Beyond Hospital-Level Aggregated Data: A Methodology to Adapt Clinical Data From the Electronic Health Record for Nursing Unit-Level Research.

BACKGROUND: Studies of nurse staffing frequently use data aggregated at the hospital level that do not provide the appropriate context to inform unit-level decisions, such as nurse staffing. OBJECTIVES: Describe a method to link patient data collected during the provision of routine care and recorded in the electronic health record (EHR) to the nursing units where care occurred in a national dataset. RESEARCH DESIGN: We identified all Veterans Health Administration acute care hospitalizations in the calendar year 2019 nationwide. We linked patient-level EHR and bar code medication administration data to nursing units using a crosswalk. We divided hospitalizations into segments based on the patient's time-stamped location (ward stays). We calculated the number of ward stays and medication administrations linked to a nursing unit and the unit-level and facility-level mean patient risk scores. RESULTS: We extracted data on 1117 nursing units, 3782 EHR patient locations associated with 1,137,391 ward stays, and 67,772 bar code medication administration locations associated with 147,686,996 medication administrations across 125 Veterans Health Administration facilities. We linked 89.46% of ward stays and 93.10% of medication administrations to a nursing unit. The average (standard deviation) unit-level patient severity across all facilities is 4.71 (1.52), versus 4.53 (0.88) at the facility level. CONCLUSIONS: Identification of units is indispensable for using EHR data to understand unit-level phenomena in nursing research and can provide the context-specific information needed by managers making frontline decisions about staffing.

A Novel Use of Bar Code Medication Administration Data to Assess Nurse Staffing and Workload.

OBJECTIVE: The aim of the study is to introduce an innovative use of bar code medication administration (BCMA) data, medication pass analysis, that allows for the examination of nurse staffing and workload using data generated during regular nursing workflow. METHODS: Using 1 year (October 1, 2014-September 30, 2015) of BCMA data for 11 acute care units in one Veterans Affairs Medical Center, we determined the peak time for scheduled medications and included medications scheduled for and administered within 2 hours of that time in analyses. We established for each staff member their daily peak-time medication pass characteristics (number of patients, number of peak-time scheduled medications, duration, start time), generated unit-level descriptive statistics, examined staffing trends, and estimated linear mixed-effects models of duration and start time. RESULTS: As the most frequent (39.7%) scheduled medication time, 9:00 was the peak-time medication pass; 98.3% of patients (87.3% of patient-days) had a 9:00 medication. Use of nursing roles and number of patients per staff varied across units and over time. Number of patients, number of medications, and unit-level factors explained significant variability in registered nurse (RN) medication pass duration (conditional R2 = 0.237; marginal R2 = 0.199; intraclass correlation = 0.05). On average, an RN and a licensed practical nurse (LPN) with four patients, each with six medications, would be expected to take 70 and 74 minutes, respectively, to complete the medication pass. On a unit with median 10 patients per LPN, the median duration (127 minutes) represents untimely medication administration on more than half of staff days. With each additional patient assigned to a nurse, average start time was earlier by 4.2 minutes for RNs and 1.4 minutes for LPNs. CONCLUSION: Medication pass analysis of BCMA data can provide health systems a means for assessing variations in staffing, workload, and nursing practice using data generated during routine patient care activities.

Virtual Levels and Role Models: N-Level Structural Equations Model of Reciprocal Ratings Data.

A general latent variable modeling framework called n-Level Structural Equations Modeling (NL-SEM) for dependent data-structures is introduced. NL-SEM is applicable to a wide range of complex multilevel data-structures (e.g., cross-classified, switching membership, etc.). Reciprocal dyadic ratings obtained in round-robin design involve complex set of dependencies that cannot be modeled within Multilevel Modeling (MLM) or Structural Equations Modeling (SEM) frameworks. The Social Relations Model (SRM) for round robin data is used as an example to illustrate key aspects of the NL-SEM framework. NL-SEM introduces novel constructs such as 'virtual levels' that allows a natural specification of latent variable SRMs. An empirical application of an explanatory SRM for personality using xxM, a software package implementing NL-SEM is presented. Results show that person perceptions are an integral aspect of personality. Methodological implications of NL-SEM for the analyses of an emerging class of contextual- and relational-SEMs are discussed.

HIV-related sexual decisions made by African-American adolescents living in different family structures: study from an ecodevelopmental perspective.

PURPOSE: The purpose of this study was to explore the association between the dynamics of family structure and sexual behaviors of African-American adolescents using the ecodevelopmental theory. METHODS: This study stratified data from 1,617 African-American adolescents of the Add Health Wave I respondents with an identified family composition. It examined the associations between family structure, parenting function, and adolescents' sexual decision-making: age of first sexual intercourse, sexual initiation before age 16, and using a condom during the first and last sexual intercourse. RESULTS: Emotional connection between parents and children (feeling more love from the father: ß=0.17, P=0.0312; feeling more love from the mother: ß=0.3314, P=0.0420) and mothers' less permissive attitude toward adolescents' sexual experience in their teens (ß=0.33, P=0.0466) are positively associated with late age of sexual initiation of adolescents living in two-parent households. School-level factors (ß=0.07, P=0.0008) and the adolescents' characteristics (being older: 0.42, P=0.0002; heterosexuality: ß=2.28, P=0.0091) are the factors most positively related to the age of sexual initiation for those living with a single parent. Immediate social determinants, other than family factors (such as land use of immediate area [rural]: ß=9.84, P<0.0001; the condition of living unit: ß=1.55, P=0.0011; and safety of neighborhood: ß=4.46, P=0.004), are related to late age of sexual initiation among those living with other relatives/alone. A higher tendency of condom use consistency was present in adolescents living with two parents compared to those living in other family structures. CONCLUSION: Less parent/child connection and parent/family influence were found in African-American adolescents living with other relatives or alone, suggesting that living with two residential parents plays an essential role in their late sexual initiation and could account for an important element to combat high HIV incidence of African-American adolescents.

