9 10 Completely 19.Discussing approach of the last days and importance for family members of relationship, emotional, or spiritual gifts NA None at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 20.Physical signs and symptoms of approaching death NA None at all 0 1 2 3 4 5 6 7 8 9 10 A great deal 21.Work place support NA Not at all 0 1 2 3 4 5 6 7 8 9 10 A great deal
List by number the items where you feel that you do NOT have sufficient knowledge and skills to counsel or treat patients and families:
Please comment on very low or very high scores:
Spiritual Area How effective do you think you are as a provider in addressing patient and family concerns regarding 22.Participation in spiritual or religious experiences (e.g. meditation, spiritual traditions or rituals, praying, or going to a place of worship) NA None 0 1 2 3 4 5 6 7 8 9 10 A great deal 23.Extent to which illness has made a positive change in life NA None 0 1 2 3 4 5 6 7 8 9 10 A great deal 24.Sense of a purpose / mission for life or a reason for being alive NA None 0 1 2 3 4 5 6 7 8 9 10 A great deal 25.Hopefulness NA None 0 1 2 3 4 5 6 7 8 9 10 A great deal 26.Opportunity to reflect on life NA None 0 1 2 3 4 5 6 7 8 9 10 A great deal
NA None 0 1 2 3 4 5 6 7 8 9 10 A great deal 28.Experience of healing in spiritual, emotional, relational areas of life NA None 0 1 2 3 4 5 6 7 8 9 10 A great deal List by number the items where you feel that you do NOT have sufficient knowledge and skills to counsel or treat patients and families:
Please comment on very low or very high scores:
Please share other comments about your experience **Modified by Supportive Care of the Dying: A Coalition for Compassionate Care Information About You Please complete the following questions about you. This information will be kept strictly confidential. Primary Practice Areas: (May select more than one) ___Home Health Age __________ Gender: ____Male ___Female Years in Practice_______ Highest Level of Professional Education ____________ Professional Discipline_______________________________________________
___White/Caucasian Health Services that you facilitate referrals to or refer patients to: ___Home Health (specify):_______________________________
Primary diagnosis or illness that seem to be life - threatening for the patients you care for. List all that apply:
Approximate number of patients with life-threatening illness you have cared for in the past 3 months _____________
Number of your patients who have died during past year _____________ Date Questionnaires completed _______________ I.D. number_____________
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