Research Critiques and PICOT Statement Final Draft
The role of the nurses in optimal patient outcomes is extremely important, especially for patients that are in critical care. Nurse practices are greatly impacted if there is a staffing shortage, and this, in turn, can negatively affect the patients as well. It may lead to exposing the patients to risk through medical errors and poor quality of patient care. Problems of inadequate staffing that result in diminished patient satisfaction have led to the questions relating to the patient-to-staff ratio. The most important factor to ensure patient safety is vigilance by nurses at the bedside, which is compromised when the number of patients increases. Research has highlighted the relationship between patient safety and staffing ratio by documenting events of increased risk, patient morbidity, and mortality in case of a high patient-to-staff ratio (Health, 2018). This paper will explore the problem presented and research an adequate solution regarding the problem.
PICOT Statement, Research Article, and Nursing Practice Problem Link
The PICOT question for the above-mentioned nursing practice problem is as follows:
“Will patient care, improve by limiting the number of patients a nurse can take care of in critical care units? What intervention method should a nurse employ to combat the nurse short-staffing to patient outcome ratios? Is the considered intervention method within a nurse’s scope? If not then what other methods can be employed? What is the desired outcome expected from this intervention? Lastly how long will it take to yield the desired results?”
Many articles have been written regarding the short staffing of the nurses and the impact of it on patient outcomes. The one solution that is always presented is that more nurses should be hired so that the patients do not suffer, however; this solution is out of the scope of the nurses. Staffing comes under admiration and management so this solution although does not help the nurses but the problem is none of the articles researched provided any solution to the nurses for intervention. Thus, the solution suggested is out of the scope of the nurses, however, through these articles one can deduce an alternative method and develop an intervention method that will benefit the nurses.
Background of Studies
Qualitative Studies
Budd et al. conducted this study that presented strategies to provide a safe environment for the patients. This study aimed to outline an intervention using traditional and no-traditional collective bargaining (CB) so that the nurses can have a safe practice that will improve patient outcomes. CB empowers the nurses to conduct timely interventions and have a voice in important matters. This study provides the nurses to be a voice of solution as many important tasks cannot be left to the management and it is up to the nurses to be the voice of the patients (Budd et al., 2004). Nevidjon and Erickson conducted a study, in which they state that just hiring more nurses will not solve the problem regarding patient outcomes. Nurse Leaders need to be included in this matter so that they can also be part of the solution. Senior nurses need to guide junior nurses so that they may gain experience quickly to take care of critical patients. This article provides a different solution for various problems contributing to the nursing shortage (Nevidjon & Erickson, 2001).
Quantitative Studies
Lee et al., identify the concern that although the imperative job of nurses in the critical care units has been established, the connection between nurse work capacity and patient endurance is not clear (Lee et al., 2017). Similarly, Neuraz et al., posit that the key factor to quality care is a match between staffing and patients’ needs. However, the optimal match is yet not established (Neuraz et al., 2015).
The study conducted by Lee et al. explores whether patient survival diminishes if the staffing ratio threshold is not optimally maintained. The study also explores the impact of being exposed to insufficient staffing at any point during the ICU stay on risk-adjusted hospital survival. Similarly, the study conducted by Neuraz et al. assesses the relationship between staffing ratios and nurses’ workloads on the life-sustenance of patients admitted to the ICU.
Methods
This section of the paper analyzes the methods utilized by the different researchers in gathering data for their studies.
Qualitative Studies
The method that Budd et al. proposed was to use traditional and non-traditional collective bargaining. This method allows the application to a different problem that the nurses are facing, to get the desired outcome. The problem identified in this study was the insecure environment for the patients due to the lack of an optimal work environment for the nurses. This strategy has helped the nurses in past to secure better wages so using it for such a problem will allow them to yield the results they seek (Budd et al., 2004). Nevidjon and Erickson studied the recent work trends to understand the reasons behind the lack of nurse staffing. They determined that it is due to trends like seeking more personal time, wanting to create work and life balance, wanting less stressful jobs, etc. Through the study of recent trends, they were able to outline many underlying problems (Nevidjon & Erickson, 2001).
Quantitative Studies
The quantitative study by Lee et al. employs “retrospective cohort analysis” of the data gathered from a group of adult patients that were admitted to two ICUs. The data used included nursing workload, the average bedside nurses, and the severity of illness. This study was conducted in two ICUs in Hong Kong where 845 patients were admitted over five months. The statistical analysis of this study includes as Shapiro-Wilk’s test, Chi-square test, and Pearson’s correlation among others. Neural et al. employed longitudinal analysis for their research. the analysis was aimed at the routinely collected hospital data, for which statistical analysis was conducted to generate results. The longitudinal analysis was conducted from January to December 2013 in eight ICUs with 5718 inpatient stays.