Multidisciplinary design and analytic approaches to advance prospective research on the multilevel determinants of child health.

PURPOSE: Characterizing the determinants of child health and development over time, and identifying the mechanisms by which these determinants operate, is a research priority. The growth of precision medicine has increased awareness and refinement of conceptual frameworks, data management systems, and analytic methods for multilevel data. This article reviews key methodological challenges in cohort studies designed to investigate multilevel influences on child health and strategies to address them. METHODS: We review and summarize methodological challenges that could undermine prospective studies of the multilevel determinants of child health and ways to address them, borrowing approaches from the social and behavioral sciences. RESULTS: Nested data, variation in intervals of data collection and assessment, missing data, construct measurement across development and reporters, and unobserved population heterogeneity pose challenges in prospective multilevel cohort studies with children. We discuss innovations in missing data, innovations in person-oriented analyses, and innovations in multilevel modeling to address these challenges. CONCLUSIONS: Study design and analytic approaches that facilitate the integration across multiple levels, and that account for changes in people and the multiple, dynamic, nested systems in which they participate over time, are crucial to fully realize the promise of precision medicine for children and adolescents.

Hierarchical model of vulnerabilities for emotional disorders.

Clark and Watson's (1991) tripartite model of anxiety and depression has had a dramatic impact on our understanding of the dispositional variables underlying emotional disorders. More recently, calls have been made to examine not simply the influence of negative affectivity (NA) but also mediating factors that might better explain how NA influences anxious and depressive syndromes (e.g. Taylor, 1998; Watson, 2005). Extending preliminary projects, this study evaluated two hierarchical models of NA, mediating factors of anxiety sensitivity and intolerance of uncertainty, and specific emotional manifestations. Data provided a very good fit to a model elaborated from preliminary studies, lending further support to hierarchical models of emotional vulnerabilities. Implications for classification and diagnosis are discussed.

Semi-Nonparametric Methods for Detecting Latent Non-normality: A Fusion of Latent Trait and Ordered Latent Class Modeling.

Ordered latent class analysis (OLCA) can be used to approximate unidimensional latent distributions. The main objective of this study is to evaluate the method of OLCA in detecting non-normality of an unobserved continuous variable (i.e., a common factor) used to explain the covariation between dichotomous item-level responses. Using simulation, we compared a model in which probabilities of class membership were estimated to a restricted submodel in which class memberships were fixed to normal Gauss-Hermite quadrature values. Our results indicate that the likelihood ratio statistic follows a predictable chi-square distribution for a wide range of sample sizes (N = 500-12,000) and test instrument characteristics, and has reasonable power to detect non-normality in cases of moderate effect sizes. Furthermore, under situations of large sample sizes, large numbers of items, or centrally located item difficulties, simulations suggest that it may be possible to describe the shape of latent trait distributions. Application to data on the symptoms of major depression, assessed in the National Comorbidity Survey, suggests that the latent trait does not depart from normality in men but does so to a small but significant extent in women.

People are variables too: multilevel structural equations modeling.

The article uses confirmatory factor analysis (CFA) as a template to explain didactically multilevel structural equation models (ML-SEM) and to demonstrate the equivalence of general mixed-effects models and ML-SEM. An intuitively appealing graphical representation of complex ML-SEMs is introduced that succinctly describes the underlying model and its assumptions. The use of definition variables (i.e., observed variables used to fix model parameters to individual specific data values) is extended to the case of ML-SEMs for clustered data with random slopes. Empirical examples of multilevel CFA and ML-SEM with random slopes are provided along with scripts for fitting such models in SAS Proc Mixed, Mplus, and Mx. Methodological issues regarding estimation of complex ML-SEMs and the evaluation of model fit are discussed. Further potential applications of ML-SEMs are explored.

Squeezing interval change from ordinal panel data: latent growth curves with ordinal outcomes.

A didactic on latent growth curve modeling for ordinal outcomes is presented. The conceptual aspects of modeling growth with ordinal variables and the notion of threshold invariance are illustrated graphically using a hypothetical example. The ordinal growth model is described in terms of 3 nested models: (a) multivariate normality of the underlying continuous latent variables (yt) and its relationship with the observed ordinal response pattern (Yt), (b) threshold invariance over time, and (c) growth model for the continuous latent variable on a common scale. Algebraic implications of the model restrictions are derived, and practical aspects of fitting ordinal growth models are discussed with the help of an empirical example and Mx script (M. C. Neale, S. M. Boker, G. Xie, & H. H. Maes, 1999). The necessary conditions for the identification of growth models with ordinal data and the methodological implications of the model of threshold invariance are discussed.