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Title: DOES SAFETY CULTURE PREDICT CLINICAL OUTCOMES?.
Creator: Wilson, Katherine, Salas, Eduardo, University of Central Florida
Abstract / Description: Patient safety in healthcare has become a national objective. Healthcare organizations are striving to improve patient safety and have turned to high reliability organizations as those in which to model. One initiative taken on by healthcare is improving patient safety culture--shifting from one of a 'no harm, no foul' to a culture of learning that encourages the reporting of errors, even those in which patient harm does not occur. Lacking from the literature, however, is an...
Show morePatient safety in healthcare has become a national objective. Healthcare organizations are striving to improve patient safety and have turned to high reliability organizations as those in which to model. One initiative taken on by healthcare is improving patient safety culture--shifting from one of a 'no harm, no foul' to a culture of learning that encourages the reporting of errors, even those in which patient harm does not occur. Lacking from the literature, however, is an understanding of how safety culture impacts outcomes. While there has been some research done in this area, and safety culture is argued to have an impact, the findings are not very diagnostic. In other words, safety culture has been studied such that an overall safety culture rating is provided and it is shown that a positive safety culture improves outcomes. However, this method does little to tell an organization what aspects of safety culture impact outcomes. Therefore, this dissertation sought to answer that question but analyzing safety culture from multiple dimensions. The results found as a part of this effort support previous work in other domains suggesting that hospital management and supervisor support does lead to improved perceptions of safety. The link between this support and outcomes, such as incidents and incident reporting, is more difficult to determine. The data suggests that employees are willing to report errors when they occur, but the low occurrence of such reportable events in healthcare precludes them from doing so. When a closer look was taken at the type of incidents that were reported, a positive relationship was found between support for patient safety and medication incidents. These results initially seem counterintuitive. To suggest a positive relationship between safety culture and medication incidents on the surface detracts from the research in other domains suggesting the opposite. It could be the case that an increase in incidents leads an organization to implement additional patient safety efforts, and therefore employees perceive a more positive safety culture. Clearly more research is needed in this area. Suggestions for future research and practical implications of this study are provided.
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Date Issued: 2007
Identifier: CFE0001924, ucf:47472
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFE0001924

Title: The Role of Resilience on Second-Victim Outcomes: Examining Individual and External Factors of Medical Professionals.
Creator: Hernandez, Claudia, Burke, Shawn, Bowers, Clint, Porter, Marissa, University of Central Florida
Abstract / Description: The present work is intended to bring awareness to medical professionals impacted by the occurrence of errors they have committed or witnessed (i.e., second-victims) and highlight the negative effects that may result from such errors. The purpose of this research is to test whether resilience and negative affect that is experienced after a medical error are related. Additionally, four variables are tested as moderators of this relationship, two of which are considered individual variables (i...
Show moreThe present work is intended to bring awareness to medical professionals impacted by the occurrence of errors they have committed or witnessed (i.e., second-victims) and highlight the negative effects that may result from such errors. The purpose of this research is to test whether resilience and negative affect that is experienced after a medical error are related. Additionally, four variables are tested as moderators of this relationship, two of which are considered individual variables (i.e., self-efficacy and work meaningfulness), and two of which are characterized as external variables (i.e., co-worker support and organizational support). Twenty-two healthcare professionals from a hospital's Cardio-Vascular Intensive Care Unit participated in a short survey. Results showed a relationship exists between resilience and negative affect experienced by second victims, post-error. The limitations of the current work, practical implications, and ideas for future research will be expanded upon herein.
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Date Issued: 2019
Identifier: CFE0007651, ucf:52475
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFE0007651

