Frontline Supervisor Survey Instrument Report

Peter Kemper, Diane Brannon, Teta Barry and Melissa Hobbs

Pennsylvania State University, Center for Health Care and Policy Research

This report was prepared under contract #HHSP23320044303EC between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Pennsylvania State University. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Marie Squillace, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Marie.Squillace@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

INTRODUCTION

In this report, we describe the processes that we have undertaken to develop the data collection procedures for the Frontline Supervisor Survey. These processes include: identifying our target group; collecting contact information for frontline supervisors; testing and revising the survey instrument; and specifying how the domains that are measured in the data collection will be relevant to the analysis of the direct care worker (DCW) workforce and the improvement of DCW jobs.

IDENTIFYING SUPERVISORS

We conducted a series of telephone consultations with individuals from two home health care trade associations, two home care agencies, one adult day services center, four nursing home facilities and one assisted living facility to gain a better understanding of the supervisory structures in each type of organization. We spoke with one informant in each of these organizations. These organizations represented all five states in the Better Jobs Better Care (BJBC) Demonstration -- Iowa, North Carolina, Oregon, Pennsylvania, and Vermont. We contacted mainly larger providers under the assumption that these organizations would have more elaborate supervisory structures that would make identifying the frontline supervisor more complex.

The phone calls allowed us to explore the concept of “supervisory functions” with the respondents by dividing functions into tasks, allowing us to define frontline supervisors based on the tasks they perform. The calls also allowed us to define tasks in a way that delineate higher order supervision from frontline supervision. For example, while the function of “clinical training” could be performed by a higher-level employee or an employee outside of the agency, the task of conducting on-the-job clinical training appears to be performed by frontline supervisors, the respondent of interest. As a result of these conversations, ten supervisory tasks emerged as those that best characterize frontline supervision in long-term care organizations:

• Acting as a mentor to DCWs;
• Ensuring that DCWs are giving proper care to clients/residents;
• Scheduling DCWs;
• Initiating disciplinary action;
• Documenting DCW performance problems;
• Recommending training for DCWs;
• Providing feedback (positive or negative) to DCWs on job performance;
• Conducting on-the-job clinical training activities;
• Responding directly to client/resident complaints about DCW performance;
• Responding directly to job concerns raised by DCWs.

Though most of the key informants at each provider readily identified employees as frontline supervisors, because of the diversity among titles and functions within organizations these tasks will be used to define the population of frontline supervisors for this study. We subsequently removed from the list “directly responds to client/resident complaints about DCW performance” because it is likely that this responsibility is carried out not only by supervisors, but by administrators at different levels within the organization. Also, this task corresponds with the responsibilities to ensure that DCWs are giving proper care to clients/residents and to document DCW performance problems.

Based on these inquiries, we learned that frontline supervisor responsibilities are sometimes shared between two individuals. Specifically, we identified three types of frontline supervisory structures:

1. One supervisor performs all or most of the functions listed on the protocol.

2. Two supervisors on the same level of the administrative hierarchy perform supervisory functions, with one emphasizing clinical functions and the other emphasizing administrative functions.

3. Two supervisors on different levels of the hierarchy (e.g., supervisor and supervisor’s supervisor) share supervisory responsibility, both performing many of the supervisory functions.

When frontline supervisory tasks are performed by more than one person, all determined to be supervisors will be included in the population of frontline supervisors to be surveyed. We are including information on the tasks performed in the survey instrument itself so that we can identify the tasks performed according to the supervisor.

We also found that in smaller organizations, it is possible that the person identified as the clinical manager may also serve as the frontline supervisor. This is possible because the clinical manager is identified based on his or her position in the organization whereas the frontline supervisor is identified based on the supervisory tasks performed. These persons will be asked to complete a Clinical Manager Survey with added Supervisor Survey items to minimize respondent burden.

