There are times when a nursing problem arises as a result of a number of findings, and these findings are pulled together into a summary in order to see the big picture created out of these findings. This act of pulling together is what Brown & Ochs (2018) calls a systematic research review (SRR) or systematic review, which helps researchers identify “what is known with certainty, what is tentatively known, and what the gaps in knowledge are regarding an issue” (p.175). It serves as a link between the individual studies performed and the decision making done in order to create or revise a clinical practice method that would solve the problem regarding the issue. One of the current problems nowadays includes staffing problems, specifically the nurse-patient ratios or the number of nurses caring for every single patient. There is growing evidence that there is strong association between nurse-patient ratios and patient outcomes (Cherry & Jacob, 2017, p.128). This paper will critique a systematic research review related to the nurse-patient ratios, including the relevance of the research problem, its rigor, its implications, and the clarity of its findings in the SRR.
Relevance of the Research Problem
A growing proportion of patients die during, or shortly, after hospitalization as an effect of staffing problems and the nurse-patient ratio. In the systematic review of Shekelle (2013), he mentioned a study wherein, out of the 232,342 surgical discharges from a number of hospitals in Pennsylvania, 4,535 patients died within 30 days of hospitalization (p.404). According to Shekelle (2013), “the investigators estimated that the difference between 4:1 and 8:1 patient-nurse ratios may be approximately 1,000 deaths in a group of this size” (p.404). The same thing was discovered in other studies, in which there were approximately 1 to 5 fewer deaths every 1,000 patient days if there were more nurse staffing per patient (Shekelle, 2013, p.404). It appears that by increasing the ratio of registered nurses (RNs) to patients, it will lead to decreased illness and mortality rates, since there is more attention and care given to patients. With this, the problem of decreasing ratio of RNs to patients will lead to higher mortality rates within the United States. By implementing strategies that increase the ratios of RNs to patients, it will improve the morbidity and mortality rates, decrease burnout, and prevent nurses from leaving the hospitals because of inadequate staffing. It will have an impact on job satisfaction, teamwork, nurse turnover, and better use of leadership. A decrease in the ratios of RNs to patients usually leads to errors and preventable harms that may cause the patient his/her life. The statistics of patients who die because of errors in nursing care are high. Still, about 44,000 to 80,000 patients die annually as a result of diagnostic error, while 68,000 patients die of decubitus ulcers, as a result of communication and teamwork errors and failure to receive evidence-based interventions (Wachter, Pronovost, & Shekelle, 2013, p.350). There are also harms related to the need to implement PSSs that are aimed at a target, which can greatly reduce errors and harm. For this, studies show that the degree of success in trying to eradicate harm, has not really matched the investment and the effort, as well as the financial resources used. Research groups have stated that with an increase in the ratios of RNs to patients, it will reduce mortality, since “surveillance is a critical factor that can be improved with more staff” (Shekelle, 2013, p.404). It will therefore lead to better, more successful patient outcomes.
Critique of Research Rigor and Levels of Evidence
In the paper, Shekelle (2013) systematically reviews the evidences about nurse staffing ratios, as well as, in-hospital deaths in September 2012. Out of the 550 titles, about 87 articles were reviewed, as well as 15 new studies that augmented two existing reviews (Shekelle, 2013, p.404). There were two existing reviews that were identified using the methods of Whitlock and his colleagues, in which the author searches the Web of Science for a set of articles published in 2009 until 2012, which cites any of the 4 key articles in the field. In implementing the search strategy, the author mentioned 546 titles, as well as, 4 articles from the references mining (Shekelle, 2013, p.404). The researcher also reviewed some abstracts and titles, especially those that contain data that define the connection between nurse-patient ratios, as well as, the rate of mortality and other nursing-sensitive consequences. Specifically there was 1 cross-sectional study, and another one that exempted another cross-sectional one evaluating a quasi-intervention. There were 9 longitudinal studies that were identified, as well as 1 systematic review article and 4 simulation studies. The author used 2 frameworks but did not use any experimental study. Shekelle (2013) applied a number of systematic reviews or AMSTAR criteria to identify the excellence of the systematic reviews. In the 11 AMSTAR criteria, only 2 of those appeared to be applicable to the reviews involving meta-analysis were applied to the systematic review.
Melnyk & Fineout-Overholt (2015) defined a systematic review as “a compilation of like studies to address a specific clinical question using a detailed, comprehensive search strategy and rigorous appraisal methods” (p.121). Meanwhile, it appears that Shekelle (2013) used search terms that were clear and that the databases were consistently done and identified thoroughly. Only peer-reviewed randomized control trial (RCT) were included in the systematic research review (SRR) of Shekelle (2013), so it presents the highest level of evidence under the SRR and holds more validity. This SRR’s RCT fall into the Level I category on the Levels of Evidence table, which is “evidence from a systematic review of all relevant randomized controlled trial, or evidence-based clinical practice guidelines based on systematic reviews of RCTs” (University of Wisconsin-Madison, 2016).
