1. Preamble Consent, Demographics, Intent to Leave and Open-Ended Questions

Preamble Consent:

Date October 1, 2016

Dear Hospice or Palliative Nurse,                   :

You are being invited to participate in a research study by answering the attached survey about compassion satisfaction, burnout, secondary trauma and overall work satisfaction as you experience it in your work as a hospice or palliative nurse. There are no known risks for your participation in this research study. The information collected may not benefit you directly. The information learned in this study may be helpful to others. The information you provide will be used to describe compassion satisfaction, burnout and secondary traumatic stress among hospice and palliative nurses and determine if being certified in hospice and palliative care makes a difference on these factors. Your completed survey will be stored on a password protected computer in a locked office at the University of Louisville. The survey will take approximately 30 minutes to complete.

Individuals from the University Of Louisville Department Of Medicine, Hospice Palliative Nurses Association, the Institutional Review Board (IRB), the Human Subjects Protection Program Office (HSPPO), and other regulatory agencies may inspect these records. In all other respects, however, the data will be held in confidence to the extent permitted by law. Should the data be published, your identity will not be disclosed.

Taking part in this study is voluntary. By completing this survey you agree to take part in this research study. You do not have to answer any questions that make you uncomfortable. You may choose not to take part at all. If you decide to be in this study, you may stop taking part at any time. If you decide not to be in this study or if you stop taking part at any time, you will not lose any benefits for which you may qualify. At the end of the survey you will be given the opportunity to be entered into a drawing for a $50 gift  card  by  supplying  your  name  and  contact  information.  Participation  in  the  drawing  is  totally voluntary. Once the drawing occurs, your name and contact information will be destroyed.

If you have any questions, concerns, or complaints about the research study, please contact: Barbara Head PhD. 502-852-3014.

If you have any questions about your rights as a research subject, you may call the Human Subjects Protection Program Office at (502) 852-5188. You can discuss any questions about your rights as a research subject, in private, with a member of the Institutional Review Board (IRB). You may also call this number if you have other questions about the research, and you cannot reach the research staff, or want to talk to someone else. The IRB is an independent committee made up of people from the University community, staff of the institutions, as well as people from the community not connected with these institutions. The IRB has reviewed this research study.

If you have concerns or complaints about the research or research staff and you do not wish to give your name, you may call 1-877-852-1167. This is a 24 hour hot line answered by people who do not work at the University of Louisville.



Barbara Head, PhD., CHPN, ACSW, FPCN
Principal Investigator 


* 1. I have read above consent form and agree to participation in this study

* 2. Age in years

* 3. Gender

* 4. Please indicate your race/ethnicity

* 5. How long have you worked for your current employer?  (years & months)

* 6. How long have you worked in hospice and palliative nursing:  (years & months)

* 7. Nursing Education:

* 8. Licensure:

* 9. Are you certified in hospice and palliative care?

* 10. If so, types of certification:

* 11. If not certified in hospice and Palliative care, please indicate the reason(s) why. Mark all that apply.

* 12. How many hours per week do you work?

* 13. Approximate annual salary:

* 14. What type of organization do you work for?

* 15. Overall, how satisfied are you with your job?

* 16. How likely is it that you will leave this job in the next year?

* 17. How often do you think about quitting?

* 18. List the three things that cause you the most stress in your  job:

* 19. List the three top activities you do for your self-care and/or to deal with the stress of your job:

* 20. What is the most important thing your employer could do to improve your job satisfaction?