Relationship of Nursing Characteristics to Quality Outcomes

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Title:
Relationship of Nursing Characteristics to Quality Outcomes
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english
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O'Neill, Martha A
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University of Florida
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Gainesville, Fla.
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Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Nursing Sciences, Nursing
Committee Chair:
NEFF,DONNA C
Committee Co-Chair:
GREGG,ANDREA C
Committee Members:
STACCIARINI,JEANNE-MARIE R
GATTONE,CHARLES F
BARRETT,ANNE

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Subjects / Keywords:
adverse -- certification -- education -- experience -- nursing -- quality -- safety
Nursing -- Dissertations, Academic -- UF
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Nursing Sciences thesis, Ph.D.
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theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
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Abstract:
Preventable adverse events contribute to an estimate of 210,000 to 400,000 hospital deaths per year (James, 2013). Registered nurses (RN), comprising the largest health care professional, are frontline clinicians having direct influence on providing safe, efficacious care. RN experience, education, and/or certification status may influence the ability to provide quality care. The purpose of this secondary analysis was to examine the relationship between years of nursing experience, national nurse certification, and educational level of the registered nurse and nurse reported adverse events, hospital quality, and safety. This study also examined moderation effects of nurse certification in combination with years of nursing experience and/or the educational level of the nurse on nurse reported adverse events, hospital quality, and safety. An adaptation of The Process of Care and Outcomes Model (PCOM) (Aiken et al., 2002) provided the theoretical framework. The study sample (n=6515) included RNs who averaged 44.1 years of age and 14.4 years of experience. The majority of RNs were prepared at the Associate degree level. Certified nurses represented 25 percent (n= 1629) of the sample and were significantly older (46.9 years of age) and more experienced (17.6 years of experience) than non-certified nurses (43 years of age with 13.3 years of experience). RN years of experience were associated with reported incidents of adverse events affecting physiological outcomes (pressure ulcer development, falls with injury, urinary tract infections, and central line associated blood stream infections). Certification reflected nurse reported outcomes affecting patient safety (use of restraints). Lastly, level of education, specifically Diploma educated nurses, reported concerns for quality of nursing care and ability of patients to manage their care upon discharge. While the findings support differences in reporting adverse events, hospital quality, and safety based on years of experience, certification status, or educational level of the nurse, there is still a need to better quantify the impact of nurses characteristics on nurse sensitive outcomes and quality patient care.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Martha A O'Neill.
Thesis:
Thesis (Ph.D.)--University of Florida, 2014.
Local:
Adviser: NEFF,DONNA C.
Local:
Co-adviser: GREGG,ANDREA C.

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lcc - LD1780 2014
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UFE0046662:00001


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RELATIONSHIP OF NURSING CHARACTERISTICS TO QUALITY OUTCOMES By A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2014

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To my l oving husband and best friend, L en

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4 ACKNOWLEDGMENTS I want to thank my dissertation committee members (Donna Felber Neff, Andrea Gregg, Jeanne Marie Stacciarini, Anne Barrett, and Charles Gattone) for sharing their insight, imparting their knowledge, and guiding me throug hout this journey. I also want to thank Dr. Cynthia Garvan for her time, patience, and guidance in the statistical review process. I would be amiss if I did not make special acknowledgment to Dr. Barrett for introducing me to th e world of sociology and as sisting me in my minor course selections. A very special thanks goes to Dr. Neff who provided a tremendous amount of encouragement patience, and time to help me through this process from start to finish. I sincerely appreciate her countless hours proofre ading and sharing her writing skills to steer me in the right direction for a clear concise document. She supported my professional growth from student to beginning researcher to nursing colleague. She has been strong role model, mentor, and friend. I also want to acknowledge my friends and colleagues in nursing who stood by me through the ups and downs. They were always there to encourage me, listen to me, and believe in me. I am most appreciative to my university colleagues who supported me and even a djusted their own assignments to give me a teaching schedule that would meet my doctoral demands. of nursing as the guiding light in my career and professional growth. She was a true and will remain my most influential mentor. I want to thank my husband, Len, who inspired me to strive for higher education knowing he would not be alive to see it come to fruition Last but not least I want to thank my daughter, Katie, for being my stabl e force whose smile, laughter and sense of h umor reinforced my sanity while pleasantly encouraging me to push on and reach my goal.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURE S ................................ ................................ ................................ .......... 9 LIST OF ABBREVIATIONS ................................ ................................ ........................... 10 ABSTRACT ................................ ................................ ................................ ................... 12 INTRODUCTION ................................ ................................ ................................ ........... 14 Statement of the Problem ................................ ................................ ....................... 14 Sign ificance of the Study ................................ ................................ ........................ 16 National Nurse Certification ................................ ................................ .............. 17 Educational Level of the Nurse ................................ ................................ ......... 18 Years of Experience ................................ ................................ ......................... 20 Summary ................................ ................................ ................................ ................ 21 Conceptual Framework ................................ ................................ ........................... 21 Structure Process and Outcomes ................................ ................................ ..... 22 Adapted Theoretical Model ................................ ................................ ............... 25 Purpose and Specific Aims ................................ ................................ ..................... 26 Su mmary ................................ ................................ ................................ ................ 27 REVIEW OF LITERATURE ................................ ................................ ........................... 28 Nurse Sensitive Outcomes ................................ ................................ ..................... 28 National Certification ................................ ................................ ............................... 30 Overview ................................ ................................ ................................ .......... 30 Perceived Value of National Certific ation ................................ ......................... 33 Research on Patient Safety and Quality of Care ................................ .............. 36 Nurse Certification and Nurse Sensitive Patient Outcomes .............................. 36 Years of Nursing Experience ................................ ................................ .................. 41 Development of Experience ................................ ................................ ............. 41 Experience and Nurse Sensitive Outcomes ................................ ..................... 43 Education ................................ ................................ ................................ ................ 47 Summary ................................ ................................ ................................ ................ 48 METHODOLOGY ................................ ................................ ................................ .......... 52 Purpose ................................ ................................ ................................ .................. 52 Study Aims ................................ ................................ ................................ .............. 52 Design ................................ ................................ ................................ ..................... 53 Sample ................................ ................................ ................................ .................... 54

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6 Parent Study: Multi St ate Nursing Care and Patient Safety ............................. 54 Parent Study: Survey Instrument ................................ ................................ ...... 54 Description of Secondary Analysis Sample ................................ ...................... 56 Inclusion Criteria ................................ ................................ ............................... 57 Exclusion Criteria ................................ ................................ ............................. 57 Power Analysis ................................ ................................ ................................ 5 7 Proposed Measures ................................ ................................ ................................ 58 Independent Variables ................................ ................................ ..................... 58 Education level ................................ ................................ ........................... 58 Years of experience ................................ ................................ ................... 58 National nurse certification ................................ ................................ ......... 59 Outcome Variables ................................ ................................ ........................... 59 Adverse events ................................ ................................ .......................... 59 Quality ................................ ................................ ................................ ........ 60 Safety ................................ ................................ ................................ ......... 61 Procedures ................................ ................................ ................................ ............. 61 Protection of Human Subjects ................................ ................................ .......... 61 Management of Data ................................ ................................ ........................ 61 Data Analy sis ................................ ................................ ................................ .......... 62 AIM 1 ................................ ................................ ................................ ................ 63 AIM 2 ................................ ................................ ................................ ................ 64 AIM 3 ................................ ................................ ................................ ................ 64 AIM 4 ................................ ................................ ................................ ................ 65 AIM 5 ................................ ................................ ................................ ................ 65 AIM 6 ................................ ................................ ................................ ................ 66 AIM 7 ................................ ................................ ................................ ................ 68 AIM 8 ................................ ................................ ................................ ................ 68 Summary ................................ ................................ ................................ ................ 68 RESU LTS ................................ ................................ ................................ ...................... 75 Sample characteristics ................................ ................................ ............................ 75 AIM 1 ................................ ................................ ................................ ................ 76 AIM 2 ................................ ................................ ................................ ................ 77 AIM 3 ................................ ................................ ................................ ................ 78 AIM 4 ................................ ................................ ................................ ................ 78 AIM 5 ................................ ................................ ................................ ................ 78 AIM 7 ................................ ................................ ................................ ................ 79 AIM 8 ................................ ................................ ................................ ................ 79 Summary of findings ................................ ................................ ............................... 80 DISCUSSION AND IMPLICATIONS ................................ ................................ ............. 91 Study Results ................................ ................................ ................................ .......... 91 Sample Description ................................ ................................ .......................... 91 Nurse Characteristic: Years of Experience ................................ ....................... 92 Nurse Characteristic: National Nurse Certification ................................ ........... 93

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7 Nurse Characteristic: Level of Education ................................ .......................... 96 Moderation Effect of Certification on Years of Experience and Education ....... 98 Strengths and Limitations of the Study ................................ ................................ ... 98 Implications ................................ ................................ ................................ ........... 101 Implications for Nursing Practice ................................ ................................ .... 101 Implications for Theory ................................ ................................ ................... 102 Implications for Future Research ................................ ................................ .... 104 Conclusion ................................ ................................ ................................ ............ 105 SURVEY ................................ ................................ ................................ ..................... 108 LIST OF REFERENCES ................................ ................................ ............................. 121 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 129

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8 LIST OF TABLES Table page 2 1 Comparison of ANA and NQI nurse sensitive outcomes ................................ .... 50 2 2 PVCT Value statements ................................ ................................ ..................... 51 3 1 Concepts, operational definitions, and survey empirical indicators for NCQO The study uses the Multi State Nursing Care and Patient Safety Study Survey ................................ ................................ ................................ ................ 69 3 2 Study aims, variables, level of measurement, and statistical tests ..................... 71 3 3 Dependent variables, survey questions, likert type scale, and dichotomous categories for logistic regression. ................................ ................................ ....... 73 4 1 Description of sample (n = 6515) ................................ ................................ ........ 82 4 2 Comparison of certified to non certified nurses ................................ .................. 83 4 3 Relationship of years of experience to nurse reported adverse events, quality and safety ................................ ................................ ................................ ........... 84 4 4 Differences in RN educational level with RN reported adverse events, hospital quality, and safety ................................ ................................ ................. 85 4 5 Differences between certified and non certified nurses in RN reported adverse events, hospital quality, and safety ................................ ....................... 86 4 6 Differences between certified and non certified nurses both with 5 or more years of experience to RN reported adverse events, hospital quality, and safety. ................................ ................................ ................................ ................. 88 4 7 Odds ratio indicating the effect of education on nurse reported adverse events, hospital quality, and safety. ................................ ................................ .... 89 4 8 Odds ratio indicating the association of education and certification on RN reported adverse events, hospital quality, and safety. ................................ ........ 90 4 9 Odds ratio indicating the association of certification on RN reported adverse events, hospital quality, and safety. ................................ ................................ .... 90

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9 LIST OF FIGURES Figure page 1 1 Linear relationship depicting Donabedian quality paradigm ............................... 22 1 2 Quality Health Outcomes Model. ................................ ................................ ........ 23 1 3 Process of Care and Outcomes Model (Aiken et al., 2002a). ............................. 24 1 4 Adapted theoretical model: Nursing Characteristics affecting Quality of Care .... 26 2 1 Nursing organizational involvement in certification process ............................... 33

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10 LIST OF ABBREVIATION S AACN American Association of Critical Care Nurses AACN Amer ican Association of Colleges of Nursing ABNS American Board of Nursing Specialties ACEN Accreditation Commission for Education in Nursing ACLS Advance Cardiac Life Support ADN Associate Degree in Nursing AHPN Association of Hospice and Palliative Nurses ANA American Nurses A ssociation ANCC American Nurses Credentialing Center AORN Association of Operating Room Nurses ANCC American Nurses Credentialing Center BLS Basic Life Support BSN Baccalaureate Degree in Nursing CCRN Critical Care Registered Nurse CERP Continuing Education Recognition Points CNOR Certified Nurse of Operating Room ENA Emergency Nurses Association HAPU Hospital Acquired Pressure Ulcer IOM Institute of Medicine NCCA National Commission of Certifying Agencies NCQO Nursing Characteristics Out come Model

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11 NDNQI National Data Base for Nursing Quality Indicators NQF National Quality Forum MSN Master Degree in Nursing OR Operating Room PCOM Process Care Outcomes Model PVCT Perceived Value Certification Tool RN Registered Nurse

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12 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy RELATIONSHIP OF NURSING CHARACTERISTICS TO QUALITY OUTCOMES By May 2014 Chair: Donna Felber Neff Major: Nursing Sciences Preventable adverse events contribute to an estimate of 210,000 to 400,000 hospital deaths per year (James, 2013). Registered nurses (RN), comprising the largest health care professional, are frontline clinicians having direct influence on providing safe, effica cious care. RN experience, education, and/or certification status may influence the ability to provide quality care. The purpose of this secondary analysis was to examine the relationship between years of nursing experience, national nurse certification, and educational level of the registered nurse and nurse reported adverse events, hos pital quality, and safety. This study also examined moderation effects of nurse certification in combination with years of nursing experience and/or the educational level of the nurse on nurse reported adverse events, hospital quality, and safety. An ada ptation of The Process of Care and Outcomes Model (PCOM) (Aiken et al. 2002) provided the theoretical framework. The study sample (n=6515) included RNs who averaged 44.1 years of age and 14.4 years of experience. The majority of RNs were prepared at the Associate degree level. Certified nurses represented 25 percent (n= 1629) of the sample and were

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13 significantly older (46.9 years of age) and more experienced (17.6 years of experience) than non certified nurses (43 years of age with 13.3 years of experienc e). RN y ears of experience were associated with reported incidents of adverse events affecting physiological outcomes (pressure ulcer development, falls with injury, urinary tract infections, and central line associated blood stream infections). Certifica tion reflected nurse reported outcomes affecting patient safety (use of restraints). Lastly, level of education, specifically Diploma educated nurses, reported concerns for quality of nursing care and ability of patients to manage their care upon discharge While the findings support differences in reporting adverse events, hospital quality, and safety based on years of experience, certification status or educational level of the nurse, there is still a need to better quantify the impact of nurses charact eristics on nurse sensitive outcomes and quality patient care.

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14 CHAPTER 1 INTRODUCTION role in quality care outcomes. A specific focus will be on the nurse demographic characteristics of education, national certification, and years of experience which are believed to contribute to clinical assessment and c ompetency in nursing practice. Discussion will link the need for further research using an adaptation to the theoreti cal framework and Process of Care Outcomes Model (Ai ken, Clarke, & Sloane, 2002). Furthermore, the chapter will introduce the study concepts, measures, purpose, and specific aim s guiding this doctoral study. Statement of the Problem The initial Institute o f Medicine ( IOM ) report in 2000, To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000) identified preventable medical errors as contri buting to over 98,000 hospital deaths per year. Since that report, estimates for 2011 range from 210,000 to 400,000 hospital deaths per year from preventable adverse events that are within the control of the health care provider (James, 2013). Registered nurses acting as the primary health care provider in the hospital setting, have a direct im pact on identifying and preventing adverse events Registered Nurses (RN) comprise the largest health care professional group in the United States estimated at 3 million licensed RNs (Buerhaus, Staiger, & Auerback, 20 09). As many as 1.3 million RN s work in the acute care setting as frontline clinicians having direct influence on safe, efficac ious care provided to patients. Despite the large RN workforce and pivotal position in patient care, there remains a need to quantify the RN contribution to quality c are outcome s (Kurtzman & Jennings, 2008). The RN role is

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15 integrated in a complex sys tem of care affecting outcomes. Aiken and colleagues (2002 a ) assert a relationship exists among structures, processes, and outcomes of care in the conceptual model, Process of Care and Outcomes. Operationally the model depicts characteristics of the hospital organization which include Registered Nurse staffing levels and demographic characteristics (education, experience, and certification) as influencing the process of car e and outcomes. Outcomes of a particular interest at a systems level are adver se events, quality, and safety. The quality outcomes that measure RN contributions are known as nurse sensitive outcomes. Nurse sensitive outcomes comprise those processes or res ults that are affected, provided, a nd/or influenced by the nurse. Nursing may not be exclusively responsible for the outcome but the outcome is quantifiably influenced by nursing, particularly the RN (Kurtzman & Jennings, 2008). Nurse sensitive outcomes ma y include positive or negative outcomes. For example, positive nurse sensitive outcomes success in breast feeding following lactation teaching, or appropriate patient reca ll on med ication use and administration. Negative nurse sensitive outcomes, known as adverse patient outcomes or events, involve such items as mortality rate, failure to rescue, infections, falls, medicat ion errors, or restraint usage. Negative nurse sensi tive outcomes directly impact on hospital death rates. Nurse sensitive outcomes result from the relationship and interplay between both the structure and the process of care. Structure of care involves characteristics of hospitals, staff, or clients that will affect how care is implemented and delivered. Structure characteristics of nursing staff include such items as staff mix, staffing hours,

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16 nurse to patient ratios, years of experience, educational level, or certification status. Processes of care invo lve RN performance with interventions, treatments, or modalities which eventually result in positive or negative outcomes. It is important to identify what care in an effort to optimize quality outcomes. More specifically, do nurse demographic characteristics, such as educational level, national nurse certification, or years of experience affect process of care, lead to positive nurse sensitive outcomes, and/or affect question serves as the foundation for this study. Significance of the Study The predominate research on nurse characteristics link s staffing ( e.g., skill mix, staffing hours, nur se patient ratios) to quality outcomes, particularly patient safety outcomes (Needleman, Kurtzman, & Kizer, 2007). A limited number of studies exist that examine the impact of nurse demographic characteristics (education, national certification, and years of experience) on nurse sensitive outcomes in the acute care setting. Nurse sensitive outcomes in the acute care setting include infection rates (urinary tract and central venous device infections), restraint usage, medication errors, development of press ure ulcers, inpatient mo rtality, and failure to rescue. For purposes of this study, these outcomes will be captured as nurse respondents perception and not actual hospital and occurrence rates. This study will add to the body of nursing knowledge on nurse perceptions of care with specific reference to how that perception may change based on their education, certification, or years of experience. In addition, this study explores how certification may influence years of experience or education for nurse repor ted adverse