CLINICAL MANAGER CONTACT TO PILOT TEST SUPERVISOR REPORTING

The goals of developing the chief clinical manager contact procedures were to establish a strategy for soliciting frontline supervisor contact information and systematically reviewing the tasks that supervisors do to determine how to screen out non-supervisors from frontline supervisors. Chief clinical managers at local provider organizations similar to those in the BJBC study were contacted and asked to provide information about frontline supervisors in their respective organization. We contacted the clinical managers by telephone, briefly described the Frontline Supervisor Study, and asked if they would be willing to indicate which tasks each of their supervisors perform. If they agreed, the list of supervisory tasks was sent to the clinical manager by fax with the following comments:

Thank you so much for helping us with our project evaluating the impact of the Better Jobs, Better Care Demonstration. Please indicate the supervisor of direct care workers who is responsible for each task at [name of provider organization], and as you do so, keep in mind that the definition of a direct care worker for the Better Jobs, Better Care Demonstration is an individual who provides hands-on personal care as a significant part of their job. Although activities may sometimes overlap, we do not include LPNs or RNs in this definition. Also excluded are workers who help with cleaning, meal preparation and chores, but do not provide personal care.

Once you’ve identified the frontline supervisor(s) for your organization, please fax the completed form back to 814-865-3098. If you have any questions or would like additional information regarding this request, do not hesitate to contact me at 814-863-0170. Thank you again for your time and assistance.

Overall, we contacted 12 chief clinical managers, and nine replied. From these nine, we received supervisor task information for 22 supervisors. We learned that, according to the chief clinical managers, not all of the supervisors performed each of the tasks, but most documented DCW performance problems, recommended training for DCWs, and directly responded to job concerns raised by DCWs. Less than half of these supervisors were noted to conduct on-the-job clinical training. Out of the 22 reported to performed each of the tasks on our list:

• 13 act as a mentor to DCWs;
• 17 ensure that DCWs are giving proper care to clients/residents;
• 10 schedule DCWs;
• 13 initiate disciplinary action;
• 17 document DCW performance problems;
• 17 provide feedback to DCWs on job performance;
• 18 recommend training for DCWs;
• 13 conduct on-the-job clinical training;
• 17 directly respond to client/resident complaints about DCW performance;
• 18 directly respond to job concerns raised by DCWs.

Out of these 22 supervisors, we contacted five to participate in a cognitive interview to test the survey instrument. The results from the cognitive interviews are explained in the next section of this report. During the cognitive interview, supervisors were asked to indicate which tasks for which they were responsible. We compared the tasks each supervisor reported with the tasks their clinical manager reported they did. Table 1 summarizes these comparisons. The chief clinical managers under-reported job responsibilities for Supervisors #3 and #4. For Supervisor #5, the chief clinical manager over-reported job responsibilities. These findings justify the inclusion of the task list on the Frontline Supervisor Survey and support the hypothesis that supervisors’ perceptions of the work environment may differ from those of the clinical managers’.

Based on the information from providers, clinical managers, and supervisors, we developed the definition of supervisor that defines our study population. We intend to be inclusive at this stage; when we conduct the analysis, we will be able to test whether a more restrictive definition affects our finding. If one or more of the following primary supervision tasks is checked, a person qualifies as a frontline supervisor under our definition:

• Ensure that DCWs are giving proper care to clients/residents;
• Initiate disciplinary action;
• Document DCW performance problems;
• Provide feedback to DCWs on job performance;
• Directly respond to job concerns raised by DCWs.

In addition, if a person performs at least two of the following secondary supervision tasks, the person meets our definition of frontline supervisor:

• Act as a mentor to DCWs;
• Schedule DCWs;
• Recommend training for DCWs;
• Conduct on-the-job training.

The clinical managers who participated in this testing gave us feedback on our task list distribution procedures. From their comments, we learned that it is more effective and efficient for most to receive the task list as an e-mail attachment. This approach will work for our population of clinical managers at participating BJBC provider organizations because we have e-mail addresses for most of them. For the few clinical managers that do not have e-mail addresses, we will be able to contact them by telephone and send the task list via fax. The comments that will accompany the task list can be found in Appendix A.

