What am I missing PICO(T) research question

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Deliverable 6-Evidence-Based Practice Proposal

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NUR3643CBE Section 01CBE Research and Theory

Rasmussen University

August 16, 2021

Describe a potential practice problem

Currently I work on the Progressive Care Unit (PCU), this is a 32-bed, high acuity level of care unit- a step down from ICU. A frequent practice problem at the rural hospital in which I am employed is the inadequate staffing of nurses during the night shift. With the higher acuity of patients, the level of care increases and more frequent observations, interventions and safety issues arise. During the recent influx of Covid-19 patients on the rise again; nurses have been subjected to taking higher acuity patients and larger patient loads. This recent influx has increased patient loads to 1:6 opposed to the normal 1:max 4 patients dependent on acuity level. The effects of inadequate staffing places patients and nurse at risk; the patient is at risk from the lack of frequent monitoring to ensure patient stays stable, to the increase patient loads which jeopardizes the nurses critical thinking skills and limited time with these critical situations affecting patient outcomes.

Formulate an evidence-based practice question

(P) Nurses

(I) Adequate staffing and reduction of high acuity of care patient per nurse

(C) Inadequate nursing staff levels with a comparison of having higher patient loads of 1-

6 as opposed to 1-4 more staff with a lower nurse to patient proportion

(O) Reduction of workload for nurses and increase in quality of care and safety for

patients  

Does lower patient load increase nurse workflow and provide better quality of care and safety for patients resulting in better patient outcomes?

Locate and review two current peer -reviewed, research articles that address the identified clinical problem

Article 1

Nurse staffing level and overtime associated with patient safety, quality of care and care left undone in hospitals: A cross-sectional study

Purpose: To examine the correlation between nurse staffing and overtime with nurse-perceived patient safety, quality of care, and care left undone.

Cho, E., Lee, N. J., Kim, E. Y., Kim, S., Lee, K., Park, K. O., & Sung, Y. H. (2016). Nurse staffing level and overtime associated with patient safety, quality of care, and care left undone in hospitals: A cross-sectional study. International journal of nursing studies, 60, 263–271. https://doi.org/10.1016/j.ijnurstu.2016.05.009

Article 2

Acuity, nurse -staffing, and workforce missed care and patient outcomes: A cluster‐unit‐level descriptive comparison

Purpose: To analyze the patient acuity, nurse staffing and workflow, patient outcomes and missed nursing care between hospital unit-clusters

Juvé-Udina, M. E., González-Samartino, M., López-Jiménez, M. M., Planas-Canals, M., Rodríguez-Fernández, H., Batuecas Duelt, I. J., Tapia-Pérez, M., Pons Prats, M., Jiménez-Martínez, E., Barberà Llorca, M. À., Asensio-Flores, S., Berbis-Morelló, C., Zuriguel-Pérez, E., Delgado-Hito, P., Rey Luque, Ó., Zabalegui, A., Fabrellas, N., & Adamuz, J. (2020). Acuity, nurse-staffing, and workforce missed care and patient outcomes: A cluster-unit-level descriptive comparison. Journal of nursing management, 28(8), 2216–2229. https://doi.org/10.1111/jonm.13040

Article 3

A longitudinal online diary study 83 hospital nurses Perceived staffing and safety at the individual nurse level on a day-to-day basis.

Purpose: To show nurses are more favorable and can act as safe practitioners with lower patient-to-nurse ratios rather than a higher nurse-to-patient ratio.

Louch, G., O’Hara, J., Gardner, P., & O’Connor, D. B. International Journal of Nursing Studies 2016 A longitudinal online diary study 83 hospital nurses Perceived staffing and safety at the individual nurse level on a day-to-day basis. Vol. 59 27-37

Article 4

Missed nursing care, staffing levels, job satisfaction, and intent to leave among Jordanian nurses

Purpose: The purpose of this article was to investigate the correlation between missed nursing care, staffing levels and job satisfaction amongst a group of Jordanian nurses and their intent to leave using a cross-sectional descriptive design and analyzed through descriptive analysis.