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17 events, qualit y, and safety. At present, while no studies exist that examine the moderating effects of certification, it will be explored in this study. The following section highlights the need for further research on the impact of nur se demog raphic characteristics. National Nurse Certification The Institute of Medicine (IOM) made a recommendation in 2010 for periodic re licensure and reevaluation of practice for health care providers (Institute of Medicine, 2011). Although there is no process in place for RN re licensure, national nursing certification does provide a mechanism for a structured periodic review process intended to assure knowledge and high standards in clinical practice (American Board of Nursing Spe cialties, 2006). The American Board of Nurse Specialties (ABNS) estimates as many as 500,000 nurses are certified among the 3 million licensed Registered Nurses ( ABNS, 2009 b ). Despite the large number of certified nurses and the claim that certification eq uates to expert clinical practice, there are limited studies linking nurse certification to quality outcomes. The limited research available on the impact of national nurse certification and nurse sensitive outcomes focuses on specialty nurse practice (Wou nd Care, ICU, or Oncology) with contradictory results on whether certification positively impacts on outcomes. Hart and colleagues (2006) found a positive relationship between wound staging and pressure ulcer identification with certified nurses supportin g better assessment of wounds while others found no relationship with nurse certification and skin breakdown (Kendall Gallagher & Blegen, 2009; Krapohl, Manojlovich, Redman, & Zhang, 2010 ). Two intensive care studies found conflicting results between cert ification and blood stream infections although the relationships were weak and statistically

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18 insignificant (Kendall Gal lagher & Blegen, 2009; Krapohl et al. 2010). In one study conducted in 48 intensive care unit a positive relationship between certifica tion and blood stream infections was found (p =. 0.07) such that, as the number of bloo d stream infections increased, the proportion of certified nurses increased (Kendall Gallagher & Blegen, 2009). These findings were not supported in a study of 25 ICU where an inverse relationship between certification and central line catheter associated blood stream infections was found supporting a decrease in central line catheter blood stream infections as the number of certi fied nurses increased (Krapohl et al. 2010). Frank Stromberg, et al. (2002) conducted a retrospective chart review of home bound oncology patients and found a positive statistically significant difference in patient infection rates between certified and noncertified oncology nurses. Patien ts cared for by certified oncology nurses had higher infection rates than patients cared for by noncertified nurses (p < 0.05). Conflicting research results and a narrow RN specialty focus supports the need for continued research using a larger sample of n urses from a variety of nurse practice areas to better examine the impact of national nurse certification on nurse sensitive outcomes. There is also the need to determine if the certified nurses differ in their perceptions of adverse events, hospital qual ity, and safety when comp ared with non certified nurses. Educational Level of the N urse The Institute of Medicine (2011) made the recommendation in 2010 to increase the number of baccalaureate ( BSN ) prepared nurses in staff positions from 50 percent to 80 percent by 2020. This recommendation follows studies where the higher the level of RN education resulted in improved patient outcomes: with every 10 percent increase

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19 percent decrease in mortality and failure to rescue (Aiken, Clarke, Sloane, Sochalski, Smith, & Silber, 2002; Aiken, Clarke Cheung, Sloane, & Silber, 2003; Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Aiken, et. al., 2011). Although research validates the link with educational level of t he nurse and mortality rate, there are few studies that address the impact of nurse educational level on other quality outcomes. The few studies available on educational level and nurse sensitive outcomes are primarily limited to medica tion errors and skin breakdown with only one study addressing the impact of educational level on infection rates (Blegen, Goode, Park, Vaughn, & Spetz, 2013). The research results fail to provide a strong link between BSN education and the decrease or prevention of medication errors or skin breakdown incidents (Blegen, Vaughn, & Goode, 2001; Kendall Pallas, et al. 2002). For example, Blegen, Vaughn, & Goode (2001) found an increase in medication errors with RNs who had a BSN as opposed to nu rses with no BSN. These findings were explained by a large number of inexperienced BSN nurses on the study units. Although Kendall Gallagher and Blegen (2009) found a decrease in skin breakdown with BSN nurses, the study only involved certified nurses in the ICU setting. These findings were consistent with Blegen et al (2013) research that patients cared for by BSN prepared RNs when compared to ADN/DIP, had statistically significant lower rates of decubitus ulcers and failure to rescue. Yet, they found no effect on infection rates. Additionally, educational level was related to lower congestive heart failure mortality, lower rates of postoperative deep vein thrombosis, and shorter length

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20 of stay. However, there are no studies examining the relationship o f nurse educational level and nurse sensitive out comes related to restraint use. Years of E xperience The conventional thought is that experience over time leads to b etter performance and outcomes. Studies support this premise when comparing accident rates with novice and experienced driver s (Donmez, Boyle, & Lee, 2010). The research is unclear, however, when relating years of nursing experience to clinical expertise and management of patient care. For instance, Benner, a nursing theorist and educator expert in the process of RN critical thinking, avoided linking years of experience to critical thinking and clinical expertise (Benner 1984; Benner & Tanner, 1987). In advanc ement through stages of assessing, applying, and processing information as opposed to longev ity in practice (Benner, 1984). The few studies that do examine the impact of years of experience on nurse sensitive outcomes only examined skin breakdown falls, a nd medication errors. The National Database of Nursing Quality Indicators (NDNQI) provided data on 8 of 15 quality indicators from over 1100 participating hospitals and found an inverse relationship between years of experience and fall rate and hospital ac quired pressure ulcers (HAPU), such that, there was a 1 percent lower fall rate and 1.9 percent lower HAPU for each year of RN experience (Hart, Bergquist, Gajewski, & Dunton, 2006). The results from this study were limited to only those hospitals voluntar ily reporting data the National Database. The research on medication errors and years of experience presents interesting and contradictory results. Blegen,Vaughn, and Goode (2001) found an inverse

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21 relationship with medication errors and years of experienc e in contrast to the findings from Kendall medication errors with years of experience. The differences in findings could be a result of more exposure for medication administration and errors a s opposed to experience enhancing clinical skill to assure less errors. There are no studies examining the impact of years of experience on infec tion rate and restraint usage. Summary Registered Nurses hold a pivotal position in providing safe efficacious care. as education level, national certification status, and years of experience, affect nurse sensitive outcomes and nurse reported adverse events, hospital quality, an d safety. Research examining the impact of nurse characteristics on nurse sensitive outcomes care. A conceptual model that illustrates the role of nursing in qualit y care and achievement of quality outcomes will provide the framewo rk for application to practice. Conceptual Framework A conceptual framework provides structure and direction to research relationships of variables and effectiveness of interve ntions to out comes (Meleis, 2011 ; Sidani, Doran, & Mitchell, 2004). The conceptual framework also assists in explaining both direct and indirect effects of outcomes to better understand implications for clinical practice (Sidani, et al. 2004). The framework for this study is a modification of the Process of Care and Outcomes Model (PCOM) (Aiken et al. 2002 a ), The PCOM originates from the Donabedian quality paradigm of structure process outcomes (Donabedian, 1966) and the Quality Health Outcomes Model (Mitchell Ferke tch, &

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22 Jennings, 1998). The following section will provide an overview of the conceptual models used to formulate th e adapted model for this study. The adapted model will support research for both direct and indirect effects of specific nurse chara cteristi cs on quality outcomes. Structure Process and Outcomes The Donabedian paradigm, recognized in health care for over 3 decades, provides a conceptual framework that illustrates a linear relationship in which system and client characteristics directly affect health care processes leading to positive or negative heal th outcomes (Donabedian, 1966). System characteristics involve specifics about the organization or persons providing health care which includes hospital size, ownership, and clinical focus, as well as, staff ratios, skill mix, and educational level of staff. The client characteristics depict specific client demographics such as age, gender, and race including such items as medical diagnosis and identified or proposed health care needs. The premise of the Donabedian paradigm is that the system, along with the client, contributes to a prescribed health care process (treatment, modality, or plan of care) that eventually lead to desirable or undesirable outcomes (see Figure 1 1). Figure 1 1 Linear relationship depicting Donabedian quality paradigm Mitchell and colleagues representing the American Academy of Nursing Expert Panel on Quality Care, created the Quality Health Outcomes Model by adapting the System Characteristic s Client Characteristi cs Process Outcomes

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23 Donabedian paradigm in two ways: provision for a bidirectional flow among constructs and implication of an indirect relat ionship with interv entions (process) and outcomes (Mitchell et al. 1998). The Quality Health Outcomes Model supports a reciprocal feedback mechanism for all the constructs illustrating how change in one construct affects the reactions or characteristics o f another construct. For example, aggressive nursing observations and treatments (interventions) may lead to a stable cardiac status (client characteristic) promoting transfer to a less acute hospital unit (system characteristic) which will eventually affe ct the discharge outcome. This example also illustrates how interventions directly impact system and client characteristics but have no direct bearing on outcomes. Figure 1 2 provides a schematic of the Quality Health Care Outcomes Model. Figure 1 2 Qual ity Health Outcomes Model. Aiken et al. (2002 a ) devised the Process of Care and Outcomes Model (PCOM) by expanding the Quality Health Outcomes Model (Mitchell et al. 1998) to address the e optimize patient outcomes. The model depicts five constructs impacting patient outcomes: hospital organization, medical staff qualifications, organizational support o f nursing care, process of care, and nursing outcomes. The hospital organization Client Characteristics Interventio ns (process ) Outcomes O utcomes S ystem characteristics

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24 construct includes staff characteristics with particular focus on concepts related to Registered Nurse (RN) staffing which include such items as nurse pat ient ratios/staffing skill mix. The model posits that the nurse staffing ratios and skill mix have a direct relationship on the ability to provide ongoing surveillance and early detection of complications (Aiken et al. 2002 a ; Lucero, Lake, & Aiken, 2010). Hospital organizatio n facilitates the organizational support for nursing care through resource adequacy, nurse autonomy, nurse control, and nurse physician relations. The process of care is then implemented based on identified patient care needs, medical staff qualifications, and the quality of organizat ional support for nursing care. Lastly, the constructs of process of care, medical staff qualifications, and nursing outcomes contribute to and determine patient outcomes. Aiken provides extensive research on how particular hos pital, nursing organization, and medical staff characteristics affect patient outcomes, (Aiken et al. 2011; Aiken et al. 2008; Aiken et al. 2003; Aiken et al. 2002 a; Aiken et al. 2002b ). Figure 1 3 provides a diagram of the Process of Care and Outco mes Model (Aiken et al. 2002 a ). Figu r e 1 3. Process of Care and Outcom es Model (Aiken et al. 2002 a ).

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25 Adapted Theoretical Model This study uses an adaptation of the Process of Care and Outcomes Model (PCOM) (Aiken et al. 2002 a ) as the theoretical fram ework. The investigator for this study adapted the PCOM to study the relationship of education, years of experience, and certification on nurse sensitive outcomes and nurse reported adverse events, hospital quality, and safety. The adapted model, Nurse Cha racteristics affecting Quality Outcomes (NCQO), consists of four constructs: education, years of experience, certification, and quality outcomes. The constructs of education, years of experience, and certification correspond to staff characteristics eviden t in the PCOM (Aiken et al. 2002 a ) under hospital organization. The quality outcomes construct include specific nurse sensitive outcomes which are components of the patient outcomes construct in the PCOM. The adapted theoretical model is shown in Figure 1 4. Table 1 lists each construct (or concept as depicted in the table), theoretical definition, and empirical means of measurement. There are no published studies addressing the impact of these three variables on nurse sensitive outcomes and nurse reported adverse events hospital quality, and safety. In addition, the adapted model implies two indirect relationships with modifying effects: national nurse certification as a modifier to years of experience and national nurse certificati on as a modifier to edu cation. There are no research studies to date addressing indirect effects of national nurse certification on years of experience or education with respect to nurse sensitive outcomes and nurse reported quality variables.

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26 Figure 1 4. Adapted theoretical model: Nursing Characteristics affecting Quality of Care Purpose and Specific Aims The purpose of this retrospective study was to examine the relationship between years of nursing experience, education, and national nurse certification on nurs e reported adverse events hospital quality and safety. Such information would provide an understanding of how specific nurse characteristic affect quality of patient care. The study also provide s initial information on whether or not certification has an indirect effect on education or years of experience relatin g to nurse sensitive outcomes. The specific aims for the study are: 1. To explore the relationship between years of experience and RN reported adverse events [ wrong medication or dose, pressure ulce rs developed, falls with injury, use of physical restraints (vest or limb), use of physical restraint for 8 hours or more, use of medication as a restraint, healthcare associated infections (surgical site, urinary tract, central line associated bloodstrea m, and ven tilator

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27 associated pneumonia ] hospital quality (nursing quality of care delivered to patients in the work setting confident that patient will be able to manage care when discharged and confident that management will act to resolve problems in patient care that the nurse reports ), and s afety (overall grade on patient s afety and actions of management show that patient safety is a top priority ). 2. adverse events, hospital qual ity, and safety. 3. To examine diff erences between national nurse certification status and RN r eported adverse events, hospital quality, and safety. 4. To examine differences between nationally certified RNs with greater than 5 years of experience in reported a dverse events, hospital quality, and safety as compared to non certified RNs with the same years of experience. 5. To examine the effect of RN educational level on RN reported adverse events, hospital quality, and safety. 6. To examine the effect of certificatio n status on RN reported adverse event, hospital quality, and safety. 7. To determine if national RN certification moderates the relationship between years of RN experience and RN reported adverse events, hospital quality, and safety. 8. To determine if natio nal RN certification moderates the relationship between educational level of the nurse and nurse reported adverse events, hospital quality, and safety. Summary In summary, the Registered Nurse has a paramount role in supporting, providing, and directing patient focused quality care. The nurse has personal control over education, certification, and years of experience which may impact the ability to provide safe, effective, and efficient care. Understanding the impact of personal nurse characteristics on quality outcomes addresses a gap in the literature and adds to the body of nursing knowledge. Chapter 2 will introduce the relevant literature sup porting this research endeavor.

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28 CHAPTER 2 REVIEW OF LITERATURE The proposed research model, Nursing Character istics affecting Quality Outcomes (NCQO), originates from the sociological perspective that social structures affect how individuals act or process information in order to accomplish a particular outcome or social consequence. NCQO depicts education, year s of experience, and national nurse certification as social structures within the nursing profession. The purpose of this chapter is to present and synthesize current research on the effects of these nursing structures (national certification, years of nur sing experience, and education) on quality of care and nu rse sensitive patient outcomes. The review will begin with an explanation of nurse sensitive patient outcomes. This chapter will then provide an overview of national nurse certification and studies o n the value of certification followed by research describing the relationship of national certification to specific patient outcomes. Lastly, this section will discuss how nursing experience and education influence quality of care and nurse sensitive outco mes. Nurse Sensitive Outcomes Nurse sensitive outcomes are responsive to the presence or lack of nursing care ( Albanese et al. 2010 ; Gallagher & Rowell 2003; Maas, Jo hnson, & Moorhead, 1996 ). Nurse sensitive outcomes may involve a series of complex and integrated actions or nursing interventions such as medication administration. In this study, the following nurse sensitiv e indicators will be examined: adverse events s uch as pressure ulcers, nosocomial infections, falls, physical res traints, and medication errors.

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29 In 1995, the American Nurse Association (ANA) implemented a Safety and Quality Initiative which initially identified 71 indicators as possible outcomes affect ed by nursing care and/or nursing interventions ( Albane se et al. 2010; Gallagher & Rowell, 2003 ; Haberfelde, Bedecarre, & Buffum, 2005; Maas et al. 1996 ) Following several pilot studies and collaboration with several nursing organization, the ANA confirmed 10 indicators which are presently used to measure quality of pat ient care in hospital settings. (NQF) expanded the list of nurse sensitive patient outcomes to address nursing staff concerns (education, certification and turnover) and specialty unit issues (psychiatric and pediatric) The National Data Base of Nursing Quality Indicators (NDNQI) was developed by the ANA in 1998 to act as the national repository to capture, analyze, r eport, and aggregate data. NDNQI provides a confidential database for over 1500 hospitals comparing data from both ANA and NQF quality indicators totaling a comprehensive review of 16 nurse sensitive outcomes at the national, local, hospital, a nd unit level (Albanese et al. 2010). Table 1 provides a comparison between ANA and NQI nurse sensitive outcomes. The IOM report in 2000 produced the publication, To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000) which br ought attention to serious quality care and pote ntial patient safety concerns. While t he initial report identified preventable medical errors as contributing to over 98,000 deaths in ye ar 2000 estimates for 2011 reflect rates as high as 210,000 to 400,000 per year (James, 2013). Although there are no estimate s on the number of preventable medical errors nurses have influence over, monitoring nurse sensitive outcomes with a particular focus on

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30 preventable adverse events will directly impact the overall prev entable medical error rates. The nurse sensitive outcomes identified by ANA and NQF depict preventable adverse patient events which could lead to death; for example, infections, falls with injury, 30 day mortality, and failure to rescue present scenarios o f preventable patient death. Nursing researchers identified the key role nursing plays in preventing adverse patient outcomes and how nurse characteristics ( e.g.,, education level) impact nurse sensitive outcomes. The first nursing characteristic under rev iew is the potential impact of national certificatio n on nurse sensitive outcomes. National Certification Overview Professional licensure supports the minimum requirements for knowledge and practice in nursing to ass ure public safety (AACN, 2003). Since licensure is a onetime process, there is no assurance that the health care practitioner continues to maintain safe clinical practice and a current knowledge base. In an effort to support continuing professional education, the Boards of Nursing for 33 states mandate continuing education hours as part of biennial licensure renewal (Iowa Board of Nursing, 2012). In addition, the IOM outlined several recommendations to assure quality health outcomes and patient safety which include the need for health c are providers to have a mechanism for periodic re licensure and reevaluation of practice (Institute of Medicine, 2011). While there is no process in place for re licensure, national nursing certification does provide a mechanism for augmenting professional knowledge and practitioner compe tence on a periodic basis (ABNS 2009 a ; Biel, 2007; Briggs Brown, Kesten & Heath, 2006; V alente, 2010 ; Wilkerson, 2011). National certification is a voluntary process that requires coordination at three nursing organization al levels to define,

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31 initia te, and maintain certification. The three nursing organizational levels involve the American Board of Nursing Specialties (ABNS), the National Commission for Certifying Agencies (NCCA), and specific nursing specialty org anizations such as the Association of Critical Care Nurses (AA CN), Emergency Nursing Association (ENA), Association of Operating Room Nurses (AORN). The American Board of Nursing Specialties (ABNS) is a not for profit organization established in 1991 for the purpose of supporting research, practice, and public awareness of nat ional specialty certification. The ABNS acts as the umbrella organization working in collaboration with the National Commission for Certifying Agencies (NCCA) and other specific nurse specialty organizations to provide oversight of the professio nal specialty nurse standards. The ABNS represents more than 36 nurse certifications with as many as 500,000 certified nurses among the 3 million licensed registered nurses (Collins, 2006; Messm er, Rodriquez, Williams, Ernst, & Tahmo oressi, 2011; Wilkerson, 2011). The organization defines certification as the the achievement of standards identified by a nursin g specialty to promote optimal health b ). The NCCA acts as the second nursing organizational level by defining the requirements for all national certifications examinations to assure consistency and rigor among specialties. The require ments provide guidelines on basic education, continuing education, hours of clinical practice, professional accomplishments, and documentation of applicable supervision (Valente, 2010). For example, The NCCA sets a minimum of 1750 clinical practice hours i n the specialty as a minimum eligibility requirement for any specialty certifying examination. The third and

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32 final organizational tier in the certification process is the specific nursing specialty involving one of 57 specialty organizations such as the Am erican Association of Critical Care Nurses (AACN), Association of Hospice and Palliative Nurses (AHPN), and Association of Operating Room Nurses (AORN) (Institute of Medicine, 2011). The specific nursing specialty completes the certification process by des igning the examination content to include the American Nursing Association (ANA) scope of e standards (Wilkerson, 2011). The nursing specialty maintains the primary role of re gulating the renewal process which typically involves continuing education specific to the specialty, documentation of current specialty clinical practice, and/or periodic reexamination. As an example, the renewal process for Critical Care Registered Nurse Certification (CCRN from the AACN) is every three years with completion of either a reexamination or proof of 432 direct care hours in clinical practice, with 144 hours worked in the renewal year along with 100 Continuing Education Recognition Points (C E RP) (AACN, 2013 ). Figure 2 1 illustrates the relationship of the three nursing groups with respect to certification oversight, requirements, and exam content.