Title: The Development and Testing of a Measurement System to Assess Intensive Care Unit Team Performance.
Creator: Dietz, Aaron, Salas, Eduardo, Jentsch, Florian, Sims, Valerie, Rosen, Michael, Burke, Shawn, University of Central Florida
Abstract / Description: Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). Complex procedures are conducted with a diverse team of clinicians with unique roles and responsibilities. Information about care plans and goals must also be developed, communicated, and coordinated across multiple disciplines and transferred effectively between shifts and personnel. The intricacies of routine care are compounded during emergency events, which require ICU teams...
Show moreTeamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). Complex procedures are conducted with a diverse team of clinicians with unique roles and responsibilities. Information about care plans and goals must also be developed, communicated, and coordinated across multiple disciplines and transferred effectively between shifts and personnel. The intricacies of routine care are compounded during emergency events, which require ICU teams to adapt to rapidly changing patient conditions while facing intense time pressure and conditional stress. Realities such as these emphasize the need for teamwork skills in the ICU. The measurement of teamwork serves a number of different purposes, including routine assessment, directing feedback, and evaluating the impact of improvement initiatives. Yet no behavioral marker system exists in critical care for quantifying teamwork across multiple task types. This study contributes to the state of science and practice in critical care by taking a (1) theory-driven, (2) context-driven, and (3) psychometrically-driven approach to the development of a teamwork measure. The development of the marker system for the current study considered the state of science and practice surrounding teamwork in critical care, the application of behavioral marker systems across the healthcare community, and interviews with front line clinicians. The ICU behavioral marker system covers four core teamwork dimensions especially relevant to critical care teams: Communication, Leadership, Backup and Supportive Behavior, and Team Decision Making, with each dimension subsuming other relevant subdimensions. This study provided an initial assessment of the reliability and validity of the marker system by focusing on a subset of teamwork competencies relevant to subset of team tasks. Two raters scored the performance of 50 teams along six subdimensions during rounds (n=25) and handoffs (n=25). In addition to calculating traditional forms of reliability evidence [intraclass correlations (ICCs) and percent agreement], this study modeled the systematic variance in ratings associated with raters, instances of teamwork, subdimensions, and tasks by applying generalizability (G) theory. G theory was also employed to provide evidence that the marker system adequately distinguishes teamwork competencies targeted for measurement. The marker system differentiated teamwork subdimensions when the data for rounds and handoffs were combined and when the data were examined separately by task (G coefficient greater than 0.80). Additionally, variance associated with instances of teamwork, subdimensions, and their interaction constituted the greatest proportion of variance in scores while variance associated with rater and task effects were minimal. That said, there remained a large percentage of residual error across analyses. Single measures ICCs were fair to good when the data for rounds and handoffs were combined depending on the competency assessed (0.52 to 0.74). The ICCs ranged from fair to good when only examining handoffs (0.47 to 0.69) and fair to excellent when only considering rounds (0.53 to 0.79). Average measures ICCs were always greater than single measures for each analysis, ranging from good to excellent (overall: 0.69 to 0.85, handoffs: 0.64 to 0.81, rounds: 0.70 to 0.89). In general, the percent of overall agreement was substandard, ranging from 0.44 to 0.80 across each task analysis. The percentage of scores within a single point, however, was nearly perfect, ranging from 0.80 to 1.00 for rounds and handoffs, handoffs, and rounds. The confluence of evidence supported the expectation that the marker system differentiates among teamwork subdmensions. Yet different reliability indices suggested varying levels of confidence in rater consistency depending on the teamwork competency that was measured. Because this study applied a psychometric approach, areas for future development and testing to redress these issues were identified. There also is a need to assess the viability of this tool in other research contexts to evaluate its generalizability in places with different norms and organizational policies as well as for different tasks that emphasize different teamwork skills. Further, it is important to increase the number of users able to make assessments through low-cost, easily accessible rater training and guidance materials. Particular emphasis should be given to areas where rater reliability was less than ideal. This would allow future researchers to evaluate team performance, provide developmental feedback, and determine the impact of future teamwork improvement initiatives.
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Date Issued: 2014
Identifier: CFE0005482, ucf:50356
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFE0005482

