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Objective This study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs. Data Sources Seven hundred and eighty-nine medical-surgical units (215 hospitals) in 2009. Study Design Using unit-level data, HAPUs were modeled with Poisson regression with zero-inflation (due to low prevalence of HAPUs) with significant covariates as predictors. Data Collection/Extraction Methods Hospitals submitted data on NQF endorsed ongoing performance measures to CALNOC registry. Principal Findings Fewer HAPUs were predicted by a combination of unit/patient characteristics (shorter length of stay, fewer patients at-risk, fewer male patients), RN workload (more hours of care, greater patient [bed] turnover), RN expertise (more years of experience, fewer contract staff hours), and processes of care (more risk assessment completed). Conclusions Unit/patient characteristics were potent HAPU predictors yet generally are not modifiable. RN workload, nurse expertise, and processes of care (risk assessment/interventions) are significant predictors that can be addressed to reduce HAPU. Support strategies may be needed for units where experienced full-time nurses are not available for HAPU prevention. Further research is warranted to test these finding in the context of higher HAPU prevalence.

As leaders, we recognize the importance of professional scholarship to provide the evidence needed to transform practice. One key initiative for the American Organization of Nurse Executives (AONE) is the elevation of nursing research and AONE competencies for nurse executives emphasize utilization, dissemination and participation in studies. 1 However, given our current healthcare climate and competing priorities, nurse leaders must often focus efforts on fiscal responsibility and operational effectiveness, making time and resources to support nursing research challenging. Initiatives that do not directly impact patient care, such as research, may be given a lower priority. Given today's pressures, nurse leaders may question whether support for nursing research is feasible for their organization.

Public demand for safer care has catapulted the healthcare industry's efforts to understand relationships between patient safety and hospital performance. This study explored linkages between staff perceptions of safety culture (SC) and ongoing measures of hospital nursing unit-based structures, care processes, and adverse patient outcomes. Relationships between nursing-sensitive measures of hospital performance and SC were explored at the unit-level from 9 California hospitals and 37 nursing units. SC perceptions were measured 6 months prior to collection of nursing metrics and relationships between the two sets of data were explored using correlational and regression analyses. Significant relationships were found with reported falls and process measures for fall prevention. Multiple associations were identified with SC and the structure of care delivery: skill mix, staff turnover, and workload intensity demonstrated significant relationships with SC, explaining 22-45% of the variance. SC was an important factor to understand in the quest to advance safe patient care. These findings have affordability and care quality implications for hospital leadership. When senior leaders prioritized a safety culture, patient outcomes may have improved with less staff turnover and more productivity. A business case could be made for investing in patient safety systems to provide reliably safe care.

The aim of this study was to assess the cost savings associated with implementing nursing approaches to prevent hospital-acquired pressure ulcers (HAPU).Hospitals face substantial costs associated with the treatment of HAPUs. Interventions have been demonstrated as effective for HAPU prevention and management, but it is widely perceived that preventative measures are expensive and, thus, may not be a good use of resources.A return-on-investment (ROI) framework from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Toolkit was used for this study. The researchers identified achievable improvements in HAPU rates from data from the Collaborative Alliance for Nursing Outcomes and measured costs and savings associated with HAPU reduction from published literature.The analysis produced a baseline ROI ratio of 1.61 and net savings of $127.51 per patient.Hospital-acquired pressure ulcer surveillance and prevention can be cost saving for hospitals and should be considered by nurse executives as a strategy to support quality outcomes.

The value of the ambulatory care nurse remains undocumented from a quality and patient safety measurement perspective and the practice is at risk of being highly variable and of unknown quality. The American Academy of Ambulatory Care Nursing and the Collaborative Alliance for Nursing Outcomes propose nurse leaders create a tipping point to measure the value of nursing across the continuum of nursing care, moving from inpatient to ambulatory care. As care continues to shift into the ambulatory care environment, the quality imperative must also shift to assure highly reliable, safe, and effective health care.

The Institute of Medicine released a consensus report in October 2010, titled The Future of Nursing (FON): Leading Change, Advancing Health, which concluded significant change was needed in nurses' roles, responsibilities, and education to meet the increased demand for care that will be created by health care reform and to advance improvements in America's increasingly complex health system (http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx). Dr. Donna Shalala, Chair of the study, and Dr. Linda Burnes Bolton, Vice Chair of the study, spoke about the Future of Nursing (FON) at the Collaborative Alliance for Nursing Outcomes (CALNOC) conference to a predominately nursing and quality professional audience. This follow-up interview expands the discussion specifically for quality professionals, many of whom are nurses.