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33 Figure 2 1. Nursing organizational involvement in certification process The intent of natio nal certification is to assure knowledge and high standards in clinical practice with the ultimate outcome of quality patient care and safety through expert nursing. There is, however, limited research on how certification affect s patient safety and outcom es. The following section will present current research on the perceived value of certification, as well as, and findings related to quality of car e and nurse sensitive outcomes. Perceived Value of National C ertification Cary (2001) conducted a large inter national study based on a random sample of 19,400 certified nurses from the United States and Canada representin g 23 certifying organizations. The study examined the perceived value of certification on personal, professional, and performance outcomes. Nine ty five percent of the nurses responding ABNS Provides oversight supporting research, practice and public awareness NCCA Defines certification requirements Specialty Organization Designs exam content

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34 to th e survey actively worked in the nursing field with the highest distribution in a hospital setting (50 % ) and 3 7 percent practicing as staff nurses. Certified nurses perceived certification as promoting a higher confidence level for interpreting patient symptoms and assessing potential complications. The nurses attributed certification as cultivating a sense of accountability leading to less disciplinary actions in the work setting and less adverse patient events The nurses reported higher patient satisfaction scores and enhanced communication with other health care team members. Gaberson, Schroeter, Killen, & Valentine (2003) conducted a study with certified perioperative nurses to determine the value of certifi cation as an internal versus external motivator in achieving personal or professional goals. Internal motivators referred to perceptions of self concept and attributes of personal development internal to the individual. External motivators included rewards and recognitions external to the individual or defined by others such as employers, physician, patients, or colleagues. Perioperative nurses perceived certification as having the strongest influence as an internal motivator for enhancing personal value an d augmenting professional practice. Nurses related certification to feelings of personal accomplishment, professional commitment, or person al challenge (Gaberson, et al. 2003) Several researchers conducted similar studies but expanded the respondents to include certified and noncertified nurses, as well as, managers and administrators with or without certification (Byrne, Valentine, & Carter, 2004; Sechris t, Valentine, & Berlin, 2006). The findings were consistent with other studies supporting the value o f certification as an individual internal motivator as opposed to being strongly influenced by external factors such as salary or other forms of recognition.

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35 The American Board of Nursing Specialties (ABNS) conducted a cross sectional exploratory study usi ng an on line survey to examine the perceived value of certification, incentives for certification, and barriers affecting certification (ABNS, 2006). The on line survey, the Perceived Value Certification Tool (PCVT), listed a total of 18 value statements with 12 measuring intrinsic factors (internal motivators) and 6 measuring extrinsic factors (external motivators). Table 2 2 provides a listing PVCT values statements based on intri nsic versus extrinsic factors. A total of 11,427 nurses, representing 20 specialty nursing organizations, completed the on line survey with the following participants: 8615 (75 % ) certified nurses including 77 percent of the managers (n=1608) holding certification, and 2815 (25 % ) non certified nurses (ABNS, 2006). Certified nurs es rated 16 of the 18 value statements as agree to strongly agree as compared with the noncertified nurses who rated 12 of the value statements as agree to strongly agree. Noncertified nurses disagr eed that certification provides, indicates clinical compet ency, or e nhances professional autonomy. The findings were consistently higher for certified nurses in the intrinsic factor component illustrating personal and professional commitment to practice with an enhanced sense of accountabilit y, satisfaction, and challenge. Additionally, the ABNS study focused on incentives and barriers for certification. Incentives and barriers were found to be related to low extrinsic value statement results. The study participants noted only 18.6 percent of the facilities offered a monetary incentive through salary or certification reimbursement with a 21.4 percent indicating no

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36 facility recognitio n or incentive for certification. The top three barriers for certification were the cost of the examination, lack of institutional reward, and lack of facility support to achieve or mainta in certification (ABNS, 2006). While the study found that certificat did not examine the impact of certification on clinical practice and speci fically patient care outcomes. The ABNS study did, however, provide the springboard for the particip ating nursing specialties to abstract their individual results and report findings specific to their nursing specialty ( ABNS, 2006 ; Bekemeier, 2007 ; Biel, 2010 ; B yrne et al. 2004 ; Grief, 2007 ; Haskins, Hnatiuk, & Yoder, 2011 ; Messmer et al. 2011 ; Prowant, Neibuhr, & Biel, 2007 ; Sechrist, Valentine, & Berlin, 2006 ). Research on Patient Safety and Quality of C are The bulk of research on patient safety and quality of care addresses the impact of national nurse certification on surgical complications and morta lity rate. Several studies found certification is associated with reduced mortality rates and fewer complications (Kendall Gallagher, Aiken, Sloan, & Cimotti, 2011; Kendall & Blegen, 2009; Newhouse, Johantgen, Pronovost, & Johnson, 2005). This s tudy does not measure these outcomes and therefore, this section will focus on variab les consistent with this study. Nurse Certification and Nurse Sensitive Patient O utcomes Nurse sensitive patient outcomes are directly affected by nursing care and include pressure ulc ers, infection rates, falls, medication errors and restraint use The limited research available presents conflicting results. For example, some studies indicate a positive relationship between nurse certification and detecting and staging of pressure ulcers (Bergquist Beringer, Gajewski, Dunton, & Klaus 2011; Hart, Bergquist

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37 Beringer, Gajewski, & Dunton 2006; Zulk owski, Ayello, & Wexler 2007). Other studies show no relationship between nurse c ertification and assessment of pressure u lcers ( Boltz, Capezuti, Wagner, Rosenberg, & Secic, 2013; Kendall Gallagher & Blege n, 2009; Krapohl, G., Manojlovich, M., Redman, R. & Zhang, L., 2010). The studies that found a positive relationship between certification and pressure ulcer staging examined stagi ng processes comparing wound care certified nurses with non certified wound care nurses. Whereas, the studies that found no relationship between certification and assessment of pressure ulcers resulted from retrospective chart reviews of intensive care pat ients comparing critical care certified nurses with non certified nurses. Nurses certified in wound, ostomy, and continence care exhibit higher knowledge score differences when compared with nurses with no wound care certification yet the relationship of k nowledge and actual practice remains blurred (Bergquist Beringer, et.al., 2011; Hart, et.al.,20 06; Zulkowski, et al. 2007). Hart et al. (2006) and Bergquist Beringer and colleagues (2011) conducted studies using the data from the National Database of Nursing Quality Indicators (NDNQI) for nursing assessment of pressure ulcers. Hart et al. (2006) conducted a prospective cross sectional study with 48 hospitals and 256 nurses to examine how nurses identify, stage, and rate p ressure ulcers through a web based program. Seventeen percent (n= 43) of the nurses were certified in wound, continence, and ostomy care. The study used a web based program focusing on three aspects: identification, staging, and rating of the ulcer based on a given patient care scenario. The findings confirmed that certified nurses had higher rates for pressure ulcer identification, correctly staging ulcers, and rating severity of ulcers than nurses with no

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38 certification. Bergquist Beringer and colleagues (2011) repeated the study but included a comparison of web based with direct observation and again found that in direct observation, wound certified nurses had higher scores than noncertified nurses. The study included 31 hospitals with 39 of the 180 nurse s certified in wound, ostomy, or continence care. However, both studies found no statistically significant difference in scores between certified and noncertified nurses when nurses evaluated the pressure ulcer in a case study. The samples of certified nu rses for both studies were small limiting generalizations. There are mixed results when researchers reviewed the impact of ICU certification on nurse sensitive outcomes. Studies do not show agreement on the relationship of ICU nurse certification to press ure ulcer prevalen ce or blood stream infections. Kendall Gallagher and Blegen (2009) performed a cross sectional exploratory study that looked at the relationship between the proportion of certified intensive care nurses in a unit and six quality indicator s (medication errors, falls, skin breakdown, central catheter infections, bloodstream infections, and urinary tract infections). The researchers, controlling for the Medicare case index and magnet status environment, used a secondary data sample of 48 adul t ICU units in 29 hospitals with a total of 279 patients. While not statistically significant, certification was associated with a decrease in bloodstream infections (p<.07). The proportion of certified nurses on the unit had an inverse relationship to fa as the number of certified nurses increased on a unit the number The total sample size for the studies (patients and nurses) were small and

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39 geographically restricted with no clear in dication on the number and type of specialty nurse certification. In contrast, Krapohl, Manojlovich, Redman, and Zhang (2010) performed a correlational descriptive study of 866 ICU nurses in 25 different ICU units and examined the relationship between the number of certified ICU nurses and three nurse sensitive outcomes: blood stream infection; ventilator associated pneumonia; and pressure ulcers. There were no significant relationships with certification and any of the three nurse sensitive outcomes. Int erestin gly, Kendall Gallagher and Blege infections as those in the blood stream and central line infections as opposed to Krapohl and colleagues (2010) who did not separate these infections but rather combined them in the analysis. This m ay explain the differences in outcome results. Both studies, however, found no effect on skin breakdown with increased numbers of certified ICU nurses. These findings are not consistent with previous studies that found positive correlation between nurses c ertified in wound therapy and decreased pressure ulcer prevalence (Bergquist Beringer et al. 2011; Hart et al. 2006; Zulkowski et al. 2007). Boltz and colleagues (2013) performed a descriptive retrospective study of 35 medical units and 9 medical surgic al units and found no relationship with nurse certification and injurious falls, pressure ulcer development, and restraint use. However, certification was a sig nificant predictor of fall rate, such that, as the number of certified nurses increased on the unit, the number of falls decreased. These findings were consistent with Kendall 2009) findings on fall rates in intensive care units. Both studies had small samples sizes and were limited to special ty nursing units.

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40 There are sever al outcome studies that examined the effects of oncology nurse certification and the ability to assess, document, and treat nausea, vomiting, and pain critical to cancer patients. Findings are however conflicting. Frank Stromberg et al. (2002) conducted a retrospective chart review of home bound oncology patients for the purpose of evaluating differences in documentation, intervention, and care between certified oncology nurses and noncertified nurses. One hundred eighty one charts of 7 certified oncology nurses and 13 noncertified nurses were assessed. Documentation and interventions reviewed included the symptom management for chemotherapy induced patient factors such as pain, nausea, and fatigue; adverse patient outcomes from infections or skin breakdown and unexpected care issues requiring hospitalization or additional home visits. The oncology certified nurses had more experience in RN years, oncology practice, and home care as opposed to the noncertified nurses. There were no significant differences in documentation of pain assessments (initial or ongoing), initial fatigue assessment, or unplanned episodic care interventions between groups. Patients receiving care from certified nurses had more frequent documentation of ongoing fatigue assessment and infections, and fewer documentation entries of patient teaching than patients under t he care of noncertified nurses. Because this study is limited by its retrospective chart review, a small sample size of both patients and nurses, and data from only one ho me care agency, it is difficult to generalize the results. Coleman, et al. (2009) conducted a prospective study with 270 patients, 35 certified oncology nurses, and 58 noncertified nurses to compare them in knowledge and clinical behaviors related to symp tom management of oncology patients. The patients completed three questionnaires that addressed the following : 1) knowledge of

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41 pain and manage ment of chronic cancer pain; 2) experience with cancer and che motherapeutic symptoms; and 3) a measure of patient satisfaction with care and interaction with health care providers. The nurses completed questionnaires that measured nurses perceptions on the following : 1) identified education needs related to pain management; 2) knowledge on symptoms; 3) work satisfact ion. The researchers also conducted a chart audit to verify documentation on symptoms and management of chemotherapy induced nausea and vomiting. Certified nurses had more continuing education and a higher knowledge base of chemotherapeutic nausea and pai n than noncertified nurses. The patient respondents indicated satisfaction with their care but were unable to differentiate care from a certif ied versus noncertified nurse. There was no significant differ ence in documentation, care, or management of cancer symptoms between the groups. This study was limited because it was conducted at one academic center and the sample size was small for certified and noncertified nurses. Years of Nursing Experience Development of Experience The conventional thought is that experience over time leads to better performance and outcomes. Studies support this premise when comparing accident rates with novice and experienced drivers. The novice driver must develop and then refine skills in strategic, tactical, and operationa l maneuvering for vehicle control and driving performance which occurs over time and with repeated driving experiences (Donmez, Boyle, & Lee, 2010; Mueller & Trick, 2012). Unfortunately, the research is not as clear in studies dealing with nursing experie nce. Nurse researchers do agree, however, that inexperienced clinical nurses are less able to detect complications and the occurrence of adverse patient events (Dellon, Lippmann, Galanko, Sandler, &

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42 Shaheen, 2009; Morrison, Beckmann, Cu rie, Carless, & Gil lies, 2001). Nursing expertise develops with continued exposure to experiential learning (Benner, 1984; Benner & Tanner, 1987; Burritt & Steckel, 2009; Dunton, Grajewski, Klaus, & Pierson, 2007). Benner (1984) addressed the role of experiential learning w hen outlining the five stages of clinical proficiency and explaining how a nurse moves from one stage to another in developing co mpetence and clinical judgment. As a researcher, Benner is cautious in labeling a specific time frame for each stage explaining proficiency progression requires sequentially higher levels of competency, judgment, and intuitive decision making. However, nurse researchers exploring the impact of years of g a minimum of 5 years clinical experience (Atencio, Cohen, & Gorenberg, 2003; Azzarello, 2003; Blegen,Vaughn, & Goode, 2001: Burritt & Steckel, 2009; Dellon et al. 2009; James, S impson, & Knox, 2003; Morrison et al. (2001); Orsolini Hain & Malone, 2007 ; Taylor, 2002). While exposure and repeated practice reinforces critical thinking and judgment, research is both limited and unclear in defining how and what impact years of nurse experi ence have on patient outcomes. Rapid technological changes and exposu re to volumes of potential errors add to the confusion when relating outcomes to years of experience. Changes in technology, information, and organizational priorities demand continuous education and adaptability by the experienced health care practitioner For example, Choudhry, Fletcher, and Soumerai (2005) conducted an extensive review of literature for the purpose of exploring the relationship of years of physician experience to quality of care and mortality rates. Despite limited ar ticles (62) address ing the

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43 concern, they found a negative association between years of experience and quality of care, indicating as years of physician experience increased, performance and quality outcomes decreased. Researchers hypothesized that senior physicians may lack continuing education and exposure to new modalities and treatments resulting in poor quality outcomes. When examining nurses, Atencio, Cohen, and Gorenberg (2003) found a decline in perceived autonomy and task orientation as years of nursing experience in creased. Atencio and colleagues performed a longitudinal, descriptive study on 257 nurses with repeated surveys every 6 months for two years to determine their perceptions on autonomy, task or ientation, and intent to leave. There was a statistically signif icant difference (p < 0.001) of perception of autonomy and task orientation between senior nurses (6 or more years of experience) and less senior nurses (5 years or less experience). The nurses with less experience perceived more autonomy than experienced nurses in terms of freedom to make decisions, use of initiative for patient care issues, and independent functioning. The nurses with less experience also perceived higher task orientation than experienced nurses in terms of perceived efficiency in the wor k unit, work oriented attitudes, and work completion as a priority (Atenc io, et al 2003). Experience and Nurse Sensitive Outcomes Research is both limited and contradictory when exploring the relationship between nurse years of experience and nurse sensi tive outcomes. The predominate focus of research on years of experience has been on 30 day mortality rates and failure to rescue (Aiken et al. 2003; Sasichay Akkadechanunt, Scalzi, & Jawad, 2003, Tourangeau, Giovannetti, Tu & Wood, 2002; Tourangeau, et. a l., 2007 ). The research found years of experience have no effect on mortality rates and failure to rescue. This

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44 study explores the relationship of nurse experience to nurse sensitive outcomes other than mortality and failure to rescue. The following section will address research examining the relationship of nursing experience with nurse sensitive ou tcomes pertinent to this study. Blegen,Vaughn, and Goode (2001) conducted a secondary analysis of data from two previous studies to examine the effect of years of experience and nurse education on falls and medication errors. The first study (Blegen, Goode, & Reed, 1998) included 42 units from one large hospital while the second study (Blegen & Vaughn, 1998) included 39 units from 11 hospitals. The combine d data did support an inverse relationship of medication errors and years of exp erience, such that, the more experienced the nurse, the fewer medication errors. An interesting finding from the secondary analysis was that more medication errors occurred on units with higher ratios of BSN nurses. The researchers explained the result as an effect of less experienced but mo re BSN graduates on the units. Repeated exposure over time to a volume of potential errors complicates the critique of years of experience t o patient outcome measurements, particular ly medication error tracking. Kendall Gallagher and Blegen (2009) reported an increase in medication errors with increased clinical nursing experience but explained the finding as a result of administeri ng more med ications over time. Clarke, Rockett, Sloane, and Aiken (2002) expressed similar concerns when studying needlestick injuries. They studied 2287 nurses in 22 hospitals for the purpose of determining how staffing and organizational climate affe ct patient and nurse outcomes. Part of the study involved questionnaire data on needl estick exposures and injuries. While the experienced nurse

