| Name: |
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| Age (in years): |
Gender: |
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| Highest degree: |
Workplace setting: |
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| Area of workplace: |
Marital status: |
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| Department of residency/specialization/working: |
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| Number of years of experience after completion of MBBS/BSc (count Internship as first year of experience): _________________ |
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| Section A: Forms of discord |
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| Item numbers 1-5 intend to assess the frequency of various forms of discord (bullying, harassment, and discrimination) experienced by healthcare workers in healthcare settings. Mark the most appropriate option |
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| A1: How often do you get bullied (e.g., mockery, insult, etc. by your colleagues and/or seniors) at your workplace? |
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| Nearly daily |
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| About once a week |
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| About once a month |
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| About once every six months |
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| About once a year or less |
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| A2: How often do you experience harassment/discrimination based on race/community/caste/religion at your workplace? |
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| About once in a month or more |
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| About once every six months |
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| About once a year |
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| Less than once a year |
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| Never |
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| A3: How often do you experience harassment/discrimination based on your state of origin at your workplace? |
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| About once in a month or more |
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| About once every six months |
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| About once a year |
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| Less than once a year |
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| Never |
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| A4: “As per the guidelines, sexual harassment includes any unwelcome sexually determined behavior (whether directly or by implication) as: a) physical contact and advances; b) a demand or request for sexual favors; c) sexually colored remarks; d) showing pornography; e) any other unwelcome physical, verbal, or non-verbal conduct of sexual nature.” How often does an incident of sexual harassment at your workplace come to your knowledge? |
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| About once in a month or more |
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| About once every six months |
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| About once a year |
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| Less than once a year |
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| Never |
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| Section B: Impact of incidences of discord |
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| Following are the statements/questions regarding the effect of discord (like bullying, harassment, and discrimination) at your workplace on the different aspects of life. Mark the most appropriate response among the options given below with each statement: |
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| B1: On the basis of the episodes of discords (like bullying, harassment, and discrimination) at my workplace, I have developed the following feelings: ______ |
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| Not affected |
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| Mildly affected |
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| Moderately affected |
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| Severely affected |
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| Very severely affected |
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| B2: Personal wellbeing and self-care include activities such as sleep schedule, eating pattern, fitness, grooming, dressing, etc. How much have the episodes of discords (i.e., bullying, harassment, and discrimination) at your workplace affected your personal wellbeing and self-care? |
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| Not affected |
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| Mildly affected |
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| Moderately affected |
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| Severely affected |
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| Very severely affected |
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| B3: “Family life is defined as the routine interactions and activities that a family have together especially with the members who live together, such as parents, spouse, children.” How much has your family been affected due to the episodes of discords (i.e., bullying, harassment, and discrimination) at your workplace? |
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| Not affected |
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| Mildly affected |
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| Moderately affected |
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| Severely affected |
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| Very severely affected |
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| B4: “Social life is defined as the part of a person's time spent doing enjoyable things with others like friends, colleagues, or people living in the society other than close family members.” How much has your social life been affected due to the episodes of discords (i.e., bullying, harassment, discrimination) at your workplace? |
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| Not affected |
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| Mildly affected |
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| Moderately affected |
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| Severely affected |
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| Very severely affected |
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| B5: How much have the episodes of discords (i.e., bullying, harassment, discrimination) at your workplace affected your mental and psychological wellbeing (increased aggressiveness, irritability, low self-esteem, etc.)? |
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| Not affected |
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| Mildly affected |
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| Moderately affected |
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| Severely affected |
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| Very severely affected |
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| Section C: Reporting of incidence |
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| This domain assesses how comfortable or confident workers are about reporting the incidences of discord to the higher authorities. C1: Are you comfortable in reporting the incidences of discords (bullying, harassment, and discrimination) at your workplace to the authorities? |
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| Significantly |
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| Somewhat significantly |
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| Insignificantly |
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| The statements given below are some of the reasons why the incidences of violence are underreported to the authorities. To what extent do these following reasons lead to underreporting? Select the most appropriate choice in your opinion. C2: Feeling ashamed of reporting the incidences of discords (bullying, harassment, and discrimination) at the workplace |
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| Significantly |
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| Somewhat significantly |
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| Insignificantly |
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| C3: A belief that no action will be taken against the perpetrator |
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| Significantly |
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| Somewhat significantly |
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| Insignificantly |
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| C4: Lack of organizational support |
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| Significantly |
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| Somewhat significantly |
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| Insignificantly |
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| C5: Believe that violence is a part of our job |
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| Significantly |
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| Somewhat significantly |
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| Insignificantly |
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| C6: Lack of provision to report such incidences |
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| Significantly |
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| Somewhat significantly |
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| Insignificantly |
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| C7: The process of reporting is/was time-consuming |
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| Significantly |
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| Somewhat significantly |
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| Insignificantly |
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| C8: Fear that the appraisal or promotion avenues will be affected |
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| Significantly |
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| Somewhat significantly |
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| Insignificantly |
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| Section D: Mitigation strategies |
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| This domain focuses on the strategies that can be useful in preventing episodes of discord at the workplace. The statements given below are some of the strategies that can check the episodes of discord (bullying, harassment, and discrimination) at the workplace. To what extent do you think that the respective strategy can be useful in preventing such episodes? |
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| D1: Regular training of healthcare workers regarding their legal rights and responsibilities |
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| Very useful |
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| Somewhat useful |
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| Not useful |
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| D2: Improved management policies (e.g., 360-degree evaluation/bi-directional appraisal, where the boss and the subordinates can provide feedback for each other) |
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| Very useful |
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| Somewhat useful |
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| Not useful |
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| D3: Effective complaint redressal system |
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| Very useful |
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| Somewhat useful |
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| Not useful |
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| D4: Strong legislative measures like provision of significant punishment for offenders |
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| Very useful |
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| Somewhat useful |
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| Not useful |
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| Section E: Risk factors related to incidents of workplace discord |
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| This section intends to assess the factors that might be an important reason in the genesis/continuation of the episodes of discord (bullying, harassment, and discrimination) in healthcare settings |
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| E1: Institutional attributes: This includes dominance due to hierarchy between the boss and the employees. Tolerance towards discord has been an accepted norm in the work environment over the years. How much (in your opinion) do the Institutional attributes contribute to the genesis/continuation of such episodes at the workplace? |
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| Very important |
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| Somewhat important |
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| Not important |
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| E2: Interpersonal attributes: Misbehaving with someone or tolerating an episode of discord may be a personal attribute. There is always some difference in the inherent nature and behavior of individuals to initiate or tolerate things like bullying, harassment, and discrimination. How much (in your opinion) do the Interpersonal attributes contribute to the genesis/continuation of such episodes at the workplace? |
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| Very important |
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| Somewhat important |
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| Not important |
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| E3: Social attributes: Social exclusion/marginalization of individuals due to discrimination on the basis of race/ethnicity/community/social status, etc. How much (in your opinion) do the social attributes contribute to the genesis/continuation of such episodes at the workplace? |
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| Very important |
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| Somewhat important |
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| Not important |
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| E4: Legislative attributes: It may include factors like lack of stringent laws and policies, inadequate redressal system, etc. How much (in your opinion) do the legislative attributes contribute to the genesis/continuation of such episodes at the workplace? |
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| Very important |
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| Somewhat important |
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| Not important |
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