Pamela Ratner

Professor

Relevant Degree Programs

 

Graduate Student Supervision

Doctoral Student Supervision (Jan 2008 - May 2019)
The influence of information exchange processes on the provision of person-centred care in residential care facilities (2014)

Purpose: The movement away from task-oriented care toward the consistent provision of person-centred care (i.e., care based on residents’ needs and preferences) is widely recognized as the goal of the residential care culture change movement. The purpose of this study was to explore why the attainment of this goal has remained elusive for many residential care facilities (RCFs), despite significant effort to alter practice. Methods: I conducted an institutional ethnography to explore the textually mediated work processes that influence the day-to-day work practices of front-line care staff in RCFs. The social organization of RCFs was explored through the observation of resident care attendants’ (RCAs') practices and the interaction of those practices with institutional texts. The data were derived from three RCFs and included 104 hours of naturalistic observation, 76 in-depth interviews, and document analysis. Results: Practical access to institutional texts containing care-related information was dependent on job classification. Regulated healthcare professionals (e.g., RNs) frequently accessed these texts to exchange information. Although RCAs provided 80% of the care to residents, in all sites studied, they lacked practical access to the institutional texts that contained important information relevant to the residents’ individualized care needs and preferences (e.g., assessments, care plans, social histories). The RCAs primarily received and shared information orally; however, the organizational systems in the facilities studied mandated the written exchange of information and did not formally support an oral exchange. Consequently, the oral exchange of care information was largely dependent upon the quality of the RCAs' working relationships with one another and especially with management. Implications: Access to detailed knowledge of residents’ needs and preferences is fundamental to the provision of person-centred care. The transfer of this knowledge to and between front-line care staff is dependent upon the quality of the relationships managers develop with and among RCAs. Initiatives aimed at building supportive and collaborative work teams are essential to the inclusion of RCAs in the care planning process and to the attainment of the goal of person-centred care.

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Change in patient-reported outcomes after cardioverter-defibrillator implantation (2013)

Some people, because they have a genetic predisposition or heart disease, are at high risk for cardiac arrhythmias that could cause their hearts to stop. The implantable cardioverter-defibrillator (ICD) is an effective therapy that recognises abnormal heart beats, can administer an electrical shock to stop a potentially lethal heart rhythm, and affords protection from the devastating consequences of sudden cardiac arrest. Patient-reported outcomes (PROs) are assessments provided directly by patients about various aspects of their health and quality of life. We sought to study the change in PROs after ICD implantation to identify people’s patterns of change, explore individual trajectories of change, and identify predictors of differences in individuals’ trajectories. The study was grounded in the Wilson and Cleary (1995) conceptual framework of quality of life and informed by the Patient-Reported Outcomes Measurement Information System domain framework. Using a prospective, longitudinal study design, data were obtained from 171 people undergoing ICD implantation at quaternary centres in British Columbia, Canada (55.5% response rate). PRO assessments were obtained immediately before implantation and at one, two, and six months following implantation. We employed individual growth modelling to analyse change within and between people. The participants had different physical, mental, and social health status PROs at baseline and, on average, demonstrated improvement. At most of the measurement occasions, the participants’ PROs remained poorer than those of average adult, urban-dwelling Canadians. There was significant individual variability in most of the trajectories, especially in the social functioning domains. Relative to men, women reported worse PROs initially (the relative mean difference in men’s and women’s scores ranged from 4.5% to 24.7% for 6 of the 12 indicators). Yet, the women’s rates of improvement were significantly faster than those of men. Women equalled or exceeded the men’s PROs at the six-month assessment (the relative mean difference ranged from 4.5% to 10.4%, depending on the PRO). Further research is needed to explore the individual change trajectories identified in this study, especially for those patients who did not improve over time, fully test the conceptual model that framed the research, and evaluate interventions aimed at improving PROs after ICD implantation.