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45 had a higher exposure rate, the inexperienced nurse had a 1.5 to 2 factor likelihood of having an actual needlestick injury in the first 5 years (Clarke, et al. 2002). Research on the relationship of years of nursing experience and fall rates are contradictory. Blegen, Goode, and Reed (1998) found a significant relationship between the nurse experience and rates of falls support ing the more experienced the nurse, the fewer the fall rate. In contrast, Blegen and Vaughn (1998) found no significant relationship between years of experience and fall rate from the study of 39 units and 11 hospitals. The exposure to multiple hospitals a nd less nursing units in the sample may have impacted the results (Blegen & Vaughn). In a more recent study, Dunton, Gajewski, Klaus, and Pierson (2007) conducted a review of 8 of the15 quality indicators from the NDNQI noting a lowering in the fall rate b y 1 percent for every increase in year of RN experience. In addition, an inverse relationship with years of experience and hospital acquired pressure ulcers (HAPU) indicating a decrease of pressure ulcers of 1.9 percent for each year of RN experience (Dunt on et al. 2007). In current research, there are conflicting findings concerning the relationship between nurse years of experience and their clinical assessment of patient care needs. James, Simpson, and Knox (2003) conducted a qualitative study of 54 ex pert labor the care of labor and the birth process provided the intuitive nursing knowledge necessary to make a differen ce in labor and birth outcomes. The more experien ced the nurse, the better able the laboring mother was to proceed through the laboring and birth process. S imilarly, Ross and Bell (2009) studied nurses who worked in 10 critical access hospitals (30 beds or less) to determine their comfort levels with eme rgency

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46 interventions based on their years of experience and certification status. Nurses who were certified and who had 6 or more years of experience reported higher levels of confidence (78 percent comfort level) when compared to nurses with less ex perien ce and no certification. On the other hand, Considine, Botti, and Thomas (2007) conducted a literature review noting five studies investigating the relationship of knowledge and experience in triage decision making and found no significant relationship bet ween years of nursing experience, particularly emergency room nursing experie nce and triage decision making. Similarly, Marcin, et al. (2005) reviewed 55 unplanned extubations on 1004 pediatric patients over a 4 year period and found no relationship with nu rses years of experience and ability to assess and prevent unplanned extubations. Simulations were conducted in other studies to observe nurse reactions to emergent clinical situati ons. Thompson et al. (2008) implemented patient vignettes to examine the n experienced nurses and found no statistically significant interaction between clinical experience and time pressure to react to proposed cli nical emergency interventions. There were limitat ions in this study in that these were not real time emergencies. Yang and Thompson (2011) studied the differences with student nurses and experienced nurses with paper based scenarios using manikin simulated patient scenarios. They found no significant dif ferences in nurse judgment for students or expert nurses. The study limitations includes use of only one hospital group of nurses, students from only one school of nursing, and the inability to mock emergency situations when using a paper based test with manikin simulations. With limited confirmation on the impact of

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47 years of experience on nurse sensitive outcomes, researchers turn to education as another possible indicator to eva luate quality of care. Education The Institute of Medicine (2011) recommended to increase the number of BSN prepared nurses from 50 percent to 80 percent of staff by 2020 based on research showing a positive relationship of educational level on patient care outcomes. Research does confirm a relationship between educational level of the nurse and 30 day mortal ity and failure to rescue rates, such that, the an increase in the proportion of hospital BSN prepared nurses leads to a decrease in failure to rescue and mortality rate (Aiken et al. 2011; Aiken et al. 2003; Aiken, Clarke, & Sloane, 2008; Estabrook, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Kendall Gallagher et al. 2011; Tourangeau et. al., 2007; Van den Heede et al. 2009). This study purposefully addresses other hospital bas ed nurse sensitive outcomes. There level on other nurse sensitive outcomes. Blegen, Vaughn, and Goode (2001) conducted a secondary analysis using data from two earlier studies for the purpose of determining the eff ect of education and experience on medication errors and fall rates. In the first study (Blegen, Goode, & Reed, 1998) 42 nursing units were included from one large hospital, and an inverse relationship between years of nurse experience and medication erro rs was found; as years of nurse experience increased, medication errors decreased. However, educational level was positive ly related to medication errors, such that, units with higher numbers of BSN nurses had hig her rates of medication errors. The second study (Blegen & Vaughn, 1998) included 39 unit s from 11 different hospitals. There was a statistically significant decrease in fall rates and medication errors with nurses who

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48 had more than five years of nursing experience when compared to those with less than on f all rates or medication errors. In their review of 279 adult ICU patient charts in 29 hospitals, Kendall Gallagher gnificant decreases in skin breakdown with higher proportion of certified BSN nurses. These findings were confirmed in a recent cross arters of quality data (Blegen et al. 2013). In addition, the y found statistically significant lower rates of congestive heart failure mortality (p <.05), deep vein thrombosis (p<.05), and length of h ospital stay ((p<.05). Pallas et al. (2002) conducted a longitudinal two part study to determine the cost and quality of home care services for 751 client s in a one home health agency. Clients who received care from a RN with BSN education showed a 1.8 times higher score on knowledge and 2.2 times higher score on behavior change when compared with care from an RN without a BSN education. Summary There is a paucity of research that examined nurse national certification, years of experience, and educational levels and their effects on nurse sensitive patient outcomes. The studies examining each nurse characteristic (national nurse certification, years of experience, and educational level) present conflicting results. For example, some studies on national nurse certification found that certified nurses were able to stage and assess for pressure ulcer detection more ef fectively than non certified nurses (Bergquist Beringer, et al. 2011; Hart et al. 2006; Zulkowski, et al. ,2007), while other studies found no effect on decreased skin breakdown with certified ICU nurses (Kendall Gallagher & Blegen, 2009; Krapohl et al. 2010). Similarly, Kendall Gallagher

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49 and Blegen (2009) found a statistically significant decrease in bloodstream infections with certified ICU nurses in contrast to Krapohl and colleagues (2010) wh o found no relationship between ICU nurse certification and blood stream infection rates. The studies examining the relationship of years of nurse experience to nurse sensitive patient outcomes h ad inconsistent findings. Blegen and colleagues (2009) found t he more experienced the nurse ( five years or more), the fe wer the medication errors as opposed to Kendall Gallagher and Blegen (2009) who found an increase in medication errors with five or mor e years of experience. The bulk of studies examining the effect of education on nurse sensitive outcomes focus 30 day mor tality and failure to rescue (Aiken et al. 2011; Aiken et al. 2003; Aiken, Clarke, & Sloane, 2008; Estabrook, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Tourangeau et. al., 2007; Van den Heede et al. 2009). The few studies that examine the effect of the nurse education on other nurse sensi tive outcomes are conflicting. Blegen,Vaughn, and Goode (2001) conducted a secondary analysis on data from two previous studies only to find differing results. The first study (Blegen, Goode, & Reed, 1998) found m edication errors increased on units with higher proportion of BSN nurses as opposed to the second study (Blegen & Vaughn, 1998) that found no relationships. Kendall Gallagher and Blegen (2009) found a statistically significant decrease in skin breakdown wi th certified BSN nurses. The study was limited, however, to certified nurses and did not investigate the effects of educational level on skin breakdown. While studies are available for each of these nurse characteristics, only a few studies examine the eff ect of more than one nurse characteristic on nurse patient

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50 sensitive outcomes (Aiken et al. 2003; Blegen et al. 2001; Kendall Gallagher & Blegen, 2009; Kendall Gallagher et al. 2011). Examining more than one nurse characteristic in a study may provide in formation on how the individual nurse characteristics influence each other and how that influence may then affect nurse sensitive patient outcomes. Lastly, the studies that did examine national nurse certification, education, and years of nurse experience focused on nurse sensitive outcomes in specific specialty units (oncology, intensive care, wound care) as opposed to examining the impact of nurse characteristics on nurse reported adverse events in a variety of hospital units (Bergquist Beringer et al. 2 011; Hart et al. 2006; Kendall Gallagher & Blegen, 2009; Kendall Gallagher et al. 2011; Krapohl et al. 2010; Zulkowski et al. 2007). The proposed study attempts to provide additional research to validate the effect of all three nurse characteristics (n urse national certification, years of experience, and education) on nurse sensitive patient outcomes for all hospital acute care units. Table 2 1. Comparison of ANA and NQI nurse sensitive outcomes American Nurse Association National Database Nursing Quality Indicators Structure outcomes Nursing care hours Skill mix Process outcomes Nursing Satisfaction Patient focused outcomes Pressure Ulcers Falls Falls with injury Nosocomial infections Patient satisfaction with Patient education Overall care Nursing care Structure outcomes Nursing care hours per patient day Skill mix Turnover Nursing education and cert ification RN satisfaction Pediatric pain assessment cycle Pressure ulcer(community acquired, hospital acquired, unit acquired) Falls Falls with injury Nosocomial infections Ventilator associated p neumonia(VAP) Central l ine catheter associated blood stream infections (CLABSI) Urinary catheter associated urinary tract infections (CAUTI) Pediatric IV infiltration (pediatrics/neonatal units only) Physical/sexual assaults (psychiatric units only)

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51 Table 2 2. PVCT Value statements Intrinsic Factors Extrinsic Factors Enhances feeling of personal accomplishment Provides personal satisfaction Provides professional challenge Enhances professional credibility Provides evidence of professional commitment Indicates professional growth Validates specialized knowledge Indicates attainment of practice standard Enhances personal confidence in clinical abilities Provides evidence of acco untability Enhances professional autonomy Indicates level of clinical competency Promotes recognition from peers Increases marketability Promotes recognition from other health professionals Promotes recognition from employers Increases consumer confidence Increases salary

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52 CHAPTER 3 METHODOLOGY Purpose The proposed conceptual model, Nursing Characteristics Affecting Quality of Care asserts a relationship exists between three nursing structures, the process of care, and outcomes measured by nurse reported information. The purpose of this study is to examine the relationship among years of nursing experience, national nurse certification, and educational level of the registered nurse and nurse reported adverse events, hosp ital quality, and safety. Further, this study examine d whether national nurse certification in combination with years of nursing experience and/or the educational level of the nurse affects nurse reported adverse events, hospital quality, and safety. A mod ification of the Process of Care and Outcomes Model (PCOM) (Aiken et al. 2002 a ) provided the theoretical framework guiding this secondary analysis of the parent cross sectional survey study. This chapter will provide descriptions of the research design, s ample procedure, instruments, and proposed statistical analysis to address each study aim. Study A ims The specific aims for the study are: 1. T o explore the relationship between years of experience and RN reported adverse events [ wrong medication or dose, pre ssure ulcers developed, falls with injury, use of physical restraints (vest or limb), use of physical restraint for 8 hours or more, use of medication as a restraint, healthcare associated infections (surgical site, urinary tract, central line associated bloodstream, and ventilator associated pneumonia] hospital quality (nursing quality of care delivered to patients in the work setting confident that patient will be able to manage care when discharged and confident that management will act to resolve pr oblems in patient care that the nurse reports ), and sa fety (overall grade on patient safety and actions of management show that patient safety is a top priority ).

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53 2. adverse events, ho spital quality, and safety. 3. To exami ne differences between national nurse cert ification status and RN reported adverse events, hospital quality, and safety. 4. To examine differences between nationally certified RNs with greater than 5 years of experience in reported adverse events, hospital quality, and safety as compared to non certified RNs with the same years of experience. 5. To examine the effect of RN educational level on RN reported adverse events, hospital quality, and safety. 6. To examine the effect of ce rtification status on RN reported adverse events, hospital quality, and safety. 7. To determine if national RN certification moderates the relationship between years of RN experience and RN reported adverse events, hospital quality, and safety. 8. To determine if national RN certification moderates the relationship between educational level of the nurse and nurse reported adverse events, hospital quality, and safety. Design sectional survey, Multi State Nursing Care and Patient Safety Study: State of Florida The parent study provided cross sectional data using a state wide nursing survey of registered nurses licensed and residing in Florida (Neff, Cimiot ti, Heusinger, & Aiken, 2011). The surv ey tool used in the parent study provided an available source of data from a large number of registered nurses and addressed all the research variables for this study. This doctoral study extracted secondary survey data to explore relationships between yea rs of experience, education, and national nurse certification on nurse reported adverse events, hospital quality, and saf ety. This design and use of secondary data provided the means to investigate these phenomena, and was both logi cally and financially fe asible.

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54 Sample Parent Study: Multi State Nursing Care and Patient Safety The parent study, Multi State Nursing Care and Patient Safety Study, was a mailed survey sent in 2008 to a 25 percent (49, 385) random sample of the licensed and registered nurses in F lorida. The purpose of the study was to obtain information from registered nurses on nursing work conditions to address quality, patient safety, and nu rsing workforce concerns (Neff et al. 2011). The study was approved by the University of Florida Institu tional Review board. The principal investigator, Donna Felber Neff, PhD, RN obtained public mailing lists fro m the Florida Board of Nursing. Attached to the survey was a letter that included the purpose for the study, explanation that participation and co mpletion of the survey was a voluntary process, and assurance that survey results were strictly confidential with information aggregated and de identified for research purposes. To encourage participation, reminder post card were sent following the first m ailing and after the second mailing. Additionally, non respondents received two automated phone messages following both survey mailings. The survey process led to a 39 percent response rate reflecting 19,657 nurses with a final sample of employed 10,832 di rect care nurses. Parent Study: Survey Instrument The survey tool had six sections. The first section provided demographic information on age, race, ethnicity, education, certification, current position, and expected position one ye ar from completing the survey. The second section, focusing job, and plans to stay in the current position. The Maslach Burnout Inventory Human Services Survey (Maslach & Jackson, 1986) measur ed work related emotional

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55 exhaustion. Human et al. 2002 a ; Aiken et al. 2003). The tool addressed the global construct of nurse satisfact ion as a single item using a 4 point Likert type scale (1 = very dissatisfied to 4 = very satisfied). Youngblut and Casper (1993) identified single item statements as reliable in measuring global constructs. Published reliability coefficients of 0.70 supp ort use of a single item for overall job satis faction (Wanous, Reichers, & Hu dy,1997) This section also included a yes/no question for nurse intent to continue workin g with their present employer. The third section, intended only for direct care nurses, pr ovided information on Scale of the Nursing Work Index (PES NWI) (Lake, 2002). PES NWI is a 31 item Likert type scale with responses ranging from strongly disagree (1 ) to strongly agree (4) 0.86 to 0.96 (Lake, 2002, Neff et al. 2011). T he nurse identified the hospital of primary employment in the fourth section. the work environment. This section included four single item statements measuring quality of nursing care delivered to patients in the work setting (from excellent to poor), confidence that patients are able to manage their care when discharged (from very confident to not applicable), confidence that management will act to resolve problems in pati ent care that they report (from very confident to not at all confident), and an overall grade of patient safety (A= excellent to F = failing). This section asked the nurse to rate

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56 the frequency of adverse events using a range of 7 frequencies: never; a few times a year; once a month; a few times a month; once a week; a few time s a week; and every day. The nurse then identified the number of patients (out of 100) who experienced five specific adverse events: healthcare associated pressure ulcers; falls; w rong medication or dose; healthcare associated infections; and physical restraints. The list of adverse events are nurse sensitive outcomes monitored as a measure of quality in the acute c are setting (Farquhar, 2008). This section also provided information on needle stick safety, experiences of physical and verbal nurse abuse, and organizational staffi ng changes over the last year. The sixth and final section of the Multi State Nursing Care and Patient Safety work day as to shift, patient ratio, hours worked, and nursing activities. This section required nurses to provide numbers or ident ify specific selected options. This overall instrument has been use d in surveys, conducted by Dr. Aiken and her team, for ove r 10 years and is a valid instrument to measure nurse perceived organizational processes and survey items and consistently predicts quality of care. Except for the Maslach Burnout Inventory Human Services Survey and the PEW NWI, there have been no reliabi lity or validity of the instrument. Description of Secondary Analysis Sample Participants in this doctoral study were licensed registered nurses who completed the 2008 Multi State Nursing Care and Patient Safety Study: State of Florida and meet the following inclusion criteria.

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57 Inclusion Criteria Registered nurses ages 21 75, who were licensed and employed in Florid a were included in this study. Twenty one years of age provides the minimum time for an individual to obtain the basic Associate Degree training (two years post secondary education) with the inclusion criteria of one year of hospital experience. The span of 21 to 75 years of age provides the adequate span for years of hospital employment. Additionally, only RNs with at least one year clin ical experience in the United States (U.S.) who provide direct care in a hospital setting were included in the sample. Registered nurses with at least 1750 hours of direct care, which approximate to one year full time employment, are qualified to take the national critical care certification exams (American Association of Cri tical Care Nurses, 2014 ). Since this study explores the relationship of national nurse certification impact on nurse sensitive outcomes and quality indicators, the inclusion criteria of one year clinical experience captured all eligible registered nurses with national certification. The study sample included all applicable ages, races/ethnicities, and employment status (full time, part time, or per diem). Exclusion Criteria This study pu rposively excluded registered nurses with less than one year clinical experience in United States. Nurses with less than one year experience are considered novice in clinical practice and decision making and therefore may not fully appreciate nurse sensit ive or quality care concerns (Benner, 1984). Power Analysis To prevent a type II error, a sample size of 79 respondents was necessary to support the power analysis for a minimum power of 80 percent a medium effect size

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58 (0.5), and a significance level of 05 using logistic regression with three predictors (years of experience, education, and national certification). The final sample was 6515 direct c are hospital registered nurses. Proposed Measures The following section provides a detailed description of th e study constructs and specific variable. Table 3 1 provides a summary of concepts, operational definitions from the survey, a nd survey empirical indicators. Independent Variables Education level Nursing education included basic and addition al academic deg ree completion as a four category variable. Associate degree nursing (ADN) provides basic nursing education from a two year technical college. A Diploma nursing degree (DIP) provides basic nursing education from a three ye ar hospital based environment. Th e third category of educational preparation is baccalaureate which operationally defines registered nurses with a minimum of a bachelor degree education. The fourth relate d field. Since only one respondent had a doctoral degree, this category was excluded from the statistical analysis. When performing logistic regression, the education variables included: associate degree, diploma, and baccalaureate degree with the masters degree variable acting as the reference category. Years of e xperience Years of experiences includes the number of years the respondent worked as a registered nurse. This variable included clinical employm ent outside the United States.

