Q01
Message
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Employee Concern for Patient Care and Safety Survey
Measures how attuned staff feel to patients' needs and how safe they feel speaking up about care or safety concerns, surfacing barriers to raising issues and signs of moral distress. Built for healthcare and care-setting HR and quality teams, with an AI follow-up that reconstructs what actually happened the last time an employee flagged a concern.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
12 questions · ~7 min
Q02
Multiple ChoiceRequired
How much direct contact do you have with patients in a typical week?
- None
- Occasional (a few times a week)
- Frequent (daily)
- Constant (most of my shift)
Q03
Opinion ScaleRequired
In the last 30 days, how often did you notice something that made you concerned about a patient's care, safety, or comfort?
Scale: 1 – 5
Min:NeverMax:Constantly
Q04
MatrixRequired
How much do you agree with each statement about your workplace?
4 rows × 5 columns
- I feel comfortable speaking up when I notice something that could affect a patient's care or safety.
- My supervisor takes it seriously when I raise a concern about a patient.
- I trust that raising a concern about patient care won't affect how I'm treated at work.
- My team responds quickly when a patient's needs change.
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q05
Multiple Choice
The last time you noticed a concern about a patient, what did you do?
- Reported it to a supervisor or charge nurse
- Documented it in the patient's chart
- Raised it directly with the care team
- Escalated it to a manager or safety officer
- Didn't do anything
Q06
Rating Scale
How would you rate the organization's response the last time you raised a concern about a patient?
Range: 1 – 5
Min:PoorMax:Excellent
Q07
Best–Worst Trade-off (MaxDiff)Required
Which of these most and least holds you back from raising a concern about a patient's care?
- Fear of being blamed
- Not sure who to tell
- Too busy, no time
- Belief that nothing will change
- A past negative experience raising concerns
- Unclear reporting process
- Worry about my relationship with coworkers
Pick best & worst per setBest:Holds me back the mostWorst:Holds me back the least
Q08
Opinion ScaleRequired
How often do you feel unable to do what you believe is right for a patient because of time, staffing, or policy constraints?
Scale: 0 – 10
Min:NeverMax:Constantly
Q09
AI Interview
Reconstruct the most recent time the respondent noticed a concern about a patient's care or safety: what specifically they noticed, who (if anyone) they told, what happened after, and whether it was resolved to their satisfaction. If they said they didn't do anything, probe what stopped them and what would have made it easier to speak up. Anchor on their rating scale answers about comfort speaking up and organizational response to understand the gap between how safe they feel raising concerns and what actually happens when they do.
Q10
Multiple Choice
Which best describes your role?
- Nursing or clinical staff
- Physician or provider
- Allied health professional
- Administrative or support staff
- Other
- Prefer not to say
Q11
Multiple Choice
How long have you worked here?
- Less than 1 year
- 1-3 years
- 3-7 years
- 7+ years
- Prefer not to say
Q12
Message
Thank you for your honesty. These responses go directly to leadership to identify where staff need more support to raise and resolve concerns about patient care.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Includes an AI follow-up interview that reconstructs exactly what happened the last time an employee flagged a patient concern, rather than stopping at a static rating
- Combines quantitative measures (opinion scale on frequency of concerns, matrix on workplace agreement, rating of the organization's response, max-diff on barriers) with open reconstruction of a real incident
- Directly probes moral distress with a dedicated opinion-scale item ('unable to do what you believe is right for a patient because...'), which generic workplace-safety forms don't ask
- Segments by patient contact level, role, and tenure so healthcare/quality teams can see which staff groups feel least safe speaking up
QuestionPro
Employee Concern for Patients Survey TemplateThis is a directly comparable, fielding-ready template on the exact topic of employee concern for patients. It's a static questionnaire without any adaptive follow-up, so every respondent answers the same fixed set of questions regardless of what they report.
What it does well
- Purpose-built for the same patient-concern topic
- Backed by an established survey platform with broad question-type support
- Ready to deploy without custom build-out
Where it falls short
- No adaptive AI follow-up to reconstruct what actually happened in a flagged incident
- No automated per-response quality scoring
- No published prompt-level methodology for how questions probe deeper
SurveySparrow
Free Workplace Safety Templates That Actually WorkThis reads as a general workplace-safety template collection/guide rather than a template specifically built around patient care or moral distress. It's useful for general safety-concern intake but not tailored to healthcare/care-setting dynamics.
What it does well
- Conversational form format that may feel less clinical than a traditional survey
- Free to use
- Covers general workplace safety concerns broadly
Where it falls short
- Not specific to patient care or clinical moral distress
- Static form with no adaptive probing of what happened in a specific incident
- No transparent, published methodology behind question flow
Jotform
Workplace Safety and Concerns Form TemplateA general-purpose workplace safety and concerns intake form, not tailored to patient care settings or moral distress specifically. It's a fielding-ready static form, good for basic incident logging but not for nuanced attitudinal measurement.
What it does well
- Simple, ready-to-use form builder template
- Familiar Jotform ecosystem for embedding and routing submissions
- Flexible for general safety-concern reporting
Where it falls short
- No patient-care-specific framing or moral distress measurement
- No adaptive AI interview to reconstruct incidents
- No automated quality scoring of open responses
Typeform
Employee Safety Survey TemplateA general employee safety survey template, not specific to patient care or healthcare settings. Typeform's conversational UI is polished, but the template itself is a fixed question set without adaptive follow-up.
What it does well
- Polished, conversational one-question-at-a-time interface
- Easy to customize branding and question wording
- Established platform with wide integration support
Where it falls short
- No healthcare/patient-care-specific content or moral distress items
- Static question flow with no AI-driven follow-up on flagged incidents
- No automated per-response quality scoring or transparent prompt methodology
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.