1
|
Sanner-Stiehr E, Garcia A, Polivka B, Dunton N, Williams JA, Walpitage DL, Hui C, Spreckelmeyer K, Yang F. Support from Work and Intent to Stay Among Nurses During COVID-19: An Academic-Practice Collaboration. Nurse Lead 2022; 20:594-600. [PMID: 35464634 PMCID: PMC9013670 DOI: 10.1016/j.mnl.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The COVID-19 pandemic created stressful working conditions for nurses and challenges for leaders. A survey was conducted among 399 acute and ambulatory care nurses measuring availability of calming and safety resources, perceptions of support from work, and intent to stay. Most nurses reported intent to stay with their employer, despite inadequate safety and calming resources. High levels of support from work were significantly influenced nurses' intent to stay. Leadership actions at the study site to provide support are described, providing context for results. Nurse leaders can positively influence intent to stay through consistent implementation of supportive measures.
Collapse
|
2
|
Staggs VS, Turner K, Potter C, Cramer E, Dunton N, Mion LC, Shorr RI. Unit-level variation in bed alarm use in US hospitals. Res Nurs Health 2020; 43:365-372. [PMID: 32515837 DOI: 10.1002/nur.22049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/19/2020] [Indexed: 11/10/2022]
Abstract
Bed and chair alarms are widely used in hospitals, despite lack of effectiveness and unintended negative consequences. In this cross-sectional, observational study, we examined alarm prevalence and contributions of patient- and unit-level factors to alarm use on 59 acute care nursing units in 57 US hospitals participating in the National Database of Nursing Quality Indicators®. Nursing unit staff reported data on patient-level fall risk and fall prevention measures for 1,489 patients. Patient-level propensity scores for alarm use were estimated using logistic regression. Expected alarm use on each unit, defined as the mean patient propensity-for-alarm score, was compared with the observed rate of alarm use. Over one-third of patients assessed had an alarm in the "on" position. Patient characteristics associated with higher odds of alarm use included recent fall, need for ambulation assistance, poor mobility judgment, and altered mental status. Observed rates of unit alarm use ranged from 0% to 100% (median 33%, 10th percentile 5%, 90th percentile 67%). Expected alarm use varied less (median 31%, 10th percentile 27%, and 90th percentile 45%). Only 29% of variability in observed alarm use was accounted for by expected alarm use. Unit assignment was a stronger predictor of alarm use than patient-level fall risk variables. Alarm use is common, varies widely across hospitals, and cannot be fully explained by patient fall risk factors; alarm use is driven largely by unit practices. Alarms are used too frequently and too indiscriminately, and guidance is needed for optimizing alarm use to reduce noise and encourage mobility in appropriate patients.
Collapse
Affiliation(s)
- Vincent S Staggs
- Biostatistics & Epidemiology, Division of Health Services & Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | | | - Emily Cramer
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas
| | - Nancy Dunton
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas
| | - Lorraine C Mion
- School of Nursing, The Ohio State University, Columbus, Ohio
| | - Ronald I Shorr
- Department of Epidemiology, University of Florida, Gainesville, Florida.,Geriatric Research Education and Clinical Center, Malcom Randell VAMC, Gainesville, Florida
| |
Collapse
|
3
|
Shorr RI, Staggs VS, Waters TM, Daniels MJ, Liu M, Dunton N, Mion LC. Impact of the Hospital-Acquired Conditions Initiative on Falls and Physical Restraints: A Longitudinal Study. J Hosp Med 2019; 14:E31-E36. [PMID: 31532748 DOI: 10.12788/jhm.3295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/03/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS) implemented the Hospital-Acquired Conditions (HACs) Initiative in October 2008; the CMS no longer reimbursed hospitals for fall injury. The effects of this payment change on fall and fall injury rates are not well described, nor its effect on physical restraint use. OBJECTIVE The aim of this study was to examine the effects of the 2008 HACs Initiative on the rates of falls, injurious falls, and physical restraint use. DESIGN/SETTING This was a nine-year retrospective cohort study (July 2006-December 2015) involving 2,862 adult medical, medical-surgical, and surgical nursing units from 734 hospitals. MEASUREMENTS Annual rates of change in falls, injurious falls, and physical restraint use during the two years before the payment rule went into effect were compared with one-, four-, and seven-year rates of annual change after implementation, adjusting for unit- and facility-level covariates. Stratified analyses were conducted according to bed size and teaching status. RESULTS Compared with prior to the payment change, there was stable acceleration in the one-, four-, and seven-year annual rates of decline in falls as follows: -2.1% (-3.3%, -0.9%), -2.2% (-3.2%, -1.1%), and -2.2% (-3.4%, -1.0%) respectively. For injurious falls, there was an increasing acceleration in the annual declines, achieving statistical significance only at seven years post CMS change as follows: -3.2% (-5.5%, -1.0%). Physical restraint use prevalence decreased from 1.6% to 0.6%. Changes in the rates of falls, injurious falls, and restraint use varied according to hospital bed size and teaching status. CONCLUSIONS AND RELEVANCE Since the HACs Initiative, there was at best a modest decline in the rates of falls and injurious falls observed primarily in larger, major teaching hospitals. An increase in restraint use was not observed. Falls remain a difficult patient safety problem for hospitals, and further research is required to develop cost-effective, generalizable strategies for their prevention.
Collapse
Affiliation(s)
- Ronald I Shorr
- Geriatric Research Education & Clinical Center (GRECC), Malcom Randall VAMC, Gainesville, Florida
- Department of Epidemiology, University of Florida, Gainesville, Florida
| | - Vincent S Staggs
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Teresa M Waters
- Department of Health Management and Policy, University of Kentucky College of Public Health, Lexington, Kentucky
| | - Michael J Daniels
- Department of Statistics, University of Florida, Gainesville, Florida
| | | | - Nancy Dunton
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, Ohio
| |
Collapse
|
4
|
Abstract
Patient falls remain a leading adverse event in hospitals. In a study of 65 rural hospitals with 222 nursing units and 560 urban hospitals with 4274 nursing units, we found that geographic region, unit type, and nurse staffing, education, experience, and outcomes were associated with fall rates. Implications include specific attention to fall prevention in rehabilitation units, creating better work environments that promote nurse retention, and provide RN-BSN educational opportunities.