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59 The study required participants have at least one year work experience in the US hospital health care system, Nati onal nurse c ertification National nurse certification is operationally defined to include successful completion of a nationally certified examination with eviden ce of meeting clinical practice criteria pertinent to the specific specialty nursing organizational requirements. The American Board of Nurse Specialties (ABNS) represents more than 36 nurse certifications within the 20 specialty nursing org anizations (Me ssmer et al. 2011). This study defined certification as national certification recognized from the ANA and ABNS and therefore excluded basic clinical certifications such as basic life support (BLS), advanced cardiac life support (ACLS), or pediatri c card iac life support The variables were coded as 1 indicating certifica tion status and 2 indicating no certification status. Outcome Variables Adverse events This study operationally defined RN reported adverse events as untoward patient occurrences during inpatient hos pitalization (Farquhar, 2008). The Agency of Healthcare Research and Quality (AHRQ) developed a list of quality indicators to measure quality of care in inpatient and outpatient settings. The quality measures exist in four modules: Prevention Quality Indicators (PQIs), Inpatient Quality Indicators (IQIs), Patient Safety Indicators (PSIs) and Pediatric Quality Indic ators (PDIs) (Farquhar, 2008). This study addressed nurse reported adverse events from the patient safety indicator module (AHRQ: PS I) identified as nurse sensitive outcomes which include: pressure ulcers developed; physical restraint (vest/limb); physical restraint for 8 hour or more; wrong medication or dose; surgical site infections; urinary tract infections; central

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60 line associated bloodstream infections; and ventilator associated pneumonia. The nurse reported the frequency of adverse events using a 7 point likert type scale: never, a few times a year or less; once a month or less; a few times a month; once a week; a few times a we ek, or every day. The responses were then summed for each independent variable. Quality urse confidence that management will resolve problems in patient care that the nurse u measured with a 4 point Likert type scale from excellent (0) to poor (3). The nurse mana point Likert type scale from (5) very confident are you that management will act to resolve problems in patient care that you repo point Likert type scale indicating (0) not all co nfident to (4) very confident The responses for each individual quality item were averaged based on the breakdown of the independent variable. For example, the nurse perception of quality of c are was averaged for Associate Degree nurse response, averaged for Baccalaureate nurse response, e tc.

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61 Safety This survey operationally defined safety in two ways: an overall grade for patient safety on the unit or practice area and an opinion that action s of management show that pat ient safety is a top priority. point Likert type scale ranging from A (excellent ) to F (failing ). The safety question represents a single item global construct with research evidence of reliability (Youngblat & Casper, p oint likert type scale ranging from stron gly agree to strongly disagree. Procedures Protection of Human Subjects T he researcher obtained exempt approval for the study from the University of Florida College of Nursi ng Institutional Review Board. This doctor al study posed no threat to individual human rights since the researcher had no access to individual respondent identifying information and received encrypted data from the parent study. Management of Data The researcher supported and maintained data integ rity and storage in acc ordance with the parent study. Data was obtained and stored on network storage drives at the University of Florida College of Nursing, accessible only with a password through a secured shared drive controlled by the research database investigator, Dr. Cynthia Garvan. Upon completion of the study, all data and statistical information for this doctoral study will be maintained and accessed.

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62 Data Analysis The Statistical Package for the Social Sciences (SPSS) version 21(2013 SPSS, Inc., Chicago, Il) and Statistical Analysis Software (SAS version 9.3, SAS Institute, Cary, N.C) were used for the statistical analysis. Prior to conducting the analysis, data were screened and cleaned for entry errors, missing data, and outliers. Missing data for each variable calculated at less than 5 percent an acceptable rate for statistical analysis, demonstrating a random pattern for missing data common with survey or questionn aire completion (Munro, 2005 ). Although the parent study had 10,83 2 direct care respondents, this study narrowed the sample to include only direct care RNs working in the hospital setting leadi ng to a potential sample of 6648 nurses. Cleaning the data and eliminating dup licate respondents resulted in a final sample of 65 15 nurses. Table 3 2 provides a review of the study aims, variables, levels of measurement, and statistical tests. Data was coded as categorical and numeric variables based on appropriateness for each variable. The researcher used descriptive statistics to explain sample characterist ics and categorical variables. Data analysis for continuous variables included use of descriptive statistics for means, ranges, maximums, min imums and standard deviations. The researcher examined frequency distributions to ass ure reasonable approximations to normality for all interval/ratio variables and determine use of parametric or non parametric statistical procedures. Histograms were run on each variable to determine central tendency and dispersion (Field, 2009). The varia bles lacked normal distribution forcing use of non parametric statistical tests: Spearman correlation coefficient, Kruskal Wallis, and Wil coxon rank sum. (Field, 2009). Logistic regression was used for predic tive modeling.

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63 AIM 1 To explore the relationshi p between years of experience and RN reported adverse events [ wrong medication or dose, pressure ulcers developed, falls with injury, use of physical restraints (vest or limb), use of physical restraint for 8 hours or more, use of medication as a restrain t, healthcare associated infections (surgical site, urinary tract, central line associated bloodstream, and ventilator associated pneumonia ] hospital quality (nursing quality of care delivered to patients in the work setting, confident that patient will be able to manage care when discharged, and confident that management will act to resolve problems in patient care that the nurse reports), and safety (overall grade on patient safety, and actions of management show that patient safety is a top priority ) The independent variable, years of experi ence, is a continuous variable. The outcome variables for adverse events, quality, and safety are ordinal variables using likert type scales. Adverse events ranged from never to everyday on a 7 point likert like s cale (never, a few times a year or less, once a month or less, a few times a month, once a week, everyday). The quality outcome included three statements nursing care from excellent to poor on a 4 point likert type scale (e xcellent, good, fair, and poor); 2) ge their care upon A 5 point likert type scale ranging from very confident to not confident at all with the added option to indicate a not applicable response was used (very confident, confident, somewhat confident, not at all confi dent, and not applicable) and; confid ent are you that management will act to resolve problems in patient care that they

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64 report? A 4 point likert type scale from very confident to not confident at all (very confident, confident, somewhat confident, not at all confident) was used. The two sta t ements addressing safety used a (excellent), B (very good), C (acceptable), D (poor), or F (failing) and; s of point likert type scale from strongly agree to strongly disagree (strongly agree, agree, neither, disagree, strongly disagree) was used. Spearman correlation coefficient was conducted because it is a non parametric statistical analysis for determining a relationship (correlation) between ordinal and continuous data (Field, 2009). The assumptions for this test were met: variables lack normal distribution and were either ordinal, interval, or ra tio, and support a monotonic relationship, i.e. when one variable increase the other variable increases or decreases without a linear relationsh AIM 2 adverse events; hospital quality, and; safety. Kruskal Wallis correlation coefficient, a non parametric statistical analysis, provided the comparison among the ordinal variables: independent variable (education)and outcome variables (adverse events, hospi tal quality, and safety). The assumptions for Kruskal Wallis were met: variables lack normal distribution, dependent variables are ordinal level, and independent AIM 3 To reported adverse events; hospital quality, and; safety. Kruskal Wallis correlation

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65 coefficient, a non parametric statistical analysis, provided the comparison among the ordinal varia bles: independent variable (certification) and outcome variables (adverse events, hospital quality, and safety). The assumptions for Kruskal Wallis were met: variables lack normal distribution, dependent variables are ordinal level, and independent variabl es are two or more categorical independent gro statistics, 2013). AIM 4 To examine differences between nationally certified RNs with greater than 5 years of experience in RN reported adverse events, hospital quality, and safety as compared to n on certified RNs with the same years of experience Wilcoxon rank sum, a non parametric statistical test, addresses differences among ordinal groups (certified versus non certified) with unequal number of respondents (Fields, 2009). The assumptions for use this test were met: independent variable was categorical and contained two level (certified nurses with 5 years or more experience and non certified nurses with 5 or more years of experience), homogeneity of variance for the dependent variables, and lack of normal distribution for the dep endent variables (Munro, 200 9 ). AIM 5 To examine the effect of RN educational level on RN reported adverse events hospital quality, and safety. Ordinal logistic regression was used to evaluate the effect of RN educationa l level and certification status between groups of nurses (ordinal variables) with varied educational levels and certification status. The assumptions for ordinal logistic regression were evaluated and found to have no violations in linearity, independence of error, or multicollinearity (Field, 2009). The statistical analysis excluded the one doctoral respondent and addressed the educational levels of Diploma,

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66 the effects of e ducational levels to RN reporting of adverse events, hospital quality, and educational levels. AIM 6 To examine the effect of certification status on RN reported adverse events, hospital quality, and safety. Ordinal logistic regression was us ed to evaluate the effect of RN cert ification status between certified and non certified nurses (ordinal variables). As previously stated t he assumptions for ordinal logistic regressio n were met. To prepare data for logistic regression, the likert type scales were dichotomized into two categories: category 0 illustrating few to no patient care incidents while category 1 indicated potential or e xisting patient care incidents. Table 3 3 provides a listing of dependent variables, survey questions, likert type scale, and dichotomized categories used for logistic regression. RN reported adverse events were originally measured with a 7 point likert type scale that included categories of neve r, a few times a year or less, once a month or less, a few times a month, once a week, a few times a week, and every day. These possible responses were merged to category 0, few to no patient incidents (never, few times a year or less, and once a month or less) and category 1, potential or existing patient care incidents (a few times a month, once a week, a fe w times a week, and every day). The three quality outcome ques tions were also dichotomized. The nurse eral, how would you describe the quality of point Likert type scale from excellent (0) to poor (3). Responses were collapsed to category 0,

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67 few to no patient care incidents (excellent and good) and category 1, potential or existing patient care incidents (fair and poor). The nurse responded to the question, using a 5 point Likert type scale from (5) very confident to (0) not applicable. These responses were dichotomized to category 0, few to no patient incidents (very confident and confident) and category 1, potential or existing patient care incidents (somewhat confident, not confide nt at a ll and not applicable). Lastly, the nurse responded to a point Likert type scale indicating (0) not all confident to (4) very confident T he dichotomous categories were: category 0, few to no patient care incidents (very confident and confident) and category 1, potential or existing patient care incidents (somewhat confident, not confident at all and not applicable). Similarly the safety outcome responses were collapsed to two categories. The 5 point Likert type scale ranging from A (excellent) to F (failing). Responses were merged to the following 2 categories: category 0, few to no patient care incidents [(A (excellent), B (good), and C (acceptable)] and category 1, potential or existing incident s [D (poor), and F (failing)]. show that patient s point likert type scale ranging from stron gly agree to strongly disagree. Responses were merged to category 0, few to no patient care incidents (strongly agree, agree and neither) and category 1, poten tial or existing patient care incidents (disagree or strongly disagree).

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68 AIM 7 To determine if national RN certification moderates the relationship between years of RN experience and RN reported adver se events, hospital quality, and safety. There were no v iolations of ordinal logistic regression assumptions of linearity, independence of error, and multicollinearity Therefore, logistic regre ssio n was used in the analysis specifying an interaction effect which is the effect (on each outcome variable) of the combination of years of experience and certification. AIM 8 To determine if national RN certification moderates the relationship between educational level of the nurse and nurse reported adverse events, hospital quality and safety. Since there were no vio lations of the ordinal logistic regression assumptions, this statistical test was used in this analysis Logistic regression provided the interaction effect of educa tional level and certification and each outcome variable. Summary This chapter presented the study design, survey instrument, study aims and secondary data analysis procedures. The researcher reviewed the study variables and operational defin itions for this doctoral study. Further, the researcher proposed methods of statistical analysis for ea ch research question.

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69 Table 3 1. Concepts, operational definitions, and survey empirical indicators for NCQO The study uses the Multi State Nursing Care and Patient Safety Study Survey Construct Concept Operational definition/Survey Survey Empirical Indicator Demographic Characteristics Education Years of Experience Certification Nursing education which includes basic and/or additional academic degree completion beyond basic nurse education. ADN Associate Degree from a 2 year technical college Section A: Item #13 DIP Diploma degree from a 3 year hospital based diploma school Section A: Item #13 BSN Bachelor of Science in Nursing or academic degree of Bachelors in a related field Section A:Item # 13 MSN s in a related field Section A: Item #13 1 4 years 5 years or greater Number of years worked as a registered nurse in the US Section A: Item #8 Yes No Acknowledgment of successful completion of a national certification exam with evidence of meeting clinical practice criteria pertinent to the specific organizational requirements Section A: Item #14 Outcomes Nurse sensitive Outcomes Adverse events Indicating how often each of the following occur involving you or your patient (never, a few times per year or less; once a month or less; a few times a month; once a week; a few times a week; everyday): Wrong medication or dose Pressure Ulcers developed hospital acquired skin breakdown Patient falls with injury Physical restraint (vest/limb) device to restrict movement applied to chest/limbs) Physical restraint for 8 hours or more device to restrict movement for 8 hours Use of medication as restraint medication to restrict behavior or patient movement Section E: Item #6

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70 Table 3 1 Co ntinued Construct Concept Operational definition/Survey Survey Empirical Indicator Adverse events Healthcare related infections Surgical site infections Urinary tract infections Central line associated bloodstream infections Ventilator associated pneumonia Section E: Item #6 Quality Safety Nurse perception of quality of care on work unit: In general, how would you describe the quality of nursing care delivered to patients in your work setting? Excellent/good/fair/poor. Nurse confidence in patient caring for self How confident are you that your patients are able to ma nage t heir care when Very confident/confident/somewhat c onfident/not at all confident/not applicable Nurse confidence that management will act to resolve problems How confident are you that management will ac t to resolve problems in patient care that you report somewhat confident, not at all confident Nurse reported overall grade on patient safety P lease give your unit/practice area an overall grade on patient safety : A (excellen t); B (Very good); C (Acceptable); D (Poor); F (Failing) Patient safety as a top priority: Opinion that the actions of management show that patient safety is a top priority. Strongly agree, agree, neither, disagree, strongly disagree Section E: Item #1 Section E: Item #2 Section E: Item #3 Section E: Item #4 Section E: Item #5g

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71 Table 3 2. Study aims, variables, level of measurement, and statistical tests Study aims Independent(IV) and Outcome variables (DV) Level of measurement Statistical test 1. To explore the relationship between years of experience and RN reported adverse events (wrong medication or dose, pressure ulcers developed, falls with injury, use of physical restraints (vest or limb), use of physical restr aints for 8 hours or more, use of medication as a restraint, healthcare associated infections (surgical site, urinary tract, central line associated bloodstream and ventilator associated pneumonia); hospital quality (nursing quality of care, confident tha t patient is able to manage care when discharged, and confident management resolves patient care problems reported by the nurse), and safety (overall grade on patient safety, and management shows patient safety as a top priority. IV Years of experience DV Adverse events: wrong medication or dose pressure ulcers developed falls with injury use of physical restraint (vest/limb use of physical restraints for 8 hours or more use of medication as a restraint Healthcare associated infections: Surgical site urinary tract central line associated bloodstream ventilator associated Pneumonia DV : Quality Nursing quality of care Confident patient able to manage care when discharged Confident management will act to resolve patient care problems the nurse reports. DV : Safety Overall grade on patient safet y Actions of management show that patient safety is a top priority Continuous level (1 50) Continuous ratio level with range of 7 frequencies (never to everyday) Continuous ratio level with 4 point Likert type scale (excellent to poor) Continuous ratio level with 5 point Likert type scale (Very confident to not applicable) Descriptive statistics including mean, standard deviation, and range Spearman correlation coefficient 2. To examine differences betwe en and RN reported adverse events, hospital quality, and safety. IV : Level of education DV : Adverse events Quality Safety Ordinal/categorical (5 levels: DIP, ADN, BSN, MSN, PhD) Continuous ratio Kruskal Wallis

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72 Table 3 2. Continued Study aims Independent(IV) and Outcome variables (DV) Level of measurement Statistical test 3To examine differences between nurse certification status and RN reported adverse events, hospital quality, and safety. IV : National certification DV : Adverse events Quality Safety Dichotomous categorical/ordinal (Yes, No) Continuous ratio Kruskal Wallis 4 To examine differences between nationally certified RNs with greater than 5 years of experience in RN reported adverse events, hospital quality, and safety as compared to non certified RNs with the same years of experience IV : Years of experience IV : N ational certification DV : Adverse events Quality Safety Ordinal/categorical (4 levels: DIP, ADN, BSN, MSN) Dichotomous categorical/ordinal (0 or 1) Continuous ratio Wilcoxan Rank sum 5. To examine the effect of RN educational level on RN reported adverse events, hospital quality, and safety. IV : Level of education DV : Adverse events Quality Safety Ordinal/categorical (4 levels: DIP, ADN, BSN, MSN) Dichotomous categories (0 or 1) Ordinal logistic regression 6. To examine the effect of RN certification status on RN reported adverse events, hospital quality, and safety IV : National certification DV : Adverse events Quality Safety Dichotomous categorical/ordinal (0 or 1) Dichotomous categories (0 or 1) Ordinal logistic regression 7 To determine if national RN certification moderates the relationship between years of RN experience and RN reported adverse events, hospital quality, and safety IV : National certification DV : Adverse events Quality Safety Continuous ratio Dichotomous categories (0 or 1) Ordinal logistic regression 8 To determine if national RN certification moderates the relationship between education and RN reported adverse events, hospital quality, and safety IV : Level of educati on DV : Adverse events Quality Safety Dichotomous categories (0 or 1) Dichotomous categories (0 or 1) Ordinal logistic regression

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73 Table 3 3. Dependent variables, survey questions, likert type scale, and dic hotomous categories for logisti c regression Dependent Variable Survey question Likert type scale Dichotomous categories Adverse events Wrong medication or dose How often would you say each of the following incidents occurs involving you or your patients? Never A few times a year or less Once a month or less A few times a month Once a week A few times a week Everyday Category 0 = no patient care incident Category 1 = potential or existing incident. Pressure ulcers develop Patient falls with injury Use of physical restraints (vest or limb) Use of physical restraints for 8 hours or more Use of medication as a restraint Healthcare associated infections: Surgical site Urinary tract Central line associated Bloodstream Ventilator associated pneumonia Quality Quality of nursing care In general, how would you describe the quality of nursing care delivered to patients on your work setting? Excellent Good Fair Poor Category 0 = no patient care incident (Excellent and Good) Category 1 = potential or existing incident (Fair and Poor) Confident patient is able to manage care when discharged How confident are you that your patients are able to manage their care when discharged? Very confident Confident Somewhat confident Not at all confident Not applicable. Category 0 = no patient care incident (Very confident, Confident, Somewhat confident) Category 1 = potential or existing incident (Not at all confident, N ot applicable) Confident management will act to resolve problems in patient care How confident are you that management will act to resolve problems in patient care that you report? Very confident Confident Somewhat confident Not at all confident Category 0 = no patient care incident (Very confident, Confident) Category 1 = potential or existing incident (Somewhat confident, Not at all confident)

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74 Table 3 3 Continued Dependent Variable Survey question Likert type scale Dichotomous categories Safety Overall grade on patient safety Please give your unit/practice area on overall grade on patient safety. A(excellent) B (Very Good) C (Acceptable) D (Poor) F (Failing) Category 0 = no patient care incident [A(excellent, B (Very good, C (Acceptable] Category 1 = potential or existing incident [ D (Poor), F (failing)] Management actions show patient safety as a top priority The follow question asks for your opinion about patient safety iss ues in your work setting: The actions of management show that patient safety is top priority. Strongly agree Agree Neither Disagree Strongly Disagree Category 0 = no patient care incident (Strongly agree, agree, neither) Category 1 = potential or existing incident (Disagree, Strongly disagree).