Each returned task list will be reviewed by the Penn State Survey Research Center project assistant. To avoid erroneously excluding supervisors, if only one of the secondary supervisory tasks is checked, she will contact the clinical manager and probe for more information about other responsibilities this person has to double check whether or not the person performs any of the other supervisory tasks.

COGNITIVE INTERVIEW SURVEY RESULTS

We conducted five cognitive interviews with individuals who represent our target population -- three supervisors at nursing home facilities, one supervisor at an adult day services center, and one supervisor at a home care facility -- to solicit feedback on question wording, placement, and flow within the questionnaire. These supervisors were asked verbally describe their thought processes as they answered the survey questions. A staff member from the Penn State Survey Research Center recorded the respondent’s comments and suggestions.

The responses given to the items on the Frontline Supervisor Survey and comments provided by those who participated in the cognitive interviews have been summarized and are shown in Appendix B. The five supervisors who participated have been labeled as R1, R2, R3, R4, and R5. The frequencies are displayed for the purpose of looking at the responses of these five individuals. From these results, we learned which items were not clear to the respondents or were interpreted differently. The questions that our respondents had the most comments for are described below.

Question 8b: “I have the opportunity to work in teams.”

The meaning of the word “team” in question 8b differed by respondent. R1 first said "I don't know what you mean by that" but after thinking aloud she answered by defining teams as working with Hospice, Medicare, and the Office of Aging. For R2, the teams she worked with were a geriatric steering committee and a company task force team. R3 interpreted "teams" to mean an interdisciplinary group of people at the organization who develop care plans for clients. R4 understood "teams" to mean DCWs and herself carrying out their duties together.

Question 11c: The extent to which cross-training used as a management practice

R1 indicated that cross-training is done both “occasionally” and “frequently” at her organization because DCWs occasionally receive training for administering medication but frequently receive training for physical therapy. R2 said that all regular employees are required to be CPR and first-aid certified, but the requirement is not enforced for employees who work occasionally. R5 said DCWs are trained as a matter of seniority at her organization, and typically Licensed Practical Nurse (LPN) DCW receive more cross-training.

Question 11d: The extent to which self-managed work groups used as a management practice

Two of the respondents, R1 and R5, did not understand who comprised a “self-managed work group.”

Question 12: “What mechanisms are used to handle employee concerns in your organization?”

After responding to question 12, each supervisor was asked how they interpreted the term “employee concerns.” R1 understood "employee concerns" to mean any kind of concern that an employee comes to her with, whether it had to do with their employment circumstances or their ability to provide care to clients. R2 said she was thinking of disciplinary procedures when she first read the question but she then saw that the question that followed covered discipline. R3 mentioned that the organization is part of a union, and the union has a role in handling employee concerns. R4 said the mechanisms listed to handle employee concerns that she checked are available, but not necessarily used. R5 thought of employee concerns as both professional and personal.

Question 14c: “How often do DCWs in your organization write in patient/resident/client care charts?”

Respondents described procedures that were relevant to care chart documentation, and the extent to which DCWs wrote in charts varied. R1 explained that DCWs have check sheets to fill out which become part of the client's chart. R4 said DCWs at her organization always write vital statistics in the charts, but they are not allowed to document anything else. R5 explained that all DCWs can write on flow sheets, but only the LPN DCW can write in charts.

Question 16

Questions 16a and 16b asked about DCW participation in career ladder programs. None of the organizations where the supervisors we interviewed work have career ladder programs.

Question 20b: “The organizational culture encourages risk-taking.”

The meaning of the phrase “risk-taking” varied by respondent. R1 thought of risk-taking as a spontaneous change in a client's care plan to which she answered “disagree.” R2 asked if risk-taking meant exploring other avenues or new techniques. She thought the word “risk” sounded harsh. R3 thought of “risk-taking” as doing something that was related to residents' care. R4 thought “risk-taking” implied taking one's chances to make the trip into work everyday. R5 asked if “risk-taking” meant unsafe behavior and said in terms of DCW personal safety, such as lifting and moving more independently than they should, risk-taking occurs.