Collapse
Affiliation(s)
- Marianne Baernholdt
- Department of Adult Health and Nursing Systems, School of Nursing, Virginia Commonwealth University, Richmond, Virginia
| | | | | | | | | | | |
Collapse
|
5
|
Stewart M, McNealy K, Dunton N. MEASURING QUALITY IN THE UNITED STATES (U.S.) PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE). Innov Aging 2017. [DOI: 10.1093/geroni/igx004.1603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - K. McNealy
- Sundance Research Institute, Sundance, Wyoming,
| | - N. Dunton
- University of Kansas, Kansas City, Kansas
| |
Collapse
|
6
|
Yankovsky A, Gajewski BJ, Dunton N. Trends in Nursing Care Efficiency From 2007 to 2011 on Acute Nursing Units. Nurs Econ 2016; 34:266-276. [PMID: 29975489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Improving the efficiency of health care is a national priority. The purpose of this study was to estimate trends in the efficiency of nursing care. Specifically, the baseline and rate of change in efficiency in the association between select hospital and nursing unit characteristics (e.g., nurse staffing levels) and indicators of patient safety (e.g., fall rates and hospital-acquired pressure ulcer rates) was investigated. A small but significant improvement in efficiency for non-Magnet® hospitals and units with increased RN hours per patient day was found. Trends in efficiency varied by unit type, with medical units showing the greatest improvement. In general, efficiency improved most in health care settings having the greatest opportunity for improvement.
Collapse
|
7
|
He J, Staggs VS, Bergquist-Beringer S, Dunton N. Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality. BMC Nurs 2016; 15:60. [PMID: 27757068 PMCID: PMC5064797 DOI: 10.1186/s12912-016-0181-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 10/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Time trends and seasonal patterns have been observed in nurse staffing and nursing-sensitive patient outcomes in recent years. It is unknown whether these changes were associated. METHODS Quarterly unit-level nursing data in 2004-2012 were extracted from the National Database of Nursing Quality Indicators® (NDNQI®). Units were divided into groups based on patterns of missing data. All variables were aggregated across units within these groups and analyses were conducted at the group level. Patient outcomes included rates of inpatient falls and hospital-acquired pressure ulcers. Staffing variables included total nursing hours per patient days (HPPD) and percent of nursing hours provided by registered nurses (RN skill-mix). Weighted linear mixed models were used to examine the associations between nurse staffing and patient outcomes at trend and seasonal levels. RESULTS At trend level, both staffing variables were inversely associated with all outcomes (p < 0.001); at seasonal level, total HPPD was inversely associated (higher staffing related to lower event rate) with all outcomes (p < 0.001) while RN skill-mix was positively associated (higher staffing related to higher event rate) with fall rate (p < 0.001) and pressure ulcer rate (p = 0.03). It was found that total HPPD tended to be lower and RN skill-mix tended to be higher in Quarter 1 (January-March) when falls and pressure ulcers were more likely to happen. CONCLUSIONS By aggregating data across units we were able to detect associations between nurse staffing and patient outcomes at both trend and seasonal levels. More rigorous research is needed to study the underlying mechanism of these associations.
Collapse
Affiliation(s)
- Jianghua He
- Department of Biostatistics, University of Kansas Medical Center, MS 1026, 3901 Rainbow BLVD, Kansas City, KS 66160 USA
| | - Vincent S Staggs
- Health Services & Outcomes Research, Children's Mercy Hospitals & Clinics, 2401 Gillham Rd, Kansas City, MO 64108 USA
| | - Sandra Bergquist-Beringer
- School of Nursing, University of Kansas Medical Center, 3901 Rainbow BLVD, Kansas City, KS 66160 USA
| | - Nancy Dunton
- School of Nursing, University of Kansas Medical Center, 3901 Rainbow BLVD, Kansas City, KS 66160 USA
| |
Collapse
|
8
|
Abstract
The purpose of this study is to explore the relationship between nursing home staffs' perceptions of organizational processes (communication, teamwork, and leadership) with characteristics (turnover, tenure, and educational preparation) of the nursing home administrator (NHA) and director of nursing (DON). NHAs and DONs rate communication, teamwork, and leadership significantly higher than direct care staff do (registered nurses, licensed practical nurses, certified nurse aides [CNAs]). CNAs have the lowest ratings of communication and teamwork. Turnover of the NHA and DON is significantly and negatively associated with communication and teamwork. Two thirds of DONs surveyed hold less than a baccalaureate degree; this does not influence staffs' ratings of communication, teamwork, and leadership. Findings from this study highlight the need to explore differences in perceptions between administrative and direct care staff and how these may or may not influence staff development and quality improvement activities in nursing homes.
Collapse
|
9
|
Park SH, Dunton N, Blegen MA. Comparison of Unit-Level Patient Turnover Measures in Acute Care Hospital Settings. Res Nurs Health 2016; 39:197-203. [PMID: 26998744 DOI: 10.1002/nur.21715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 11/07/2022]
Abstract
High patient turnover is a critical factor increasing nursing workload. Despite the growing number of studies on patient turnover, no consensus about how to measure turnover has been achieved. This study was designed to assess the correlation among patient turnover measures commonly used in recent studies and to examine the degree of agreement among the measures for classifying units with different levels of patient turnover. Using unit-level data collected for this study from 292 units in 88 hospitals participating in the National Database of Nursing Quality Indicators®, we compared four patient turnover measures: the inverse of length of stay (1/LOS), admissions, discharges, and transfers per daily census (ADTC), ADTC with short-stay adjustment, and the number of ADTs and short-stay patients divided by the total number of treated patients, or Unit Activity Index (UAI). We assessed the measures' agreement on turnover quartile classifications, using percent agreement and Cohen's kappa statistic (weighted and unweighted). Pearson correlation coefficients also were calculated. ADTC with or without adjustment for short-stay patients had high correlations and substantial agreement with the measure of 1/LOS (κ = .62 to .91; r = .90 to .95). The UAI measure required data less commonly collected by participating hospital units and showed only moderate correlations and fair agreement with the other measures (κ = .23 to .39; r = .41 to .45). The UAI may not be comparable and interchangeable with other patient turnover measures when data are obtained from multiple units and hospitals. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Shin Hye Park
- School of Nursing, University of Kansas Medical Center, 3901 Rainbow Blvd. MS 4043, Kansas City, KS, 66160
| | - Nancy Dunton
- School of Nursing, University of Kansas Medical Center, Kansas City, KS
| | - Mary A Blegen
- Department of Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, CA
| |
Collapse
|
10
|
Waters TM, Daniels MJ, Bazzoli GJ, Perencevich E, Dunton N, Staggs VS, Potter C, Fareed N, Liu M, Shorr RI. Effect of Medicare's nonpayment for Hospital-Acquired Conditions: lessons for future policy. JAMA Intern Med 2015; 175:347-54. [PMID: 25559166 PMCID: PMC5508870 DOI: 10.1001/jamainternmed.2014.5486] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In 2008, Medicare implemented the Hospital-Acquired Conditions (HACs) Initiative, a policy denying incremental payment for 8 complications of hospital care, also known as never events. The regulation's effect on these events has not been well studied. OBJECTIVE To measure the association between Medicare's nonpayment policy and 4 outcomes addressed by the HACs Initiative: central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers (HAPUs), and injurious inpatient falls. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental study of adult nursing units from 1381 US hospitals participating in the National Database of Nursing Quality Indicators (NDNQI), a program of the American Nurses Association. The NDNQI data were combined with American Hospital Association, Medicare Cost Report, and local market data to examine adjusted outcomes. Multilevel models were used to evaluate the effect of Medicare's nonpayment policy on never events. EXPOSURES United States hospitals providing treatment for Medicare patients were subject to the new payment policy beginning in October 2008. MAIN OUTCOMES AND MEASURES Changes in unit-level rates of HAPUs, injurious falls, CLABSIs, and CAUTIs after initiation of the policy. RESULTS Medicare's nonpayment policy was associated with an 11% reduction in the rate of change in CLABSIs (incidence rate ratio [IRR], 0.89; 95% CI, 0.83-0.95) and a 10% reduction in the rate of change in CAUTIs (IRR, 0.90; 95% CI, 0.85-0.95), but was not associated with a significant change in injurious falls (IRR, 0.99; 95% CI, 0.99-1.00) or HAPUs (odds ratio, 0.98; 95% CI, 0.96-1.01). Consideration of unit-, hospital-, and market-level factors did not significantly alter our findings. CONCLUSIONS AND RELEVANCE The HACs Initiative was associated with improvements in CLABSI and CAUTI trends, conditions for which there is strong evidence that better hospital processes yield better outcomes. However, the HACs Initiative was not associated with improvements in HAPU or injurious fall trends, conditions for which there is less evidence that changing hospital processes leads to significantly better outcomes.
