Graduation Year


Document Type




Degree Granting Department

Aging Studies

Major Professor

Kathryn Hyer, Ph.D., M.P.P

Committee Member

Ross Andel, Ph.D.

Committee Member

Laurence G. Branch, Ph.D.

Committee Member

Nicholas G. Castle, Ph.D.

Committee Member

John Ferron, Ph.D.

Committee Member

Hongdao (Daniel) Meng, Ph.D.


patient safety culture, turnover, generalized estimating equations, Donabedian, patient safety outcomes


Safety of residents has gained increased popularity in recent years following a report from the Institute of Medicine attributing 98,000 hospital deaths each year to errors by staff. As a result, regulatory agencies, advocates, and health care providers have shifted their focus to understanding patient safety and developing a culture that promotes safety. However, nursing homes lag behind other health care providers in their adoption of a patient safety culture and understanding what factors affect safety in resident care. These insights are needed to ensure that nursing home residents receive the safe care.

The purpose of this dissertation is to explore factors that influence the safety of residents in nursing homes by conducting three separate studies and using Donabedian's Structure Process Outcome (SPO) framework. The first study examines facility characteristics that predict higher patient safety culture scores given by top managers among a nationally representative sample of nursing homes. Using the same sample, the second study examines the relationships among the three components of Donabedian's SPO model as they relate to patient safety: structure (patient safety culture), processes of care (restraint use) and a common patient safety outcome, resident falls. The final study uses a sample of Florida nursing homes and the SPO model to examine the relationships between nursing staff turnover, processes of care, and patient safety outcomes in nursing homes.

Findings from this dissertation can contribute to a greater understanding of what predicts higher levels of patient safety in nursing homes. In the first analysis, facility characteristics that are traditionally related to quality of care in nursing homes are predictive of higher patient safety culture scores. In the second analysis, higher ratings of patient safety culture are related to better processes of care and a decreased likelihood of resident falls. In the final analysis, results indicate that Certified Nursing Assistant (CNA) turnover had an independent effect on two patient safety outcomes, falls and UTIs, and that this effect is mediated by processes of care within the nursing home. Collectively, the findings from this dissertation may have important implications for policy makers, providers, and consumers of nursing home services.