Nancy Dunton | University of Kansas Medical Center (original) (raw)

Papers by Nancy Dunton

This article describes a method for estimating the inter-rater reliability of pressure ulcer (PU)... more This article describes a method for estimating the inter-rater reliability of pressure ulcer (PU) staging (stages I-IV) from raters in National Database of Nursing Quality Indicators (NDNQI) participating hospitals. The method models ordinal spanning data utilizing an ordinal probit Bayesian hierarchical model (BHM) across several hospitals in which raters monitor patient&amp;amp;amp;amp;amp;amp;amp;#39;s PUs. An ulcer that cannot be accurately assessed because the base of the wound cannot be seen is defined as unstageable. Our novel approach allows for an unstageable PU rating to be included in the analysis. We compare the ordinal probit BHM to an approximate random-effects (standard approach in the literature) model that assumes that the raw ordinal data are continuous.

Joint Commission journal on quality and patient safety / Joint Commission Resources

Data Envelopment Analysis (DEA) is the most commonly used approach for evaluating healthcare effi... more Data Envelopment Analysis (DEA) is the most commonly used approach for evaluating healthcare efficiency , but a long-standing concern is that DEA assumes that data are measured without error. This is quite unlikely, and DEA and other efficiency analysis techniques may yield biased efficiency estimates if it is not realized . We propose to address measurement error systematically using a Bayesian method (Bayesian DEA). We will apply Bayesian DEA to data from the National Database of Nursing Quality Indicators® (NDNQI®) to estimate nursing units' efficiency. Several external reliability studies inform the posterior distribution of the measurement error on the DEA variables. We will discuss the case of generalizing the approach to situations where an external reliability study is not feasible.

Purpose: The overarching goal of this project was to implement and evaluate an innovative transla... more Purpose: The overarching goal of this project was to implement and evaluate an innovative translational research program to measure and improve pain care processes and outcomes in a sample of United States hospitals. Background/Significance: Unrelieved pain contributes to increased recovery time, poor immune function and unwillingness to cooperate with treatment. Nurses are the front-line caregivers in pain management, whose responsibilities include assessment, initiation of pain relief strategies, evaluation of pain treatment effectiveness and collaboration with an interdisciplinary team. Currently, there is not a national consensus measure of nurse-sensitive pain quality indicator. Methods: Current NDNQI members were recruited to participate in this research study. Each facility (n=326) designated a coordinator to receive study materials. On a designated day, trained RNs collected patients' opinions of pain management on seven types of non-critical care units (n=1611). Data we...

Aims: To assess the reliability of unit-level patient day measurement using (1) an empirical inte... more Aims: To assess the reliability of unit-level patient day measurement using (1) an empirical inter-rater reliability study and (2) a simulation study. Methods: Study #1) the patient day data routinely collected with five different methods (M1-M5) for NDNQI was compared with a gold standard from a special multiple census data collection . Intra-class correlations (ICC) were calculated and a regression analysis was employed to investigate the impact of short stay patients . Study #2) data for an “average” surgical unit with a mean length of stay (LOC) of 2.6 days and a standard deviation of 1.86 days were simulated and patient day collection methods were applied. Results: Study #1) With an ICC [95% CI] of 0.967 [0.958-0.974] overall agreement was excellent. For four of the five reporting methods the agreement was as well excellent: M1 (0.98 [0.970-0.984]), M2 (0.96 [0.942-0.978]), M4 (0.996 [0.989-0.998]) and M5 (0.955 [0.812-0.991]).The agreement for M3 was considerably lower (0.643 ...

Aims: Two studies were conducted to investigate the reliability of the National Database of Nursi... more Aims: Two studies were conducted to investigate the reliability of the National Database of Nursing Quality Indicators (NDNQI) pressure ulcer indicator using novel approaches to account for the U.S. geographic distribution of member hospitals. Methods: Study #1: A criterion-referenced, web-based test was designed and administered to 256 individuals in 48 randomly sampled NDNQI member hospitals. The web-based test contained 17 digital photographs of pressure ulcers. Hospitals were randomized to take one of two test versions. The first version included a short narrative description of each pressure ulcer picture. The second version excluded the wound description. Study #2: Nurse teams in 31 NDNQI member hospitals rounded together to the bedside of patients with pressure ulcers and staged the ulcers. Team members, including the hospital wound care expert, then completed the web-based test on pressure ulcer staging. Individual participants were randomized to take one of the two test ver...