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75 CHAPTER 4 RESULTS This chapter presents the results from the secondary analysis of the parent cross sectional survey data. The purpose of the study is to examine the relationship among years of nursing experience, national nurse certification, and educational level of the registered nurse and nurse reported adverse events, hospital quality, and safety. The study results also included analysis to determine whether national nurse certification in combination with years of experience and/or educational level affected the nurse reported adverse events, hospital quality, or safety Sample characteristics Table 4 1 provides a description of the study sample. The study sample consisted of 6515 direct ca re hospital nurses with 90.4 percent female who varied in age from 21 to 75 years of age with an average age of 44.1 years (SD = 11.4). Seventy five percent (75.3 % ) of the nurses were white with 7.7 percent Hispanic/Latin o. Nurses ranged from 1 year to 5 0 years of experience with a mean of 14.4 years (SD = 11.2). Respondents represented all nursing educational levels with the largest proportion of nurses having the highest educational degree as an Associate Degree (51.8 % ) followed by Baccalaureate Degre e (36.1 % ), Diploma (9.5 % ); Masters (2.6 % ), with only one respondent having a Doctorate degree (0.02 % ). Twenty five per cent (25 % ) of the nurses were certified in specialty practice recognized from the American Nurse Association or a national nurse spe cialty organization. While all hospital nursing units were represented, the largest respondent rates came from adult intensive care units (16.1 % ), medical surgical units (15.7 % ), and emergency department (9.6 % ).

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76 There were significant differences betw een certified and non certified nurses in all demographic categories except gender. Certified nurses were significantly older (46.9 years of age (SD = 10.5) with more years of experience (17.6 years of experience (SD = 11.4) as compared to non certified nu rses (43.2 years of age (SD = 11.5) and 13.3 years of experience (SD = 11.3) (p <.0001). The ma jority of certified nurses had Associate or B accalaureate degrees and work in adult intensive care units, medical surgical units, and the emergency department. T able 4 2 provides the demographic comparison between certified and n on certified registered nurses. AIM 1 To explore the relationship between years of experience and RN reported adverse events [ wrong medication or dose, pressure ulcers developed, falls with injury, use of physical restraints (vest or limb), use of physical restraints for 8 hours or more, use of medication as a restraint, healthcare associated infections (surgical site, urinary tract, central lin e associated bloodstream, and ventilator associated pneumonia ] ; hospital quality ( are able to manage the and safety ( opinion on the actions of m anagement show that patient safety is a top priority. ). Table 4 3 provides the findings for Aim 1. A significant negative relationship was found between years of experience and sel ect adverse events such that, as years of experience increase there was a decrease in the follow ing RN reported adverse events: pressure ulcers develop ment (p<.0001) ;

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77 patient falls with injury (p<.0001) ; use of physical restraints (vest or limb ) (p<.0001) ; use of physical restraints 8 hours or more (p<.0001) ; urinary tract infe ctions (p<.0001) ; and central line associated blood stream infections (p = .0007). There were significant relationships between years of experience and the following nurse reported outcomes: 1) quality of care delivered to patients in their work setting (p =.0016), 2) confidence that management would act to resolve problems in patient care that they reported (p<.001), and 3) the overall grade of patient safety (p=.0017) Nurses with higher years of experience reported higher quality of patient care and incr eased overall grade of patient safety when compared to less experienced nurses. However, they were less confident their managers would take action to resolve problems with their patients. Table 4 3 provides findings for AIM 1. AIM 2 To examine differences adverse events, hospital quality, and safety. A significant relationship was found across the four levels of RN education in the majority of outcomes. While overall RN reported low numbers of incidents of adverse events involving them or their patients, nurses with higher levels of education reported more incidents of use of physical restraints for vest or limb and use of r estraints for 8 hours or more involving them or their patients. Nurses with MSN degr ees reported less confidence that their patients were able to manage confidence that management will act to resolve problems in patient care that the nurse reports. Few as 4 provided the findings for AIM 2.

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78 AIM 3 reported adverse e vents, hospital quality, and safety. Certified nurses reported more use of physical restraints (8 hours or more) than non certified nurses (p= .00048). No differences were found between groups in other adverse events, hospital quality, or safety. Table 4 5 pro vides the findings for AIM 3. AIM 4 To examine difference between nationally certified RNs with greater than 5 years of experience in RN reported adverse events, hospital quality, and safety as compared to non certified RNs with the same years of experience. There was a significant difference between certified and non certified nu rses who worked 5 or more years in their reported use of physical restraints (8 hours or more) (p = .0247), such that, certified nurses with 5 or more years of experience reported more use of physical restraints (8 hours or more) than non certified nurses of the same years of experience. No differences were found with other adverse events, hospita l quality, or safety outcomes. Table 4 6 provides fi ndings for AIM 4 AIM 5 To examine the effect of RN education on RN reported adverse events, hospital qual ity, and safety after adjusting for certification. After adjusting for c ertification nurses with Diplomas had higher odds for reporting more use of physical restraints (8 hours or more) and higher numbers of health care associated urinary tract infections and higher odds of expressing lack of confidence in patient being able to manage their care after discharge and with management resolving problems i n the patient care that they report. Table 4 7 provi des findings for AIM 5

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79 AIM 6 To examine the effect of national certification status on RN reported adverse event s, hospital quality, and safety after adjusting for level of education. Certified Diploma nurses had a higher odds for reporting concerns with quality of nursing care delivered to patients in their work setting. They also had a higher odds of expressing the Table 4 8 prov ided findings for AIM 6 After adjusting fo r education, certification was a significant predictor of nurses reporting incidences occurring of patients receiving the wrong medication or medication dose involving them or their patients. Nurses w ho were certified had a higher odds of reporting incidences involving them or their patients of wrong medication or wrong dose given. Table 4 9 provides findings for AIM 6. AIM 7 To determine if national RN certification moderates the relationship between years of RN experience and RN reported adverse events, hospital quality, and safety. National RN certification was not found to moderate this relationship. AIM 8 To determine if national RN certification moderates the relationship between educational lev el of the nurse and RN reported adverse events, hospital quality, and safety. There was no significant interaction of certification and education indicating no moderation effect of certification on the relationship between education and nurse reported adverse events, hospital quality, or safety.

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80 Summary of findings A relati onship of years of experience with select adverse events, hospital quality and safety outcomes was found such that, as RN experience increase d, the nurse reported le ss adverse events [ pressure ulcers develop ment ; patient falls with injury; use of physical restraints (vest or limb); use of physical restraints 8 hours or more; urinary tract infections; and central line ass ociated blood stream infections ] These same nur ses described the quality of nursing care delivered to patient on their units as good to excellent and gave a B (very good) grade to their unit/practice areas of patient safety despite reporting less confidence that management would act to resolve patient care problems. Certification had little associati on on reporting of adverse events, hospital quality, or safety with the exception of reporting incidents for the use of physical restraints ( 8 hour s or more ) Nurses who were certified reported more use of physical restraints ( 8 hours or more ) and non certified nurses. Certified nurse had a higher odds of reporting incidences involving them or their patients of wrong medication or wrong dose given. Level of ed ucation had a significant association on reporting the majority of outcom es Diploma educated nurses stood out from other educational levels in reporting select adverse events (restraints 8 hours or more, restraints (vest/limb), and urinary tract infections) and having higher odds for reporti ng quality concerns ( quality of nursing ca re delivered to patients in their work setting, confidence that their patients are able to man age their care when discharged, and confidence that management will resolve problems in patient care. Lastly, Diploma n urses were less confident than other

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81 experience or education.

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82 Table 4 1. Description of sample (n = 6515) Variable Frequency ( percent ) Gender Female Male 5889 (90.5 percent ) 621 (9.5) Hispanic/Latino No Yes 5985 (92.2) 503 (7.8) Race White Filipino Asian Pacific islander Black/African/American American Indian Mixed race Other race 4903(75.3) 489 (7.5) 168 (2.6) 6 (0.1) 519 (8.0) 11 (0.2) 132 (2.0) 232 (3.6) Highest degree held in nursing RN Diploma Associate Degree Baccalaureate Degree Doctoral Degree 616 (9.5) 3356 (51.8) 2339 (36.1) 171 (2.6) 1 (0.01) Currently certified in specialty practice by ANA or ABNS Yes No 1629 (25.1) 4849 (74.9) Hospital unit representation Intensive care adult Medical Surgical Emergency Department Telemetry Outpatient Surgery (Operating Room) Labor and Delivery (L&D) Intermediate Care Neonatal intensive care Nursery Recovery Room Other 1012 (16.1) 987 (15.7) 601 (9.6) 498 (7.9) 395 (6.3) 359 (5.7) 358 (5.4) 298 (4.8) 270 (4.3) 267 (4.3) 223 (3.7) 1247 (16.3)

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83 Table 4 2. Comparison of certified to non certified nurses Variable Certified Nurses Frequency ( percent ) Non certified Nurses Frequency ( percent ) p value Gender Female Male 1494 (91.1 percent ) 135 (8.3) 4364 (90 percent ) 482 (10) p <.05 Hispanic/Latino No Yes 1519 (93.5) 106 (6.5) 443 (92) 396 (8.2) p <.03 Race White Filipino Asian Pacific islander Black/African/American American Indian Mixed race Other race 1302 (80.4) 87(5.4) 45 (2.3) 0 (0) 100 (6.2) 8 (0.5) 25 (1.5) 53 (3.3) 3573 (74.4) 400 (8.3) 120 (2.5) 6 (0.1) 416 (8.7) 3 (0.1) 107 (2.2) 179 (3.7) p <.0001 Highest degree held in nursing RN Diploma Associate Degree Baccalaureate Degree Masters Degree Doctoral Degree 197 (12.1) 776 (42.7) 580 (35.7) 74 (4.6) 0 (0.0) 415 (8.6) 2567 (53.2) 1750 (36.2) 96 (2.0) 1 (0.02) p <.0001 Hospital unit representation Intensive care adult Medical Surgical Emergency Department Telemetry Outpatient Surgery (OR) Labor and Delivery (L&D) Intermediate Care Neonatal intensive care Nursery Recovery Room Other units 266 (18.1) 188 (12.8) 171 (11.7) 77 (5.25) 81 (5.5) 143 (9.7) 113 (7.7) 43 (2.9) 78 (5.3) 63 (4.3) 59 (4.0) 486 (12.8) 736 (16.6) 794 (17.9) 429 (9.7) 420 (9.5) 311 (7.0) 214 (4.8) 223(5.0) 255 (5.7) 190 (4.3) 204 (4.6) 163 (3.7) 910 (11.0) p <.0001

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84 Table 4 3. Relationship of years of experience to nurse re ported adverse events, quality and safety Item N Spearman correlation coefficient p value Adverse events Patie nt received wrong medication or dose 6206 0.02 0.0913 Pressure ulcers develop 6217 0.10 <.0001 Patient falls with injury 6218 0.06 <.0001 Use of physical restraints(vest or limb) 6249 0.9161 <.0001 Use of physical restraints(8 hours or more) 6256 0.1250 <.0001 Use of medication as a restraint 6206 0.0006 0.9637 Health care associated infection Surgical site infection Urinary tract infection Central line associated bloodstream infection Ventilator associated pneumonia 5982 5924 5896 5674 0.0014 0.0517 0.0443 0.0039 0.9151 <.0001 0.0007 0.7710 Hospital Quality management will act to 6458 6140 6465 0.0393 0.0198 0.0648 0.0016 0.1235 <.0001 Safety show that patient safety is 6466 6450 0.0392 0.0245 0.0017 0.0503

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85 Table 4 4. Differences in RN educational level with RN reported ad verse events, hospital quality, and safety RN Diploma N = 616 Mean (SD) Associate Degree N= 3356 Mean (SD) Baccalaureate Degree N= 2339 Mean (SD) Degree N = 171 Mean (SD) p value Adverse events Patient received wrong medication or dose 587 1.7 (0.9) 3219 1.8 (1.0) 2260 1.8 (0.9) 164 1.9 (1.0) 0.2702 Pressure ulcers develop 583 1.6 (0.9) 3227 1.8 (1.0) 2266 1.7 (1.0) 165 1.7 (0.9) 0.0001 Patient falls with injury 586 1.6 (0.8) 3238 1.8 (0.9) 2253 1.7 (0.9) 165 1.7 (0.9) 0.0003 Use of physical restraints (vest or limb) 587 2.5 (1.6) 3251 2.8 (1.7) 2269 2.8 (1.8) 164 2.8 (1.9) < .0001 Use of physical restraints (8 hours or more) 588 2.1 (1.5) 3258 2.5 (1.7) 2272 2.5 (1.8) 164 2.5 (1.9) <.0001 Use of medication as a restraint 584 2.6 (1.8) 3236 2.7 (1.8) 2250 2.8 (1.8) 161 2.7 (1.9) 0.0276 Health care associated infection Surgical site infection Urinary tract infection Central line associated bloodstream infection Ventilator associated pneumonia 550 2.0 (1.0) 546 2.0 (1.0) 543 1.8 (1.0) 515 1.6 (1.0) 3118 2.1 (1.1) 3090 2.2 (1.2) 3071 1.9 (1.1) 2947 1.7 (1.0) 2184 2.1(1.1) 2159 2.2 (1.2) 2155 2.0 (1.0) 2091 1.8 (1.1) 156 2.2 (1.2) 154 2.4 (1.2) 153 2.1 (1.2) 144 1.9 (1.1) 0.1500 0.0001 0.0009 0.0034 Hospital quality of nursing care delivered to patients in your work able to man age their care when discharged? 608 1.8 (0.7) 575 2.3 (0.8 ) 3329 1.9 (0.8) 3162 2.4 (0.8) 2322 1.9 (0.8) 2212 2.4 (0.8) 166 1.9 (0.8) 161 2.5 (0.8) 0.0039 0.0045

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86 Table 4 4 Continued RN Diploma N = 616 Mean (SD) Associate Degree N= 3356 Mean (SD) Baccalaureate Degree N= 2339 Mean (SD) N = 171 Mean (SD) p value will act to resolve problems in patient care 609 2.5 (0.9) 3332 2.6 (0.9) 2327 2.5 (0.9) 166 2.6 (0.9) 0.0009 Safety patient safety is a top 609 2.1 (0.9) 608 2.3 (1.1) 3332 2.2 (0.9) 3322 2.5 (1.2) 2326 2.2 (0.9) 2321 2.3 (1.1) 167 2.2 (1.0) 167 2.4 (1.1) 0.0023 <.0001 Table 4 5 Differences between certified and non certified nurses in RN reported adverse events, hospital quality, and safety Not certified N = 4849 Mean (SD) Certified N = 1629 Mean (SD) p value Adverse events Patient received wrong medication or dose 4671 1.8 (0.9) 1557 1.8 (1.0) 0.3735 Pressure ulcers develop 4691 1.7 (0.9) 1548 1.7 (1.0) 0.1431 Patient falls with injury 4685 1.7 (0.9) 1555 1.7 (0.9) 0.9995 Use of physical restraints(vest or limb) 4713 2.8 (1.7) 1557 2.8 (1.8) 0.1064 Use of physical restraints(8 hours or more) 4714 2.5 (1.7) 1564 2.4 (1.8) 0.0048 Use of medication as a restraint 4682 2.7 (1.8) 1546 2.7 (1.9) 0.2655

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87 Table 4 5. Continued Not certified N = 4849 Mean (SD) Certified N = 1629 Mean (SD) p value Adverse events Health care associated infection Surgical site infection Urinary tract infection Central line associated bloodstream infection Ventilator associated pneumonia 4530 2.1 (1.1) 4493 2.2 (1.2) 4468 1.9 (1.1) 4286 1.7 (1.0) 1476 2.1 (1.1) 1454 2.2 (1.2) 1449 2.0 (1.0) 1406 1.8 (1.1) 0.0954 0.2342 0.4869 0.1039 Hospital quality management will act to resolve 4804 1.9 (0.7) 4590 2.4 (0.8) 4811 2.6 (0.9) 1614 1.9 (0.8) 1519 2.4 (0.8) 1620 2.6 (1.0) 0.8307 0.6747 0.3557 Safety Please give your unit/practice area an overall grade on patient 48 09 2.2 (0.9) 4802 2.4 (1.2) 1622 2.2 (0.9) 1616 2.4 (1.2) 0.8143 0.4864