Collapse
Affiliation(s)
- Teresa M Waters
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Michael J Daniels
- Department of Statistics and Data Sciences, The University of Texas at Austin3Department of Integrative Biology, The University of Texas at Austin
| | - Gloria J Bazzoli
- Department of Health Administration, Virginia Commonwealth University, Richmond
| | - Eli Perencevich
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City6Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Nancy Dunton
- School of Nursing, University of Kansas Medical Center, Kansas City, Missouri
| | - Vincent S Staggs
- Department of Biostatistics, School of Medicine, University of Kansas Medical Center, Kansas City, Missouri
| | - Catima Potter
- School of Nursing, University of Kansas Medical Center, Kansas City, Missouri
| | - Naleef Fareed
- Department of Health Policy and Administration, Pennsylvania State University, University Park
| | - Minzhao Liu
- Department of Statistics, University of Florida, Gainesville
| | - Ronald I Shorr
- Department of Epidemiology, University of Florida, Gainesville12Geriatric Research Education & Clinical Center, Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida
| |
Collapse
|
11
|
Abstract
Although remarkable efforts have been made to improve patient fall reporting through the utilization of standardized definitions, injury falls reporting has rarely been examined. This study used an overall intra-class correlation coefficient (ICC) estimate and factor analysis to assess the reliability and validity of the National Database of Nursing Quality Indicators® (NDNQI®) falls with injury measure. Data were collected from an online Fall Injury Level Survey that was administered to 1,159 NDNQI site coordinators (39.7% response rate; 91% registered nurses [RNs]). Estimated overall ICC was .85. Exploratory factor analysis (EFA) with a Promax rotation (root mean square error of approximation [RMSEA] = 0.053) identified three latent factors: No Injury, Minor Injury, and Moderate/Major Injuries. Final confirmatory factor analysis (CFA) assessment (comparative fit index [CFI] = 0.914, Tucker Lewis Index [TLI] = 0.910, RMSEA = 0.048) confirmed an acceptable model fit. Results provided strong evidence that the NDNQI falls with injury measure is reliable and valid in supporting hospitals' fall prevention efforts and future injurious falls research.
Collapse
Affiliation(s)
- Lili Garrard
- University of Kansas School of Nursing, Kansas City, USA University of Kansas School of Medicine, Kansas City, USA
| | - Diane K Boyle
- University of Wyoming Fay W. Whitney School of Nursing, Laramie, USA
| | - Michael Simon
- University of Basel, Switzerland Inselspital Bern University Hospital, Switzerland
| | - Nancy Dunton
- University of Kansas School of Nursing, Kansas City, USA
| | - Byron Gajewski
- University of Kansas School of Nursing, Kansas City, USA University of Kansas School of Medicine, Kansas City, USA
| |
Collapse
|
12
|
Abstract
BACKGROUND Most pressure ulcers can be prevented with evidence-based practice. Many studies describe the implementation of a pressure ulcer prevention program but few report the effect on outcomes across acute care facilities. METHODS Data on hospital-acquired pressure ulcers and prevention from the National Database of Nursing Quality Indicators 2010 Pressure Ulcer Surveys were linked to hospital characteristics and nurse staffing measures within the data set. The sample consisted of 1,419 hospitals from across the United States and 710,626 patients who had been surveyed for pressure ulcers in adult critical care, step-down, medical, surgical, and medical/surgical units. Hierarchical logistic regression analysis was performed to identify study variables associated with hospital-acquired pressure ulcers among patients at risk for these ulcers. RESULTS The rate of hospital-acquired pressure ulcers was 3.6% across all surveyed patients and 7.9% among those at risk. Patients who received a skin and pressure ulcer risk assessment on admission were less likely to develop a pressure ulcer. Additional study variables associated with lower hospital-acquired pressure ulcer rates included a recent reassessment of pressure ulcer risk, higher Braden Scale scores, a recent skin assessment, routine repositioning, and Magnet or Magnet-applicant designation. Variables associated with a higher likelihood of hospital-acquired pressure ulcers included nutritional support, moisture management, larger hospital size, and academic medical center status. CONCLUSIONS Results provide empirical support for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine repositioning, but the 7.9% rate of hospital-acquired pressure ulcers among at-risk patients suggests room for improvement in pressure ulcer prevention practice.
Collapse
|
13
|
Abstract
OBJECTIVE To enhance understanding of how nurse staffing relates to unassisted falls by exploring non-linear associations between unassisted fall rates and levels of registered nurse (RN) and non-RN staffing on 5 nursing unit types, thereby enabling managers to improve patient safety by making better-informed decisions about staffing. DESIGN Cross-sectional analysis of routinely collected data using hierarchical negative binomial regression. SETTING 8069 nursing units in 1361 U.S. hospitals participating in the National Database of Nursing Quality Indicators(®). Main outcome measure Rate of unassisted falls per inpatient day. RESULTS Associations between unassisted fall rates and nurse staffing varied by unit type. For medical-surgical units, higher RN staffing was weakly associated with lower fall rates. On step-down and medical units, the association between RN staffing and fall rates depended on the level of staffing: At lower staffing levels, the fall rate increased as staffing increased, but at moderate and high staffing levels, the fall rate decreased as staffing increased. Higher levels of non-RN staffing were generally associated with higher fall rates.. CONCLUSIONS Increasing non-RN staffing seems ineffective at preventing unassisted falls. Increasing RN staffing may be effective, depending on the unit type and the current level of staffing.
