Evidence-Based Project, Part 4: Recommending an Evidence-Based Practice Change

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Shah, M. K., Gandrakota, N., Cimiotti, J. P., Ghose, N., Moore, M., & Ali, M. K. (2021). Prevalence of and factors associated with nurse burnout in the US. JAMA Network Open, 4(2), e2036469-e2036469.

Shuldham, C., Parkin, C., Firouzi, A., Roughton, M., & Lau-Walker, M. (2019). The relationship between nurse staffing and patient outcomes: A case study. International Journal of Nursing Studies, 46(7), 986-992.

Muabbar, H., & Alsharqi, O. (2021). The impact of short-term solutions of nursing shortage on nursing outcome, nurse perceived quality of care, and patient safety. American Journal of Nursing Research, 9(2), 35-44.

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal medicine, 170(8), 683-690.

Evidence Level *

(I, II, or III)

Level III

Level III

Level I

Level I

Conceptual Framework

Describe the theoretical basis for the study (If there is not one mentioned in the article, say that here).**

No theoretical basis.

No theoretical basis.

No theoretical basis.

No theoretical basis.

Design/Method

Describe the design and how the study was carried out (In detail, including inclusion/exclusion criteria).

An analysis was done using cross-sectional survey data collected from the National Sample Survey of Registered Nurses in the US.

A case study using retrospective hospital data, at ward level.

A cross-sectional study was conducted at King Abdullah Medical City (KAMC) located in Makkah, Saudi Arabia.

The researchers performed an observational study of nurses preparing and administering medications in 6 wards at 2 major teaching hospitals in Sydney, Australia.

Sample/Setting

The number and characteristics of

patients, attrition rate, etc.

All nurses who responded were included (N = 50 273).

Age, sex, race and ethnicity categorized by self-reported survey question, household income, and geographic region. Data were stratified by workplace setting, hours worked, and dominant function at work.

Setting: A tertiary cardio-respiratory NHS Trust in England, comprising two hospitals.

Participants: All patients, including day cases, who were admitted to either hospital as an in-patient over 12 months.

The study was conducted for two months (from July 20, 2020 to August 20, 2020), including both inpatient and outpatient registered nurses who had worked for, at least, one year at KAMC either as part-time or full-time.

A volunteer sample of 98 nurses (representing a participation rate of 82%) were observed preparing and administering 4271 medications to 720 patients over 505 hours.

Major Variables Studied

List and define dependent and independent variables

Independent variables: primary employment setting and full-time or part-time status.

Dependent variables: change in employment setting in the last year, hours worked per week, and reasons for employment change.

Independent variables: nursing staffing

Dependent variables: patient outcomes

Independent variables: overtime and floating

Dependent variables: nursing outcomes, nurse-perceived quality of care and patient safety.

Independent variables: total interruptions per administration.

Dependent variables: total procedural failures and total clinical errors.

Measurement

Identify primary statistics used to answer clinical questions (You need to list the actual tests done).

The researchers used descriptive statistics to characterize nurse survey responses. For continuous variables, we reported means and SDs and for categorical variables, frequencies.

The researchers examined the incidence of the following patient outcomes: pressure sores, patient falls, upper GI bleed, pneumonia, sepsis, shock and DVT.

Nurse staffing data (the nursing hours worked by permanent and temporary staff and nursing hours per patient day) were used to examine the association between nurse staffing and the patient outcomes cited above.

A pre-designed questionnaire was distributed to willing nurses. Data were non-normally distributed and Scatter plots were also generated. T-test was used to find the relation of floating and overtime with sample characteristics.

Nurses on the study wards were invited to participate during information sessions followed by a direct approach from the researchers prior to commencement of any observational sessions.

Data Analysis Statistical or

Qualitative findings

(You need to enter the actual numbers determined by the statistical tests or qualitative data).

Of the total weighted sample of nurses (N = 3 957 661), 9.5%reported leaving their most recent position (n = 418 769), and of those, 31.5%reported burnout as a reason contributing to their decision to leave their job (3.3%of the total sample).

There was an association demonstrated between nurse staffing and the majority of the outcomes.

The IRRs for falls (0.448), GI bleeds (0.952), sepsis (0.507), and DVT (0.610), were reduced where nursing hours per patient day increased.

Education level, overtime floating showed significant association with intention to leave (p <0.05).

Each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors.

Findings and Recommendations

General findings and recommendations of the research

These findings suggest that burnout is a significant problem among US nurses who leave their job or consider leaving their job. Health systems should focus on implementing known strategies to alleviate burnout, including adequate nurse staffing and limiting the number of hours worked per shift.

This case study has demonstrated the possibility of using existing hospital data to examine the relationship between nurse staffing and patient outcomes.

Hospital data showed significant association of overtime with medication error. Unmarried Saudi nurses have potential to provide quality of care to the patient with satisfied patient safety, especially in the days of overtime and increased workload.

Among nurses at 2 hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors.

Appraisal and Study Quality

Describe the general worth of this research to practice.

What are the strengths and limitations of study?

What are the risks associated with implementation of the suggested practices or processes detailed in the research?

What is the feasibility of use in your practice?

Clinician burnout is a major risk to the health of the US. Nurses make up most of the health care workforce, and estimating nursing burnout and associated factors is vital for addressing the causes of burnout.

Findings are from cross-sectional data and limit causal inference. However, these data represent the most recent and, to our knowledge, the only national survey with data on nurse burnout.

There are no notable risks identified.

The recommendations can easily be incorporated for use in my practice.

Research has shown a direct relationship between staffing levels and patient outcomes for specific nurse-sensitive indicators, with lower patient to nurse ratios (i.e. less patients per nurse) associated with better outcomes.

The researchers gathered nurse-sensitive indicators from existing corporate systems and therefore relied on retrospective data.

There are no notable risks identified.

The recommendations can easily be incorporated for use in my practice.

The objective of the study was to determine the relationships between overtime and floating as short-term solutions and nursing outcomes, nurse-perceived quality of care and patient safety among registered nurses

Its cross-sectional design and questionnaire-based data collection as the study may fall a victim to non-response bias, volunteer-bias and ascertainment bias.

There are no notable risks identified.

The recommendations can easily be incorporated for use in my practice.

Interruptions have been implicated as a cause of clinical errors, yet, to the researchers’ knowledge, no empirical studies of this relationship exist.

A particular strength of our study is the consistency of the findings regarding the effect of interruptions on procedural failures and clinical errors at both hospitals.

There are no notable risks identified.

The recommendations can easily be incorporated for use in my practice.

Key findings

These findings suggest that burnout is a significant problem among US nurses who leave their job or consider leaving their job.

This case study has demonstrated the possibility of using existing hospital data to examine the relationship between nurse staffing and patient outcomes.

Hospital data showed significant association of overtime with medication error.

Among nurses at 2 hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors.

Outcomes

Health systems should focus on implementing known strategies to alleviate burnout, including adequate nurse staffing and limiting the number of hours worked per shift.

The experience and information gained is being used to inform the design of further work to establish the relationship between nurse staffing and patient outcomes.

Nurses have the potential to provide quality of care to the patient with satisfied patient safety, especially in the days of overtime and increased workload.

The results elevate the importance of interruptions as a contributor to medication errors in hospitals and provide a direction for prevention strategies and further research.

General Notes/Comments

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