Using the comments and suggestions from the cognitive interviews, we examined the items relative to how they will be compared with matched items on the complimentary BJBC Direct Care Worker and Clinical Manager Surveys. In weighing the potential improvement that could be made to questions against the loss of the ability to make these direct comparisons of frontline supervisor-DCW and frontline supervisors-clinical manager responses, we feel that making changes to the wording to these questions is not warranted. However, the cognitive interview exercise helped to flag certain questions and provide information that will be helpful when analyzing responses.

SURVEY MODIFICATIONS

The following modifications to the survey have been made based on the cognitive interviews and on feedback we received from ASPE :

• Question 7 -- the task “Directly respond to client/resident complaints about DCW performance” has been removed.

• Question 7i -- “Conduct on-the-job clinical training activities”: The word “activities” has been removed.

• Question 10 -- We have added the word “Training” at the top of the table for clarification.

• Question 32 -- “Do you currently work for pay at another job as a supervisor of direct care workers?” has been changed to “What is your gender?”

• Added “Are you of Hispanic or Latino origin?” before we ask the respondent to indicate their race, and “Hispanic or Latina/Latino” has been removed as a category to check for race.

• The categories for race have been reordered alphabetically.

The revised version of the survey is shown in Appendix C.

SCOPE OF DOMAINS MEASURED

The domains included for the Supervisor Survey are adopted from the BJBC Clinical Manager and Direct Care Worker Surveys, thereby allowing frontline supervisors (a middle layer) to respond to questions about the activities related to BJBC interventions. The overlap in the domains from the larger study is intentional. Responses will be used to enhance the validity of the data in determining the effects of BJBC interventions on DCW job outcomes, as well as to determine the role supervisors play in the effectiveness of interventions. Table 2 summarizes the domains associated with the three broader research questions, and Appendix D lists the survey items associated with each domain. We will use the domains to compare what clinical managers think is happening to what supervisors are really doing. We will use the information about supervisors to see the extent to which clinical managers and frontline supervisors agree on management practices. Domains will be used to determine: (a) how the agreement between clinical managers and supervisors’ perceptions affect DCW outcomes; and (b) how frontline supervisors perceptions of management practices affect DCW job quality and turnover.

APPENDIX A: Memo to Accompany Task List and Task List

Dear [clinical manager],

As part of the data collection for the Better Jobs, Better Care Demonstration evaluation, we are preparing to survey staff members who have a role in supervising direct care workers at participating provider organizations. I would like to ask for your help in identifying staff at [name of provider organization] who are responsible for carrying out specific tasks. Attached is a form that will take about 5 minutes to complete. On this form, please indicate the staff member(s) responsible for each task listed.

As you complete the form, keep in mind that the definition of a direct care worker for the Better Jobs, Better Care Demonstration is an individual who provides hands-on personal care as a significant part of their job. Although activities may sometimes overlap, we do not include LPNs or RNs in this definition. Also excluded are workers who help with cleaning, meal preparation and chores, but do not provide personal care.

Once you’ve identified the staff member(s) who performs these tasks for your organization, please send a reply email and include the completed form as an attachment or fax the completed form to my attention at (814) 865-3098. If necessary, you may make copies of the form in order to include all relevant staff. Space is also provided for comments if you would like to further clarify how the tasks on the list are carried out at your organization.

If you have any questions or would like additional information regarding this request, do not hesitate to contact me at (800) 648-3617. Thank you again for your time and assistance.

Jennifer Sheaffer
BJBC MIS and Survey Coordinator
SSRI, Survey Research Center
The Pennsylvania State University
327 Pond Lab
University Park, PA 16802-6201
Tel: 1(800) 648-3617
Fax: 1(814) 865-3098

APPENDIX B: Responses and Comments from Cognitive Interviews

APPENDIX C: BJBC Supervisor Survey

This appendix is a recreation of the questions asked on the survey.
See the PDF version at http://aspe.hhs.gov/daltcp/reports/2008/FSSinst.pdf for a copy of the actual survey.