Collapse
Affiliation(s)
- Vincent S Staggs
- Department of Biostatistics, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 3060, Kansas City, KS 66160, USA.
| | | |
Collapse
|
14
|
Abstract
Although nursing care hours (NCH) is commonly used to examine factors related to adverse events among inpatients, the reliability of the NCH measure has rarely been examined. This study assessed the reliability of NCH data from the National Database of Nursing Quality Indicators® by estimating intraclass correlation coefficients (ICCs) with data from the California Office for Statewide Health Planning and Development. Hospital-level aggregated NCH data for critical care units were linked from each of the databases for 48 California hospitals matched in the two databases. Estimated ICCs were .96 for registered nurse (RN) hours and .72 for non-RN hours. Findings provide evidence that NCH data of the national database were substantially reliable for use in national comparable benchmarking reports for hospitals' quality improvement activities and research.
Collapse
Affiliation(s)
- JiSun Choi
- 1University of Kansas School of Nursing, Kansas City, USA
| | | | | |
Collapse
|
15
|
He J, Staggs VS, Bergquist-Beringer S, Dunton N. Unit-level time trends and seasonality in the rate of hospital-acquired pressure ulcers in US acute care hospitals. Res Nurs Health 2013; 36:171-80. [DOI: 10.1002/nur.21527] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2012] [Indexed: 11/11/2022]
|
16
|
Gajewski BJ, Dunton N. Identifying individual changes in performance with composite quality indicators while accounting for regression to the mean. Med Decis Making 2012; 33:396-406. [PMID: 23035127 DOI: 10.1177/0272989x12461855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Almost a decade ago Morton and Torgerson indicated that perceived medical benefits could be due to "regression to the mean." Despite this caution, the regression to the mean "effects on the identification of changes in institutional performance do not seem to have been considered previously in any depth" (Jones and Spiegelhalter). As a response, Jones and Spiegelhalter provide a methodology to adjust for regression to the mean when modeling recent changes in institutional performance for one-variable quality indicators. Therefore, in our view, Jones and Spiegelhalter provide a breakthrough methodology for performance measures. At the same time, in the interests of parsimony, it is useful to aggregate individual quality indicators into a composite score. Our question is, can we develop and demonstrate a methodology that extends the "regression to the mean" literature to allow for composite quality indicators? Using a latent variable modeling approach, we extend the methodology to the composite indicator case. We demonstrate the approach on 4 indicators collected by the National Database of Nursing Quality Indicators. A simulation study further demonstrates its "proof of concept."
Collapse
Affiliation(s)
- Byron J Gajewski
- Department of Biostatistics, University of Kansas School of Medicine, Kansas City, Kansas (BJG)
| | - Nancy Dunton
- University of Kansas School of Nursing, Kansas City, Kansas (ND)
| |
Collapse
|
17
|
Gajewski BJ, Lee R, Dunton N. Data Envelopment Analysis in the Presence of Measurement Error: Case Study from the National Database of Nursing Quality Indicators® (NDNQI®). J Appl Stat 2012; 39:2639-2653. [PMID: 23328796 DOI: 10.1080/02664763.2012.724664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Data Envelopment Analysis (DEA) is the most commonly used approach for evaluating healthcare efficiency (Hollingsworth, 2008), but a long-standing concern is that DEA assumes that data are measured without error. This is quite unlikely, and DEA and other efficiency analysis techniques may yield biased efficiency estimates if it is not realized (Gajewski, Lee, Bott, Piamjariyakul and Taunton, 2009; Ruggiero, 2004). We propose to address measurement error systematically using a Bayesian method (Bayesian DEA). We will apply Bayesian DEA to data from the National Database of Nursing Quality Indicators® (NDNQI®) to estimate nursing units' efficiency. Several external reliability studies inform the posterior distribution of the measurement error on the DEA variables. We will discuss the case of generalizing the approach to situations where an external reliability study is not feasible.
Collapse
Affiliation(s)
- Byron J Gajewski
- Department of Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA, 66160 ; University of Kansas School of Nursing, Kansas City, KS, USA 66160
| | | | | |
Collapse
|
18
|
Hou Q, Crosser B, Mahnken JD, Gajewski BJ, Dunton N. Input data quality control for NDNQI national comparative statistics and quarterly reports: a contrast of three robust scale estimators for multiple outlier detection. BMC Res Notes 2012; 5:456. [PMID: 22920157 PMCID: PMC3542164 DOI: 10.1186/1756-0500-5-456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 08/17/2012] [Indexed: 11/10/2022] Open
Abstract
Background To evaluate institutional nursing care performance in the context of national comparative statistics (benchmarks), approximately one in every three major healthcare institutions (over 1,800 hospitals) across the United States, have joined the National Database for Nursing Quality Indicators® (NDNQI®). With over 18,000 hospital units contributing data for nearly 200 quantitative measures at present, a reliable and efficient input data screening for all quantitative measures for data quality control is critical to the integrity, validity, and on-time delivery of NDNQI reports. Methods With Monte Carlo simulation and quantitative NDNQI indicator examples, we compared two ad-hoc methods using robust scale estimators, Inter Quartile Range (IQR) and Median Absolute Deviation from the Median (MAD), to the classic, theoretically-based Minimum Covariance Determinant (FAST-MCD) approach, for initial univariate outlier detection. Results While the theoretically based FAST-MCD used in one dimension can be sensitive and is better suited for identifying groups of outliers because of its high breakdown point, the ad-hoc IQR and MAD approaches are fast, easy to implement, and could be more robust and efficient, depending on the distributional property of the underlying measure of interest. Conclusion With highly skewed distributions for most NDNQI indicators within a short data screen window, the FAST-MCD approach, when used in one dimensional raw data setting, could overestimate the false alarm rates for potential outliers than the IQR and MAD with the same pre-set of critical value, thus, overburden data quality control at both the data entry and administrative ends in our setting.
