Running Head: Critical Question Paper
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Critical Question Paper
Nichole Roback
Ferris State University
CRITICAL QUESTION
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Abstract
High nurse to patient ratios have a huge impact on patient safety and nurse burnout rate.
Many people have discussed approving a nurse to patient ratio to improve these factors but only
California has approved one. This project tries to answer the PICOT question, Will limiting the
number of patients a nurse can take care of improve the care on patient units. The paper will
explain the clinical question, critique three research articles on this subject, discuss the
significance to nursing, and discuss my methodology used to search for these articles.
CRITICAL QUESTION
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Critical Question Paper
Using evidence-based research in the nursing profession is a very important aspect to the
nursing profession. By evaluating nursing research the nurses are able to support and make
decisions that directly affect their daily practice. How the nurse interprets nursing knowledge to
use in their personal and professional lives will be discussed in this paper. Patient safety and
earlier discharge is the current push for many hospitals and insurance companies, this question
leads to this PICOT question discussed in this paper.
Clinical Question
“The PICOT question format is a consistent "formula" for developing answerable,
researchable questions”. When a good PICOT question is written it makes finding and
evaluating evidence easier” (Koshar, n.d.).
Population/Patient Problem
Population refers to the sample of subjects you wish to recruit for your study. Disease or
health status, age, race or sex can be used to identify your patient.
Intervention
Intervention refers to the treatment that will be provided to the participants enrolled in a
Research study. Examples can be specific tests, therapies or medication.
Comparison
What is the alternative to your plan? An alternative plan might include no treatment, or
different types of treatment. Comparison identifies what you plan on using as a reference
group to compare with your treatment intervention. Many study designs refer to this as
the control group.
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Outcome
What outcome are you hoping for? Less symptoms, no symptoms, full health, safer care
for your patient. Outcome represents what result you plan on measuring to examine the
effectiveness of your intervention.
Time
This element is not always used but it is asking what time frame is this to be complete, if
it is it represents the duration of data collection (Riva, 2012).
By answering the PICOT question discussed in this paper, it will hopefully be determined
if lower nurse to patient ratios will improve patient safety and over all outcome. The results of a
PICOT question will benefit patients and nursing staff by improving safety and patient care.
Nurse satisfaction and lower burn-out rate can be decreased if a PICOT question is answered.
Methodology
Databases were searched including CINAHL, PubMed and then by subject of Nurse to
Patient ratio. Multiple articles were the result of this search. Multiple reasons were resulted as
to why the research was being done such as patient safety, nurse burn-out, job satisfaction and
patient mortality. Nursing research articles were reviewed so it could be related to my current
nursing practice.
The PICOT question that was researched was; will limiting the number of patients a
nurse can take in their daily assignment improve the inpatients care and safety? Patient safety is
a component of patient care because it affects many aspects of their hospitalization such as early
discharge, appropriate evaluations by auxiliary department and improving patient involvement in
their care.
CRITICAL QUESTION
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Levels of evidence (sometimes called hierarchy of evidence) are assigned to studies
based on the methodological quality of their design, validity, and applicability to patient care.
The assignments to the studies are given the grade or strength of recommendation (Spector, n.d.).
Level I
A synthesis of evidence from all relevant randomized, controlled trials and is called a
systematic review or meta-analysis.
Level II
An experiment in which subjects are randomly assigned to a control vs. treatment group
is called a randomized control trial.
Level III
Subjects are systematically assigned to a specific trial or group this is called controlled
trial without randomization.
Level IV
A case control study or a cohort study represents this level. Subjects are observed to
determine the development of an outcome such as a disease. Case-control study is when subjects
are compared to each other because of their condition with those that do not have the condition
to determine the characteristics for the development of a disease.
Level V
This involves a synthesis of evidence to answer a clinical question from either a
qualitative or descriptive study.
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Level VI
A qualitative study is one that asks why and how decisions are made by gathering data on
human behaviors. A descriptive study selects a subject of interest and provides information to
answer the what, where and when of the topic.
Level VII
This level deals with opinions or consensus of an expert committee.
Discussion of literature
The first article reviewed is from the New England Journal of Medicine and it is titled
Nurse-staffing levels and the quality of care in hospitals. The study was approved by the
Harvard School of Public Health Human Subjects Committee. As stated in the article “It is
uncertain whether lower levels of staffing by nurses at hospital are associated with an increased
risk that patients will have complications” (Needleman, 2002). Administrative data of
discharges of medical and surgical patients was reviewed from 1997 for 799 hospitals in 11
states. They examined the amount of care provided and related it to the patients outcome. A
regressive analysis was conducted where they controlled for the patients’ risk of adverse
outcome, differences in nursing care needed for each patient taking into account multiple other
variables. Level of evidence is V.
Measures of outcome for the study population were done in the 11 states, originally 1041
hospitals were included, they excluded hospitals with an average daily census of under 20, and
occupancy rate below 20 percent, or missing data on staffing. Measure of staffing by registered
nurses, licensed practical nurses and nurses’ aides were estimated in hours. From this data they
came up with “adjusted patient-days”. The unit of analysis was the hospital and the length of
stay, rates of adverse outcomes, hours of nursing care per inpatient day, and the proportion of
CRITICAL QUESTION
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hours on nursing care provided by each category of nursing personnel was calculated. The
results showed a higher proportion of total hours of nursing care provided by registered nurse
were more frequently associated with lower rates of adverse outcomes (Needleham, 2002).