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88 Table 4 6. Differences between certified and non certified nurses both with 5 or more years of experience to RN reported adverse events, hospital quality, and safety. Not certified N = 3402 Mean (SD) Certified N = 1404 Mean (SD) p value Adverse Events Patient received wrong medication or dose 3268 1.8 (0.9) 1340 1.9 (1.0) 0.4760 Pressure ulcers develop 3271 1.7 (0.9 1329 1.7 (1.0) 0.3741 Patient falls with injury 3269 1.7 (0.9) 1339 1.7 (0.9) 0.8982 Use of physical restraints(vest or limb) 3289 2.8 (1.7) 1338 2.7 (1.8) 0.0913 Use of physical restraints(8 hours or more) 3290 2.5 (1.7) 1346 2.4 (1.8) 0.0247 Use of medication as a restraint 3274 2.8 (1.9) 1330 2.8 (1.9) 0.1858 Health care associated infection Surgical site infection Urinary tract infection Central line associated bloodstream infection Ventilator associated pneumonia 3145 2.1 (1.1) 3111 2.2 (1.2) 3088 1.9 (1.1) 2947 1.8 (1.1) 1258 2.1 (1.1) 1236 2.2 (1.2) 1232 1.9 (1.1) 1192 1.8 (1.1) 0.1442 0.5670 0.7054 0.5672 Hospital quality nursing care delivered to patients in your work to resolve probl ems in patient care that your re 3366 1.9 (0.80 3199 2.4 (1.8) 3368 2.6 (0.9) 1392 1.9 (0.8) 1306 2.4 (0.8) 1397 2.6 (1.0) 0.741 0.8658 0.8566

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89 Table 4 6. Continued Not certified N = 3402 Mean (SD) Certified N = 1404 Mean (SD) p value Safety overall grade on patient safety is a top priority 3368 2.2 (0.9) 3364 2.4 (1.2) 1398 2.2 (0.9) 1393 2.4 (1.2 0.8508 0.9031 Table 4 7. Odds ratio indicating the effect of education on nurse reported adverse events, hospital quality, and safety. Category OR 95 percent CL P value Adverse Events Education impact : Restraints (vest/limb) Nursing degree 0.0100 Certification 0.0074 0.66 (0.45, 0.96) 0.0014 0.92 (0.65, 1.29) 0.30 0.92 (0.66, 1.3) 0.26 Education impact : Restraints (8 hours or more) Nursing degree 0.001 Certification 0.972 0.64 (0.42, 0.96) 0.0003 0.97 (0.68, 1.39) 0.16 1.01 (0.70, 1.46) 0.04 Urinary tract infections Nursing degree 0.005 Certification 0.28 0.48 (0.28, 0.81) 0.0004 0.83 (0.53, 1.29) 0.21 0.81 (0.02, 1.2) 0.41 Hospital quality Nursing degree 0.009 Certification 0.431 0.66 (0.46, 0.93) 0.01 0.82 (0.60, 1.13) 0.46

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90 Table 4 7. Continued Category OR 95 percent CL P value 0.72 (0.52, 1.00) 0.12 Nursing degree 0.03 Certification 0.43 0.80 (0.57, 1.13) 0.11 0.97 (0.71, 1.33) 0.16 0.85 (0.62, 1.17) 0.29 Safety Nursing degree 0.0001 Certification 0.40 0.79 (0.55, 1.13) 0.11 1.01 (0.73, 1.40) 0.02 0.80 (0.57, 1.10) 0.05 Table 4 8. Odds ratio indicating the association of education and certification on RN reported adverse events, hospital quality, and safety. Category OR 95 percent CL P value Quality statement: In general, how would you describe the quality of nursing care delivered to patients in your work setting? Nursing degree 0.013 Certification 0.040 0.65 (0.42, 1.00) 0.003 0.96 (0.66, 1.40) 0.12 0.90 (0.61, 1.32) 0.55 Tab le 4 9. Odds ratio indicating the association of certification on RN reported adverse events, hospital quality, and safety. Certification impact: Wrong med or dose Nursing degree 0.1006 Certification 0.0074 0.45 (0.23, 0.91) 0.03 0.71 (0.40 1.25) 0.63 0.63 (0.36, 1.13) 0.61

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91 CHAPTER 5 DISCUSSION AND IMPLI CATIONS This study explored the relationship of three nurse characteristics of the registered nurse (years of nursing experience, national nurse certification, and educational level) and their effect on nurse reported adverse events, hospital quality, and safety. This study also in cluded an analysis of the impact of national nurse certification in combination with years of experience and education on nurse reported adverse events, hospital quality, and safety. This chapter presents a discussion of the study findings and conclusion o f results by nurse characteristic (years of experience, national nurse certification, and level of education) followed by a critique of study strengths and limitations. Lastly, this section will provide a discussion of implications for nursing practic e, th eory, and future research. Study R esults Sample D escription Although the sample is limited to one state (Florida) the demographic characteristics are similar to national statistics for registered nurses in age, race, and gender. National RN statistics indi cate the typical RN is 41 45 years of age, white, and female (Health Resource and Service Administration, 2013). The RNs in this study averaged 44.1 years of age, were white, and female with 14.4 years of experience. Certified nurses represented 25 perce nt than national average (17.1 percent ) (Collins, 2006; Wilkerson, 2011). Certified nurses in this study were significantly older and more experienced than the average nurse (46.9 years of age with 17.6 years of experience respectively). The educational level of the RN in this study differed from national levels in all categories: Diploma Degree 9.5

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92 percent in this study as compared to 6.9 percent nationally; Associate Degree 51.8 percent in this study v 37.9 percent nationally; Baccalaureate degree 36.1 percent in this study v 44.6 percent nationally; and Masters 2.6 percent in this study v 8.6 percent nationally (U.S. Health Resources and Service Administration, 2008). Florida has more nurses with the Associat e Degree as the highest educational level with lower percentages of BSN or higher education than national percentages (Florida Center for Nursing, 2010; Neff, Cimio tti, Heusinger, & Aiken, 2011). Nurse Characteristic: Years of E xperience This study found a significant relationship between years of e xperience and nurse reported select adverse events [ pressure ulcer develop, patient falls with injury, use of physical restraints (vest/limb), use of physical restraints (8 hours or more), urinary tract infection s, and central line ass ociated blood stream infections ] such that, as years of experience increased, nurse reporting of sel ect adverse events decreased. These findings are consistent with other research where years of experience were found to be related t o falls, pressure ulcers, and urinary tract infections : as years of experience increased these outcomes decrease d (Dunton, Gajewski, Klaus, & Pi erson, 2007 ; Kendall Gallagher & Blegen, 2010). However, Kendall Gallagher and Blegen (2010) found that years of RN experience was not related to central line associated blood stream infections. T knowledge t here is no published research examining the relationship of years of ex perience and use of restraints. This study found as years of experience increased, nurses reported increased quality of care in their work setting and an overall grade of patient safety on their unit/practice setting increased. In contrast, as years of RN experience increased, the level of confidence that the manager would act to resolve problems reported by the

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93 nurse decreased. management while reporting a high rate i n quality of care contradicts other research where nurses reported trust and confidence in management and also reported high unit quality of care outcomes and less adverse events ( Wong & Giallondardo, 2013 ). Further, Mullarkey, Duffy, and Timmons (2011) as sert a trusting relationship between employees and management supports a healthy work environment enhancing staff retention and effective patient care. Th e difference in findings may be a result of sample size and unit representation. The current study ha d a larger sample size (n= 6515) with a broader representation of ho spital nurses (all hospital units providing direct patient care) as opposed to medical surgical and critical care units. In addit ion, m anager s are able to interact more readily with staff in smaller, specialized units. The theoretical model for this study, Nursing Characteristics Affecting Quality of Care (NCQO), did not address interaction s between manager s and employee s which was a component of the process construct in the parent model, Process of Care Outcome Model (Aiken et al., 2002a). Nurse Characteristic: National Nurse C ertification National nurse certification provides formal recognition of clinical practice and knowledge The certification process requires proof of strong clinical skills, continuing education, and completion of a certification exam that tests knowledge and critical thinking in the nursing specialty. Each nurse specialty req uires periodic evaluation of clinical practice and current continuing education in order to maintain active certification The Institute of Medicine and key influential nursing associations [ American Association of Certified Nurses (AACN) American N urses Association (ANA) and American Nurses Credentia ling Center (ANCC)] credit the

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94 certified nurse as functioning at a higher clinical and knowledge level than the non certified nurse ( AACN, 2014, ANA, 2014, IOM, 2011 ). Further, certified nurses have gr eater clinical competency and knowledge than non certified nurses ( Coleman et al. 2009; Zulkowski et al. 2007 ). This study found only one difference between certified and non certified nurses in nurse reported outcomes Certified nurses reported more us e of restraints (8 hours or more) than non certified nurses. In addition, this study explored differences between certified and non certified nurses with 5 or more years of experience. In other studies 5 years was identified as the time frame to achieve ex pert nurse status (Atencio et al. 2003; Azzarello, 2003; Blegen et al. 2001: Burritt & Steckel, 2009; Dellon et al. 2009; James et al. 2003; Morrison et al. ,2001; Orsolini Hai n & Malone, 2007; Taylor, 2002). Certified nurses with 5 or more years of exp erience reported more incidents of use of restraints (8 hours or more) than non c ertified nurses with the same expe rience. O nly one other study exploring the se relationship s of certification and use of restraints consistent. Boltz et al. (2013) did not find a relationship between certification and use of physical restraints medical surgical units and used quarte rly unit level quality indicators as opposed to this study that used nurse reported outcome survey data and involved all patient care units, including intensive care units. B oth certification and Diploma level of education significantly affected nurse re ported quality of nursing care delivered to patients Certified Diploma nurses had higher odds for reporting conce rns for quality of nursing care Diploma educated nurses have more clinical experience in their educational program than other nursing program s

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95 (Black, 2014). They are frontline clinicians providing direct patient care. One explanation for this finding may be that cert ified Diploma nurses may be more attuned to quality issues based on their patient care exposure, strong clinical experience and expert knowledge. This finding also supports a relationship between cer tification and education depicted in the theoretical model (NCQO). T his study found that certification had an association on nurse reported incidents of the use of restraints for them or their patients more than other nurse characteristics (years of experience or education). Although health care policies limit the use of restraints, other studied found the decision to use physical re straints continues to be based on experience and individual judgment using patient safety as the primary reason for restraint use (Amato, Salter, & Mion, 2006; Boltz, Capezuti, Wagner, Rosenberg, & Secic, 2013). The use of physical restraints in this stud y suggests that the experience and expert knowledge of certified nurses may contribute to better surveillance skills and higher sensitivity for patient safety concerns. outcome variables may be a result of the specialization focus for each national nurse certification. The specialty certification and recertification process concentrates on knowledge and clinical skills parti cular to the specialty unit, e.g complications and us e of invasive monitoring evident in Critical Care certification (CCRN), knowledge and precautionary care of chemotherapy agents in Oncology certification (OCN), etc. T his study reviewed generic hospital adverse events, quality, and safety variables which may not be the primary focus of care in par ticular nursing specialty units.

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96 Nurse Characteristic: Level of E ducation A significant relationship was found across all levels of nurse education with the majority of outcomes. For example, Diploma nurses had hi gher odds for reporting use of restraints (8 hours or more and vest or limb) and health care associated urinary tract infections and were less confident that their managers would help to resolve problems finding may be that during their educational programs, Diploma nurses have more clinical experience providing direct patient care than nurses who graduate d from other undergraduate programs (Black, 2014). Diploma education, established in 1872 as the olde st nursing educational level involved a three year hospital based nursing program that provided nursing courses in concert with substantial clinical hours providing patient care in the hospital setting Despite a peak of over 2000 programs in the (Black, 2014), h ospital economic c onditions and competition with Baccalaureate and A ssociate degree education forced reduction in program length (24 months) and closure of schools. Today there are 36 US Di ploma schools accredited by the Accreditatio n Commission for Education in Nursing (ACEN, 2013). Associate Degree (ADN) nurses also were less confident in their management to resolve reported patient problems. Additionally, they reported that based on the actions of their management, they were not c onfident that patient safety was a top priority in their institution. ADNs, as frontline direct care providers, may have minimal exposure or interaction with management affecting their confidence in management. Research on frontline nurses found staff nurs es are concerned with immediate action and resolution on patient care problems and perceive management as distant from patient care and more concerned with administrative and financial issues (Aronson et al. 2013; Rouse,

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97 2009). The direct care provider r elates well to an authentic or transformational leadership style where the immediate manager is visible, transparent, and willing to actively pursue staff nurse concerns (Aronson et al. 2013; Casida, & Parker, 2011; Rouse, 2009; Wong, Laschinger, & Cummin gs, 2010). BSN prepared nurses reported greater frequencies of incidents in the use of physical restraints (8 hou rs or longer and vest or limb) and medication as restraint s involving their patients These findings differed from Boltz et al. (2013) who f ound no relationship with BSN educational level and use of restraints ( vest or limb). As described above, the current study included nurse reported survey data from all patient care area whereas Boltz and colleagues (2013) examined retrospective outcome da ta from only medical su rgical units and referenced only use of vest or limb restraints with no time frame on restraint usage or application. Master prepared nurses (MSN) were less confid ent in the ir patient s ability to manage their care when discharged a nd also in their nurse reported patient care problems. MS N prepared nurses critically evaluate issues in health care and nursing practice and in their educational programs receive organizational and system leadership educati on (AACN, 2014 ). There may be several explanations for these findings. The MSN prepared nurse may be more educated than their unit manager and have more knowledge of leadership principles and organizational processes. In addition, the MSN as a direct p atient care provider, may patient care problems. As previously mentioned, the theoretical model (NCQO) does not

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98 address the process of ca re construct which would focus on interac tions and follow through on clinical issues brought to management Moderation Effect of Certification on Years of Experience and E ducation Since certification is a national nurse recognition of expert clinical practice and specialty kn owledge, this study prop osed certification may influence the effect of years of experience or level of education with nurse reported adverse events, hospital quality, and safety. There was no moderation effect of certification on either years of experience or education. Although certified nurses were significantly more experienced than non certified nurses (17.6 years of experience as compared to 13.3 years of experience), the overall years o f experience for both groups were already above recognized expert levels (5 years or more) (Atencio, Cohen, & Gorenberg, 2003; Azzarello, 2003; Blegen,Vaughn, & Goode, 2001: Burritt & Steckel, 2009; Dellon et al. 2009; James, S impson, & Knox, 2003; Morrison et al. (2001); Orsolini Hain & Malone, 2007; Taylor, 2002) w hich could negate any influence certification might add to nurse reported outcomes. Another possible factor was there was little variation in the levels of education of certified nurses: approximately 80 percent of certified nurses had either associate or baccalaureate degrees. Therefore, the effects of certification were moot. This study is the first attempt to study certification as having a moderation effect on nurse characteristics. Strengths and Limitations of the Study The strengths of the study inc lude d the use of a large data base (n= 6515) from the parent study, Multi State Nursing Care and Patient Safety Study The study was conducted by Donna Felber Neff, PhD and colleagues who have an established research history on nursing workforce issues, impacts on practice environment s, and

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99 hospital quality (Aiken et al. 2011; Everhart, Neff, Al Amin, Nogel, & Weech Maldonado, 2013 ; Neff et al. 2011 ). Other strengths of the study include d : me asurement integrity of a one time survey completion; use of stable variables with standard definitions readily known to direct care RNs (Farquhar, 2008); previous literature and research supporting the relationship of nurse sensitive outcomes, quality, a nd safety to education, years of experience, and natio nal nurse certification (Blegen et al. 2001, Blegen et al. ,2013, Cary, 2001,Coleman,et.al, 2009, Kendall Gallagher & Blegen, 2009); and lastly, the survey tool, variables, and proposed conceptual frame work, Nursing Char acteristics of Quality Outcomes (NCQO). The limitations of this study are inhere nt with a secondary analysis. This study relied on the parent survey data base a convenience sample from one state (Florida) with data collected from registe red nurses licensed and working at the time of the survey. Although a convenience sample is often used in health care research, the sample may not represent a true population limiting the ability to generalize the find ings (Portney & Watkins, 2009). This study is prone to bias of self selection, hidden bias, and insufficient numbers of respondents from selected nursing structures. Bias of self selection occurs with self reported data from nurses who choose to participate in the survey. Although several stu dies confirm reliability of nurse reported and nurse recall data, bias of selection is still evident when nurses choose to participate in the survey process (Gerolamo, 2 008; McHugh & Stimpfel, 2012). Hidden bias ensues when certain groups are excluded from the study. However, the sample of nurses from the parent study were randomly selected from the Florida Board of Nursing database. Therefore, bias and underrepresentation were minimized

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100 A major threat to reliability through two types of measurement error: random error and systematic error Random error occurs when u npredictable environmental or personal factors affect the individual completing the survey. Fatigue, inattention, noise, and external distractions are examples of random errors affecting reliabi lity. Although random errors are a potential for this study, the large sample size should diminish any negative impact from random error (Portney & Watkins, 2009). Systematic error occurs when there are biases in the measurement or survey tool. The instru ment needs to have items that measure a single underlying trait, i.e. the items nee ds to be internally consistent. established instruments having recommended levels of 0.80 or gre ater (Hi ggins & Straub, 2006). T he measures used in this study have no history or calculation of e events, the quality questions, or the overall evidence of reliabil ity (Youngblat & Casper, 1993). In addition, this researcher had no ability to clarify statements or questions pertinent to this study and had to rely exclusively on verbiage and rating previous esta blished with the parent study and in prior studies conducted by Aiken and colleagues. The proposed research model, Nursing Characteristics Affecting Quality Outcomes (NCQO), explores how three personal nurse characteristics (years of experience, level of education, and national nurse certification), functioning as nursing structures, impact care and outcomes. This study only addresses nurse reported outcomes grouped by specific nurse characteristics (structures) and fails to address other variables in the

