Nursing is among those believed to be oppressed who are at risk for horizontal violence, yet no known evidence of a relationship between these concepts exists. Studies of horizontal violence suggest that some nurses suffer personal consequences, yet almost nothing is known about the consequences for patients. Furthermore, no known framework exists to guide research to explain these potential consequences.

The purpose of the study was to describe staff registered nurses' (RNs) work-related views of themselves, nursing as a group, their interactions and relationships with other RNs, and quality of care. Five hypotheses were tested from the horizontal violence and quality and safety of care model.

A random sample of 173 hospital staff nurses drawn from the California Board of Registered Nursing's mailing list participated online or with a paper survey. The Nurses Workplace Scale measured nurses' work-related beliefs exhibitive of an oppressed self or group. The Negative Acts Questionnaire-Revised measured horizontal violence, also called bullying if it occurs frequently. Peer relations, the quality and safety of patient care and adverse events were also measured.

Horizontal violence was reported by 21.4% of participants. Nurses' who exhibited more internalized sexism (oppressed group beliefs) reported more horizontal violence (r=.463, p=.000). Nurses' who minimized themselves more (oppressed self beliefs) reported more horizontal violence (r=.451, p=.000). Nurses' who experienced more horizontal violence reported less supportive relationships with peers (r= -.638, p=.000), lower quality and safety of patient care (r= - .459; p=.000), and a higher frequency of adverse events (r= .408; p= .000). Findings suggested that peer relationships mediated the effect of horizontal violence on the quality and safety of patient care, but not on adverse events.

Horizontal violence was reported by one fifth of staff nurses in hospitals. Hypotheses tested were supported. Nurses who perceived more oppression of self and nurses as a group reported more horizontal violence. Nurses perceived that horizontal violence negatively impacted peer relationships and the quality and safety of patient care and increased the frequency of adverse events. Education in practice settings is recommended to improve peer relationships in the presence of horizontal violence. Reducing horizontal violence may rely on changing the social structure in hospitals.

The current measures of competency for nurse anesthetists for recertification are continuing education units for each biennial recertification cycle, and records of current practice and state licensure. Recently, the National Board of Certification and Recertification of Nurse Anesthetists (NBCRNA) adopted new standards that include a written examination every 8 years, an increase of 40 continuing education units per year, and completion of four core competency modules each four-year recertification cycle. However, little is known about the validity of these competency measures.

The purpose of this study was to determine relationships between written examination scores, self-assessment scores, and performance scores in a simulated environment. Eighteen nurse anesthetists from three hospitals completed the written exam, self-assessment, and 8 scenarios in the simulation lab.

The mean score on the 30 item written exam was 67.22%, SD = 11.42. There were no significant differences in scores between groups CRNA employed at different hospitals or of differing age and experience. The mean percentage score of the eight scenarios was 77.28%, SD = 7.35, with a range of scores from 64.50-89.00%. The only statistically significant correlation among the three competency measure was a negative correlation between the written examination and total performance scores (r = -.407, p = .094). No statistically significant correlations were found between the competency measures and age, years of experience, workplace, and prior exposure to simulation. Self-assessments were completed before and after taking the multiple-choice exam and the simulation performance tests; scores were lower after the tests but still correlated at .496(p = .036).

These results bring attention to the need to address the relationship between knowledge and performance. Utilizing performance assessments that have been validated and deemed reliable will help to improve practice standards. This in turn will lead to greater safety in anesthesia patient care.

Purpose. This study describes: (1) the practice of emergency department (ED) boarding of medical and mental health patients in the U.S.; and (2) how patient, hospital and community characteristics relate to ED boarding.

Background. ED crowding has been associated with a multitude of negative outcomes. The practice of boarding admitted patients in the ED is a significant factor associated with ED crowding. However, no quantitative analysis has been published that characterizes the extent of these boarding practices. Furthermore, few studies have focused on the population of mental health patients boarding in EDs.