Collapse
Affiliation(s)
- Qingjiang Hou
- Department of Biostatistics, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA.
| | | | | | | | | |
Collapse
|
19
|
Klaus SF, Dunton N, Gajewski B, Potter C. Reliability of the nursing care hour measure: a descriptive study. Int J Nurs Stud 2012; 50:924-32. [PMID: 22874589 DOI: 10.1016/j.ijnurstu.2012.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 07/12/2012] [Accepted: 07/15/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The nursing care hour has become an international standard unit of measure in research where nurse staffing is a key variable. Until now, there have been no studies verifying whether nursing care hours obtained from hospital data sources can be collected reliably. OBJECTIVES To examine the processes used by hospitals to generate nursing care hour data and to evaluate inter-rater reliability and guideline compliance with standards of the National Database of Nursing Quality Indicators(®) (NDNQI(®)) and the National Quality Forum. DESIGN AND SETTING Two-phase descriptive study of all NDNQI hospitals that submitted data in third quarter of 2007. METHODS Data for phase I came from an online survey created by the authors to ascertain the processes used by hospitals to collect nursing care hours and their compliance with standardized data collection guidelines. In phase II, inter-rater reliability was measured using intra-class correlations between nursing care hours generated from clock hour files submitted to the study team by participants' payroll/accounting departments and aggregated data submitted previously. RESULTS Phase I data were obtained from a total of 714 respondents. Nearly half (48%) of all sites use payroll records to obtain nursing care hour data and 70% use one of the standardized methods for converting the bi-weekly hours into months. Unit secretaries were reportedly included in NCH by 17.4% of respondents and only 26.2% of sites could accurately identify the point at which newly hired nurses should be included. The phase II findings (n=11) support the ability of two independent raters to obtain similar results when calculating total nursing care hours according to standard guidelines (ICC=0.76-0.99). CONCLUSIONS Although barriers exist, this study found support for hospitals' abilities to collect reliable nursing care hour data.
Collapse
Affiliation(s)
- Susan F Klaus
- University of Kansas Hospital, University of Kansas School of Nursing, 3901 Rainbow Blvd., Kansas City, KS 66160, United States.
| | | | | | | |
Collapse
|
20
|
Abstract
Content validity elicits expert opinion regarding items of a psychometric instrument. Expert opinion can be elicited in many forms: for example, how essential an item is or its relevancy to a domain. This study developed an alternative tool that elicits expert opinion regarding correlations between each item and its respective domain. With 109 Registered Nurse (RN) site coordinators from National Database of Nursing Quality Indicators®, we implemented a randomized Bayesian equivalence trial with coordinators completing “relevance” or “correlation” content tools regarding the RN Job Enjoyment Scale. We confirmed our hypothesis that the two tools would result in equivalent content information. A Bayesian ordered analysis model supported the results, suggesting that evidence for traditional content validity indices can be justified using correlation arguments.
Collapse
Affiliation(s)
- Byron J. Gajewski
- Department of Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA
- University of Kansas School of Nursing, Kansas City, KS, USA
| | | | - Diane K. Boyle
- University of Kansas School of Nursing, Kansas City, KS, USA
| | - Marjorie Bott
- University of Kansas School of Nursing, Kansas City, KS, USA
| | - Larry R. Price
- College of Education, Texas State University, San Marcos, TX, USA
| | - Jamie Leopold
- University of Kansas School of Nursing, Kansas City, KS, USA
| | - Nancy Dunton
- University of Kansas School of Nursing, Kansas City, KS, USA
| |
Collapse
|
21
|
Staggs VS, Dunton N. Hospital and unit characteristics associated with nursing turnover include skill mix but not staffing level: an observational cross-sectional study. Int J Nurs Stud 2012; 49:1138-45. [PMID: 22521853 DOI: 10.1016/j.ijnurstu.2012.03.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 03/12/2012] [Accepted: 03/28/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nursing turnover is expensive and may have adverse effects on patient care. Little is known about turnover's association with most hospital and nursing unit characteristics, including nurse staffing level and registered nurse skill mix. OBJECTIVE To explore associations between nursing unit turnover rates and several hospital- and unit-level variables, including staffing level and skill mix. DESIGN Observational cross-sectional study of longitudinal data. SETTINGS 1884 nursing units in 306 U.S. acute care hospitals. METHODS During a 2-year period units reported monthly data on staffing and turnover. Total nursing staff turnover and registered nurse turnover rates were modeled as dependent variables in hierarchical Poisson regression models. The following hospital characteristics were considered as predictors: Magnet(®) status, ownership (government or non-government), teaching status, locale (metropolitan, micropolitan, or rural), and size (average daily census). The U.S. state in which the hospital was located was included as a covariate. Unit-level variables included total nursing hours per patient day, size of nursing staff, registered nurse skill mix, population age group (neonatal, pediatric, or adult), and service line (critical care, step-down, medical, surgical, medical/surgical, psychiatric, or rehabilitation). RESULTS Government ownership, Magnet designation, and higher skill mix were associated with lower total turnover and registered nurse turnover. Neonatal units had lower total and registered nurse turnover than pediatric units, which had lower total and registered nurse turnover than adult units. Unit service line was associated only with total turnover. Psychiatric, critical care, and rehabilitation units had the lowest mean turnover rates, but most differences between service lines were not significant. The other explanatory variables considered were not significant. CONCLUSIONS Several hospital and unit characteristic variables have significant associations with nursing turnover; these associations should be taken into account in nursing turnover research and need to be explored further. Controlling for hospital ownership, Magnet status, unit service line, and unit population age group, registered nurse skill mix is apparently more important than total nurse staffing level in predicting nursing turnover.
Collapse
Affiliation(s)
- Vincent S Staggs
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, United States.
| | | |
Collapse
|
22
|
Hou Q, Mahnken JD, Gajewski BJ, Dunton N. The Box-Cox power transformation on nursing sensitive indicators: does it matter if structural effects are omitted during the estimation of the transformation parameter? BMC Med Res Methodol 2011; 11:118. [PMID: 21854614 PMCID: PMC3201036 DOI: 10.1186/1471-2288-11-118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 08/19/2011] [Indexed: 11/16/2022] Open
Abstract
Background Many nursing and health related research studies have continuous outcome measures that are inherently non-normal in distribution. The Box-Cox transformation provides a powerful tool for developing a parsimonious model for data representation and interpretation when the distribution of the dependent variable, or outcome measure, of interest deviates from the normal distribution. The objectives of this study was to contrast the effect of obtaining the Box-Cox power transformation parameter and subsequent analysis of variance with or without a priori knowledge of predictor variables under the classic linear or linear mixed model settings. Methods Simulation data from a 3 × 4 factorial treatments design, along with the Patient Falls and Patient Injury Falls from the National Database of Nursing Quality Indicators (NDNQI®) for the 3rd quarter of 2007 from a convenience sample of over one thousand US hospitals were analyzed. The effect of the nonlinear monotonic transformation was contrasted in two ways: a) estimating the transformation parameter along with factors with potential structural effects, and b) estimating the transformation parameter first and then conducting analysis of variance for the structural effect. Results Linear model ANOVA with Monte Carlo simulation and mixed models with correlated error terms with NDNQI examples showed no substantial differences on statistical tests for structural effects if the factors with structural effects were omitted during the estimation of the transformation parameter. Conclusions The Box-Cox power transformation can still be an effective tool for validating statistical inferences with large observational, cross-sectional, and hierarchical or repeated measure studies under the linear or the mixed model settings without prior knowledge of all the factors with potential structural effects.