Benchmarking is an indispensable tool as hospital leaders face challenges to balance efficiency with safe and effective care. Selection of appropriate "like" hospitals is critical to the benchmarking aim of understanding comparative performance. Based on 10 years of observed outcome differences between small and large hospitals, the Collaborative Alliance for Nursing Outcomes (CALNOC) sought to empirically define small hospitals, and to determine if there were statistical differences between small and large hospitals for selected nursing sensitive outcome indicators. This article reports the examination of hospital size as a proxy characteristic to define "like" hospitals for the purpose of benchmarking outcomes. Findings suggest that optimal classifications into small and large hospital size based on the outcome indicators of falls, falls with injury, and hospital-acquired pressure ulcers stage 2 or worse (HAPU 2+) were not consistent with historical administrative categories based on average daily census and not consistent by outcome. Statistical differences were only found with HAPU 2+ in critical care units, with no differences in the fall outcomes. These data did not support the use of size-based categories to define like hospitals for benchmark comparisons.

Numerous research reports have examined patterns of nurse staffing (Aiken, Sochalski, and Anderson 1996; Unruh, Fottler, and Talbott 2003; Aydin et al. 2004) and the relationship between nurse staffing and patient outcomes (Aiken et al. 2002; Needleman et al. 2002; Lang et al. 2004; Donaldson et al. 2005). These studies often reach different conclusions about historical changes in nurse staffing and the relationship of nurse staffing to patient outcomes. For example, two publications in the 1990s offered opposing findings about whether nurse staffing had declined in California, using different data sources (Anderson and Kohn 1996;Spetz 1998). Discrepancies also are found in the literature on the relationship between nurse staffing and patient outcomes. While many studies that use hospital-level data have found that higher levels of nurse staffing are associated with improved patient outcomes and lower mortality rates (Aiken et al. 2002; Needleman et al. 2002), most studies that examine data at the level of the hospital unit have found a weaker relationship or no relationship at all (e.g., Donaldson et al. 2005). It is unknown whether these different findings are the result of the use of varying measures of nurse staffing, differences in the importance of overall hospital staffing versus unit-level staffing, measurement error, or some other factor. Why do these studies obtain such different results? One possibility lies in different methods of measuring nurse staffing. Datasets used to measure nurse staffing can provide data by hospital, type of hospital unit, or specific unit. Nurse staffing can be measured as full-time equivalent employment (FTEE), nursing hours per patient day, share of registered nurses in total nursing staff, nurse-to-patient ratios, or other metrics. This paper compares nurse staffing measurements in two commonly used datasets—the American Hospital Association (AHA) Annual Survey of Hospitals and California's Office of Statewide Health Planning and Development (OSHPD) Hospital Annual Disclosure Report—as well as unit-level data collected by the California Nursing Outcomes Coalition (CalNOC) and the California Workforce Initiative (CWI). In 2006, Jiang, Stocks, and Wong analyzed disparities between AHA and OSHPD data, concluding that the OSHPD data on nurse staffing appeared more complete and, thus, more closely associated with patient outcomes. In this report, we examine principal differences between the AHA and OSHPD datasets as well as unit-level CalNOC and CWI data, compare the levels of nurse staffing measured by each, and discuss the ramifications of using alternative data sources and measures for nurse staffing and outcomes research.

This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 postratios regulation data. For the current study we used postregulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.

The purpose of this article is to present findings from a review of published systematic/integrative reviews and meta-analyses on nursing interventions and patient outcomes in acute care settings. A literature search was conducted for the period 1999-2005, producing 4,000 systematic/integrative reviews and 500 meta-analyses covering seven topics selected by the authors: elder care, caregivers, developmental care of neonates and infants, symptom management, pressure ulcer prevention/treatment, incontinence, and staffing. The association between nursing care interventions/processes and patient outcomes in acute care settings was found to be limited in the articles reviewed. The strongest evidence was for the use of patient risk-assessment tools and interventions implemented by nurses to prevent patient harm. We observed significant variation in methods to measure the effect of independent variables (nursing interventions) on patient outcomes. Results indicate the need for more research measuring the effect of specific nursing interventions that may impact acute care patient outcomes.

This article presents the first analysis of the impact of mandated minimum-staffing ratios on nursing hours of care and skill mix in adult medical and surgical and definitive-observation units in a convenience sample of 68 acute hospitals participating in the California Nursing Outcomes Coalition project. Findings, stratified by unit type and hospital size, reveal expected changes as hospitals made observable efforts toward regulatory compliance. These data cannot affirm compliance with ratios per shift, per unit, at all times; however, they give evidence of overall compliance. Assessment of the impacts of the mandated ratios on two common indicators of patient care quality, the incidence of patient falls and the prevalence of pressure ulcers, did not reveal significant changes despite research linking nurse staffing with these measures. These findings contribute to understanding unit level impacts of regulatory staffing mandates and the preliminary effect of this legislation on core quality of care indicators.

