This document summarizes the PhD journey and research of Heather Gilmartin, a nurse researcher. It discusses her application and program of study, which focused on organizational culture change in healthcare. It outlines her central research question of how organizational context impacts adherence to patient safety practices and healthcare-associated infections. Her guiding theoretical model and planned studies using VA data are described. The document also provides advice on pursuing a post-doc and different types of research careers.

1. MIND THE GAP
Health Systems Research and the Search for
Answers
Heather M. Gilmartin, PhD, NP
Post-doctoral Nurse Fellow
Denver-Seattle Center of Innovation
Department of Veterans Affairs
September 9, 2015
1

2. Do not worry
About things falling into place
Where they fall is the place
Mark Hartley
2

3. GOALS
Present a path from PhD application to
graduation and beyond
Discuss my program of research
To post-doc or not to post-doc
Top 10 things I learned in my PhD
3

4. PHD APPLICATION
Organizational Culture Change:
 How can healthcare move from a
physician/treatment system to a
nursing/caring/prevention/safety system?
 Can organizational change come from within?
 Can grass roots to middle management efforts
change the focus of an organization?
 Behavior modification in healthcare workers – can
old habits be unlearned?
 What makes a great culture in healthcare?
4

5. There are certain personal characteristics associated with
being a successful clinician-scientist investigator:
1. Be intensely curious about [the subject]
2. Be profoundly dissatisfied with the current state of
knowledge
3. Carry a profound desire to know more as a way of
helping one’s patients
P.S. Having personality characteristics associated with
oppositional-defiant disorder can be quite helpful
A pattern of disobedient, hostile, and defiant behavior toward authority
figures and requests from adults (re: chairs, deans, management), best
treated by mental health professionals (re: mentors) and family therapy (or
friends). Oxman, A.D., Sackett, D.L. (2013). Ways to advance your career by saying ‘no’ –
part 2: When to say ‘no’ and why.. Clinical Trials; (10) 181-187.
5

6. The time spent at a patient’s bedside
makes nurses the perfect people to
pursue an understanding of the health
care system.
We move from the patient, through the
systems of care, and back to the patient.
6

7. Central thesis of the patient
safety movement is that most
medical errors are the results
of bad systems, not bad
people
7

8. WHERE IS THE GAP IN THE
LITERATURE?
Mind the Gap
8

9. "In school, we're rewarded for
having the answer, not for asking
a good question.”
Richard Saul Wurman
9

10. Does a proven patient safety
program vary in it’s
effectiveness in different
contexts?
If so, how and why?Shekelle PG, Pronovost PJ, Wachter RM, et al. Assessing the evidence for
context-sensitive effectiveness and safety of patient safety practices:
Developing criteria. Rockville, MD: Agency for Healthcare Research and
Quality;2010. Prepared under Contract No. HHSA-290-2009-10001C.
10

11. Context is everything
Bate P. Context is everything. London, England: Health Foundation;2014.
11

12. CONTEXT
 The soil in which a thousand flowers will bloom
 All intervening concepts between the independent and dependent
variable
12

13. 13

14. In health care, there are no outcomes
more important or tangible than the
outcomes of patients.
There are no outcomes worse than
patient injury or death resulting from
preventable errors.
14

15. WHAT IS YOUR GUIDING
THEORY?
Be Guided into the Gap
15

16. “…for atheoretical investigations hinder
the generalization of findings, delay the
development of a coherent body of
knowledge, and limit the development of
health care policy”(Verran, 1997).
16

17. THE QUALITY HEALTH OUTCOMES MODEL
Client
Context
Intervention Outcome
Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality health outcomes model. Image - the Journal of Nursing
Scholarship, 30(1), 43-46. (with permission)
17

18. WHAT IS YOUR QUESTION?
Fill a Really Small Gap
18

19. ORGANIZATIONAL CONTEXT AND HAI:
TESTING THE QUALITY HEALTH OUTCOMES MODEL
 Objective:
 Test a middle-range theoretical model to explain the relationships between:
 Adherence to central line bundle interventions
 Organizational context
 CLABSI outcomes
 Methods:
• Secondary data analysis
• 614 U.S. hospitals in 2011 – PNICER Study (Stone et al., 2014)
19

20.  Relational Coordination Survey (Gittell, 2012; Gilmartin et al., 2015)
 Effective coordination between healthcare workers is determined by the:
 Quality of communication
 Quality of underlying relationships
 Shared goals, knowledge, and mutual respect
PNICER - WORK ENVIRONMENT
20

21. PNICER - ORGANIZATIONAL CLIMATE
 Leading a Culture of Quality (Nembhard et al., 2012)
 Employee perceptions of unit level:
 Quality focus
 Change orientation
 Openness
 Work group cooperation
 Alignment with leadership and direction
 Accountability
 Psychological safety
21