Collapse
Affiliation(s)
- Qingjiang Hou
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS 66160, USA.
| | | | | | | |
Collapse
|
23
|
Simon M, Yankovskyy E, Klaus S, Gajewski B, Dunton N. Midnight census revisited: Reliability of patient day measurements in US hospital units. Int J Nurs Stud 2010; 48:56-61. [PMID: 20673896 DOI: 10.1016/j.ijnurstu.2010.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 06/04/2010] [Accepted: 07/01/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patient days are widely used in nurse staffing research and for nursing quality measurement. Nursing hours per patient day (NHPPD) and fall rates incorporate patient days in the denominator and are endorsed by the US National Quality Forum (NQF) as nursing sensitive consensus measures. Measurement error introduced by patient days would affect the accuracy of these nursing quality indicators. OBJECTIVES The aim of this study was to assess the reliability of five patient day reporting methods accepted by the National Database of Nursing Quality Indicators (NDNQI). The specific aims were (1) to investigate the agreement of five patient day measurements with a defined quasi-gold standard, (2) to explore method bias by investigating the association of potential confounding variables with the differences between the routine measurements and the quasi-gold standard, and (3) to extrapolate the potential effect of bias of the patient day methods on nursing quality indicators. DESIGN A multiple census study with a national convenience sample of hospital units in the US was conducted. SETTING 260 out of 282 units (92%) from 54 hospitals sent bi-hourly patient census data for seven randomly selected days in September 2008. METHODS The multiple census data comprised the quasi-gold standard and was compared with data routinely submitted to the database. Intraclass correlations were calculated for an agreement analysis. A Bayesian regression analysis was conducted to explore the impact of different data collection methods and the degree of short stay patients. RESULTS Overall agreement between routine data and the quasi-gold standard was excellent (ICC [95% CI]: 0.967 [0.958-0.974]). A Bayesian regression analysis identified that two methods underestimated patient days and an interaction between the degrees of short stay patients and one of the data collection methods also affected patient day measurement by up to 7.6%.
Collapse
Affiliation(s)
- Michael Simon
- University of Kansas Medical Center, Kansas City, 66160, United States.
| | | | | | | | | |
Collapse
|
24
|
Neuberger JS, Davis K, Nazir N, Dunton N, Winn K, Jacquot S, Moler D. Indoor smoking ordinances in workplaces and public places in Kansas. Nicotine Tob Res 2010; 12:828-33. [PMID: 20534777 DOI: 10.1093/ntr/ntq089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The purpose of this study was to investigate the preferences of elected city officials regarding the need for a statewide clean indoor air law and to analyze the content of local smoking ordinances. METHODS A survey of elected officials in 57 larger Kansas cities obtained information on the perceived need for statewide legislation, venues to be covered, and motivating factors. Clean indoor air ordinances from all Kansas cities were analyzed by venue. RESULTS The survey response rate was 190 out of 377 (50.4%) for elected officials. Over 70% of the respondents favored or strongly favored greater restrictions on indoor smoking. Sixty percent favored statewide legislation. Among these, over 80% favored restrictions in health care facilities, theaters, indoor sports arenas (including bowling alleys), restaurants, shopping malls, lobbies, enclosed spaces in outdoor arenas, and hotel/motel rooms. Officials who had never smoked favored a more restrictive approach. Employee and public health concerns were cited as influential by 76%-79% of respondents. Thirty-eight ordinances, covering over half of the state's population, were examined. They varied considerably in their exemptions. DISCUSSION Official's attitudes toward smoking regulations were associated with their smoking status. The examination of existing ordinances revealed a piecemeal approach to smoking regulations.
Collapse
Affiliation(s)
- John S Neuberger
- Department of Preventive Medicine and Public Health, School of Medicine, University of Kansas Medical Center, Kansas City, KS 66160, USA.
| | | | | | | | | | | | | |
Collapse
|
25
|
Simon M, Bergquist-Beringer S, Gajewski B, Dunton N. Pressure ulcer prevention as an indicator of nursing care quality: a comment on Jull and Griffiths (2010). Int J Nurs Stud 2010; 47:1194-5. [PMID: 20537644 DOI: 10.1016/j.ijnurstu.2010.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 04/28/2010] [Indexed: 11/24/2022]
Affiliation(s)
- Michael Simon
- School of Nursing, National Database of Nursing Quality Indicators, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA.
| | | | | | | |
Collapse
|
26
|
Gajewski BJ, Boyle DK, Miller PA, Oberhelman F, Dunton N. A multilevel confirmatory factor analysis of the Practice Environment Scale: a case study. Nurs Res 2010; 59:147-53. [PMID: 20216017 DOI: 10.1097/nnr.0b013e3181d1a71e] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Practice Environment Scale (PES) data are collected from RNs in nursing units in hospitals that are members of the National Database of Nursing Quality Indicators (NDNQI). Patient and RN information are collected to aid in quality improvement and research at the nursing unit level. The data were collected from the individual RN, but items are worded so that analyses can be conducted at the individual, unit, or hospital level. There is a need to examine the validity of the PES at both the individual and the unit level. OBJECTIVE To describe multilevel confirmatory factor analysis via a case study for investigating the validity of the PES, a measure of the nursing practice environment. APPROACH The PES was administered to 72,889 RNs from 4,783 nursing units (16 unit types; e.g., critical care and obstetric) in 2007. The PES has 31 items in five different domains. A multilevel confirmatory factor analytic model was fit with a structure on the basis of the five domains. From this model, an estimate was sought between unit loadings and within unit loadings to investigate factorial, convergent, and discriminant validity at both the unit and the RN levels. To investigate criterion-related validity, the five PES domains were correlated with the seven job enjoyment items adapted from the National Database of Nursing Quality Indicators at the unit and RN levels (also using a multilevel model). RESULTS The multilevel factor analysis provides evidence of factorial, convergent, discriminant, and criterion-related validity at both the unit and the RN levels. DISCUSSION The PES is a valid instrument for use in quality improvement and research both at the unit and individual RN levels.
