Demographic Data Form

Thank you for agreeing to participate in this study. These data are being collected as part of a research study titled “Registered Nurses knowledge about and recognition of displaced tracheotomy tubes in patients with unobstructed airways”. Please complete all portions of the instrument. Your comments are very important. In the measure, please select or enter the response that bests describe your choice of the answer(s).

1. Age: Please enter your age in years.

2. Gender (select one)
Male
Female

3. Please indicate your income level by selecting the appropriate amount.
Below $40,000
$40,000-$49,999
$50,000-$59,999
$60,000-$69,999
$70,000-$79,999
$80,000-$89,999
$100,000-$109,999
$110,000-$119,999
$120,000-$129,999
$130,000-$139,999
$140,000 and over

4. Please select number of years practicing as a registered nurse.
3 years or less
4-7 years
8-11 years
12-15 years
16-19 years
20 years or >

5. Indicate all educational levels that apply.
Associate Degree
BSN
MSN
PhD
Other: Specify

6. If currently enrolled in a nursing program, please indicate the level of your studies.
BSN
MSN
PhD
Clinical Nurse Specialist
Nurse Practitioner

7. Please indicate work/practice setting.
Inpatient
Outpatient
Home Care
Research
Consultation
Academia
Nursing Home
Other: specify

8. Please indicate specific area(s) of practice. Specify if not listed
Medical
Surgical
Operating Room
Oncology
Staff Development/Educator
College Professor/Instructor
Radiation Oncology
Surgical Intensive Care
Pediatric
Pediatric Intensive Care
Clinical Coordinator
Nurse Manager
Gastroenterology
Cardiac Catherization Laboratory
Obstetrics
Informatics
Quality Management
Spinal Cord Injury
Ambulatory Care
Outpatient Surgery
Emergency Room
Urgent Care
Home Care
Telephone Triage
Radiology
Medical Intensive Care
Neonatal Intensive Care
Post Anesthesia Care Unit
Administrator
Hospice
Research
Chemotherapy Infusion Clinic
Gynecology
Risk Management
Hemodialysis
Rehabilitation
Other: Specify

9. Are you Basic Cardiac Life Support (BCLS) certified?
Yes
No

10. Are you Advanced Cardiac Life Support (ACLS) certified?
Yes
No

11. Are you certified in any nursing specialty?
Yes
No

12. Please list all specialty certifications:

13. Have you had instructions in any nursing program in tracheotomy management ?
No
Yes: Specify program type

How long ago did instruction take place?
Less than 2 years ago
Between 2 to 4 years
Over 5 years
Over 10 years

How many hours of instruction did you receive?
2 hours or less
2.1 to 4 hours
4.1 hours or greater

14. Have you ever talked with a patient with a tracheotomy?

No
Yes: How often?
Weekly
Monthly
Quarterly
Bi-annually
Annually
15. Have you ever provided care for a patient with a tracheotomy?
No
Yes: How often?
Weekly
Monthly
Quarterly
Bi-annually
Annually
16. Have you had any instruction including seminars, or employee orientation in the last two years that specifically discussed displaced or dislodged tracheotomy tubes?
Yes
No
17. Have you read any articles in the last two years on tracheotomy care?
No
Yes: Specify journal

18. In the last year, how many patients have you cared for with a tracheotomy?

19. Do you think you have adequate time when caring for patients with tracheotomies?
5 out of 5 times
4 out of 5 times
3 out of 5 times
2 out of 5 times
1 out of 5 times
20. Do you think that patients with tracheotomies present special nursing problems?
5 out of 5 times
4 out of 5 times
3 out of 5 times
2 out of 5 times
1 out of 5 times
21. Do you think that you are able to provide adequate tracheotomy care in the hospital setting?
5 out of 5 times
4 out of 5 times
3 out of 5 times
2 out of 5 times
1 out of 5 times
22. Do you think that you are able to provide adequate tracheotomy care in the home setting?
5 out of 5 times
4 out of 5 times
3 out of 5 times
2 out of 5 times
1 out of 5 times
23. Do you think that you are able to provide adequate tracheotomy care in the Nursing Home setting?
5 out of 5 times
4 out of 5 times
3 out of 5 times
2 out of 5 times
1 out of 5 times
24. Do you think that you have adequate teaching time when you are caring for a patient with a tracheotomy?
5 out of 5 times
4 out of 5 times
3 out of 5 times
2 out of 5 times
1 out of 5 times
25. Do you think tracheotomy care and competency education should be a component in the required standards of care?
Yes
No
26. Please select the choice that best describes your perception of your current knowledge competency related to care of the patient with a tracheotomy.
Lack competency
Minimal competency
Average competency
Above average competency
Advanced competency
Expert competency

27. Please specify the state(s) where you are licensed to practice:


Proceed