Methods. This study uses data from the 2008 National Hospital Ambulatory Medical Care Survey, a national probability sample of visits to U.S. EDs, to determine the proportion of EDs that board medical and mental health patients, the proportion of patients that are boarded, boarding times for these patients, and the characteristics of patients, hospitals, and community that are associated with boarding.

Results. Bivariate analyses confirmed that boarding was practiced by a majority of EDs in the U.S. in 2008 (57.8%). The proportion of ED visits resulting in boarding was significantly higher for the mental health population (21.5%) than for other visitors (10.3%), and was especially high for the population of homeless mental health patients (43.4%). Mean patient boarding time was also significantly higher for the mental health population (292.7 minutes) compared to other visitors (205.0 minutes). One out of every eight hours of visit time spent in U.S. EDs in 2008 was consumed by boarding. Multilevel regression analyses demonstrated associations between longer boarding times and all mental health patients (1.4 additional hours, p<0.001), and especially homeless mental health patients (3.8 additional hours, p=0.001).

Discussion. This is the first study known to describe U.S. ED boarding practices on a national level. Several important findings emerged from this study: 1) ED boarding is a nationwide problem; 2) mental health related visits are consistently associated with both a higher proportion of boarding and longer boarding times; and 3) the U.S. is in need of both increased facilities and services, and improved legislation and policies geared toward the mental health population.

KEEPING PATIENTS SAFE: THE RELATIONSHIP BETWEEN PATIENT SAFETY CLIMATE AND PATIENT OUTCOMES

Roxanne Louise O'Brien

Increasing complexity and use of technology in health care has provided life-saving advances in patient care and also increased risks of medical error. Developing a culture of safety and assessing the safety climate or measurable attitudes of staff, in hospitals has been recommended as approaches to enhancing the safety of hospitalized patients. This study used a cross-sectional, descriptive, model testing design to evaluate the relationship between patient safety climate, patient outcomes, staffing, and hospital performance measures. The sample consisted of multiple patient care units and ancillary departments in 10 hospitals. Secondary databases used in this research included responses to a patient safety attitudes survey, unit level patient falls and hospital acquired pressure ulcers, unit staffing data, and hospital level performance measures. Bivariate correlations, descriptive statistics, ANOVA, and hierarchical linear modeling were used to describe unit and hospital level safety attitudes. Patient safety climate was found to vary significantly across units and among hospitals. There were no relationships found between patient safety climate, falls and hospital acquired pressure ulcers. Higher staffing hours in ICU were a confounder in the analysis of a significant relationship between patient safety climate and nurse staffing. A reduction in the failure rate for the community acquired pneumonia hospital performance measure was associated with staff perception of support from unit managers. Understanding how patient safety climate influences the safety of hospitalized patients is currently evolving. Continuing research in this area is warranted to explore this relationship.

Background: Registered nurses (RNs) take care of patients at the bedside and play a critical role in protecting them from adverse events through monitoring and surveillance. Researchers have examined the effect of nurse staffing on patient outcomes, but studies have produced inconsistent findings. The mixed findings might have resulted from various staffing measurements and insufficient adjustment for the effect of high patient turnover on nursing workload.

Purpose: This dissertation was to refine evidence of the relationship between nurse staffing and patient outcomes while minimizing measurement errors. The specific aims were: (1) to compare various staffing measures and select the best methods; (2) to examine the association of nurse staffing with patient outcomes for surgical care; and (3) to evaluate the effect of patient turnover on the relationship between nurse staffing and patient outcomes.

Methods: Three studies were performed using data obtained from the University HealthSystem Consortium (UHC) for the year 2005. Multivariate regressions were conducted while controlling for patient and hospital characteristics. For the first aim, the Akaike Information Criterion (AIC) was used to determine which nurse staffing measure performed the best. For the second aim, surgical intensive care unit (ICU) and non-ICU staffing levels were included in the regression models to examine the association with surgical patient outcomes. The interaction between patient turnover and RN staffing was examined for the third aim.

