MSJ Imposition Single pgs January-February 2013 • Vol. 22/No. 126 Marie Boltz, PhD, RN, is Assistant Professor, New York University, College of Nursing, New York, NY. Elizabeth Capezuti, PhD, RN,...

MSJ Imposition Single pgs
January-Fe
uary 2013 • Vol. 22/No. 126
Marie Boltz, PhD, RN, is Assistant Professor, New York University, College of Nursing, New York,
NY.
Elizabeth Capezuti, PhD, RN, FAAN, is Dr. John W. Rowe Professor in Successful Aging, New
York University, College of Nursing, New York, NY.
Laura Wagner, PhD, RN, is Assistant Professor, University of California, San Francisco School of
Nursing, San Francisco, CA.
Marie-Claire Rosenberg, PhD, RN, is Assistant Professor, New York University, College of
Nursing, New York, NY.
Michelle Secic, MS, is President, Biostatistician, Secic Statistical Consulting, Inc., Chardon, OH.
Acknowledgments: This work was supported by the Margretta Madden Styles Credentialing
Scholars Grants Program and the John A. Hartford Foundation’s Building Academic Geriatric
Nursing Capacity Award Program.
Patient Safety in Medical-Surgical
Units: Can Nurse Certification
Make a Difference?
Adults age 65 and older repre-sent approximately 38% ofall admissions to hospitals
and approximately 60% of patients
on medical-surgical units (DeFrances
& Hall, 2007; Wier, Pfuntner, &
Steiner, XXXXXXXXXXCom pared to younge
patients, older adults are more at
isk for complications from safety-
elated events, including increased
falls and injurious falls (Agency fo
Healthcare Research and Quality
[AHRQ] 2007; Centers for Disease
Control and Prevention, 2012) pres-
sure ulcers (Baumgarten et al.,
2006), catheter-associated urinary
tract infections (Fakih et al., 2010),
and adverse outcomes associated
with restraint use (AHRQ, 2007).
Complications in older adults are
associated with higher mo
idity,
mortality, and costs (DeFrances,
Lucas, Buie, & Golosinskiy, 2008;
Jencks, Williams, & Coleman, 2009).
Such outcomes are considered nurs-
ing-sensitive clinical indicators; they
are regarded widely as having strong
links to quality (Dunton & Motalvo,
2009; Hart, Bergquist, Gajewski, &
Dunton, 2006) and determine reim-
ursement in the pay-for-perform-
ance Medicare system (McNair, Luft,
& Bindman, 2009).
Nursing-sensitive quality indica-
tors are those in which the quality o
quantity of nursing interventions in -
fluence a patient’s outcome. The
National Database of Nursing Quality
Indicators (NDNQI®) is a database of
the American Nurses Association that
collects and evaluates nurse-sensitive
data from U.S. hospitals (Dunton,
Montalvo, & Dunton, XXXXXXXXXXThese
indicators are used in quality im -
provement activities, research, staff
development, and registered nurse
Research for PracticeResearch for Practice
Marie Boltz, Elizabeth Capezuti, Laura Wagner,
Marie-Claire Rosenberg, and Michelle Secic
(RN) retention efforts, and to satisfy
eporting requirements for regulato-
y agencies or Magnet® designation
(Draper, Felland, Liebhaber, &
Melichar, 2008; Montalvo &
Dunton, XXXXXXXXXXNursing-sensitive
quality indicators are related to
staffing (e.g., RN hours/patient day),
turnover, staff mix, job satisfaction,
education/certification levels, and
patient safety outcomes, such as
patient falls, injurious falls, pressure
ulcers, and restraints (Dunton et al.,
2011). Because older adults are the
highest users of hospital services on
medical-surgical units (DeFrances et
al., 2008), the NDNQI patient safety
indicators can have a tremendous
impact on older adult care.