Title: SUPERVISOR EXPECTATIONS, EVENT REPORTING, AND PATIENT SAFETY PERCEPTIONS: EXPLORING POTENTIAL MODERATORS AND MEDIATORS.
Creator: Hernandez, Claudia, Burke, Shawn, University of Central Florida
Abstract / Description: Given the high number of errors and negative events committed within medical settings, the emphasis on patient safety culture is becoming more prevalent. Despite this effort, underreporting has been and continues to be an issue in this area. Some research has shown a link between underreporting and lack of management responsiveness, but more work is necessary to identify reasons for underreporting and potential mitigating solutions. The objective of the present research is to answer questions...
Show moreGiven the high number of errors and negative events committed within medical settings, the emphasis on patient safety culture is becoming more prevalent. Despite this effort, underreporting has been and continues to be an issue in this area. Some research has shown a link between underreporting and lack of management responsiveness, but more work is necessary to identify reasons for underreporting and potential mitigating solutions. The objective of the present research is to answer questions regarding the impact supervisors have on staff's patient safety perceptions and event reporting, through the use of archival survey data collected with the AHRQ Hospital Safety Culture Survey (2004). Probable moderators and mediators of key relationships were explored as well. Results are presented and their implications are discussed herein.
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Date Issued: 2016
Identifier: CFH2000084, ucf:45551
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFH2000084

Title: THE IMPACT OF INTRAORGANIZATIONAL TRUST AND LEARNING ORIENTED CLIMATE ON ERROR REPORTING.
Creator: Sims, Dana Elizabeth, Salas, Eduardo, University of Central Florida
Abstract / Description: Insight into opportunities for process improvement provides a competitive advantage through increases in organizational effectiveness and innovation As a result, it is important to understand the conditions under which employees are willing to communicate this information. This study examined the relationship between trust and psychological safety on the willingness to report errors in a medical setting. Trust and psychological safety were measured at the team and leader level. In addition,...
Show moreInsight into opportunities for process improvement provides a competitive advantage through increases in organizational effectiveness and innovation As a result, it is important to understand the conditions under which employees are willing to communicate this information. This study examined the relationship between trust and psychological safety on the willingness to report errors in a medical setting. Trust and psychological safety were measured at the team and leader level. In addition, the moderating effect of a learning orientation climate at three levels of the organization (i.e., team members, team leaders, organizational) was examined on the relationship between trust and psychological safety on willingness to report errors. Traditional surveys and social network analysis were employed to test the research hypotheses. Findings indicate that team trust, when examined using traditional surveys, is not significantly associated with informally reporting errors. However, when the social networks within the team were examined, evidence that team trust is associated with informally discussing errors was found. Results also indicate that trust in leadership is associated with informally discussing errors, especially severe errors. These findings were supported and expanded to include a willingness to report all severity of errors when social network data was explored. Psychological safety, whether within the team or fostered by leadership, was not found to be associated with a willingness to informally report errors. Finally, learning orientation was not found to be a moderating variable between trust and psychological safety on a willingness to report errors. Instead, organizational learning orientation was found to have a main effect on formally reporting errors to risk management and documenting errors in patient charts. Theoretical and practical implications of the study are offered.
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Date Issued: 2009
Identifier: CFE0002818, ucf:48050
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFE0002818