Findings: Measuring nurse staffing as productive hours by both direct and indirect patient care providers was best. Higher RN staffing in surgical non-ICUs was related to lower rates of failure to rescue and post-operative sepsis. We found that there was a significant interaction between patient turnover and RN staffing on general units.

Conclusions: The findings show that higher RN staffing contributes to patient safety by decreasing failure to rescue. However, using only surgical staffing did not reveal more different effects on surgical patient outcomes than previous work. While productive hours of direct and indirect providers were better than other measures of nurse staffing, the differences were small. Further work is needed to determine the reasons for the inconsistency in research findings.

BACKGROUND: Various clinical guidelines have been developed to prevent ventilator-associated pneumonia (VAP). However, the availability of guidelines does not ensure adherence by clinicians to recommended strategies. Studies indicate prevention practices for VAP differ across settings. To date, there has been no study that comprehensively describes factors that influence VAP guideline adherence, nor the relationship between provider guideline adherence and VAP occurrence. AIM:The purpose of this study was to identify factors that influence VAP prevention guideline adherence. The specific aims were to: (a) describe guideline user-related factors, guideline qualities, and contextual factors associated with guideline adherence; (b) test the relationships among these factors and guideline adherence rates; and (c) explore the relationships between adherence rates and VAP occurrence. This study examined institution specific VAP prevention guidelines and non-pharmacologic VAP prevention interventions (oral hygiene, head of bed elevated patient positioning, spontaneous breathing trial, and hand hygiene). METHODS: A cross-sectional descriptive study was guided by a conceptual model. A survey was created to capture guideline user characteristics, qualities of the clinical guideline, and contextual factors that influence clinicians' guideline adherence RESULTS: A total of 576 critical care nurses and 15 directors of infection control, critical care educators, and nurse managers from eight hospitals participated in the study. Each hospital had unique VAP prevention guidelines. In general, nurses had positive attitudes and reported to adhere to the guidelines always to most of the time. However, there were variations among the units. Also, factors associated with guideline adherence were different by intervention. The guideline user attitude scale was the strongest and most consistent predictor of guideline adherence across interventions (OR 3.89-19.68). Guideline quality and context indicators were also significant predictors (OR 1.54-3.57). For unit level analyses, VAP rates were correlated with HOB adherence scores (-.52, p<=.05). CONCLUSION: Use of clinical guidelines has become a norm in patient care. To maximize the benefit of guideline implementation, efforts must be made to enhance nurses' attitudes, guideline quality, and environmental support.

Serious quality of care problems in nursing homes has been a persistent problem in the United States for over 40 years. Staffing shortages and inadequate staff expertise were major contributors to many chronic and recurring quality problems.

The purpose of this study was to examine multidimensional associations among organizational characteristics, nurse staffing levels, and comprehensive aspects of quality of care considering resources (payer mix), residents (case mix), and market characteristics. The quality of care was assessed by nurse staffing levels, processes and outcomes of care, and facility deficiencies.

From various theories: Donabedian's structure-process-outcome model, organizational theory, and economic theory, a conceptual framework and key factors of nursing home and market characteristics were formulated with the support of previous literature.

This study used secondary data from Online Survey Certification and Reporting (OSCAR) data, Minimum Data Set (MDS) 2.0, quarterly staffing data from state inspections, and Area Resource File (ARF). The population of 195 nursing homes out of 199 Colorado freestanding homes in 2000 was used for data analyses. Depending on outcomes, various types of multivariate regression models were used.

The major findings of this study were: (1) quality of care in Colorado nursing homes was highly dependent on resources from the external environment, (2) Medicaid reimbursement rates and proportion of Medicare residents were important resources for nurse staffing, and (3) deficiencies in nursing home care were significantly higher in for-profit and chain-affiliated nursing homes. A useful conceptual framework was confirmed with strong support of theoretical background, literature review, and empirical findings.

Considering different staffing decisions, regulatory systems need to be designed carefully and systematically to improve quality of care. Given the findings, this study suggests that higher nurse staffing levels can improve quality of care in nursing homes.

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