Care Interventions and Quality of Care in Rural and Urban Nursing Units

描述（由申请方提供）：本研究涉及医疗保健研究和质量管理局（AHRQ）关于患者安全性的研究组合。患者安全组合的目的是识别风险并防止与医疗保健提供相关的患者损伤，包括检查进行系统更改的有效方法，并在医疗保健环境中创建防止患者安全事件的环境。压疮和福尔斯是最常见、可预防且代价高昂的患者安全事件。尽管有充分的证据和广泛实施的预防性护理干预措施，全国压疮率（PUR）和跌倒率（FR）仍然很高。许多研究已经检查了改善或阻碍护理质量（QOC）的因素，包括QOC指标PUR和FR。总的来说，可以理解，在检查PUR和FR时，背景因素是重要的，但是，很少有证据表明背景因素对PUR和FR的纵向影响。所述研究包括概念化为护士工作环境（NWE）因素的背景因素（人员配备和专业护理实践）和NWE居住的环境概念化为3个层次的卫生保健系统（社区、医院和护士单位）。NWE因素影响护士的结果（满意度和营业额）和护理干预。因此，PUR和FR受到护理干预的影响，而护理干预又受到护士结果和NWE因素的影响，NWE因素受到社区、医院和护理单位特征的影响。这些关系在农村医院研究不足。农村和城市医院的QOC指标的比较结果喜忧参半，这表明除了位置之外，其他背景因素对QOC也很重要。纵向研究，测量背景和确定整个医疗保健系统的资源，可以阐明这些复杂的关系。在6项初步研究的基础上，我们提出了一个非实验性的纵向设计，比较农村和城市护理单位，使用2009-2013年（20个季度）国家护理质量指标数据库中的单位级数据，并补充了其他数据库中的社区和医院特征数据。我们将首先（具体目标1）确定5年内压疮和跌倒预防护理干预对PUR和FR的影响。然后，我们将添加NWE因素和护士的结果（具体目标2），并检查NWE因素和护士的结果对护理干预措施和PUR和FR的关系的影响。最后，我们将（具体目标3）确定农村和城市的差异，护理干预措施对PUR和FR的影响，并评估在何种程度上的潜在差异归因于NWE因素和护士的结果。对于所有3个目标，我们将控制社区，医院和护理单位的特点。我们的研究结果将为检查和改善农村和城市护理单位的QOC提供行政和政策策略。

DESCRIPTION (provided by applicant): This study addresses the Agency for Healthcare Research and Quality (AHRQ) research portfolio on patient safety. The aim of the patient safety portfolio is to identify risks and prevent patient injury associated with delivery of health care including examining effective ways to make systems changes and creating an environment within health care settings that prevents patient safety events. Pressure ulcers and falls are among the most common, preventable and costly patient safety events. Despite well-established evidence and widespread implementation of preventive care interventions national pressure ulcer rates (PUR) and fall rates (FR) remain high. Numerous studies have examined factors that improve or hinder quality of Care (QOC), including the QOC indicators PUR and FR. By and large it is understood that contextual factors are important to consider when examining PUR and FR, but there is little evidence on the longitudinal influence of contextual factors on PUR and FR. The prosed study includes contextual factors conceptualized as the nurse work environment (NWE) factors (staffing and professional nursing practice) and the environment within which the NWE resides conceptualized as the 3 levels of the health care system (community, hospital and nurse unit). The NWE factors affect nurse outcomes (satisfaction and turnover) and care interventions. Thus PUR and FR are affected by care interventions which in turn are affected by nurse outcomes and NWE factors which are impacted by community, hospital, and nursing unit characteristics. These relationships are understudied in rural hospitals. Comparisons of QOC indicators in rural and urban hospitals show mixed results suggesting other contextual factors besides location are important for QOC. Longitudinal studies, measuring context and identifying resources across the healthcare system, can elucidate these complex relationships. Building on 6 preliminary studies we propose a non-experimental longitudinal design, comparing rural and urban nursing units, using 2009-2013 (20 quarters) unit-level data from the National Database of Nursing Quality Indicators augmented with data on community and hospital characteristics from other data bases. We will first (specific aim 1) determine effects of care interventions for pressure ulcer and fall prevention on PUR and FR over 5 years. We will then add NWE factors and nurse outcomes (specific aim 2) and examine the effect NWE factors and nurse outcomes have on the relationships of care interventions and PUR and FR. Finally we will (specific aim 3) determine rural and urban differences in the effects of care interventions on PUR and FR and assess the extent to which the potential differences are attributed to NWE factors and nurse outcomes. For all 3 aims we will control for community, hospital, and nursing unit characteristics. Our study's results will inform administrative and policy strategies for examining and improving QOC in rural and urban nursing units.