Better Jobs Better Care
Building a Strong Long-Term Care Workforce

Tell Us About Your Job

A Confidential Survey
Conducted by the Survey Research Center at Penn State

INSTRUCTIONS: If circles are provided, please completely fill in the circle next to your answer (example: Yes No). If boxes are provided, write your numeric answer in the boxes (example: ). If you are asked to specify an answer, please clearly print your response in the space provided.

1. How long have you worked as a supervisor of direct care workers? _______years _______months

2. Have you ever worked as a direct care worker? _______Yes _______No

3. How long have you worked for this employer? _______years _______months

4. How long have you worked as a supervisor for this employer? _______years _______months

5. How many direct care workers do you typically supervise? _______

6. Do any direct care worker supervisors report to you? _______Yes _______No

7. Please indicate the extent of your responsibility as a direct care worker supervisor to perform the following tasks.

   	My responsibility alone	My responsibility but others do this too	Not my responsibility but I sometimes do this	I never do this
   a. Act as a mentor to direct care workers.
   b. Ensure that direct care workers are giving proper care to clients/residents.
   c. Interview direct care worker applicants.
   d. Schedule direct care workers.
   e. Provide feedback to direct care workers on job performance.
   f. Document direct care worker performance problems.
   g. Initiate disciplinary action.
   h. Recommend training for direct care workers.
   i. Conduct on-the-job clinical training
   j. Directly respond to job concerns raised by direct care workers.

8. For each statement below, please indicate if you strongly disagree, somewhat disagree, somewhat agree, or strongly agree.

   	Strongly disagree	Somewhat disagree	Somewhat agree	Strongly agree
   a. I have learned the skills necessary to do my job well.
   b. I have the opportunity to work in teams.
   c. I am confident in my ability to do my job.
   d. I could get a job that paid more than this job.

9. Overall, how satisfied are you with your job?
   _______Extremely satisfied
   _______Somewhat satisfied
   _______Somewhat dissatisfied
   _______Extremely dissatisfied
   _______Don't know

10. During the past year, did you receive any formal training (inservice, workshop, etc.) on ...

    Training		If yes, how useful was it?
    		Not At All Useful	Somewhat Useful	Very Useful	Extremely Useful
    a. Communicating effectively with other employees	_______Yes --> _______No
    b. Communicating effectively with patients/residents/clients	_______Yes --> _______No
    c. Diversity or cultural issues	_______Yes --> _______No
    d. Effective disciplinary procedures	_______Yes --> _______No
    e. Skills for managing people	_______Yes --> _______No

11. How often are the following management practices used for the direct care workers you supervise?

    	Never	Seldom	Occasionally	Frequently	Always
    a. Permanent assignment to patients/residents/clients.
    b. Rotation of assignments to different services or units.
    c. Cross-training (learning new skills not traditionally used by direct care workers, such as medication administration or assisting with physical therapy).
    d. Self-managed work groups that include direct care workers.
    e. Flex time for direct care workers.

12. What mechanisms are used in your organization to handle employee concerns? (Mark all that apply)
    _______Talk with supervisor
    _______Toll-free "hotline"
    _______Organizational ombudsman
    _______Mediation
    _______Arbitration
    _______Other:_________________________
    _______Don't use any specific method

13. What approaches are used to handle poor performance or negative behaviors at your organization? Mark all that apply)
    _______Counseling by supervisor in the work unit
    _______Counseling by senior manager
    _______Written documentation
    _______Final warning conference
    _______Probation
    _______Suspension
    _______Termination
    _______Other:_________________________
    _______Don't use any specific method

14. How often do direct care workers in your organization ...

    	Never	Seldom	Occasionally	Frequently	Always
    a. Have input into changes in patient/resident/client care plans
    b. Actively participate in developing patient/resident/client care plans
    c. Write in patient/resident/client care charts
    d. Communicate in writing with other direct care workers to rely information about residents/patients/clients
    e. Communicate verbally with other direct care workers to relay information about residents/patients/clients
    f. Communicare information either in writing or verbally about residents/patients/clients by reporting to their supervisors
    g. Meet formally or informally with a supervisor to discuss patient/resident/client care issues
    h. Receive verbal feedback about their everyday job performance
    i. Receive written feedback about their everyday job performance