OBJECTIVE To examine the relationship between nurse staffing and patient perceptions of nursing care in a convenience sample of 40 California hospitals.Growing concern about the adequacy of nurse staffing has led to an increased emphasis on research exploring the relationships between nurse staffing and patient outcomes. Patient satisfaction with nursing care is one of the 21 indicators identified by the American Nurses Association as having a strong "theoretical link to the availability and quality of professional nursing services in hospital settings." This prospective study examined the relationship between nurse staffing and patient perceptions of nursing care in multiple hospitals using common definitions of both nurse staffing and patient perceptions of care.Nurse staffing (structural variables) and patient perceptions of nursing care (outcome variables) from hospitals participating in both the ongoing California Nursing Outcomes Coalition statewide database project and the statewide Patients' Evaluation of Performance in California project, with data available on both measures for the same time periods, were examined. Analytic methods included both descriptive and inferential statistics.Hospitals with wide ranges of staffing levels showed similar results in patient perceptions of nursing care. Regression analysis revealed a statistically significant relationship between nursing hours per patient day, and 1 of the 6 dimensions of care measured ("respect for patient's values, preferences, and expressed needs").Nurse staffing alone showed a significant but weak relationship to patient perceptions of their care, indicating that staffing is likely only one of several relevant variables influencing patient perceptions of their nursing care. This research contributes data to the body of knowledge regarding nurse staffing. It is essential that nurse executives integrate results from this and other studies in developing strategic and tactical staffing plans that yield positive patient care outcomes.

The Kaiser Permanente North East Bay service area redesigned its quality program beginning in 1995, to better mirror how care was provided across the continuum. The old model had evolved over time, was based on departmental structure, and did not focus on all patient populations. The purpose of this article is to describe the redesign process, the quality model implemented, and future directions, with the hope that the lessons learned will provide other healthcare quality professionals some of the knowledge needed and, perhaps, the courage to "design" their quality programs.

OBJECTIVE: The objective of this study was to assess the cost savings associated with implementing nursing approaches to prevent in-hospital falls. BACKGROUND: Hospital rating programs often report fall rates, and performance-based payment systems force hospitals to bear the costs of treating patients after falls. Some interventions have been demonstrated as effective for falls prevention. METHODS: Costs of falls-prevention programs, financial savings associated with in-hospital falls reduction, and achievable fall rate improvement are measured using published literature. Net costs are calculated for implementing a falls-prevention program as compared with not making improvements in patient fall rates. RESULTS: Falls-prevention programs can reduce the cost of treatment, but in many scenarios, the costs of falls-prevention programs were greater than potential cost savings. CONCLUSIONS: Falls-prevention programs need to be carefully targeted to patients at greatest risk in order to achieve cost savings.

The California Nursing Outcomes Coalition (CalNOC) project is an initiative that has become the largest ongoing nursing quality measurement repository in the nation. Launched in 1996 by California nursing leaders concerned with trends in hospital care, CalNOC has created reliable quality benchmark data to define patient safety thresholds in California. This article describes CalNOC's effort, which aligns with the strategy of the National Quality Forum for measuring and reporting healthcare quality. By tracing the evolution of the CalNOC project and its future potential, we hope to encourage other grassroots efforts to build the database repositories needed for healthcare quality measurement in the 21st century.

Purpose: To explore the need for evidence-based health policy, as illustrated by the mandatory staffing bill passed by the California state legislature in 1999. Design: Prospective data were collected from a voluntary sample of California acute care representatives to describe selected patient safety and clinical outcomes and nurse staffing variables at the patient-care unit level. Methods: Data for descriptive analysis were collected on hospital nurse staffing, patient falls, and pressure ulcers from 257 medical, surgical, medical-surgical combined, step-down, 24-hour observation units, and critical care patient care units in 38 California acute care hospitals from June 1998 to June 1999. Findings: Nursing staffing ratios varied among the 257 units. RNs provided 91% of the nursing care in critical care units. Patients in medical-surgical units received 59% of their care from RNs, 11% from licensed vocational nurses, and 30% from other caregivers. Preliminary data showed no relationships between reported staffing ratios in these hospitals and the incidence of patient falls or hospital-acquired pressure ulcers. Conclusions: California Nursing Outcomes Coalition (CalNOC) data showed wide variations in staffing ratios, patient falls, and hospital-acquired pressure ulcers among nursing units and hospitals. These early findings indicate the need for additional research before determining minimal RN staffing requirements. Analysis of multiple sources of data may be necessary to determine safe staffing ratios and to provide evidence-based data for public policy.