Literature Review
Nursing-Sensitive Quality
Indicators
Falls and injurious falls. Medical
and medical-surgical units have the
largest number of falls and fall
injuries, with one study reporting
3.15 to 4.18 falls per 1,000 patient-
days (Dykes et al., XXXXXXXXXXApproxi -
mately 26% of falls result in injury
(Dunton, Gajewski, Klaus, & Pierson,
2007). The incidence of both falls
and injurious falls increases with
patient age,attributed to both intrin-
sic and extrinsic factors (Oliver,
Healey, & Haines, XXXXXXXXXXRecom -
mended fall prevention programs
include multi-modal interventions,
with nursing knowledge and clinical
competence considered to be critical
elements in implementing such pro-
grams (Coussement et al., 2008;
Dykes et al., 2010; Krauss et al.,
2008). More hours per patient day
and a higher percentage of RNs,
especially those with more experi-
ence, are associated with lower fall
and injurious fall rates (Dunton et
al., 2007).
Restraint use. The rate of restraint
use has declined in the past 20 years
on general medical and surgical
units. However, evidence of contin-
ued utilization, despite health care
policies limiting their use, exists.
Additionally, wide variation in
estraint prevalence rates persists (3
to 123 restraint-days/1,000 patient-
January-Fe
uary 2013 • Vol. 22/No. 1 27
days), demonstrating major practice
differences even when controlling
for patient population (Minnick,
Mion, Johnson, Catrambone, &
Leipzig, XXXXXXXXXXThe decision to use
physical restraint continues to be
ased on individual judgment and
eliefs rather than evidence-based
guidelines, and is associated with
lack of knowledge and skills specific
to the care of older adults.The use of
approaches to enhance cognitive
and physical function, staff educa-
tion, organizational strategies, and
environmental interventions can
educe physical restraints and also
educe fall rates (Amato, Salter, &
Mion, 2006; Capezuti et al., 2008).
Unit-acquired pressure ulcers. Ac -
cording to VanGilder, Ha
ison, and
Meyer (2009), a study of 86,932 U.S.
acute care facilities found an overall
pressure ulcer prevalence rate of
11.9%; the facility-acquired rate was
5.0%, and 3.1% when stage I ulcers
were excluded. Effective interven-
tions (assessment of skin, skin care,
pressure redistribution, reposition-
ing, and nutrition) are provided
directly by nurses or through thei
supervision or coordination. Highe
staffing levels, skill mix, and nurses’
professional tenure are associated
with decreased iatrogenic pressure
ulcer rate (Dunton et al., XXXXXXXXXXAlso,
the use of protocols, staff education
programs, and nurse-coordinated
quality improvement activities are
ecommended to prevent the occur-
ence of facility-acquired pressure
ulcers (Black et al., 2011).
Certification and Quality
Increased public concern fo
adverse events and patient safety,
together with mandates for quality,
and cost-effective care, has empha-
sized nursing responsibility for the
outcomes of patient care (Institute of
Medicine [IOM], XXXXXXXXXXState licen-
sure provides the legal authority to
practice professional nursing; certifi-
cation, which is provided by individ-
ual specialty nursing organizations,
demonstrates a voluntary commit-
ment to a standard of excellence
eyond licensure (Shirey, 2005;
Wade, 2009).
Although definitions of certifica-
tion vary, certification generally is
defined as the validation of cognitive
knowledge (Landon, XXXXXXXXXXThe
International Study of the Certified
Nurse Workforce reported more than
410,000 nurses in North America
were certified in 2000 by 67 certify-
ing bodies representing 34 specialty
organizations (Cary, XXXXXXXXXXThe
NDNQI guidelines (Montalvo, 2007)
on certification acknowledge certifi-
cation for specialty practice by a
national nursing specialty organiza-
tion.