The two methods i.e., retrospective analysis and longitudinal analysis have certain benefits and shortcomings. Retrospective cohort analysis provides the advantage of being relatively less expensive as compared to other cohort studies. Moreover, it can be performed immediately; however, there is less control over covariates, exposure factors, and potential confounding variables. In contrast, longitudinal studies help in gathering detailed data over some time, enabling researchers to build a reliable and accurate account of events by reducing the impact of recall bias. However, this method has its shortcomings as it may lead to the conditioning of the participants which may result in influenced behavior and responses (Suchmacher & Geller, 2012).
Results of Studies
The purpose of this section is to analyze the results yielded by the researchers during their studies and the way these relate to the PICOT statement presented.
Qualitative Results
Budd et al. presented an ongoing example of CB which was being employed to change the environment for the patients. This method allowed them to reach a consensus with the management as they were able to reach an agreement (Budd et al., 2004). Several solutions were suggested by Nevidjon and Erickson after they identified different problems. These solutions are implementable and can lead to improved patient outcomes, however; it may take a few years to see the results of some of these solutions (Nevidjon & Erickson, 2001).
Quantitative Results
The results of the study conducted by Lee et al. reveal that for critically ill patients, the risk of death substantially increases if they are exposed to high staffing ratios/ workload even for one day. This establishes that excess nursing workload is linked to an increased rate of mortality. Similarly, the results of the study conducted by Neuraz et al. present a research-based threshold of patient-to-nurse ratios. When exceeded, it may endanger the safety of patients in the ICU.
The results of both studies answer the PICOT question that the quality of patient care would improve significantly if nurse workload is manageable. Both studies have important implications for nursing practice as it guides the health care providers that staffing for ICU must adhere to the expected workload and not only the patient numbers. It emphasizes the importance of real-time monitoring of workload and staffing ratios to adjust resources as per the patients’ care needs.
Proposed Evidence-Based Practice Change
The articles present extensive solutions for nurse short-staffing; these solutions require nurses’ intervention so that patient outcomes can be improved. The interventions proposed by these articles will allow the nurses to prompt a change in their working environment which, in turn, will help in improving the care provided to patients.
Ethical Considerations
This section of the paper highlights the ethical repercussions of each article used in this study and the outcomes of these ethical dilemmas.
Qualitative Studies
The ethical considerations that the study conducted by Budd et al. presents are that “collective bargaining”, can become hostile if not conducted properly. This type of intervention should only be utilized as a last resort as it can get out of hand if the dialogue heats up (Budd et al., 2004). The study conducted by Nevidjon and Erickson provides ethical solutions to every problem identified, their solutions are well researched and can be implemented effectively (Nevidjon & Erickson, 2001).
Quantitative Studies
The ethical considerations of a retrospective study pertain to the anonymity of data and informing the participants of using it for research purposes. Similarly, for longitudinal study ethical dilemmas of informed consent, confidentiality, and data integrity must be considered among others. Lee et al. obtained approval to conduct the study from the “Clinical Research Ethics Committee of the Chinese University of Hong Kong”. The ethics committee waived off the need to get patient consent. Neuraz et al.’s study was exempted from ethical approval as per the French law.
Conclusion or Summary
All the articles chosen for the PICOT questions state that hiring more staff will improve the patient outcome, however; nurse staffing is not under nurses’ jurisdiction. Fortunately, other solutions have been provided that will allow the nurses to intervene and create better working for themselves so that they can provide better care for their patients. Other than the solutions presented in the articles; nurses may also identify the patients that are in critical condition as compared to other patients and prioritize their care. It is also important for the nurses to voice their concerns so that they may be able to do their job in an optimal environment
References
Budd, K. W., Warino, L. S., & Patton, M. E. (2004, January 31). Traditional and Non-traditional Collective Bargaining: Strategies to Improve the Patient Care Environment. The Online Journal of Issues in Nursing. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No1Jan04/CollectiveBargainingStrategies.html
Health, S. (2018, August 14). How Nurse Staffing Ratios Impact Patient Safety, Access to Care. PatientEngagementHIT. https://patientengagementhit.com/news/how-nurse-staffing-ratios-impact-patient-safety-access-to-care
Lee, A., Cheung, Y. S. L., Joynt, G. M., Leung, C. C. H., Wong, W.-T., & Gomersall, C. D. (2017). Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Annals of Intensive Care, 7(1), 46. https://doi.org/10.1186/s13613-017-0269-2
Neuraz, A., Guérin, C., Payet, C., Polazzi, S., Aubrun, F., Dailler, F., Lehot, J.-J., Piriou, V., Neidecker, J., Rimmelé, T., Schott, A.-M., & Duclos, A. (2015). Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study*. Critical Care Medicine, 43(8), 1587–1594. https://doi.org/10.1097/CCM.0000000000001015
Nevidjon, B., & Erickson, J. I. (2001, January 31). The Nursing Shortage: Solutions for the Short and Long Term. The Online Journal of Issues in Nursing. https://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/workforce/NursingShortage/Resources/NursingShortageSolutions.html