This article describes nurse staffing in 330 critical care, medical surgical, and step-down units in 52 acute care California hospitals that was reported over nine quarters between April 1998 and June 2000. These data, representing more than 3 million patient days of care, comprise the largest prospective descriptive sample of nurse staffing, using standardized indicators, reported to date. These data are especially timely as the profession, policy makers, and regulators in California and the nation respond to the legislative mandate to establish nurse-to-patient staffing ratios that ensure patient safety and develop methods to monitor the impact of ratios on the quality and outcomes of patient care. Findings reveal relative stability over the nine calendar quarters, no significant differences between groups of hospitals stratified by using average daily census to cluster by hospital size and wide variation in staffing across hospitals within the same unit type categories.

The purpose of this study was to explore hospital discharge preparation for elderly patients returning to their homes, and to examine knowledge and satisfaction outcomes. A descriptive correlational design was used in an urban health maintenance organization medical center. The convenience sample included 140 English-speaking patients with medical diagnoses. Knowledge scores were obtained for those patients who went home with a regime change, and the majority were discharged with changes in diet medications, treatments, or activities. Medication knowledge was identified as an area that needed improvement, low scorers for medication knowledge tended to be older, less ambulatory, and had more secondary diagnoses. Patients were satisfied with the instruction that they received and perceived themselves to be prepared to continue their care at home. The ability of elderly patients to learn instruction for their continued health care is still unclear Patients may have been too ill to learn, or length of stay may have been too short, or patients may not have had the need to learn what health care providers considered essential.

Hospital-acquired pressure ulcers (HAPUs) are a serious nosocomial problem that has been viewed as a ubiquitous consequence of immobility. This article provides data from the Collaborative Alliance for Nursing Outcomes (CALNOC) that shows a significant reduction in HAPUs in adults from 78 acute care hospitals over 8 years (2003-2010).

Benchmarking expedites the quest for best practices and is crucial to hospitals' effective, reliable, and superior performance. Comparative performance data are used by accrediting and regulatory bodies to evaluate performance and by consumers in making decisions on where to seek healthcare. Nursing-sensitive quality measures affirmed by the National Quality Forum are now used in public reporting and pay-for-performance in addition to traditional medical outcome metrics. This report provides hospital nursing-sensitive benchmarks from medical/surgical, critical care, and step-down units drawn from 196 hospitals during six quarters in 2007 and 2008. Outcome measures include pressure ulcer prevalence rates and fall/falls with injury rates. Additional indicators that describe nursing care (nurse staffing care hours, skill mix, nurse/patient ratios, workload intensity, voluntary turnover, and use of sitters) and patient descriptors (age, gender, and diagnosis description) were also included. Specific benchmarks are provided using the 10th and the 90th percentiles, as well as quartiles to allow hospitals an opportunity to understand comparative performance with specificity. The purpose of this article is to provide hospitals not currently participating in comparative benchmarking databases with nursing-sensitive data from the Collaborative Alliance for Nursing Outcomes for use in performance improvement processes.

Quality professionals are the first to understand challenges of transforming data into meaningful information for frontline staff, operational managers, and governing bodies. To understand an individual facility, service, or patient care unit's comparative performance from within large data sets, prioritization and focused data presentation are needed. This article presents a methodology for translating data from large data sets into dashboards for setting performance improvement priorities, in a simple way that takes advantage of tools readily available and easily used by support staff. This methodology is illustrated with examples from a large nursing quality data set, the California Nursing Outcomes Coalition.

Using nursing quality benchmarks in operational dashboards and translating those data to drive performance excellence is a strategic imperative. Since access to unit-level, hospital-generated nurse-related benchmarks is an emerging arena, the authors provide an overview of aggregated trends and benchmarks gleaned from the California Nursing Outcome Coalition acute care database for 2 established nurse-related quality indicators-patient falls incidence and hospital-acquired pressure ulcer prevalence. Integrating these acute care benchmarks into clinical dashboards can be invaluable to clinicians, administrators, and policy makers who share a common commitment to expediting evidence-based improvement in patient care safety, outcomes, and excellence.