Certified nurses have demonstrated
higher knowledge of care related to
pressure ulcers (Zulkowski, Ayello, &
Wexler, 2007) and familiarity with
cancer care guidelines (Coleman et al.,
2009). Nurse supervisors have rated
certified nurses, with higher perform-
ance scores for education/collabora-
tion, care planning, and evaluation
when compared to non-certified nurs-
es (Redd & Alexander, XXXXXXXXXXCertified
nurses have reported their perception
that certification demonstrates profes-
sional growth and credibility (Ameri -
can Board of Nursing Specialities,
2006; Gaberson, Schroeter, Killen, &
Valentine, 2003; Kendall-Gallagher &
Blegen, XXXXXXXXXXCertification also has
een associated with professional
opportunities (e.g., access to continu-
ing education and job promotion)
(Sechrist, Valentine, & Berlin, 2006)
and higher salaries
enefits (Stierle et
al., 2006).
While many positive professional
and process outcomes associated
with certification are known, the
elationship between specialty certi-
fication and patient safety outcomes
is a relatively new area of inquiry
in nursing. Kendall-Gallagher and
Blegen XXXXXXXXXXinvestigated the rela-
tionship between nurse certification
and the risk of harm to patients in 48
intensive care units in 29 hospitals.
In addition to finding total hours of
nursing care were related to medica-
Introduction
Hospitalized older adults experience more safety-related complications than
younger patients, including increased falls and injurious falls, pressure ulcers, and
adverse outcomes associated with restraint use. These clinical areas are dominant-
ly under the control of nursing practice and thus are regarded as nursing-sensitive
quality indicators. Certified nurses have demonstrated competency in evidence-
ased gerontological nursing care practice. However, the influence of nursing cer-
tification upon quality indicators is not established.
Purpose
The purpose of this study was to examine the relationship between nurse certifi-
cation (in any specialty practice as well as gerontological) and unit-level, nursing-
sensitive quality indicators in units that primarily serve older adults.
Method
In a sample of 44 medical and medical-surgical units in 25 NICHE (Nurses
Improving Care for Healthsystem Elders) hospitals, a retrospective descriptive
design used multivariate regression techniques.
Findings
Binary logistic regression modeling yielded a significant relationship between cer-
tification in any specialty and falls (chi-square wald=3.80, p=0.05, df=1).
Conclusion
Nursing-sensitive outcomes in hospitalized older adults may be influenced by
nurse certification. The data from this pilot study support a larger prospective
study that will investigate the relationship between nurse certification, workforce
factors, and nursing-sensitive quality indicators in all types of units in both NICHE
hospitals and non-NICHE hospitals. The inability of some program coordinators to
obtain unit-level patient data points to the need for management tools and edu-
cation related to quality improvement for mid-level managers.
Patient Safety in Medical-Surgical Units: Can Nurse Certification Make a Difference?
January-Fe
uary 2013 • Vol. 22/No. 128
Research for Practice
tion administration e
ors, and years
of experience were related to the fre-
quency of urinary tract infections,
authors concluded the unit propor-
tion of certified RNs was related
inversely to the rate of falls. Results
did not establish a relationship
etween certification and three
other quality indicators (injurious
falls, restraint prevalence, unit pres-
sure ulcer prevalence). Researchers
acknowledged this study was limited
y a small sample size and the use of
secondary data; however, findings of
this study suggest a relationship
etween specialty certification and
patient safety in intensive care units.
A substantial gap in research
exists in addressing the contribution
of certification to patient safety out-
comes in medical-surgical units.
These areas primarily serve olde
adults as the age cohort most vulner-
able to adverse events. Age-related
changes and numerous co-mo
idi-
ties may predispose elders to adverse
events (Covinsky, Pierluissi, &
Johnston, XXXXXXXXXXClinician knowl-
edge and skill play a critical role in
preventing negative safety outcomes
and in developing organizational
strategies for reducing adverse events
(Boltz et al., 2008a; Boltz et al.,
2008b; Capezuti et al., 2012).
Recognizing the substantive and
positive impact of nursing interven-
tions in reducing adverse events
(IOM, 2010), the Nurses Improving
Care for Healthsystem Elders
(NICHE) program provides staff edu-
cation programs, clinical protocols,
and organizational strategies to pre-
vent avoidable complications in hos-
pitalized older adults (Boltz et al.,
2008a; Boltz et al., 2008b; Capezuti
et al