Appendix D

SURVEY QUESTIONNAIRE

Assigned Number: ______

Hospital Number: ______

Part I. Personal Contact Information

Age (in years old)

1) 21-25
2) 26-30
3) 31-35
4) 36-40
5) 41-45
6) 46-50
7) 51-55
8) 56-60

Sex Category:
1) Male
2) Female

Marital Status:
1) Single
2) Married
3) Separated
4) Widowed/Widower

Religion:
1) Roman Catholic
2) Protestants
3) Islam
4) Others, pls specify __________

Part II. Attitude

Please rate the following statements as honestly as possible. Refer to the scale
presented below for your answers.
5 – Strongly Agree; 4 – Agree; 3 – Neutral; 2 – Disagree; 1 – Strongly Disagree

Adaptability
Items 5 4 3 2 1
AA1. My plans change when there is a need to do so
AA2. When something important does not work out, I can
easily adjust with the situation
AA3. I am open to changes that could bring progress
AA4. I do not easily give up even if something is not working as
expected
AA5. When I am stuck in a difficult situation, I usually seek for
the advice of someone who is more experienced

Agility
Items
AG1. I am flexible and quick to adapt when environmental
threats and other situations in clinical areas arises
AG2. I am agile at optimizing teamwork processes and care
enabling me to undergo rapid change as well as enhanced
safe and effective team performance in improving quality
nursing care
AG3. I am quick at providing operational performance in order
to meet the demands of my work which is needed for
providing essential service during a pandemic in the
performance of my profession
AG4. I am capable of multi-tasking and sound decision
making, adopting technology and innovations as well as being
cost- effective
AG5. I am agile as long as there is commitment, trust,
responsibility, constructive attitude, and purposefulness
among my fellow nurses

Resourcefulness
Items
AR1. If something is broken or there is a problem, I try to find a
way to fix it
AR2. When I get stuck, I am inclined to improvise solutions
AR3. When people need solutions to problems, they call on me
AR4. My strength is to find ways around obstacles
AR5. I look in unusual places to find solutions

Passion
AP1. I can’t wait for my day to get started
AP2. I cannot relax if I know that I am doing nothing
AP3. I push myself to my limits
AP4. I am restless and bursting with energy to accomplish my
work
AP5. I am full of vigour and passion for my work
Part III. KNOWLEDGE ADEQUACY

Clinical Assessment
Items 5 4 3 2 1
KC1. I am able to carry out a complete and accurate clinical nursing
assessment with a suspected/confirmed patient
KC2. I am able to identify if a patient has signs of COVID-19 or not
(e.g. fever, cough, dyspnea, fatigue, headache,etc.)
KC3. I am able to determine whether the patient has been in
direct/indirect contact with a confirmed COVID-19 individuals
KC4. I am able to accurately identify patients who are at risk of
having one or more health problems (comorbidities)
KC5. I am able to correctly identify suspected/confirmed patients’
needs that will be the basis of identifying patient-centered goals
(e.g. fever, dyspnea, loss of taste and smell, etc.)

Diagnostic Assessment

Items 5 4 3 2 1
KD1. I am able to analyze patients’ well-being from many
perspectives (i.e. results from RTPCR, CBC, rapid antigen, rapid
antibody, etc.)
KD2. I am able to arrange expert help for patients when needed

KD3. I am able to recognize situations which may pose a threat to

life
KD4. I am able to plan activities flexibly according to clinical
situations
KD5. I can incorporate relevant knowledge to provide optimal care

Part IV. SKILLS IN NURSING PROCEDURE

Handling of Personal Protective Equipment
Items 5 4 3 2 1
SPPE1. I already have previous training experience in handling
personal
protective equipment even before the COVID-19 outbreak
SPPE2. I can touch my face or adjust the PPE with gloves after or
while handling the patient
SPPE3. The sequence of wearing and removing the PPE is the
same
SPPE4. It is beneficial to use both the N95 respirators and a face
shield that covers the forehead, extends below the chin, and
wraps around the side of the face while handling patients with
COVID-
19
 SPPE5. After handling patients with COVID-19, it is important to
dispose the PPE kit according to standard guidelines

Hand Washing

Items 5 4 3 2 1
SH1. I wash my hands after sneezing or coughing

SH2. I wash my hands before and after touching sick people

SH3. I wash my hands even in non-hospital settings

SH4. I wash my hands applying the proposed technique by the

World Health Organization
SH5. I am aware of the preventive techniques proposed by the
WHO and CDC