Purpose: To explicate a replicable methodology for designing and analyzing a large ongoing reliable and valid quality database to examine nurse staffing and patient care outcomes in acute care hospitals. Design: Prospective nurse staffing, process of care, and patient outcomes data based on the American Nurses Association's (ANA) nursing quality indicators collected from a voluntary convenience sample at acute care hospitals in California with rolling-site accrual. Methods: The ongoing CalNOC database development and repository project, the largest statewide effort of its kind in the United States (US), currently includes data on hospital nurse staffing, patient days, patient falls, pressure ulcer and restraint prevalence, registered nurse (RN) education, and patients' perceptions of satisfaction with care. Findings: As of May 2003, the CalNOC database contained staffing data from 842 units in 134 acute care hospitals over 20 quarters from April 1998 to March 2003. The repository also included clinical outcome information on 34,262 reported patient falls, pressure ulcer prevalence data on 41,982 patient observations, and service outcome data on patient satisfaction from 26,461 patients. Participating hospitals receive quarterly reports allowing them to benchmark their own performance against other participating hospitals. CalNOC methods have been adapted and replicated by both the Military Nursing Outcomes Database and VA Nursing Outcomes Database projects, and CalNOC nursing-sensitive measures have been endorsed by the National Quality Forum. Conclusions: This working model for collecting reliable and valid data was derived from multiple hospitals across California. The data are the basis for studies to contribute to the development of evidence-based public policy, and for ongoing study of the effects of nurse staffing on clinical and service outcomes.

Healthcare quality professionals in the United States have opportunities to teach healthcare providers in other countries how to measure and monitor quality. Special preparation is required to effectively teach an international audience. This article offers tips for teaching basic quality concepts based upon the authors' experiences in the People's Republic of China. Working with health professionals in other countries is exciting and challenging for everyone involved. Approaching the opportunity with systematic preparation may be the key to success.

According to a survey of 753 nurses in Northern California, nurses with higher levels of education are more involved in research utilization and research activities. The data support the American Nurses' Association model of progressive involvement in research utilization and research conduct. Recommendations to improve research utilization in clinical and academic settings are provided.

The malignant cells of acute promyelocytic leukemia (APL) contain a reciprocal chromosomal translocation that fuses the promyelocytic leukemia gene (PML) with the retinoic acid receptor α gene (RARα). To test the hypothesis that the chimeraPMLRARα plays a role in leukemogenesis, we expressed aPMLRARα cDNA in myeloid cells of transgenic mice.PMLRARα transgenic mice exhibited impaired neutrophil maturation early in life, which progressed at a low frequency over the course of several months to overt APL. Both the preleukemic state and the leukemia could be transplanted to nontransgenic mice, and the transplanted preleukemia could progress to APL. The APL recapitulated features of the human disease, including a response to retinoic acid. Retinoic acid caused the leukemic cells to differentiatein vitroandin vivo, eliciting remissions of both the preleukemic state and APL in mice. Our results demonstrate thatPMLRARα impairs neutrophil differentiation and initiates the development of APL. The transgenic mice described here provide an apparently accurate model for human APL that includes clear evidence of tumor progression. The model should be useful for exploring the molecular pathogenesis of APL and the mechanisms of the therapeutic response to retinoic acid, as well as for preclinical studies of therapeutic regimens.

Kinesin and dynein are motor proteins that move in opposite directions along microtubules. In this study, we examine the consequences of having kinesin and dynein (ciliary outer arm or cytoplasmic) bound to glass surfaces interacting with the same microtubule in vitro. Although one might expect a balance of opposing forces to produce little or no net movement, we find instead that microtubules move unidirectionally for several microns (corresponding to hundreds of ATPase cycles by a motor) but continually switch between kinesin-directed and dynein-directed transport. The velocities in the plus-end (0.2-0.3 microns/s) and minus-end (3.5-4 microns/s) directions were approximately half those produced by kinesin (0.5 microns/s) and ciliary dynein (6.7 microns/s) alone, indicating that the motors not contributing to movement can interact with and impose a drag upon the microtubule. By comparing two dyneins with different duty ratios (percentage of time spent in a strongly bound state during the ATPase cycle) and varying the nucleotide conditions, we show that the microtubule attachment times of the two opposing motors as well as their relative numbers determine which motor predominates in this assay. Together, these findings are consistent with a model in which kinesin-induced movement of a microtubule induces a negative strain in attached dyneins which causes them to dissociate before entering a force-generating state (and vice versa); reversals in the direction of transport may require the temporary dissociation of the transporting motor from the microtubule. The bidirectional movements described here are also remarkably similar to the back-and-forth movements of chromosomes during mitosis and membrane vesicles in fibroblasts. These results suggest that the underlying mechanical properties of motor proteins, at least in part, may be responsible for reversals in microtubule-based transport observed in cells.