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Characteristics of the registered nurse workforce : associations with mortality rates in general and hospital-based populations (2011)

Concerns regarding a shortage of registered nurses (RNs) have underscored the importance of improving methods for workforce planning. The goal of this dissertation was to contribute knowledge that could enhance nursing human resources (NHR) planning, with a particular focus on a population health, needs-based approach. This research relied on descriptive-exploratory analyses using repeated measures of data obtained from the College of Registered Nurses of British Columbia (BC) and publicly available reports of the BC Vital Statistics Agency and Canadian Institute for Health Information. Three studies were conducted to: a) investigate the spatial and temporal patterns and trends in the BC RN workforce (Study one); b) examine the associations between selected characteristics of the RN workforce and indicators of population health (Study two); and c) examine the associations between selected characteristics of the RN workforce and the hospital standardized mortality ratio (HSMR) (Study three). Small area analysis (Studies two and three) and mixed effects statistical models (Studies two and three) were used. The results of study one showed that geographic areas (BC’s local health areas [LHAs]) with low general population density (i.e.,
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Sex and gender differences in symptoms of acute coronary syndromes (2010)

Background: Better understanding of acute coronary syndrome (ACS) symptoms is needed to improve diagnosis. Prior research has suggested sex or gender differences in ACS symptoms, but these studies have been fraught with methodological issues. Using percutaneous coronary intervention (PCI), specifically angioplasty balloon inflation to model myocardial ischemia, this study examined whether sex or gender differences exist in reported symptoms of ACS, and other predictors of ACS symptoms.Methods: Consecutive patients having non-emergent PCI were prospectively recruited. Hemodynamic instability, left bundle branch block and total occlusion were exclusion criteria. Prior to PCI, descriptions of prior symptoms that had led to referral for PCI were obtained. Balloon inflation was sustained for two minutes unless a clinical reason to deflate occurred. During inflation, subjects were questioned about current symptoms. Concurrent ECG data were collected.Findings: Of the final sample of 305 (39.7% women; mean age 63.9 years (SD = 10.6), 245 (83%) had ECG-evident ischemia during inflation. No sex/gender differences were found in rates of reporting chest discomfort or “typical” symptoms, regardless of ischemic status. Women were significantly more likely to report throat, jaw and neck discomfort, as well as only non-chest discomfort. Controlling for age, diabetes, urgency of procedure, prior MI or prior PCI increased the sex/gender effect. Increased age, urgency, prior MI and PCI were also covariates with specific symptoms. Conclusions: This prospective study with ECG confirmation of ischemia suggests women and men have similar rates of chest discomfort and other “typical” symptoms during ACS. However women are more likely to experience throat, jaw and neck discomfort. Although other factors also influence reported symptoms, they do not diminish the effect of sex/gender. There has been suggestion in both the popular press and patient education materials that women experience ACS very differently from men. Therefore, it is important that clear educational messages be crafted to ensure both women and health professionals realise that classic symptoms of ACS are equally common in women and men.

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Do relational differences in demographics and work values result in conflict and burnout in the nursing workforce? (2009)

The consequences of diversity have not been formally considered as contributing to undesirable work environments in healthcare. I sought to address this gap by examining a conceptual model that explains how diversity within the nursing workforce gives rise to interpersonal conflict (relationship and task) within workgroups, which in turn, is linked to burnout (emotional exhaustion, depersonalization, and diminished personal accomplishment). Diversity was defined as the degree of relative difference or dissimilarity between an individual and other workgroup members on select attributes, which in this study were age, education, ethnicity/race, and work values. Using a cross-sectional survey design, data were taken from a population-based sample of 603 nurses (registered nurses and licensed practical nurses) (80% response rate) in two acute care hospitals in British Columbia, Canada. At the individual level of analysis, a two-step approach to latent variable modelling was used: (a) factor analysis techniques to test and establish the validity of the measurement model and (b) structural equation modelling to test the hypothesized model. Partial support for the proposed model was found for both the direct relationships between diversity and burnout as well as the mediating effects of interpersonal conflict. Overall, the results indicated that perceived diversity explained a greater percentage of the variance in burnout compared with the explanatory power of actual diversity. Specifically, perceived work values and educational diversity were the most important explanatory variables of depersonalization (Pratt index = 58% and 21%, respectively) and were similarly predictive of diminished personal accomplishment (Pratt index = 69% and 35%, respectively). Emotional exhaustion was solely (Pratt index = 100%) explained by perceived work values diversity; however, the total variance explained was very minimal. Both individuals’ involvement in relationship and task conflict were the predominant mediating variables of the relationships between perceived work values diversity and emotional exhaustion (59% and 76% total mediation, respectively), depersonalization (57% and 68% total mediation, respectively), and diminished personal accomplishment (28% and 32% total mediation, respectively). The implications of the study relate to nurses and decision-makers at the micro, meso, and macro level of practice to create a climate of support for, and acceptance of, diversity in healthcare workplaces.