Al, F. I., Obaidat, D. M., & AbuAlRub, R. F. (2021). Missed nursing care, staffing levels, job satisfaction, and intent to leave among Jordanian nurses. Nursing Forum, 56(2), 273–283. https://doi.org/10.1111/nuf.12537

Appraise Research Findings

Nurse staffing levels and overtime associated with patient safety, quality of care, and care left undone in hospitals: A cross-sectional study

In this study, the researchers introduced exploring the connection between nurse staffing and overtime with nurse observed patient safety, quality of care, and incomplete care. Sixty-five hospitals were chosen from all acute hospitals with 100 or more beds in South Korea using a random sample strategy centered around region and quantity of beds. Sixty hospitals participated in the analysis (Cho et al.,2016). Discovery of a more significant number of patients per RN significantly correlated with higher probabilities of reporting inadequate/failing patient safety and reduced/acceptable quality of care. Furthermore, having care left undone due to time constraints. This study infers that ensuring adequate nurse staffing and working hours is imperative to improve the quality and safety of care and decrease care left undone in hospitals. As a result of the quantitative study the discovery of the amount of patients assigned per RN, showed significant results in the quality of patient care received and patient safety was reduced when patient loads increased.

Acuity, nurse -staffing, and workforce missed care and patient outcomes: A cluster‐unit‐level descriptive comparison

The study strived to compare the patient acuity, nurse staffing, missed nursing care, and patient outcomes among hospital unit groups. The correlation between acuity, nurse staffing, workforce, missed nursing care, and patient outcomes are not understood- a descriptive study with data from four units clumps together: medical, surgical, combined, and step-down units. The study utilized quantitative research using descriptive statistics to analyze data, including acuity, nurse staffing ratios, education, expertise, omitted nursing care, and selected nurse-sensitive outcomes (Juvé-Udina et al.,2020). Patient acuity in general (medical, surgical, and combined) floors are comparable to step-down units, with an average of 5.6 hours per patient day expected of the RN.

In medical units, available RN hours per patient day reach only 50% of the expected RN hours to meet patient needs. Workforce standards are similar among unit clusters, and the average missed nursing care is 21% (Juvé-Udina et al.,2020). Patient outcomes fluctuate within unit clusters. Patient acuity is similar amongst unit clusters, while nurse staffing coverage is divided amidst medical units. While RN training, expertise, and missed care are similar amongst unit clusters, death, skin injuries, and risk of family compassion exhaustion rates are higher in medical units. Nurse managers play a crucial role in pushing policymakers to consider fundamental understaffing to maximize patient safety outcomes.

A longitudinal online diary study 83 hospital nurses Perceived staffing and safety at the individual nurse level on a day-to-day basis.

This qualitative study was conducted using a cross-sectional survey of daily staffing relationships, safety perceptions, and personality in hospital nursing. The research took place from March to July 2013 amongst eighty-three hospital nurses. Louch et al. (2016) concentrated on recognizing staffing and safety at the individual nurse level on a day-to-day basis. The study suggests that lower nurse-patient ratios guided safer practices and more efficient patient care and safety outcomes. This paper uses a within-person approach to further research nurses' daily perceptions of staffing and patient safety to understand these associations further. In addition, researchers investigated the implied role of personality factors as moderators of daily level associations (Louch et al., 2016).

The collection of information on staffing, nurse to patient ratio, and patient safety (perceptions of patient safety) was collected using online end-of-shift diaries over three-five shifts.

The data obtained was analyzed, examining the use of simple slopes analyses, which decomposed relationships at high and low levels of the moderator. On days when lower patient-nurse ratios were indicated, nurses reported being more able to act as a safe practitioner and more favorable perceptions of patient safety (Louch et al., 2016).

Additionally, this qualitative study shows when staffing was seen more favorably, nurses reported being more able to act as a safe practitioner, more favorable perceptions of patient safety, and experienced minor workplace cognitive failure.

Missed nursing care, staffing levels, job satisfaction, and intent to leave among Jordanian nurses. 

As we know, patient safety is essential for nurses who provide patient care within an environment that may increase mistakes or require them to omit care; these errors frequently arise due to staff shortage. This study aims to identify the types and reasons for "missed nursing care" and investigate the links connecting "missed nursing care," staffing, intent to leave, and job satisfaction.