15. Please estiamte the overall competency level of direct care workers you supervise using the following benchmark:
    _______0 = All require constant supervision and guidance
    _______1
    _______2
    _______3
    _______4
    _______5 = All have an average level of competency for the position
    _______6
    _______7
    _______8
    _______9
    _______10 = All perform their jobs well with minimal guidance

16. Approximately what percentage of the direct care workers you supervise ...

    	None	1-25%	26-50%	50-75%	76-100%
    a. Currently participate in a career ladder program for the direct care worker to advance to a higher level of direct care worker (for example, team leader or dementia care specialist)
    b. Currently participate in a career ladder program for the direct care worker to become a Licensed Practical Nurse
    c. Currently have a designated peer mentor
    d. Participate in formal inservice programs beyond those required for certification

17. During the past year, approximately what percentage of the direct care workers you supervise ...

    	None	1-25%	26-50%	50-75%	76-100%
    a. Have completed a self-directed educational video or computer-based training program while at work
    b. Have attended a conference or workshop away from work
    c. Received formal training (inservice, workshop, etc.) on communicating effectively with other employees
    d. Received formal training (inservice, workshop, etc.) on communicating effectively with patients/residents/clients
    e. Received formal training (inservice, workshop, etc.) on diversity or cultural issues

18. If a friend or family member asked your advice about taking a job as a direct care worker at the place where you work, would you ...
    _______Definitely recommend it
    _______Probably recommend it
    _______Probably not recommend it
    _______Definitely not recommend it

19. If a friend or family member needs care and asked your advice about getting care from the place where you work, would you ...
    _______Definitely recommend it
    _______Probably recommend it
    _______Probably not recommend it
    _______Definitely not recommend it

20. Now, we'd like to ask if you agree or disagree with the following statements about your organization. It is important that your confidential responses to these questions be honest and accurate.

    	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
    a. Employees take personal responsibility for their behavior.
    b.The organizational culture encourages risk-taking.
    c. The organizational culture encourages continuous improvement.
    d. Senior management has presented a clear vision of the future of the organization.
    e. The organization rewards staff for being innovative.
    f. Management communicates effectively with staff in all levels of the organization.
    g. Management solicits input from all levels of staff when deciding on purchases related to care delivery.
    h. Management solicits input from all levels of the organization when deciding on policies and protocols.

21. Think about your job right now. Fill in the circle that best indicates how much, if at all, each of the following is a rewarding part of your job. Is it not at all rewarding, somewhat rewarding, very rewarding, or extremely rewarding?

    	Does not apply to my job	Not at all rewarding	Somewhat rewarding	Very rewarding	Extremely rewarding
    a. Helping others is ...
    b. Being able to work on your own is ...
    c. Getting credit for your work is ...
    d. Finding your work interesting is ...
    e. Liking your coworkers is ...
    f. Making a difference in other people's lifes is ...
    g. Feeling a sense of accomplishment and competence from doing your job is ...
    h. Having your job fit your skills is ...
    i. Having the chance to learn new things is ...
    j. Being valued by supervisors and management is ...
    k. Being needed by others is ...
    l. Having the power you need to get your job done without getting permission from someone else is ...
    m. Having a lot of different things to do is ...
    n. Getting support from coworkers is ...
    o. Having your job fit your interests is ...
    p. The income you earn is ...
    q. Being valued by residents or clients and their families is ...
    r. Having the freedom to decide how to do your work is ...
    s. The team spirit in your work group is ...

22. Continue thinking about your job right now. Indicate how much, if at all, each of the following is a problem or concern in your job. Is it not at all a problem, somewhat a problem, a big problem, or an extremely big problem?

