Strongly Agree | Moderate Agree | Agree | Disagreed | Moderate Disagreed | Strongly Disagreed | Questions |
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| Work Life/Home Life Dimension |
□ | □ | □ | □ | □ | □ | I am able to balance work with my family needs. |
□ | □ | □ | □ | □ | □ | I am able to arrange for child-care when I am at work. |
□ | □ | □ | □ | □ | □ | I have energy left after work. |
□ | □ | □ | □ | □ | □ | I feel that rotating schedules negatively affect my life. |
□ | □ | □ | □ | □ | □ | My organization’s policy for family-leave time is adequate. |
□ | □ | □ | □ | □ | □ | I am able to arrange for day care for my elderly parents. |
□ | □ | □ | □ | □ | □ | I am able to arrange for day care when my child is ill. |
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| Work Design Dimension |
□ | □ | □ | □ | □ | □ | I receive a sufficient amount of assistance from unlicensed support personnel. |
□ | □ | □ | □ | □ | □ | I am satisfied with my job. |
□ | □ | □ | □ | □ | □ | My workload is too heavy. |
□ | □ | □ | □ | □ | □ | I have autonomy to make patient care decisions. |
□ | □ | □ | □ | □ | □ | I perform many non-nursing tasks. |
□ | □ | □ | □ | □ | □ | I experience many interruptions in my daily work routine. |
□ | □ | □ | □ | □ | □ | I have enough time to do my job well. |
□ | □ | □ | □ | □ | □ | There are enough RNs in my work setting. |
□ | □ | □ | □ | □ | □ | I am able to provide good quality patient care. |
□ | □ | □ | □ | □ | □ | I receive quality assistance from unlicensed support personnel. |
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| Work Context Dimension |
□ | □ | □ | □ | □ | □ | I am able to communicate well with my nurse manager/supervisor. |
□ | □ | □ | □ | □ | □ | I have adequate patient care supplies and equipment. |
□ | □ | □ | □ | □ | □ | My nurse manager/supervisor provides adequate supervision. |
□ | □ | □ | □ | □ | □ | Friendships with my co-workers are important to me. |
□ | □ | □ | □ | □ | □ | My work setting provides career advancement opportunities |
□ | □ | □ | □ | □ | □ | I feel like there is teamwork in my work setting. |
□ | □ | □ | □ | □ | □ | I feel like I belong to the “work family”. |
□ | □ | □ | □ | □ | □ | I am able to communicate with other therapists (physical, respiratory, etc.). |
□ | □ | □ | □ | □ | □ | I receive feedback on my performance from my nurse manager/supervisor. |
□ | □ | □ | □ | □ | □ | I am able to participate in decisions made by my nurse manager/supervisor. |