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Master's Student Supervision (2010 - 2018)
The effects of English proficiency on length of stay after isolated cardiac bypass surgery (2014)

Nurses often face the challenge of communicating information to patients who may not fully understand English. Limited English proficient (LEP) patients are at higher risk of misunderstanding health teaching, leading to impediments in their recovery. This study examined whether LEP patients have a prolonged length of stay (LOS) following coronary artery bypass graft (CABG) surgery when compared with English proficient (EP) patients. The study also compared the LOS of the two groups of patients (LEP and EP) with the study hospital’s clinical pathway target.A retrospective chart audit was conducted of all patients undergoing isolated CABG, over a two-year period. A screening tool was administered to determine each patient’s English proficiency based on documented information. A data abstraction tool collected pertinent pre-, intra-, and post-operative health indicators. 691 (97.1%) of the 712 charts reviewed were eligible for inclusion. The “limited or not English proficient” (LEP/NEP) patients had a median post-operative stay that was one day longer than that of the EP patients (7 days versus 6 days, p = .007). The median LOS stay of all patients, irrespective of English proficiency, exceeded the clinical pathway target of 5 days. In an unadjusted polynomial regression model, the LEP/NEP patients were found to be 2.2 times more likely to have a LOS of 9+ days (95% [CI 1.5, 7.2]). The multivariate model revealed that post-operative infection was the strongest predictor of LOS, and language proficiency was no longer statistically significant. Post-operative infections fully mediated the relationship between language proficiency and LOS. Relative to having a
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Total joint arthroplasty patients' adherence to a pre-operative staphylococcus aureus decolonization protocol (2014)

Background: Staphylococcus aureus surgical site infections and their treatment, in the total joint arthroplasty population, can significantly affect patients’ recovery and their quality of life, and can generate considerable economic cost for the health care system. The use of a pre-operative screening and decolonization protocol has shown promising eradication rates of Staphylococcus aureus and a decreased incidence of surgical site infections, however, the results have lacked statistical significance. Adherence to the decolonization protocol has been identified as a possible missing link or explanation for these equivocal findings. Objective: The purpose of this study was to examine the relationships between age, self-efficacy, and adherence to a Staphylococcus aureus screening and decolonization protocol in the total joint arthroplasty population. Methods: A descriptive correlational study design was conducted. The study sample included 40 participants who underwent primary total joint arthroplasty surgery between May 1, 2013 and October 1, 2013 at a hospital in Vancouver, British Columbia. Self-efficacy and adherence were assessed using two self-report measures: the Self-efficacy Survey and the Adherence Questionnaire. Data were analyzed using correlational and multiple linear regression analyses. Results: The findings suggest that there was a positive relationship between age and adherence to the use of chlorhexidine gluconate cloths, and a negative relationship between age and adherence to the use of nasal Mupirocin. These results were not statistically significant. There was a statistically significant and strong positive relationship between the patients’ level of self-efficacy in applying Mupirocin and their adherence to its use, timing, and application. Little if no relationship was found between the patients’ level of self-efficacy to chlorhexidine gluconate cloths and their adherence to its use, timing, and application. Age, and not self-efficacy, contributed significantly to the outcome, adherence. Conclusions: The study found inconclusive results with respect to the relationships between age, self-efficacy, and adherence. In light of these results, this study highlights the many ways in which age and self-efficacy can influence adherence in adults. This information can be useful when evaluating the effectiveness of a decolonization protocol and for nurses in their attempts to design, implement, and evaluate patient education materials relevant to the protocol.