Collapse
Affiliation(s)
- Byron J Gajewski
- Department of Biostatistics, University of Kansas Schools of Medicine and Nursing, Kansas City, KS 66160, USA.
| | | | | | | | | |
Collapse
|
27
|
Simon M, Yankovskyy Y, Dunton N. Solving the mystery of patient days and the midnight census. Nurs Manag (Harrow) 2010; 41:12-14. [PMID: 20142672 DOI: 10.1097/01.numa.0000368560.92652.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Michael Simon
- University of Kansas Medical Center School of Nursing, NDNQI, Kansas City, Kansas, USA
| | | | | |
Collapse
|
28
|
Bergquist-Beringer S, Davidson J, Agosto C, Linde NK, Abel M, Spurling K, Dunton N, Christopher A. Evaluation of the National Database of Nursing Quality Indicators (NDNQI) Training Program on Pressure Ulcers. J Contin Educ Nurs 2009; 40:252-8; quiz 259-60, 279. [PMID: 19639914 DOI: 10.3928/00220124-20090522-05] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The National Database of Nursing Quality Indicators (NDNQI) Pressure Ulcer Training Program was developed to improve nursing accuracy and reliability in identifying and staging pressure ulcers and differentiating hospital- and unit-acquired from community-acquired pressure ulcers. Of 5,200 individuals who completed the training program within 5 months of release, 937 provided written evaluation comments. Four major themes emerged from content analysis of the evaluation remarks: pressure ulcer and other wound pictures; accuracy and clarity of content; program design and technology; and the educational/informational experience. Reviewers most frequently commented on their positive learning experience. Program components that enhanced the educational experience included the array of pressure ulcer pictures at each stage and pictures of other wounds. Clarity of content, program design, and technological problems were barriers to reviewer satisfaction. Findings suggest the NDNQI Pressure Ulcer Training Program was effective for educating staff nurses on pressure ulcer identification and staging.
Collapse
Affiliation(s)
- Sandra Bergquist-Beringer
- School of Nursing, Mail Stop 4043, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- Jan Davidson
- University of Kansas Medical Center, Kansas City, Kan., USA
| | | | | |
Collapse
|
30
|
Gajewski BJ, Mahnken JD, Dunton N. Improving quality indicator report cards through Bayesian modeling. BMC Med Res Methodol 2008; 8:77. [PMID: 19017399 PMCID: PMC2596790 DOI: 10.1186/1471-2288-8-77] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Accepted: 11/18/2008] [Indexed: 11/24/2022] Open
Abstract
Background The National Database for Nursing Quality Indicators® (NDNQI®) was established in 1998 to assist hospitals in monitoring indicators of nursing quality (eg, falls and pressure ulcers). Hospitals participating in NDNQI transmit data from nursing units to an NDNQI data repository. Data are summarized and published in reports that allow participating facilities to compare the results for their units with those from other units across the nation. A disadvantage of this reporting scheme is that the sampling variability is not explicit. For example, suppose a small nursing unit that has 2 out of 10 (rate of 20%) patients with pressure ulcers. Should the nursing unit immediately undertake a quality improvement plan because of the rate difference from the national average (7%)? Methods In this paper, we propose approximating 95% credible intervals (CrIs) for unit-level data using statistical models that account for the variability in unit rates for report cards. Results Bayesian CrIs communicate the level of uncertainty of estimates more clearly to decision makers than other significance tests. Conclusion A benefit of this approach is that nursing units would be better able to distinguish problematic or beneficial trends from fluctuations likely due to chance.
Collapse
Affiliation(s)
- Byron J Gajewski
- Department of Biostatistics, School of Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
| | | | | |
Collapse
|
31
|
Dunton N, Twait M, Davidson J, Christopher A, Sharma N. Apples to apples: Defining "hospital" for performance measures. Nurs Manag (Harrow) 2008; 39:16-20. [PMID: 18690146 DOI: 10.1097/01.numa.0000333718.65486.5a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Nancy Dunton
- University of Kansas Medical Center, Kansas City, Kan, USA
| | | | | | | | | |
Collapse
|
32
|
Gajewski BJ, Hart S, Bergquist-Beringer S, Dunton N. Inter-rater reliability of pressure ulcer staging: ordinal probit Bayesian hierarchical model that allows for uncertain rater response. Stat Med 2008; 26:4602-18. [PMID: 17393413 DOI: 10.1002/sim.2877] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This article describes a method for estimating the inter-rater reliability of pressure ulcer (PU) staging (stages I-IV) from raters in National Database of Nursing Quality Indicators (NDNQI) participating hospitals. The method models ordinal spanning data utilizing an ordinal probit Bayesian hierarchical model (BHM) across several hospitals in which raters monitor patient's PUs. An ulcer that cannot be accurately assessed because the base of the wound cannot be seen is defined as unstageable. Our novel approach allows for an unstageable PU rating to be included in the analysis. We compare the ordinal probit BHM to an approximate random-effects (standard approach in the literature) model that assumes that the raw ordinal data are continuous.
Collapse
Affiliation(s)
- Byron J Gajewski
- Schools of Allied Health and Nursing, Center for Biostatistics and Advanced Informatics, The University of Kansas Medical Center, Kansas City, KS 66160, U.S.A.
| | | | | | | |
Collapse
|
33
|
Gajewski BJ, Lee R, Thompson S, Dunton N, Becker A, Wells V. Non-normal path analysis in the presence of measurement error and missing data: a Bayesian analysis of nursing homes' structure and outcomes. Stat Med 2007; 25:3632-47. [PMID: 16374902 DOI: 10.1002/sim.2478] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Path analytic models are useful tools in quantitative nursing research. They allow researchers to hypothesize causal inferential paths and test the significance of these paths both directly and indirectly through a mediating variable. A standard statistical method in the path analysis literature is to treat the variables as having a normal distribution and to estimate paths using several least squares regression equations. The parameters corresponding to the direct paths have point and interval estimates based on normal distribution theory. Indirect paths are a product of the direct path from the independent variable to the mediating variable and the direct path of the mediating variable to the dependent variable. However, in the case of non-normal distributions, the point and interval estimates of the indirect path become much more difficult to estimate. We address the issue of calculating indirect point and interval estimates in the case of non-normally distributed data. Our substantive application is a nursing home research problem in which the variables in the path analysis of interest involve variables with normal, Bernoulli, or Poisson distributions. Additionally, one of the Poisson variables is observed with error. This paper addresses estimating point and interval estimation of indirect paths for variables with non-normal distributions in the presence of missing data and measurement error. We handle these difficulties from a fully Bayesian point of view. We present our substantive path analysis motivated from a nursing home structure, process, and outcomes model. Our results focus on the impact job turnover in the nursing homes has on nursing home outcomes.
Collapse
Affiliation(s)
- Byron J Gajewski
- Schools of Allied Health and Nursing, Center for Biostatistics and Advanced Informatics, The University of Kansas Medical Center, Kansas City, KS 66160, USA.
| | | | | | | | | | | |
Collapse
|
34
|
Gajewski B, Hall M, Dunton N. Summarizing benchmarks in the national database of nursing quality indicators using bootstrap confidence intervals. Res Nurs Health 2007; 30:112-9. [PMID: 17243112 DOI: 10.1002/nur.20166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
When summarizing the benchmarks for nursing quality indicators with confidence intervals around the means, bounds too high or too low are sometimes found due to small sample size or violation of the normality assumption. Transforming the data or truncating the confidence intervals at realistic values can solve the problem of out of range values. However, truncation does not improve upon the non-normality of the data, and transformations are not always successful in normalizing the data. The percentile bootstrap has the advantage of providing realistic bounds while not relying upon the assumption of normality and may provide a convenient way of obtaining appropriate confidence intervals around the mean for nursing quality indicators.