Title: A Root Cause Analysis of the Barriers to Transparency among Physicians: A Systemic Perspective.
Creator: Perez, Bianca, Liberman, Aaron, Oetjen, Dawn, Wan, Thomas, Abel, Eileen, University of Central Florida
Abstract / Description: Transparency in healthcare relates to formally reporting medical errors and disclosing bad outcomes to patients and families. Unfortunately, most physicians are not in the habit of communicating transparently, as many studies have shown the existence of a large medical error information gap. Research also shows that creating a culture of transparency would mutually support patient safety and risk management goals by concomitantly reducing medical errors and alleviating the malpractice crisis....
Show moreTransparency in healthcare relates to formally reporting medical errors and disclosing bad outcomes to patients and families. Unfortunately, most physicians are not in the habit of communicating transparently, as many studies have shown the existence of a large medical error information gap. Research also shows that creating a culture of transparency would mutually support patient safety and risk management goals by concomitantly reducing medical errors and alleviating the malpractice crisis. Three predictor variables are used to represent the various dimensions of the context just described. Perfectionism represents the intrapersonal domain, socio-organizational climate represents the interpersonal and institutional domains, and medico-legal environment represents the societal domain. Chin and Benne's normative re-educative strategy provides theoretical support for the notion that successful organizational change hinges upon addressing the structural and cultural barriers displayed by individuals and groups.The Physician Transparency Questionnaire was completed by 270 physicians who were drawn from a multi-site healthcare organization in Central Florida. Structural equation modeling was used to determine whether perfectionism, socio-organizational climate, and medico-legal environment significantly predict two transparency outcomes, namely, error reporting transparency and provider-patient transparency. Perfectionism and socio-organizational climate were found to be statistically significant predictors. Collectively, these variables accounted for nearly half of the variance in each transparency outcome. Within socio-organizational climate, policies had the greatest influence on transparency, followed by immunity and professional norms. Multiple group analysis showed that the covariance model developed in this study generalizes across gender, medical specialty, and occupation. In addition, group means comparisons tests revealed a number of interesting trends in error reporting and disclosure practices that provide insights about the behavioral and cognitive psychology behind transparent communication: 1) Physicians are more inclined to engage in provider-patient transparency compared to error reporting transparency, 2) physicians are more inclined to report serious errors compared to less serious errors, and 3) physicians are more inclined to express sympathy for bad outcomes than they are to apologize for a preventable error or be honest about the details surrounding bad outcomes. These results suggest that change efforts would need to be directed at medical education curricula and health provider organizations to ensure that current and future generations of physicians replace the pursuit for perfectionism with the pursuit for excellence. Also, a number of institutional changes are recommended, such as clearly communicating transparency policies and guidelines, promoting professional norms that encourage learning from mistakes rather than an aversion to error, and reassuring physicians that reporting and disclosure activities will not compromise their reputation. From the perspective of patient safety advocates and risk managers, the results are heartening because they emphasize a key principle in quality improvement - i.e., small changes can yield big results. From an ethical standpoint, this research suggests that healthcare organizations can inhibit (or facilitate) the emergence of professional virtues. Thus, although organizations cannot make a physician become virtuous, it is within their power to create conditions that encourage the physician to practice certain virtues. With respect to leadership styles, this research finds that bottom-up, grassroots change efforts can elicit professional virtues, and that culture change in healthcare lies beyond the scope of the medico-legal system.
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Date Issued: 2011
Identifier: CFE0004153, ucf:49083
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFE0004153

Title: EFFECTS OF HEALTH INFORMATION TECHNOLOGY ADOPTION ON QUALITY OF CARE AND PATIENT SAFETY IN US ACUTE CARE HOSPITALS.
Creator: Seblega, Binyam, Zhang, Ning, University of Central Florida
Abstract / Description: The adoption of healthcare information technology (HIT) has been advocated by various groups as critical in addressing the growing crisis in the healthcare industry. Despite the plethora of evidence on the benefits of HIT, however, the healthcare industry lags behind many other economic sectors in the adoption of information technology. A significant number of healthcare providers still keep patient information on paper. With the recent trends of reimbursement reduction and rapid...
Show moreThe adoption of healthcare information technology (HIT) has been advocated by various groups as critical in addressing the growing crisis in the healthcare industry. Despite the plethora of evidence on the benefits of HIT, however, the healthcare industry lags behind many other economic sectors in the adoption of information technology. A significant number of healthcare providers still keep patient information on paper. With the recent trends of reimbursement reduction and rapid technological advances, therefore, it would be critical to understand differences in structural characteristics and healthcare performance between providers that do and that do not adopt HIT. This is accomplished in this research, first by identifying organizational and contextual factors associated with the adoption of HIT in US acute care hospitals and second by examining the relationships between the adoption of HIT and two important healthcare outcomes: patient safety and quality of care. After conducting literature a review, the structure-process-outcome model and diffusion of innovations theory were used to develop a conceptual framework. Hypotheses were developed and variables were selected based on the conceptual framework. Publicly available secondary data were obtained from the American Hospital Association (AHA), the Health Information and Management Systems Society (HIMSS), and the Healthcare Cost and Utilization Project (HCUP) databases. The information technologies were grouped into three clusters: clinical, administrative, and strategic decision making ITs. After the data from the three sources were cleaned and merged, regression models were built to identify organizational and contextual factors that affect HIT adoption and to determine the effects of HIT adoption on patient safety and quality of care. Most prior studies on HIT were restricted in scope as they primarily focused on a limited number of technologies, single healthcare outcomes, individual healthcare institutions, limited geographic locations, and/or small market segments. This limits the generalizability of the findings and makes it difficult to draw definitive conclusions. The new contribution of the present study lies in the fact that it uses nationally representative latest available data and it incorporates a large number of technologies and two risk adjusted healthcare outcomes. Large size and urban location were found to be the most influential hospital characteristics that positively affect information technology adoption. However, the adoption of HIT was not found to significantly affect hospitalsÃ‚Â' performance in terms of patient safety and quality of care measures. Perhaps a remarkable finding of this study is the better quality of care performance of hospitals in the Midwest, South, and West compared to hospitals in the Northeast despite the fact that the latter reported higher HIT adoption rates. In terms of theoretical implications, this study confirms that organizational and contextual factors (structure) affect adoption of information technology (process) which in turn affects healthcare outcomes (outcome), though not consistently, validating Avedis DonabedianÃ‚Â's structure-process-outcome model. In addition, diffusion of innovations theory links factors associated with resource abundance, access to information, and prestige with adoption of information technology. The present findings also confirm that hospitals with these attributes adopted more technologies. The methodological implication of this study is that the lack of a single common variable and uniformity of data among the data sources imply the need for standardization in data collection and preparation. In terms of policy implication, the findings in this study indicate that a significant number of hospitals are still reluctant to use clinical HIT. Thus, even though the passage of the American Recovery and Reinvestment Act (ARRA) of 2009 was a good stimulus, a more aggressive policy intervention from the government is warranted in order to direct the healthcare industry towards a better adoption of clinical HIT.
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Date Issued: 2010
Identifier: CFE0003327, ucf:48445
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFE0003327