22. HEALTHCARE-ASSOCIATED INFECTION
DATA
 Monthly compliance rates for central line bundle interventions for
2008-2012 – 614 hospitals
 Hand hygiene
 Maximal barrier precautions
 Chlorhexidine gluconate skin prep
 Optimal site selection
 Monthly central line infection rates (2008-2012) from CDC
National Health Safety Network
 R01 - $100,000,000+ prospective study
22

23. Organizational
Context
Adherence to
Central Line
Bundle
Client
X
XX
Leadership
Psych
Safety
Climate
MD RC
HA RC
RN RC
Estimator: WLSMV
Chi-sq (1,315) = 1,986.30
P <.0000
RMSEA = .04
CFI = .97
0.24
(p=.00) -0.07 (NS)
0.87
0.81
0.96 -0.67
-0.76
-0.65
-0.37
CLABSI
Weighted
Mean
EVS RC
23

24. THE ROLE OF ORGANIZATIONAL CONTEXT ON
ADHERENCE TO HAI BUNDLE PRACTICES AND
HAI OUTCOMES
Objectives:
 Explore the relationships between:
 Organizational context
 Adherence to central line bundle interventions
 CLABSI outcomes
 Patient characteristics in the VA
Methods:
 Secondary data analysis
 VA ICUs – 2008-2011
 Contextual variables:
 Culture, Climate, Work Environment,
24

25. Patient Weighted
Case Severity Index
(ICU level)
Organizational
Context
CL Bundle
Intervention
CLABSI Outcomes
Hand Hygiene
2% CHG
Max Barrier
Optimal Site
Organizational
Climate
Organizational
Culture
Work
Environment
Structural
Characteristics
AES Culture
Survey
AES Job
Satisfaction
AES OAI Facility
Complexity Level
30-day Standard
Mortality Ratio
The Quality Health Outcomes Model for Infection Prevention in the VA
AES: All Employee Survey
CHG: Chlorhexidine Gluconate
25

26. OPTIMIZING THE NURSE WORK ENVIRONMENT TO IMPROVE
PATIENT OUTCOMES
Objectives:
 Identify high-risk nurse work environments and assess a relationship
with adverse patient events (unit level)
 Nurse work environment
 Nurse sensitive outcomes
 30 day standard mortality
 Patient severity index
 Non-acute and critical care settings
Methods:
 Secondary data analysis
 VA non-acute and critical care settings – 2011-2014
 Nursing workforce index – practice environment scale (NWI-PES)
26

27. TO POST-DOC OR NOT TO POST-DOC
 Continued, formal mentoring
 Opportunity to expand statistical skills, research
methods, and be part of multi-disciplinary groups
 Dissemination of research findings (time to publish
your dissertation and create engaging presentations)
 Establish a research funding record via grant writing
27

28. Pro Con
100 % protected time for your
research (publish or perish)
Pay: $41,000-59,000/yr (with
benefits)
Time with really smart people who
want you to be successful (new
mentors!)
Two years away from a “real job”
Play with new data, new methods,
new topics
Figure out what type of researcher
you want to be
Time to breathe, play, etc.
Time to build partnerships (partner
or perish)
Time to read for ideas and
inspiration
28

29. TYPES OF RESEARCHER
 Academic Researcher
 Tenure track – University based
 Detached from the “bosses” (the patient and taxpayers who fund your work)
 Goal: Novel ideas, publish, continue funding cycle
 Embedded Researcher
 VA, Kaiser, IHI, government agencies
 Your boss is ever present and wants to be kept abreast of work (newsletters to patients, C-suite)
 Goal: Novel, affordable, and realistic ideas that can be implemented a.s.a.p. and given away (share everything)
 Make public and adopt before publication
 Learn, move on, improve as quickly as possible
 Clinical Researcher
 Hospital or Clinic Based – Clinician or Management level
 Your Boss: Your patients, staff, or Board
 Goal: Conduct research pertinent to your clinical setting or facilitate research in your setting
 For-profit Researcher
 Big Pharma & Tech
 Funding is not an issue – your bosses are the Board and investors
 Goal: Prove a product, sell the product
 Once you go for-profit, hard to come back to academic or embedded position
29

30. TOP 10 THINGS I LEARNED IN MY PHD
PROGRAM
10) Do no read everything they assign you –
skimming is an art
9) NEVER delete data from your files – archive
and be explicit in your naming conventions
8) Secondary data analysis for your dissertation
ROCKS!
7) Your mentor is your guide, but you have to take
the initiative and make things happen
6) Learn one statistical method really well – just
one
30

31. TOP 10
5) Do not fall into the trap @ SAS v. STATA v. SPSS v. R
4) Keep an idea book – when you think of something
amazing to research, write it in the book and go back to this
when it is time to write for $$
3) Do not compare yourself to others – they are on their own
journey – celebrate their successes as well as your own
2) Keep an eye on the big picture:
“What is the Pain You are Trying to Take Away” Karen
Sousa
1) Graduate ASAP
31

32. 32

33. 33