The second article reviewed was from the Journal of Nursing titled Literature review:
safe nurse staffing. The purpose of this review is to evaluate nurse staffing related issues and its
impact on healthcare. Safe staffing has a large impact on patient mortality, Patient satisfaction,
increased incidence of medical errors and nurse dissatisfaction and burnout. Review of literature
was limited to the last five years for a total of 15 articles were reviewed and critiqued. The
design of the study varied between quantitative and mixed method approaches. The goal of the
review was to obtain as many quantitative studies that reflect current factors that hinder, support
and influence safe nurse staffing. Level of Evidence is VI.
There are many factors that can contribute to making safe nursing staffing tolerable.
Introducing of staffing plans and state regulations that mandate hospitals to adhere to staffing
guidelines is a positive way to ensure quality nursing care, decrease adverse patient outcomes,
and nurse burnout. Research shows how adverse patient outcomes and sentinel events are
directly related to inadequate staffing levels (Camphor, 2012).
The third article that was reviewed was found in the Nursing Times journal titled The
effects of nurse to patient ratios. I do not see that the article was approved by the IRB but was by
the Royal College of Nursing. The problem is clearly stated that the nurses are concerned that
demands on them cannot be met by its current workforce. Staff is apprehensive about
guaranteeing safe, high quality nursing care. A literature review was conducted to determine if
high nurse to patient ratios cause negative outcomes for patients such as mortality, skin
CRITICAL QUESTION
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breakdown or falls and for staff. Patients on wards with the worst staffing ratios of 1 to 8 had a
31% greater mortality risk.
The article displayed 15 different articles were reviewed which appears to be an adequate
number to review. The findings are that neither the United States nor the United Kingdom
suggests an optimal nurse to patient ratio even though they allude to a 1 to 4 ratio to provide
optimal patient care. What was found as an agreement among all articles is that the more
patients a nurse is given to take care of the worse the patient outcome is likely to be. Currently
only California has a legislation supporting a nurse to patient ratio of 1 to 5 for medical surgical
units with an eventual aim of 1 to 4 (Petterson, 2011).
Significance to Nursing
The evidence is fairly clear to this writer and it makes sense. A nurse having fewer
patients promotes prompt, ethical and safe care to their patients. A standardized ratio is not
needed for all hospitals but a ratio for each individual hospital is needed. In a small town
hospital that I work in a 5 to 1 patient is acceptable but to a Level I teaching hospital it probably
isn’t. I feel there should be legislation supporting a nurse to patient ratio but it should be set by
each individual hospital with guidelines set for by each state.
According to the American Nurses Association (ANA) optimal staffing requires an
approach that recognizes different patient care settings, different units, during different shifts and
must assess; how sick the patients are and how much care they need, nursing assistances
available, and the skills, education and training of staff (ANA, 2014). With the nursing shortage
as it is, if states develop mandatory nurse to patient ratios, it may be hard to obtain qualified
nurse to fill the positions needed. The objectives are stated by “The Quality and Safety
Education for Nurses (QSEN) project addresses the challenge of preparing future nurses with the
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knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety
of the healthcare systems within which they work”(QSEN, 2014).
It is obvious that money runs hospitals and that if the nurse to patient ratios were to
increase then revenue for hospitals would decrease, but ethically can we allow patients to be
taken care of unsafely? Cuts would have to be made in other areas of hospital to make up for the
losses. California cut nursing assistants at several of the hospitals I worked at while travel
nursing. As I soon found out it is actually harder to care for 5 patients when you don’t have a
nursing assistant. Hospitalized patients are much more critical these days because either they
don’t have insurance and wait until their condition is really bad to seek help, they don’t like
hospitals, non-compliant etc. and wait not to mention the insurance companies are not covering
as much. There needs to be a solution or there will be more nurse burnout and less nurses.
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References
American Nurses Association. (2014). Nurse Staffing. Retrieved from
http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NurseSta
ffing.
Camphor, S. (2012). Literature review: safe nurse staffing. Journal of Nursing.
Retrieved from http://rnjournal.com/journal-of-nursing/literature-review-safe-nurse-staffing
Koshar, J. & Applegarth, P. What is a PICOT question? Sonoma state university
http://www.sonoma.edu/users/k/koshar/n312c/PICOT%20Samples.html
Needleham, J., Buerhaus, P., Mattke, S., Stewart, M., Zelevinsky, K. (2002). Nursestaffing levels and the quality of care in hospital. New England Journal of Medicine, 346(22),
1715-1722.
Patterson, J. (2011). The effects of nurse to patient ratios. Nursing Times, 107(2), 22-25).
The Quality and Safety Education for Nurses. (2014). About QSEN. Retrieved from
http://qsen.org/about-qsen/
Riva, J.J., Malik, K. M.P., Burnie, S.J., Endicott, A.R., Busse, J.W. (2012). What is your
research question? An introduction to the PICOT format for clinicians. The Journal of the
Canadian Chiropractic Association, 56(3), 167-171.
Spector, N. (n.d.). Evidence-based nursing regulations. A challenge for regulators.
Journal of Nursing Regulation, 1(1), 30-38.