Critique of Clarity of SRR
A flowchart is indicated in the study that Shekelle (2013) conducted, as well as a meta-analysis, including and a chronicle review, which both scored 10/10 and 7/9 specifically under the AMSTAR criteria. The meta-analysis was composed of 28 studies, in which 17 were cohort, 7 were cross-sectional, and 4 were case-control (Shekelle, 2013, p.405). Most of the studies were conducted in the United States, and it used a nurse staffing that had an normal level of 3 patients for every nurse in the intensive care unit, 4 patients for every nurse in the surgical unit, and 4.4 patients for every nurse in the medical unit (Shekelle, 2013, p.405). It is evident that the researcher was able to retrieve adequate data, while making sure the samples used were valid and reliable. Shekelle (2013) also used flow chart in representing the data. A flow chart is defined as “an efficient mechanism to account for all patients in a study and shows how the various groups progressed through the study” (Melynk & Fineout-Overholt, 2015, p.101). The flow chart that the researcher designed was easy to follow. The systematic review of the researcher can also be considered as most rigorous, since Mylynk & Fineout-Overholt (2015) stated that a systematic review of randomized RCTs is at the top of the hierarchy of evidence. This systematic review of Shekelle (2013) is also comprehensive, with studies coming from multiple countries, which means different types of environment. Meanwhile, majority of the studies were conducted in the United States. The researcher used pooled analysis in representing the nurse staffing levels and the patients/RN per shift. Pooled analysis is
the gold standard for synthesizing results from multiple studies, allows for comparison across different metrics and studies and for derivation of statistically more stable results. (Kheifets & Swanson, 2014, p.143)
With this, pooled analysis is the perfect tool for analyzing raw data from component studies, as it is capable of applying identical analyses, although it is prone to biases. As seen in the systematic research review, there is strong bias towards the conclusion that “higher RN staffing is related to lower hospital-related mortality” (Shekelle, 2013, p.406). There is however, some data insisting that other hospitals have higher staffing rations and yet, have lower patient mortality, such as those that have electronic health records in their system.
Overall Findings of the SRR
The systematic research review of Shekelle (2013) examines the evidence on what interventions can do to increase the nurse-patient ratios and how it affects illness and death. However, no evaluation of the intentional change in RN staffing has proven to improvise patient outcomes. Thus, Shekelle (2013) stated that “the patient safety strategy referred to in this article remains somewhat unclear” (p.404). Many research groups proposed that effective nursing care has a tendency to reduce inpatient mortality, as it appears that surveillance is one critical factor that improves with more staff. There is less inpatient mortality when the staffs are better educated, and if they have better working environment. From all these, it is evident that the systematic review was easy to follow and understand, especially with the use of flow charts and pooled analysis. The study was plainly written, even for a reader who may not be as learned as the researcher. It appears however, that the major strength of this systematic research review was the use of causal relationship in analyzing between the higher nurse staffing levels, as well as, the decreased inpatient mortality reflected in the data of a single hospital. However, what limits the systematic research review is the lack of an overall evaluation of an intervention that should have increased the nurse staffing ratios. With this, Shekelle (2013) says the following:
This insists that it is better to conduct future studies that allow continuous monitoring and analyses of patients, especially those included in lower RNs to patient ratios, who are more prone to becoming victims of errors and harm, which increases morbidity and mortality.
In all these findings, it appears that the SRR that the researcher wrote was easy to understand, especially as it used clear and comprehensive methods in representing the data, such as the use of effective visualization methods like flow charts. It appears however, that the major strength of this systematic review has something to do with the credible data that was used in analyzing the relationship between nurse-patient ratios and mortality rate. It appears that there should be more RNs in the workforce population to save more lives.
Conclusion & Implications
There is a vicious cycle taking place in the shortage of nurses in hospital arena. As there are fewer individuals entering the hospital workforce, those who are left working in the hospital must care for more patients under stressful working conditions. Thus, more nurses tend to leave the hospital workforce, which worsens the nursing shortage and make recruitment more difficult than ever. This would have led to repercussions in the hospitals, and would have affected not just those in the hospitals but also the social economy, as a result of decrease in burnout and an increase in the unemployment rate. It affects the GDP growth of individuals within the population, and so it has to be considered more seriously.
It appears that Shekelle (2013) did an excellent job of presenting a systematic research review of the staffing problem in connection to the increasing nurse-patient ratios in the hospital setting. For better outcome, it is best to do continuous research on the subject and assess the designing of a strategy that would create an intentional change in nurse staffing ratios. They can create a policy that would protect the nurse workforce from a decreasing nurse-patient ratios, as it may lead to burnout and the loss of many lives. Patient surveillance gets better if there are more nurses caring for every patient inside the caring unit.
Brown, S.J., & Ochs, R.S. (2018). Evidence-based nursing: The research-practice connection (4th ed.). Burlington, MA: Jones & Bartlett Learning. Print.
Cherry, B., & Jacob, S.R. (2017). Contemporary nursing: issues, trends, & management (7th ed.). St. Louis, Missouri: Elsevier. Print.
Kheifets, L., & Swanson, J. (2014). “Childhood leukemia and extremely low-frequency magnetic fields: Critical evaluation of epidemiologic evidence using Hill’’s framework. In M. Roosli’s (Ed.), Epidemiology of electromagnetic fields (pp.141-160). Boca Raton, FL: CRC Press. Print.
Melnyk, B.M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health. Print.
Shekelle, P.G. (2013). Nurse-patient ratios as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 404-410.
Wachter, R.M, Pronovost, P.J., & Shekelle, P.G. (2013). Strategies to improve patient safety: the evidence base matures. Annals of Internal Medicine, 158(5), 350-352.