Using a cross‐sectional descriptive design, a sample of 300 nurses utilizing the Arabic version of MISSCARE, which involved items measuring types and reasons for "missed nursing care," staffing adequacy, job satisfaction, and intention to leave.

The outcomes of this investigation showed that job resources were the most prevalent reason for "missed nursing care." The return results showed that a decreased number of nurses per shift was connected with a high "missed nursing care" level. To improve care, nurse managers and nurse administrators need to tackle staffing challenges that may increase missed care and result in unfavorable outcomes—using evidence‐based staffing plans to manage the nurse-to-patient ratio to minimize missed care and improve satisfaction (Al & AbuAlRub 2021).

Propose an evidence-based practice solution

Adequately staffing of nurses is a multifaceted concern; coordination of the right nurse to the right patient at the right time requires attention and assessment of the individual patient's care demands. When making assignments, specific nurse components, such as workflow and care circumstances, and nursing competency should be considered. Many experts believe patient acuity is an essential component of nurse staffing because acuity-informed staffing approaches have improved patient outcomes and enhanced nurse satisfaction. 

Based on the peer-reviewed articles and evidence-based practice, the use of adequate staffing along with lowering the number of high acuity patients on staff nurse's assignments would decrease the likely chance of patient safety and reduce the risk of jeopardizing the quality of care. Increased hospital nursing staffing would correlate with lower hospital-related mortality, failure to rescue, and other patient outcomes. 

In critical care or step-down critical care units it is essential to have adequate staffing to assure quality patient care and safety. Nurse to patient ratio should be kept to the minimum nurse to patient ratio possible. Factoring in the acuity level is essential rather than relying on a one size fits all approach. A safe nurse to patient ratio within the PCU unit is 1:4 max and 1:3 with higher acuity patients. Implementation of acuity level assignments for nurses utilizing the 1:4 or 1:3 ratio has shown better workflow and increase in patients quality of care, however there is still shortage of nurses during this influx making some days challenging and increasing patient loads to 1:5 or 1:6. The strengths of the studies are shown in the outcomes of quality patient care and patient safety and improved nurse workflow. However, there are weaknesses amongst the studies not incorporating what strategies to implement lower patient loads for nurses in case of a pandemic such as the one we are facing now with the Covid-19 delta variant influx. The studies efficiently allowed our unit to choose the best and latest EBP and resources to implement better current means of care based on acuity levels to promote better patient outcomes and nurse workflow and satisfaction.

REFERENCES

Al, F. I., Obaidat, D. M., & AbuAlRub, R. F. (2021). Missed nursing care, staffing levels, job satisfaction, and intent to leave among Jordanian nurses. Nursing Forum, 56(2), 273–283. https://doi.org/10.1111/nuf.12537

Cho, E., Lee, N. J., Kim, E. Y., Kim, S., Lee, K., Park, K. O., & Sung, Y. H. (2016). Nurse

staffing level and overtime associated with patient safety, quality of care, and care left undone in hospitals: A cross-sectional study. International Journal of Nursing Studies, 60, 263-271. https://doi.org/10.1016/j.ijnurstu.2016.05.009

Grove, S. (2019]). Understanding Nursing Research (7th Edition). Elsevier Health Sciences (US). 14, 442-452 https://ambassadored.vitalsource.com/books/9780323532051

Juvé-Udina, M. E., González-Samartino, M., López-Jiménez, M. M., Planas-Canals, M., Rodríguez-Fernández, H., Batuecas Duelt, I. J., Tapia-Pérez, M., Pons Prats, M., Jiménez-Martínez, E., Barberà Llorca, M. À., Asensio-Flores, S., Berbis-Morelló, C., Zuriguel-Pérez, E., Delgado-Hito, P., Rey Luque, Ó., Zabalegui, A., Fabrellas, N., & Adamuz, J. (2020). Acuity, nurse-staffing, and workforce missed care and patient outcomes: A cluster-unit-level descriptive comparison. Journal of Nursing Management, 28(8), 2216–2229. https://doi.org/10.1111/jonm.13040

Louch, G., O’Hara, J., Gardner, P., & O’Connor, D. B. International Journal of Nursing Studies 2016 A longitudinal online diary study 83 hospital nurses Perceived staffing and safety at the individual nurse level on a day-to-day basis. Vol. 59 27-37