Title: Determinants of hospital efficiency and patient safety in the United States.
Creator: Shettian, Kruparaj, Wan, Thomas, Noblin, Alice, Gurupur, Varadraj, Cobb, Enesha, Anderson, Kim, University of Central Florida
Abstract / Description: Hospitals engage in undertakings on a continual basis to enhance IT capabilities, diffusion of innovations, hospital-physician integration, and standardization to improve their performance. This empirical study explored the interdependence of three macro-level structural factors and their independent impact on the hospital performance measures efficiency and patient safety, with standardization as an important mediator. The researcher conducted a cross-sectional analysis of multiple data sets...
Show moreHospitals engage in undertakings on a continual basis to enhance IT capabilities, diffusion of innovations, hospital-physician integration, and standardization to improve their performance. This empirical study explored the interdependence of three macro-level structural factors and their independent impact on the hospital performance measures efficiency and patient safety, with standardization as an important mediator. The researcher conducted a cross-sectional analysis of multiple data sets from public user files on the acute care hospital industry. The theoretical underpinnings of the study included the structure-process-outcome theory and institutional isomorphism theory. The statistical analysis comprised confirmatory factor analysis (CFA) and covariance structural equation modeling (SEM). The study comprised data for 2,352 acute care hospitals in the United States, which represented more than half of the hospital population. As expected by the hypotheses, the study demonstrated that IT capability, hospital-physician integration, and innovativeness directly affect the variability in standardization, but they did not directly influence the variation in hospital efficiency and patient safety. This revealed that hospitals should focus on standardization because it is the mediating process between structural variables and performance variables. The results indicated a strong negative influence of standardization on hospital efficiency and a weak positive influence on patient safety. The study confirmed the triadic model that (")structure(") influences the process, which in turn influences organizational outcomes. As standardization through coercive, mimetic, and normative pressure mechanisms becomes more common through system integration and increased collaborative governance, more research on how the implementation of standards may perpetuate isomorphism or uniformity is imperative. The researcher recommends future studies to employ a longitudinal study design to explore the determinants of a variety of performance and outcome indicators, such as patient satisfaction, timeliness of care, the effectiveness of care, and equity/financial performance in addition to patient safety and hospital efficiency.
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Date Issued: 2017
Identifier: CFE0006794, ucf:51810
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFE0006794