Collapse
Affiliation(s)
- Byron Gajewski
- Department of Hearing and Speech, School of Nursing and School of Allied Health, Center for Biostatistics and Bioinformatics, The University of Kansas Medical Center (MS 4043), Kansas City, KS, USA
| | | | | |
Collapse
|
35
|
Abstract
Using cross-sectional data from the 2004 National Database of Nursing Quality Indicators (NDNQI) RN Satisfaction Survey, differences in RN workgroup job satisfaction were examined among 10 unit types--medical-surgical, step-down, critical care, pediatric, maternal-newborn, psychiatric, emergency department, rehabilitation, surgical services, and outpatient clinics and labs. The national sample included RN workgroups in 2,900 patient care units (55,516 RNs; 206 hospitals in 44 states). Workgroup satisfaction across all unit types was moderate. RN workgroups in pediatric units were the most satisfied, whereas those in surgical services and emergency department unit types were least satisfied. A consistent finding across all unit types was high satisfaction with the specific domains of nurse-to-nurse interaction, professional status, and professional development versus much lower satisfaction with task, decision making, and pay. Findings can be used to inform and develop investigations that examine specific aspects of the work environment for RN workgroups in various unit types.
Collapse
Affiliation(s)
- Diane K Boyle
- University of Kansas Medical Center, Kansas City, USA
| | | | | | | | | |
Collapse
|
36
|
Abstract
A criterion-referenced Web-based test was designed and administered to 256 individuals at 48 randomly sampled National Database of Nursing Quality Indicators (NDNQI) member hospitals to determine the reliability of the NDNQI pressure ulcer indicator. Overall kappa values for pressure ulcer identification, staging, and sourcing indicate moderate to near perfect reliability. Findings suggest that nurses can accurately differentiate pressure ulcers from other ulcerous wounds in Web-based photographs, reliably stage pressure ulcers, and reliably identify community versus nosocomial pressure ulcers.
Collapse
Affiliation(s)
- Sara Hart
- University of Kansas School of Nursing, Kansas City, Kan, USA.
| | | | | | | |
Collapse
|
37
|
Abstract
In the U.S., federal and state governments perform routine inspections of nursing homes. Results of the inspections allow government to generate fines for findings of non-compliance as well as allow consumers to rank facilities. The purpose of this study is to investigate the inter-rater reliability of the nursing home survey process. In general, the survey data involves 191 binary deficiency variables interpreted as 'deficient' or 'non-deficient'. To reduce the dimensionality of the problem, our proposed method involves two steps. First, we reduce the deficiency categories to sub-categories using previous nursing home studies. Second, looking at the State of Kansas specifically, we take the deficiency data from 1 year, and use Bayesian latent class analysis (LCA) to collapse the sub-categories to a binary variable. We evaluate inter-rater agreement using deficiency data from two separate survey teams on one facility, a matched-pair design. We evaluate the agreement of the two raters on binary data using the weights from the LCA. This allows a two-by-two contingency analysis using a Bayesian beta-binomial model. We elicit informative prior distributions from the nursing home providers. Together, with the experimental data, this provides a posterior distribution of the kappa agreement of the raters for nursing home deficiency citation data.
Collapse
Affiliation(s)
- Byron J Gajewski
- Schools of Allied Health and Nursing, University of Kansas, Kansas City, KS 66160, USA.
| | | | | | | | | |
Collapse
|
38
|
Affiliation(s)
- Nancy Dunton
- University of Kansas School of Nursing, Kansas City, KS, USA
| | | |
Collapse
|
39
|
Abstract
The valid measurement of nurses' job satisfaction is critical because job satisfaction is important for the retention of qualified nurses to provide patient care in hospitals. Two studies were conducted to adapt the Stamps Index of Work Satisfaction (1997b) to measure work satisfaction at the patient care unit level for use by the National Database of Nursing Quality Indicators (NDNQI). In Study 1 (n = 918 RNs) exploratory factor analysis of data obtained using the NDNQI-Adapted Index replicated the conceptual dimensions of the Stamps measure. Associations with scores on Job Enjoyment were evidence that the Index measured the intended construct. Using theta, the reliability of the composite subscales was .91. The adapted Work Satisfaction subscale scores explained 46% of the variance in Job Enjoyment, with each subscale contributing uniquely (p < .001). In Study 2 (n = 2277 RNs) confirmatory factor analysis using structural equation modeling supported the 7-subscale structure for the Adapted Index (CFI [719] = .88; RMR = .05). Replication of associations between scores on the Index subscales and Job Enjoyment provided further evidence regarding validity of the data, since the Work Satisfaction subscales explained 56% of the variance in Job Enjoyment. The feasibility of using an on-line version of the Adapted-Index for data collection was demonstrated. The findings from the two studies indicate that the adapted Index of Work Satisfaction has a structure similar to the original instrument and is a reliable and valid measure of work satisfaction at the patient care unit level.
Collapse
Affiliation(s)
- Roma Lee Taunton
- University of Kansas Medical Center, School of Nursing, Kansas City, KS 66160-7502, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Affiliation(s)
- Nancy Dunton
- University of Kansas Medical Center School of Nursing, 3901 Rainbow Boulevard, Mail Stop 4043, Kansas City, KS 66160, USA.
| | | | | | | |
Collapse
|
41
|
Abstract
A survey questionnaire assessed supplement use by free-living residents of a retirement community. Of the 318 respondents (mean age 82.2 years), 20% of women and 20% of men reported using herbal supplements, with 62% of these using them at least once per week. Most herbal supplements users (97%) also used vitamin/mineral supplements. Sixty-eight percent of herbal supplement users felt very much/somewhat informed about taking the supplements. Forty-four percent, however, were not sure whether there was testing before marketing; 33% were not sure about side effects. Half (52%) relied "very much/somewhat" on doctors/nurses as information sources; 40% relied on dietitians.
Collapse
Affiliation(s)
- Yao-Lin Weng
- Department of Nutrition and Food Management at Oregon State University, Corvallis, OR 97331-5103, USA
| | | | | | | |
Collapse
|
42
|
Cluskey M, Dunton N. Serving meals of reduced portion size did not improve appetite among elderly in a personal-care section of a long-term-care community. J Am Diet Assoc 1999; 99:733-5. [PMID: 10361539 DOI: 10.1016/s0002-8223(99)00177-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- M Cluskey
- Nutrition and Food Management, Oregon State University, Corvallis, N., USA
| | | |
Collapse
|