OVERALL IMPRESSION of the BEATA CLASP
1. How favorable was your
overall impression of the Beata Clasp® ?
Excellent
Good
Neutral
Poor
Very Poor
2. Overall, how satisfied were
you with the Beata Clasp® ?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
3. Based on your experience
with the Beata Clasp® , how interested are
you in having it available for use with your patients?
Very interested
Somewhat
interested
Not sure
Not very
interested
Not at all
interested
4. If interested, what is the
main reason you want to use the Beata Clasp®
with your patients?
GENERAL ATTRIBUTES of the BEATA CLASP
5. With how many patients have
you used the Beata Clasp® during this
study?
<10
11-20
21-40
41-50
>50
6. How effective would you
judge the Beata Clasp® to be in improving
patient safety?
Very
effective
Effective
Neutral
Ineffective
Very ineffective
7. How strongly do you
believe the patient benefits from the Beata Clasp® ?
Strongly
agree
Agree
Not Sure
Disagree
Strongly disagree
8. How strongly you believe
that you, the nurse or caregiver, benefits from the Beata Clasp® ?
Strongly
agree
Agree
Not Sure
Disagree
Strongly disagree
OUR EXPERIENCE
9. What is your job function?
Staff
nurse
Nursing Asst or Patient Care Tech
Charge Nurse or Nurse Supervisor
Nurse Practitioner or Clinical Nurse Specialist
Other
10. How many years have you
worked at your current job on this nursing unit?
<1
year
1-4 years
5-10 years
11-20 years
>20 years
11. How many years have you
worked in this role or a similar role at any hospital?
<1
year
1-4 years
5-10 years
11-20 years
>20 years
SPECIFIC ATTRIBUTES of the BEATA CLASP
How would you rate the following?
12. The concept of a line
separator system
Excellent
Good
Fair
Poor
Very Poor
13. The effectiveness of the
Beata Clasp® in keeping lines separated
Excellent
Good
Fair
Poor
Very Poor
14. The effectiveness of the
Beata Clasp® versus an alternative solution
Excellent
Good
Fair
Poor
Very Poor
15. The impact of the Beata
Clasp® on improving patient safety
Excellent
Good
Fair
Poor
Very Poor
16. The impact of the Beata
Clasp® on improving your work efficiency or
workload
Excellent
Good
Fair
Poor
Very Poor
17. The overall quality of
the Beata Clasp®
Excellent
Good
Fair
Poor
Very Poor
18. The ease of using the
Beata Clasp®
Excellent
Good
Fair
Poor
Very Poor
19. Would you recommend the
Beata Clasp® to other nurses?
Yes
Not sure
No
Poor
Very Poor
If no, why not?
20. Which of the following statements best
describes your reaction to the Beata Clasp® ?
CHOOSE ONE
I really want to use the Beata Clasp® with
my patients because it effectively solves the problem of "spaghetti lines.
The Beata Clasp® is a minor improvement in
the "spaghetti line" problem.
I'm not sure that the Beata Clasp® does
anything to help the "spaghetti line" problem.
I am not at all interested in using the Beata Clasp®
because I do not see any benefit to me or the patient.
21. Which of the following statements are
true? CHOOSE ONE
The "spaghetti syndrome" of tangled, impinged or falling lines/tubing is not
a problem for me.
I have not tried to solve the "spaghetti syndrome" of multiple lines and
tubing with any solution other than the Beata Clasp® .
Compared to other methods or products I have tried, the Beata Clasp®
is more effective at solving the problem of "spaghetti lines".
Compared to other methods or products I have tried, the Beata Clasp®
is less effective or equally effective at solving the problem of "spaghetti
lines".
22. If you have tried other products or
methods, please list or describe them:
23. What is it you liked most about the
Beata Clasp® ?
24. If you could change something about
the Beata Clasp® , what would it be?
25. Are there any other comments you have
about your experience using the Beata Clasp® ?
*Optional
First Name:
Last Name:
Hospital: