Survey date: ______________________________
[READ ALOUD] This is a survey to find out how well we prepared you to care for your baby after discharge from the Neonatal Intensive Care Unit (NICU) to the home care setting. There are no right or wrong answers, and often the first answer that comes to mind is best. Your participation will help us to improve our understanding about how to best ensure a smooth transition to life after the NICU stay.
We are only interested in your experiences regarding the quality of the discharge process in the NICU and your ability to assume your caregiver role at home. As you listen to each statement I read to you, think about whether you agree or disagree with the statement. I will then ask you to choose the term that best matches your opinion: strongly disagree, disagree, agree, strongly agree, or don't know. OK? Let's begin.
The first few statements are about the time your baby was in the hospital.
1. Before my baby left the hospital, the staff and I agreed on a plan of care for my baby's health.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
2. Members of the hospital staff gave me instructions that did not agree with each other on how to care for my baby's health at home.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
3. The hospital staff considered my opinion in deciding where my baby's followup care would take place.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
4. The hospital staff caring for my baby on the day we left the hospital knew my baby well.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
5. My baby's pediatrician knew that my baby was going home.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
The next set of statements is about when you and your baby left the hospital.
6. When we left the hospital, I received written instructions for the care of my baby's health.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
7. When we left the hospital, I felt confident that I knew what to do to care for my baby's health.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
8. When we left the hospital, I felt confident that I could actually do the things I needed to do to care for my baby's health.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
9. When we left the hospital, I knew whom to call if I had questions about my baby's health.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
10. Are you supposed to receive home visiting nurse services for your baby?
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
[IF RESPONSE TO 10 IS "NO" OR "DON'T KNOW," SKIP TO 13, ELSE GO TO 11.]
11. Has a home visiting nurse visited you yet?
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
[IF RESPONSE TO 11 IS "NO" OR "DON'T KNOW," SKIP TO 13, ELSE GO TO 12.]
12.The home visiting nurse understands my baby's health needs.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
The next statement is about your baby's followup doctors' appointments.
13.When we left the hospital, I had received a written list of upcoming appointments for my baby.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
The next set of statements is about your baby's medications.
14.Did your baby go home with medications?
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
[IF RESPONSE TO 14 IS "NO" OR "DON'T KNOW," SKIP TO 19, ELSE GO TO 15.]
15.The day we left the hospital, I had all my baby's medications.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
16.When we left the hospital, I understood what each of my baby's medications was for.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
17.When we left the hospital, I understood how to give each medication to my baby, including how much and when.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
18.When we left the hospital, I understood the side effects of each of my baby's medications.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
The next set of statements is about your baby's medical equipment and supplies.
19. Did your baby go home with medical equipment and supplies? Examples of medical equipment and supplies include, but are not limited to, a home ventilator, oxygen, a breast pump, stomach tubes, or related supplies.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
[IF RESPONSE TO 19 IS "NO" OR "DON'T KNOW," SKIP TO 24, ELSE GO TO 20.]
20.The day we left the hospital, I had all my baby's medical equipment and supplies.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
21.When we left the hospital, I understood what each piece of medical equipment is for.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
22.When we left the hospital, I understood how to use each piece of medical equipment, including how often and when.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
23.When we left the hospital, I understood what to do if there was a problem with each piece of medical equipment, including whom to call.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
The final set of statements is about your baby's feeding.
24.The day we left the hospital, I had what I needed to feed my baby.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
25.When we left the hospital, I understood how to feed my baby, including how much and how often.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
26.When we left the hospital, I felt confident in my ability to feed my baby.
| Strongly Disagree 1 |
Disagree 2 |
Agree 3 |
Strongly Agree 4 |
Don't Know 9 |
Thank You!