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The relationship between occupational noise exposure and stress in long-term care facility workers (2013)

The sound characteristics of many healthcare settings have been documented to be verypoor. There has been extensive research about the adverse effects of noise, especially on patientsin acute care settings, but little research has examined long-term residential care workers’exposure to noise. Excessive noise exposure has been associated with burnout in critical carenurses as well as with health problems, such as adverse cardiovascular effects. However, there isa lack of research evaluating the effects of occupational noise exposure on healthcare providers’ health status and stress levels. Hence, a non-experimental, correlational study was undertaken to answer the research question, “What is the relationship between occupational noise andhealthcare workers’ stress in long-term care facilities?” A stratified sample of 6 long-term care facilities was obtained within Vancouver Coastal Health and convenience samples of healthcare workers were recruited from each facility. Repeated exposure (noise) and outcome (stress) assessments over four sampling days were conducted utilizing noise dosimeters and biophysiological and self-reported measures, including salivary cortisol, heart rate variability, and Cohen’s Perceived Stress Scale. Participants were exposed to mean A-weighted average sound pressure levels ranging between 74.4 to 74.8 dB(A) and C-weighted peaking soundpressure levels as high as 143.5 dB(C). Bivariate correlation analyses revealed statisticallysignificant correlations between the A-weighted average sound pressure levels and heart ratevariability indices (i.e., standard deviation of the NN intervals and low frequency to highfrequency ratios), and the type of shift worked (i.e., evening/night versus day shift). Healthcareworkers who worked day shifts were exposed to higher sound levels, and those who were exposed to higher noise levels experienced more stress. Linear regression analyses were conducted to explore the interrelationships among the statistically significant correlations. A-weightedaverage sound pressure levels made a statistically significant contribution to two heart rate variability indices: standard deviation of NN intervals and low frequency to high frequencyratios throughout the four sampling days, when the shift worked was controlled.

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Nursing care and post-operative delirium in the cardiac surgery intensive care unit (2010)

Post-operative delirium is a debilitating and costly adverse event that has detrimental effects on patients’ recovery and complicates nursing care. Its numerous risk factors make the disorder seem unavoidable and unpreventable. Although pre-operative and intra-operative risk factors for delirium may not be controllable, the post-operative risk factors directly related to nursing practice are directly controllable. Practices to control pain through analgesia and sedation administration given at nurses’ prerogative may be associated with the onset of delirium in the immediate post-operative period. This study examined opioid and benzodiazepine administration given pro-re-nata (PRN) (“as needed”) by nurses to cardiac surgery patients to determine whether a relationship exists between delirium and nurses’ drug administration. One hundred twenty-two patients were assessed during the first three days following cardiac surgery for delirium with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Data were collected regarding potential risk factors and opioid analgesia and benzodiazepine dosages given to the patients. A retrospective chart review was conducted to determine whether the patients had a physician’s clinical assessment and diagnosis of delirium. Post-operative delirium occurred in 37.7% to 44.3% of the study sample, depending on how the cases that had positive CAM-ICU assessments and no clinical diagnoses of delirium were handled. The amount of opioid analgesia given to these patients varied widely; however, the total dosage over the 72-hour study period had no statistically significant relationship with the development of delirium (Median = 77.2 morphine equivalents (MEs) for group without delirium vs. 79.3 MEs for group with delirium; Mann-Whitney U = 1697, Z = -0.72, p = .47). The amount of Midazolam administered also varied widely. There was a statistically significant and positive relationship between the dosage of Midazolam given and the development of post-operative delirium (Median = 2.0 mg. for group without delirium vs. 4.0 mg. for group with delirium; Mann-Whitney U = 1393, Z = -2.31, p = .021). The results of this study indicate that better nursing education and changes in nurses’ practice may be required to protect patients from experiencing drug-induced post-operative delirium.

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News Releases

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