International Journal of Nursing Studies, 2015

Nursing unit is the micro-organization in the hospital health care system in which integrated pat... more Nursing unit is the micro-organization in the hospital health care system in which integrated patient care is provided. Nursing units of different types serve patients with distinct care goals, clinical tasks, and social structures and norms. However, empirical evidence is sparse on unit type differences in quality of care and its relation with nurse work environment. Nurse work environment has been found as an important nursing factor predicting nurse and patient outcomes. To examine the unit type differences in nurse-reported quality of care, and to identify the association between unit work environment and quality of care by unit types. This is a cross-sectional study using nurse survey data (2012) from US hospitals nationwide. The nurse survey collected data on quality of care, nurse work environment, and other work related information from staff nurses working in units of various types. Unit types were systematically classified across hospitals. The unit of analysis was the nursing unit, and the final sample included 7677 units of 14 unit types from 577 hospitals in 49 states in the US. Multilevel regressions were used to assess the relationship between nurse work environment and quality of care across and by unit types. On average, units had 58% of the nurses reporting excellent quality of care and 40% of the nurses reporting improved quality of care over the past year. Unit quality of care varied by unit types, from 43% of the nurses in adult medical units to 73% of the nurses in interventional units rating overall quality of care on unit as excellent, and from 35% of the nurses in adult critical care units to 44% of the nurses in adult medical units and medical-surgical combined units reporting improved quality of care. Estimates from regressions indicated that better unit work environments were associated with higher quality of care when controlling various hospital and unit covariates; and this association persisted among units of different types. Unit type differences exist in the overall quality of care as well as achievement in improving quality of care. The low rates of nurses reporting improvement in the quality of nursing care to patients suggest that further interventions focusing at the unit-level are needed for achieving high care quality. Findings from our study also suggest that improving nurse work environments can be an effective strategy to improve quality of care.

Journal of nursing care quality

In 2012, the National Database of Nursing Quality Indicators launched a project to expand its fal... more In 2012, the National Database of Nursing Quality Indicators launched a project to expand its falls indicator for use on pediatric, neonatal, and psychiatric units. We discuss challenges encountered, argue that schemes for categorizing falls by cause or supposed preventability are not suitable for large-scale efforts to track and prevent falls, express concern about the growing burden of collecting increasingly granular quality data, and discuss limitations of total and injurious fall rates as quality measures.

Western journal of nursing research, Jan 13, 2014

Although remarkable efforts have been made to improve patient fall reporting through the utilizat... more Although remarkable efforts have been made to improve patient fall reporting through the utilization of standardized definitions, injury falls reporting has rarely been examined. This study used an overall intra-class correlation coefficient (ICC) estimate and factor analysis to assess the reliability and validity of the National Database of Nursing Quality Indicators® (NDNQI®) falls with injury measure. Data were collected from an online Fall Injury Level Survey that was administered to 1,159 NDNQI site coordinators (39.7% response rate; 91% registered nurses [RNs]). Estimated overall ICC was .85. Exploratory factor analysis (EFA) with a Promax rotation (root mean square error of approximation [RMSEA] = 0.053) identified three latent factors: No Injury, Minor Injury, and Moderate/Major Injuries. Final confirmatory factor analysis (CFA) assessment (comparative fit index [CFI] = 0.914, Tucker Lewis Index [TLI] = 0.910, RMSEA = 0.048) confirmed an acceptable model fit. Results provide...

This report was prepared under contract to the Kansas Department on Aging and the Kansas Departme... more This report was prepared under contract to the Kansas Department on Aging and the Kansas Department of Health and Environment. The investigators want to thank the Departments for the substantial assistance provided to the study by many state staff. In ...

International Journal of Nursing Studies, 2010

In their editorial Jull and Griffiths (2010) discuss pressure ulcer prevention as an indicator of... more In their editorial Jull and Griffiths (2010) discuss pressure ulcer prevention as an indicator of nursing care quality. The cautionary note includes remarks on pressure ulcer risk assessment tools, pressure ulcer prevention strategies and the application of pressure ulcer rates as a quality indicator.