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101 Process of Care Model (POCM). For example, findings related to differences in process of care based on nurse characteristics are not addressed in the theoretical model. Finally, thi s study is unable to examine a causal relationship between nursing structures (years of experience, level of education, and national nurse certification), process of care, and nurse reported outcomes. Implications Implications for Nursing P ractice The fi ndings i n this study support the need for additional research to examine the effect of years of experience on adverse events, hospital quality, and safety. Nurses 50 years of age and older comprise 55 percent of the RN workforce providing 38 percent of the direct patient care in the acute care setting (Norman, et.al, 2005; Nursing Shortage Fact Sheet, 2014). A primary concern of hospital operations is the potential retirement of the older nurse with the exit of knowledge, skills, and judgment pivotal to pro viding quality patient care (Sherman, 2008 ). There is opportunity to better understand the process through which experience affects particular outcomes. In addition, research is needed to assess the impact of the level (novice, beginner, advanced, competen t, and expert) and type of experience on Lastly, hospital administrators and nursing leaders need to identify and support strategies to address the potential exit of the experienced nurs es from the acut e care setting. This study found a relationship between educational level and lack of trust and confidence in management. The IOM and nursing focus on increasing the educational level of the nurse supports the need to investigate how the educational level of the nurses af fects management interaction, communication, and trust. In addition, studies

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102 exist on the relationship of educational level to mortality and failure but few studies explore the impact of educational leve l on nurse sensitive outcomes. There is a need to confirm the impact of certification on nurse sensitive outcomes, hospital quality, and safety. There are limited studies exploring the effect of certification on patient care outcomes and specifically nurse sensitive outcomes affecting hospital reimburseme nt (hospital acquired infections, urinary tract infections, central line bloodstream infe ctions, and pressure ulcers ). In addition, the certification requirements for clinical experience, continuing education, and recertification differ based on the specia lty organization. More research is needed to und erstand if and how specialty certification differences affect patient outcomes Lastly, this study found nurses continue to report use of restraints (8 hours or more, vest and limb, and medication as a restra int). There are limited studies exploring the use of restraints in the acute care hospital setting. While studies may suggest need to explore evidence based practic e for use of restraints in supporting patient safety There is also an opportunity to review how regulatory guidelines a nd organizational policies coincide with staff nurse application and use of restraints. Implications for T heory The proposed research model, Nursing Characteristics Affecting Quality Outcomes (NCQO), is an adaptation of the Process of Care Model ( POCM ) and originates from the sociological perspective that social structures affect how individuals act or process information in order to acc omplish a particular o utcome or social consequence. The POCM depicts a relationship between nursing s tructure, process, and outcome. This study explored the impact of nursing structure on nurse reported

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103 outcomes with no intent to address the process of car e. Future research is needed to explore how specific nursing structures (years of experience, level of education, and national nurse certification) affect the process es of care and its relationship to patient care outcomes. Expanding the theoretical model (NCQO) to include the process construct provides a forum for studying how each nursing characteristics affects the process of care leading to patient outcomes. The process construct, evident in the POCM (Aiken et al., 2002a) includes individual nurse processing of information, as well as, organizational system influences that affect care. ability to manage information effect ively in order to interact in the organizational setting and impact patient care. More research is needed to explore if and how the process of care changes based on the influence of one or more nurse characteristics. For example, e ducational level s in nurs ing differ in theory and clinical exposure yet nurses from all four educational levels may work together on the same nursing unit providing basic patient care. There are no studies that clearly define differences in assignments, patient care delivery, or m anagement expectations based on the educational level. Understanding how educational level of the nurse affects the process of care may help to identify differences in pa tient care delivery and outcomes. Similarly, t he IOM (2011) supports national nurse c ertification as a mechanism to assure clinical competence of the nurse yet no research is available to show how clinical competence influences the process care Lastly, the level, type, and length of clinical experience m ay impact how a nurse manages info rmation, intervenes in clinical situations, and affects patient outcomes.

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104 Adding a process of care construct to the theoretical model (NCQO) may provide a more expansive view on how the process of care for each nurse characteristics a ffected differences in nurse reported events. T his research addresses years of experience, certification, and education as social structures in nursing. Social structures support socialization that contributes to basic processes, such as role development, role identity, va lues, beliefs, expectations, and self concept (Grecas & Burke, 1995). While years of experience is more dependent on the individual maintaining clinical practice, education and certification may be affected by structural forces in the hospital setting that contribute to or negate ability for a nurse to achieve higher education or national nurse certification. Research is needed to better understanding the se barriers In addition, this study address ed the influence of nursing structures on groups of nurses For example, the study examined how BSN nurse reported data differed from ADN nurse reported data or how certified nurses reported outcomes differently than non certified nurses. It may be just as important to explore how these nursing structures influenc e the individual nurse and how those influences affect individual personality outcomes essential to nursing assessment and evaluation of patient care. For example, does the BSN education affect the individual e events or potential quality concerns? Implications for Future R esearch Research exists on the impact of a health y work environment on nurse retention, nurse satisfaction, and health care provider communication (Aiken et al. 2002 a; AA CN, 2014; Manojlovi ck & DeCiccio, 2007). Boyle (2007) found that strong nurse manager support in the cr itical care unit reflected in decrease d prevalence of pressure ulcers and death Wong, Cummings, & Ducharme (2013) conducted a systematic review of

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105 research on the relationship of leadership style to patient o utcomes and found contradictory results with use of various type s of leadership style and their impact on patient o utcomes The review examined 20 studies totaling 43 relationships between leadership and patient outcomes. While p ositive relational leadership styles (transformational, authentic, or servant) had the greatest impact on decreasing adverse events (63 percent ), some studies showed no effect on patient outcomes based on leadership style. In addition to examining the impact of leadership style on patient outcomes, t here is also a need to better understand how manager support differs from or adds to trus t and confidence in management. Few studies explore frontline nurse perceptions of management and manage ment response to patient care concerns. Therefore, opportunities exist for future research on the role of management in supporting a healthy work environment and more specifically how management support and trust and confidence in management affects nurse sensitive outcomes and quality patient care. Conclusion This study sought to explore the impact of years of experience, national nurse certification, and level of education of the registered nurse on nurse reported adverse events, hospital quality, and safety. Something of interest was discovered. N urse characteristic s, years of experience, certification, and level of education affected a different perspective in care based on the nurse reported outcomes. Years of experience had an effect on report ed i ncidents of adverse e vents affecting physiological outcomes (pressure ulcer development, falls with injury, urinary tract infections, and central line associated blood stream infections). Certification had an effect on nurse reported outcomes affecting patient safety ( use of restraints ). Lastly, level of education,

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106 specifically Diploma educated nurses, had an effect on reporting concerns for quality of nursing care and ability of patients to manage their care upon discharge. Studying the impact of nurse characteristics contributes to understanding how they patient care. Although the basic educational level of the nurse provides the foundation for nursing practice, year s of ex perience may be the characteristic that has the greatest influence on the nurse and patient A nurse acc umulates experience over time in the work setting and uses that experience to compliment higher education and/ or national nurse certification. This stu dy provided additional information on the value of years of experience as it applies to nurse reporting and incidents of patient care, showing as years of experience increased there were fewer reported patient adverse eve nts and quality concerns While th e IOM (2011) advocates for national nurse certification as a mechanism to assure continued competency, this study found certification as the least important nurse characteristic for reporting incidents of adverse events, hospital quality, or safety. Theref ore, future studies are needed. The role of the registered nurse in providing safe efficacious care may depend on the key characteristics, such as, what type of educational program he/she attended, how long has he/she been working in the acute care setting and what is the evidence of his/her expertise (e.g. certification status)? Dissemination of the results of this study to nurse leaders and hospital administrators is important to help them appreciate the l of education, and national nurse certification and how these may impact patient outcomes.

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107 Opportunities exist to publish the findings in nursing administra tion and/or management journals. In addition, presentations at nursing research forum s will add to dissemination of information, as well as, encourage dialogue between nurse researchers. Lastly, this researcher is able to present study findings at hospital organizational settings to nurse leaders and clinicians which may foster extended re lationships.

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108 APPENDIX SURVEY

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121 LIST OF REFERENCES Accreditation Comm ission for Education in Nursing (2013). Accredited programs. Retrieved from http://www.acenursing.org/accredited programs/programSearch.html. Aiken, L.H., Clark e, S. P, & Sloane, D.M. (2002 a ). Hospital staffing, organization, and quality of care: Cross National findings. Nursing Outlook, 50 187 194 doi: 10.1067/mno.2002.126696. Aiken, L.H., Clarke, S. P, Sloane, D.M., Sochalski, J, & Silber, J.H. (2002 b ). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987 19 93. Aiken, L.H., Clarke, S. P, Cheung, R. B., Sloan e, D.M, & Silber,J.H.(2003).Educationa l levels of hospital nurses a nd surgical patient mortality. JAMA, 290 (12), 1617 1623. Aiken, L.H., Clarke, S. P, Sloane, D.M, Lake, E. T., & Cheney, T. (2008). Effects of hospital c are environment on patient mortality and nurse outcomes. JONA, 38( 5), 223 229. Aiken, L.H., Cimiotti, J.P., Sloane, D. M., Smith, H.L., F lynn, L., & Neff, D.F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with differ ent nurse work environments. Medical Care, 49 (12), 1047 1053. Albanese, M. P., Evans, D. A., Schants, C. A., Bowen, M., Moffa, J. S., Piesieski, P., & P olomano, R. C. (2010). Engaging clinical nu rses in quality and performance improvement activities. Nur sing Admin i strative Quarterly, 34 (3), 226 245. Amato, S., Salter, J.P. & Mion, L.C (2006). Physical restraint red uction in the acute rehabilitation setting: A quality improvement study. Rehabilitation Nursing, 31 (6), 235 241. American Association of Colleges of Nursing (2014). Masters Nursing programs. Retrieved from http://www.aacn.nche.edu/educ American Association of Critical Care Nurses (March, 2 003). Safeguarding the patient and the profession: the value of critical care nurse certification (White Paper). American Journal of Critical Care, 12 (2), p 154(11). American Association o f Critical Care Nurses (2014 ). Initial CCRN certification Retrieved from http://www.aacn.org/wd/certifications/content/initial ccrn certification pcms?menu=#Changes Accessed February 12, 2013

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122 American Board of Nursing Specialties ( 2006). American Board of Nursing Specialities Retrieved from http://www.nursingcertification.org/pdf/white_paper_final_12_12_06.pdf. American Board of Nursing Specialties (2009 a ). Freq uently asked questions. Retrieved from http:// www.nursingcertification.org /accreditation faqs.html American Board of Nursing Specialties (2009 b ). History. Retrieved from http:// www.nursingcertification.org /about.html. American Nurse Association (2011). Fact sheet: Registered nurses in the US. Retrieved from http://www Nursingworld.org/nursingbynumbersf actsheet. Anonson,J., Walker, M.E., Arries, E., Maposa, S., Telford, P., & Berry, L. (2013). Qualities of exemplary nurse leaders: perspectives of frontline nurses. Journal of Nursing Management, 22 127 136. Atencio, B. L., Cohen, J., & Gorenberg, B. ( 2003). Nu rse retention: Is it worth it? Nursing Economics, 21 (6), 262 299. Azzarello, J. (April, 2003). Knowledge structures and problem representations: How do Novice and Expert Home Care nurses compare? Southern Online Journal of Nursing Research, 2 (4 ), 1 26. Bekemeier, B. (2007). Credentialing for Public Health Nurses: Personally valued but not recognized. Public Health Nursing, 24 (5), 439 448. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice Menlo Park: Addison Wesley Benner, P., & Tanner, C. (1987). Clinical judgment: Ho w expert nurses use i ntuition. American Journal of Nursing, 87 (1), 23 31. Bergquist Beringer, S. Gajewski, S, Dunton, N.& Klaus, S. ( 2011). The reliability of the National Database of Nursing Quality indicators pressure ulcer indicator: A triangulation approach. Journal of Nursing Care Quality (?), 1 10. doi: 10.1097/NCQ.06013e3182169452 Biel, M. (2007). Infusion nursing certification. Journal of Infusion Nursing 30 (6), 332 338. Bl ack, B. P., (2014). Professional Nursing: Concepts and challenges St. Louis, Missouri: Elsevier. Blegen, M.A., Goode, C. J. & Reed, L. (1998). Nurse staffing and patient outcomes. Nursing Research, 47 (1), 43 50.

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123 Blegen, M. & Vaughn, T. (1998). A Mu ltisite study of nurse staffing and patient occurrences. Nursing Economics, 16 (4), 196 203. Blegen, M., Vaughn, T.E., & Goode, C.J. (2001). Nurse experience and education: Effect on quality of care. JONA, 31 (1), 33 39. Blegen, M.A., Goode, C. J., Park, S .H., Vaughn, T., & Spetz, J. (2013). Baccalaureate education in nursing and patient outcomes. Journal of Nursing Administration 43 (2), 89 94. doi: 10,1097/NNA.Ob013e31827f2028. Boltz, M.,Capezuti, E., Wagner, L. Rosenberg, M., & Secic, M. (2013). Pat ient safety in medical surgical units: Can nurse certification make a difference? Med Surg Nursing, 22 (1), 26 37. Briggs, L.A., Brown, H., Kesten, K., & Heath, J. (2006). Certification a benchmark for critical care nursing excellence. Critical Care Nur se 26 (6), 47 53. Buerhaus, P.I., Staiger, D. O., & Auerbach, D. I. (2009). The future of the nursing workforce in the United States: D ata, trends, and implications. Sudbury, Massachusettes: Jones and Bartlett Publishers. Burritt, J. & Stechel, C. (2009). Supporting the learning curve for contemporary nur sing practice. Journal of Nursing Administration, 39 (11), 479 484. Byrne, M, Valentine, W., & Carter, S. (2004). The value of certification --a research journey. AORN Journal, 79 (4), 825 828. Ca ry, A.H. (2001). Certified Registered Nurses: Results of the study of the certified workforce. AJN, 101 (1), 44 52. Casida, J. & Parker, J. (2011). Staff nurse perceptions of nurse manager leadership style and outcomes. Journal of Nursing Management, 1 9 478 486. Choudhry, N.K., Fletcher, R. H., & Soumerai, S. B. (2005). Systematic review: The relationship between clinical experience and quality of health care. Annual of Internal Medicine 142 260 273. Clarke, S.P. Rockett, J. L. Sloane, D. M., & Aiken, L. H. (2002). Organizational climate, staffing, and safety equipment as predict ors of needlestick injuries and near misses in hospital nurses. American Journal of Infection Control, 30, 207 216. doi 10.1067/mic.2002.123392. Coleman, E. A. Coon S.K,, Lockhart, K., Kennedy, R. L., Montgomery, R. Copeland, N., McNatt, P., Savell, S., & Stewart, C.(2009). Effect of certification in oncology nursing on nursing sensitive outcomes. Clinical Journal of Oncology Nursing, 13 (2), 165 172.

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124 Collins, S E. (March, 2006). Collins on current issues: Specialty certification in nursing: A hallmark of excellence. The Pennsylvania Nurse 5 and 33. Considine, J., Botti, M., & Thomas, S. (2007). Do knowledge and experience have specific roles in triage decis ion making? Acad Emerg Med 14 (8), 722 726. Dellon, E. S. Lippmann, Q.K., Galanko, J.A., Sandle r, R. S., Shaheen, N.J. (2009) Effect of GI endoscopy nurse experience on screening colonoscopy outcomes. Gastrointestinal Endoscopy, 70 (2), 331 343. Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Q.44(suppl.) ,166 203. Donmez, B., Boyle, L.N., & Lee, J. D. (2010). Difference in Off road Glances: Effects on young drivers' performance. Journal of Transportation Engineering, 13 6 (5), 403 409. Dunton, N., Gajewski, B, Klaus, S, & Pierson, B. (2007, S eptember). The relationship of nursing workforce characteristics to patient outcomes. Online Journal of Nursing Issues, 12 (3), 1 11 Estabrooks, C. A., Midodzi, W.K., Cummings, G.G., Ricker, K.L, & Giovannetti, P. (2005). The impact of hospital nursing charac teristics on 30 day mortality. Nursing Research, 54 (2), 74 84. Farquhar, M. (2008). AHRQ quality indicators. In Hughes, R. G. (Ed). Patient Safety and Quality: An evidence Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality. Field, A. (2009). Discovering statistics using SPSS (3rd ed. ) London, UK: Sage Publications. demographics, and employment characteristics. Retrieved from http://www.flcenterfornursing Frank Stromberg, M., Ward, S., Hughes, L., B rown, K. Coleman, A., Gatson Grindel, C. & Miller Murphy, C. (2002). Does certification status of oncology nurses make a difference in patient outcomes? Oncology Nursing Forum, 29 (4), 665 672. Gaberson, K.B., Schroeter, K., Killen, A.R., Valenti ne, W.A. ( 2003). The perceived value of certification by certified perioperative nurses. Nursing Outlook, 51 (6), 272 276. doi:10.1016/j.outlook.2003.09.003 G allagher, R. M, & Rowell, P. A. (2003). Claiming the fu ture of nursing through nursing sensitive quality indicators Nursing Admin i strative Quarterly, 27 (4), 273 284.

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129 B IOGRAPHICAL SKETCH Michigan, a Master of Science of Nursing from Arizona State University, and a PhD from the University of Florida. The minor course of study for her doct orate in nur sing was sociology. Martha worked as staff nurse in several spec ialties of Critical Care nursing. After receiving her Masters of Science of Nursing, she assumed a position as Critical Care Clinical Specialist. The Clinical S pecialist role allowed her to m aintain clinical practice, perform research, provide professional consultation, and actively participate in critical care education. In an effort to guid e and lead chang e in practice, she changed focus to the administrative track and continued her professional d evelopment assuming various Director positions which eventually led to role of Chief Nursing Officer. Her experience in nursing administration allowed her to open a new hospital, initiate trauma, stroke, and chest center certification, succes sfully meet CARF standards (Accreditation for R ehabilitation Facilities), establish an inpatient skilled nursing facility, and develop and manage several new services which included renal transplant, cardiac surgery, invasive cardiology, and gastric bypass programs. With the need to further her education, she left the hospital setting to teach in a university and share her administrative skills in leadership and ethics while attending doctoral classes. Martha remains active in the Girl Scout organization s haring leadership skills through committee and community responsibilities. In her spare time, she participates in quilting groups and activities with a focus on helping individuals and families facing financial hardship or terminal illness. She is active i n several nursing organizations.