Social Distancing 5 4 3 2 1
Items

SS1. I keep away from crowded places

SS2. I avoid people who have flu-like symptoms

SS3. I reduce the use of or change the way I use public transport

SS4. I have reduced my amount of going to shops

SS5. I refuse to go or postpone a social event

Please rate the following statements as honestly as possible. Refer to the scale
presented below for your answers.
5 – Strongly Agree; 4 – Agree; 3 – Fairly Agree; 2 – Disagree; 1 – Strongly
Disagree

Cohorting 5 4 3 2 1
Items

SC1. I am aware of the circumstances that would require isolation

on the part of the patient
SC2. I am able to provide immediate nursing care to patients who
develop severe symptoms of COVID-19
SC3. I am able to immediately isolate confirmed COVID-19 patients
in a single room as means of transmission-based precaution.
SC4. I am able to triage patients in the event that there is shortage of
resources but with emphasis on objectivity and ethical principles
 SC5. I am aware that patients with mild disease do not require
hospital interventions but it is still necessary for them to implement
appropriate infection prevention and control

Please rate the following statements as honestly as possible. Refer to the scale
presented below for your answers.
5 – Strongly Agree; 4 – Agree; 3 – Neutral; 2 – Disagree; 1 – Strongly
Disagree

Referral 5 4 3 2 1
Items

SR1. It is important to have clinical history of patients

SR2. Standard or formal transfer/referral documents are necessary

SR3. Specific reasons or indications that warrant or justify the

referral should be available
SR4. Referrals can happen if the current hospital is not able to
handle possible or coexisting pathologies
SR5. Referrals will take place if the current hospital lacks the ability
for specific treatment needed by a patient
 SOURCES OF STATEMENTS FOR INSTRUMENT CLINICAL ASSESSMENT

https://www.researchgate.net/publication/
6376702_Measuring_nursing_competence_Development_of_a_self-
assessment_tool_for_general_nurses_across_Europe
Cowan, D. T. (2008). Jenifer Wilson-Barnett D, Norman IJ, Murrells T. Measuring nursing competence:
development of a self-assessment tool for general nurses across Europe. Int J Nurs Stud, 45, 902-913.
DIAGNOSTIC ASSESSMENT

https://www.researchgate.net/publication/
8511794_Nurse_Competence_Scale_Development_and_psy chometric_testing
Meretoja, R., Isoaho, H., &Leino‐Kilpi, H. (2004). Nurse competence scale: development and
psychometric testing. Journal of advanced nursing, 47(2), 124-133.
HANDLING OF PERSONAL PROTECTIVE EQUIPMENT

https://www.sciencedirect.com/science/article/pii/S1546084320302054
Ojha, S., Debnath, M., Sharma, D., &Niraula, A. (2020). Knowledge of Handling the Personal protective
equipment (PPE) by frontline Allied Health professionals in COVID-19 outbreak–A Web-based Survey
Study. Journal of Radiology Nursing.
HAND WASHING

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388362/
Zil-E-Ali, A., Cheema, M. A., Ullah, M. W., Ghulam, H., & Tariq, M. (2017). A survey of handwashing
knowledge and attitudes among the healthcare professionals in Lahore, Pakistan. Cureus, 9(3).
 SOCIAL DISTANCING

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406072/
Meier, K., Glatz, T., Guijt, M. C., Piccininni, M., der Meulen, M. V., Atmar, K., Jolink, T. C., Kurth, T., Rohmann, J. L.,
Zamanipoor Najafabadi, A. H., & group, S. S. (2020). Public perspectives on protective measures during the COVID-19
pandemic in the Netherlands, Germany and Italy: A survey study. PLoS
ONE, 15(8). https://doi.org/10.1371/journal.pone.0236917
Copy
COHORTING

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233668

Azlan, A. A., Hamzah, M. R., Sern, T. J., Ayub, S. H., & Mohamad, E. (2020). Public knowledge,
attitudes and practices towards COVID-19: A cross-sectional study in Malaysia. PLOS
ONE, 15(5), e0233668. https://doi.org/10.1371/journal.pone.0233668
REFERRAL

https://www.researchgate.net/publication/
319408426_Knowledge_attitude_and_perception_of_the_referr al_system_among_tertiary_health-
care_workers_in_Kaduna_metropolis_Nigeria
Omole, V. N., Mora, A. T., Yunusa, I. U., Audu, O., Jatau, A. I., &Gobir, A. A. (2017). Knowledge, attitude,
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Nigeria. International Journal of Medical Science and Public Health, 6(10),1481-1489.
ADAPTABILITY, RESOURCEFULNESS, PASSION
https://www.ecfvp.org/uploads/tools/files/2_-
_Change_Readiness_Assessment_073112.pdf?fbclid=IwAR33BowFM8qffP5QeaPbdTgVtezMHFQhoj-
sfi2Lg5F2WA_wLu1cIHwnbsE
AGILITY

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