International Journal of Nursing Studies, 2011

International Journal of Nursing Studies, 2012

Nursing turnover is expensive and may have adverse effects on patient care. Little is known about... more Nursing turnover is expensive and may have adverse effects on patient care. Little is known about turnover's association with most hospital and nursing unit characteristics, including nurse staffing level and registered nurse skill mix. To explore associations between nursing unit turnover rates and several hospital- and unit-level variables, including staffing level and skill mix. Observational cross-sectional study of longitudinal data. 1884 nursing units in 306 U.S. acute care hospitals. During a 2-year period units reported monthly data on staffing and turnover. Total nursing staff turnover and registered nurse turnover rates were modeled as dependent variables in hierarchical Poisson regression models. The following hospital characteristics were considered as predictors: Magnet(®) status, ownership (government or non-government), teaching status, locale (metropolitan, micropolitan, or rural), and size (average daily census). The U.S. state in which the hospital was located was included as a covariate. Unit-level variables included total nursing hours per patient day, size of nursing staff, registered nurse skill mix, population age group (neonatal, pediatric, or adult), and service line (critical care, step-down, medical, surgical, medical/surgical, psychiatric, or rehabilitation). Government ownership, Magnet designation, and higher skill mix were associated with lower total turnover and registered nurse turnover. Neonatal units had lower total and registered nurse turnover than pediatric units, which had lower total and registered nurse turnover than adult units. Unit service line was associated only with total turnover. Psychiatric, critical care, and rehabilitation units had the lowest mean turnover rates, but most differences between service lines were not significant. The other explanatory variables considered were not significant. Several hospital and unit characteristic variables have significant associations with nursing turnover; these associations should be taken into account in nursing turnover research and need to be explored further. Controlling for hospital ownership, Magnet status, unit service line, and unit population age group, registered nurse skill mix is apparently more important than total nurse staffing level in predicting nursing turnover.

Research in Nursing and Health, 2013

This is a longitudinal study of the trend and seasonality in unit-level hospital-acquired pressur... more This is a longitudinal study of the trend and seasonality in unit-level hospital-acquired pressure ulcer (HAPU) rates from 2004 to 2011, for 5447 acute care nursing units in 733 US hospitals. Unit-level HAPU rates decreased significantly during 2004-2007 (OR = 0.91, 95% CI [0.90, 0.91]) and the decreasing trend was much stronger during 2008-2011 (OR = 0.84 [0.83, 0.85]). Seasonal variations in HAPU rates were strong and consistent during 2004-2008, with the highest HAPU rate in Quarter 1 (Jan-Mar) and the lowest rate in Quarter 3 (Jul-Sep). During 2009-2011, the magnitude of this seasonality was greatly reduced, and only HAPU rate in Quarter 1 remained significantly higher than HAPU rates in other quarters.

This article appeared in a journal published by Elsevier. The attached copy is furnished to the a... more This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution and sharing with colleagues.

Medical Care, 2012

Little is known about the recent development of the quality of nursing care.

Journal of patient safety, 2012

OBJECTIVES: The purpose of this study was to provide normative data on fall prevalence in U.S. ho... more OBJECTIVES: The purpose of this study was to provide normative data on fall prevalence in U.S. hospitals by unit type and to determine the 27-month secular trend in falls before the implementation of the Centers for Medicare and Medicaid Service (CMS) rule, which does not reimburse hospitals for care related to injury resulting from hospital falls. METHODS: We used data from the National Database of Nursing Quality Indicators (NDNQI) collected between July 1, 2006, and September 30, 2008, to estimate prevalence and secular trends of falls occurring in adult medical, medical-surgical, and surgical nursing units. More than 88 million patient days (pd) of observation were contributed from 6100 medical, surgical, and medical-surgical nursing units in 1263 hospitals across the United States. RESULTS: A total of 315,817 falls occurred (rate = 3.56 falls/1000 pd) during the study period, of which, 82,332 (26.1%) resulted in an injury (rate = 0.93/1000 pd). Both total fall and injurious fal...

OJIN: The Online Journal of Issues in …, 2007

Three report s from t he I nst it ut e of Medicine found t hat errors in hospit al care were m or... more Three report s from t he I nst it ut e of Medicine found t hat errors in hospit al care were m ore com m on t han previously t hought ; t hat healt h care delivery should be reorganized t o im prove t he qualit y of care; and t hat , operat ionally, nurses have a crit ical role in securing pat ient safet y. Now t he cont ribut ion of nursing t o t he reduct ion of adverse event s m ust be est ablished em pirically, so t hat nursing-sensit ive indicat ors can be incorporat ed in such healt h care-im provem ent st rat egies as public report ing of hospit al qualit y and perform ance-based paym ent syst em s. This art icle r eviews what is known from previous nursing out com es research and ident ifies gaps in t he current st at e of knowledge. I t t hen describes t he cont ribut ion t o r esearch t hat can be m ade t hrough t he Nat ional Dat abase of Nursing Qualit y I ndicat ors TM ( NDNQI ® ) . Next it report s an NDNQI st udy t hat found t hree nursing workforce charact erist ics t o be relat ed significant ly t o pat ient out com es: t ot al nursing hours per pat ient day, percent age of hours supplied by RNs, and years of experience in nursing, and concludes wit h a discussion of t he im plicat ions of t hese findings for bot h for nursing adm inist rat ors and out com es-based, qualit y-im provem ent init iat ives.