Title: Impact of Interruption Frequency on Nurses' Performance, Satisfaction, and Cognition During Patient-Controlled Analgesia Use in the Simulated Setting.
Creator: Campoe, Kristi, Talbert, Steven, Sole, Mary Lou, Andrews, Diane, Jentsch, Florian, University of Central Florida
Abstract / Description: Problem: Interruption during medication administration is a significant patient safety concern within health care, especially during the administration of high risk medications in nursing. Patient-controlled analgesia (PCA) devices are frequently associated with adverse events and have a four-fold increased risk of patient injury compared to non-PCA related adverse events. While the nature and frequency of interruptions have been established for nurses' medication processes, the impact of...
Show moreProblem: Interruption during medication administration is a significant patient safety concern within health care, especially during the administration of high risk medications in nursing. Patient-controlled analgesia (PCA) devices are frequently associated with adverse events and have a four-fold increased risk of patient injury compared to non-PCA related adverse events. While the nature and frequency of interruptions have been established for nurses' medication processes, the impact of interruption frequency on nurses' PCA interaction has not been fully measured or described.Purpose: The purposes of this study were to quantify the impact of interruption frequency on registered nurses' (RN) performance, satisfaction, and cognitive workload during PCA interaction, and to determine nurses' perceptions of the impact of interruption frequency.Methods: This study employed a mixed-method design. First, an experimental repeated measures design was used to quantify the impact of interruption frequency on a purposive sample of nine medical-surgical RNs. The RNs completed PCA programming tasks in a simulated laboratory nursing environment for each of four conditions where interruption frequency was pre-determined. Four established human factors usability measures were completed for each of the four test conditions. The research questions were answered using repeated measures analysis of variance with (RM-ANOVA), McNamar's test, and Friedman's test. After each experiment, semi-structured interviews were used to collect data that were analyzed using inductive qualitative content analysis to determine RNs' perceptions of the impact of interruption frequency. Results: Results of the RM-ANOVA were significant for the main effect of interruption frequency on efficiency F(3,24)=9.592, p = .000. McNemar's test did not show significance for the impact of interruption frequency on effectiveness (accuracy). Friedman test showed participant satisfaction was significantly impacted by interruption frequency (x2=9.47, df=3, p=0.024). Friedman test showed no significance for the main effect of interruption frequency on cognitive workload scores by condition type (x2=1.88, df=3, p=0.599). Results of the qualitative content analysis revealed two main categories to describe nurses' perception of interruption frequency: the nature of interruptions and nurses' reaction to the interrupted work environment.Discussion/Implications: The results suggested that interruption frequency significantly affected task completion time and satisfaction for participants but not participant accuracy or cognitive workload. A high error rate during PCA programming tasks indicated the need to evaluate the conditions in which RNs complete PCA programming as each error presents potential risk of patient harm. RNs' described the impact of interruption frequency as having a negative impact on the work environment and subsequently implement compensating strategies to counterbalance interruptions. RNs' perceived that patient safety was negatively impacted by frequent interruption. RNs experienced negative intrapersonal consequences as a results of frequent interruption. Additional study is needed to better understand the impact of interruption frequency on RNs' performance accuracy and cognitive workload.
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Date Issued: 2015
Identifier: CFE0005770, ucf:50099
Format: Document (PDF)
PURL: http://purl.flvc.org/ucf/fd/CFE0005770

patient safety (6)	+ -
Patient Safety (3)	+ -
error reporting (2)	+ -
human factors (2)	+ -
Affect (1)	+ -

Assessment (1)	+ -
Event Reporting (1)	+ -
HIT (1)	+ -
IT capability (1)	+ -
Intensive Care Unit (1)	+ -
Marker System (1)	+ -
Medical Errors (1)	+ -
Medical Setting (1)	+ -
Medical-surgical nursing (1)	+ -
Nonpunitive Responses (1)	+ -
Safety (1)	+ -
Safety Climate (1)	+ -
Second-Victims (1)	+ -
Supervisor Expectations (1)	+ -
Teamwork (1)	+ -
Transparency (1)	+ -
acute care hospitals (1)	+ -
efficiency (1)	+ -
error disclosure (1)	+ -
health information technology (1)	+ -
healthcare (1)	+ -
hospital performance (1)	+ -
human error (1)	+ -
incidents (1)	+ -
innovation (1)	+ -

ETD Collection (8)	+ -
Honors Collection (1)	+ -

English (8)	+ -
Engilsh (1)	+ -

University of Central Florida (9)	+ -
Burke, Shawn (3)	+ -
Salas, Eduardo (3)	+ -
Hernandez, Claudia (2)	+ -
Jentsch, Florian (2)	+ -

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