| How often in the last 7 working days did it happened that…..(question 1–5) | Never | Rarely | Sometimes | Often |
|---|---|---|---|---|
| 1. Activity of daily livings (ADLs) | □ | □ | □ | □ |
| 1(a) You could not assist a patient with a necessary sponge bath or skin care? | □ | □ | □ | □ |
| 1(b) You could not perform a necessary oral or dental hygiene to a patient? | □ | □ | □ | □ |
| 1(c) You could not feed the patient a needed? | □ | □ | □ | □ |
| 1(d) You were not able to mobilize or change the position of a patient? | □ | □ | □ | □ |
| 1(e) You had to leave a patient for longer than half an hour in urine, stool, or vomit? | □ | □ | □ | □ |
| 1(f) You could not put clean sheets on a dirty bed? | □ | □ | □ | □ |
| 2. Caring – support | □ | □ | □ | □ |
| 2(a) You could not offer emotional or psychosocial support to a patient even though you felt it was necessary e.g. dealing with insecurities and fear of his/her illness, the feeling of dependency? | □ | □ | □ | □ |
| 2(b) You could not have a necessary conversation with a patient or his/her family? | □ | □ | □ | □ |
| 3. Rehabilitation – instruction – education | □ | □ | □ | □ |
| 3(a) You had to put a patient in diapers or insert a catheter because you did not have time for toilet training? | □ | □ | □ | □ |
| 3(b) You could not perform activating or rehabilitating care? | □ | □ | □ | □ |
| 3(c) You could not teach and/or educate a patient and/or their family about their necessary self-care e.g. insulin injection, behavior or coping with illness- specific symptom (hypo-glycemia, dyspnea)? | □ | □ | □ | □ |
| 3(d) You could not prepare a patient or their family for his/her hospital discharge? | □ | □ | □ | □ |
| 4. Monitoring – safety | □ | □ | □ | □ |
| 4(a) You could not monitor a patient as closely as had been prescribed by a physician or as you felt was necessary? | □ | □ | □ | □ |
| 4(b) You had to restrain and/or give confused patients sedatives because you were not able to watch them carefully enough? | □ | □ | □ | □ |
| 4(c) A physician either did not come in person or took a long time to arrive after you called him/her because of an acute or sudden change in a patient's condition? | □ | □ | □ | □ |
| 4(d) You had to keep a patient who had rung for a nurse waiting longer than 5 min? | □ | □ | □ | □ |
| 4(e) You could not wash or disinfect your hands adequately? | □ | □ | □ | □ |
| 5. Documentation | □ | □ | □ | □ |
| 5(a) You did not have enough time to go over the patient documentation at the beginning of your shift? | □ | □ | □ | □ |
| 5(b) You could not set up or bring up to date a patient's care plan? | □ | □ | □ | □ |
| 5(c) You could not document the performed nursing care for a patient detailed enough? | □ | □ | □ | □ |
©December 2007, Schubert et al. Please contact the authors if you would like to use the instrument.