    	Not at all a problem	Somewhat a problem	A big problem	An extremely big problem
    a. Having too much work to do is ...
    b. Having to deal with emotionally hard situations is ...
    c. Not having support from your supervisor in your job is ...
    d. Finding your job boring or doing too much of the same thing is ...
    e. Having your job take too much out of you is ...
    f. Having little chance to get promoted is ...
    g. Dealing with unrealistic expectations from your supervisor for your work is ...
    h. Not having the job use your skills is ...
    i. Catching an illness is ...
    j. Not having the chance to develop job skills is ...
    k. Not being valued by your supervisor for your work is ...
    l. Being on your own too much is ...
    m. Getting hurt is ...
    n. The physical conditions (equipment, temperature, smell, etc.) at your job is ...
    o. Not having enough help when you need it is ...
    p. That your supervisor is not good at her/his job is ...
    q. That the job is physically hard is ...
    r. The time it takes to get to work is ...

23. Please indicate the degree to which you agree with the following statements about how you are respected as a part of your organization's health care team (those who provide clinical services) by filling in the appropriate circle.

    	Not at all a problem	Agree somewhat	Agree a great deal
    a. Residents' or clients' families respect me as part of the health care team.
    b. Residents or clients respect me as part of the health care team.
    c. Direct care workers respect me as part of the health care team.
    d. My supervisor respects me as part of the health care team.

24. Please indicated the degree to which you agree with the following statements about how you are respected as a part of your organization's management team (those who establish and maintain work-related policies) by filling in the appropriate circle.

    	Not at all a problem	Agree somewhat	Agree a great deal
    a. Residents' or clients' families respect me as part of the management team.
    b. Residents or clients respect me as part of the management team.
    c. Direct care workers respect me as part of the management team.
    d. My supervisor respects me as part of the management team.

25. How likely is it that you will leave this job in the next year?
    _______Very likely
    _______Somewhat likely
    _______Not at all likely

26. How often do you think about quitting?
    _______All of the time
    _______Some of the time
    _______Rarely
    _______Never

27. Now, we'd like to ask if you agree or disagree with the following statements about your organization in the context of the Better Jobs, Better Care project.

    	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
    a. The Better Jobs, Better Care project is being supported by a senior level executive in your organization.
    b. All levels of management are committed to the Better Jobs, Better Care project.
    c. Senior management has clearly articulated the need for the Better Jobs, Better Care project.
    d. The Better Jobs, Better Care project conflicts with other major activities going on in the organization.
    e. The programs that are part of the Better Jobs, Better Care project have been well executed.
    f. The Better Jobs, Better Care project's overall impact on this organization will be positive.

28. What is the single most important thing your employer could do to improve the job of direct care workers? _________________________

29. What is the single most important thing your employer could do to improve your ability to do your job as a supervisor of direct care workers? _________________________

30. In your current job with this employer, what is your hourly wage? $_______ per hour

31. Do you receive health insurance through this employer?
    _______Yes, I receive health insurance through my employer.
    _______My employer offers health insurance to me, but I am not enrolled.
    _______My employer does not offer health insurance to me.

32. What is your gender?
    _______Male
    _______Female

33. What is your age?
    _______Less than 25 years old
    _______25-34
    _______35-44
    _______45-54
    _______55-64
    _______65 or older

34. Did you earn a high school diploma or GED?
    _______No
    _______Yes ––>

    34a. If yes, what is your highest level of education?    _______High School or GED    _______Some college/trade school    _______College graduate or post-college

35. Are you a nurse?
    _______No
    _______Yes ––>

    35a. If yes, are you a ...    _______LPN    _______RN    _______Diploma RN    _______BSN    _______MSN    _______Advanced Practice Nurse

36. Are you of Hispanic or Latino origin?
    _______No
    _______Yes

37. Please indicate your race. (Please select one or more)
    _______American Indian or Alaska Native
    _______Asian
    _______Black or African American
    _______Native Hawaiian or Other Pacific Islander
    _______White

APPENDIX D: Research Domains and Associated Survey Items