Optimal nurse staffing is vital for the general healthcare system as well as nursing as a profession. Staffing impacts on nurses’ ability to deliver quality and safe care in various practice environments. Staff shortages due to cost-cutting measures, complex patient needs, aging populations and aging workforces are just but a few of the healthcare challenges that put pressure on nurses and significantly impacts patient outcomes. Evidence shows that optimum nurse staffing is linked to improved staff and patient satisfaction and better patient outcomes (Aiken et al., 2018). Over the recent years, the American Nurses Association has strived to achieve ideal nurse staffing in order to improve nurses’ working conditions and ultimately attain optimum patient outcomes.

PICOT Question

The problem of nurse staffing is therefore a crucial issue that needs addressing if the goals of healthcare are to be met. Nurse understaffing has been linked to more nurse burnout which leads to more medication errors, more infections, increased levels of poor patient outcomes, higher patient mortalities and overcrowding of emergency rooms. These issues are linked to having a high nurse to patient ratio. This paper analyzes the link between insufficient nurse staffing levels and the care quality and the interventions that can be implemented in order to achieve optimal nurse staffing and subsequently improve patient outcomes.

PICOT question: Do suitable nurse staffing levels improve the safety and quality of care as opposed to inadequate levels?

Population (P) – Patients in healthcare facilities.
Intervention (I) – Optimum staffing of nurses
Comparison(C) – Insufficient staffing of nurses
Outcome (O) – Improved patient outcomes and quality care
Time (T) – One year.

Background
One study investigated the issue of nurse staffing with the purpose of understanding the perception that nurses have concerning the present nurse staffing levels and the implementation of (PCSs) patient classification systems and (NPRs) nurse to patient ratios. PCSs and NPRs have been adopted by healthcare administrators as a strategy to achieve optimum nurse staffing (van Oostveen et al., 2015). The study found that nurses in the hospital thought that the current levels of staffing had dipped to dangerously low extents, impacting on the safety and quality of care. The article addresses the question: what are nurses’ thoughts on the present healthcare organizations staffing levels? The second study focuses on nurses’ perspectives on aspects that impact patient safety. A rise in infections and medical errors has become a global issue according to researchers (Pazokian & Borhani, 2017). By virtue of spending most of their time with patients, nurses are play a vital role in improving patient safety. This means that nurses should be conscious of the factors affecting the safety of patients. This study focused on what nurses think about the factors mentioned. The research question: What do nurses thing about patient safety and the aspects that influence the same?
The third study investigated the association between the chances of survival for patients who were critically ill and an increase in the workforce size for a hospital’s Intensive Care Unit. The results showed that the mortality rate of the patients varied depending on the size of the workforce and their workload (West et al., 2014). The article claims that more nurse staffing is linked to better patient outcomes in acute medical and surgery units. Several studies have shown that the recovery of patients can be influenced by ICU nurse staffing levels. Other factors including nurse working condition and workload could also impact on outcomes. The study proposed that the number of nurses in the ICU can have an effect on critically ill patients while workloads and staffing levels have an impact on patient mortality rates. The purpose of the study was to investigate whether a patient’s survival chances were influenced in any way by the size of the workforce including physicians, support workers and nurses. The objective of this study was to analyze the impact of nurse staffing on ICU patients’ mortality. The research question addressed in the study is: What is the effect of workforce size on the mortality of critically sick patients? The final study investigated the ration between nursing care hours per patient to required nursing care hours per patient in the ICU and comparing it to care indicators in the ICU (Nogueira et al., 2017). Factors considered in this study included the level of severity of the condition of the patient, nurse training levels, the working environment and the nurse workload. The objective was analyzing the link between how long nurses spent with ICU patients and how long the patient required care and relating this to various indicators of patient health. In what manner does the amount of care hours received versus the care hours necessary per patient relate to the outcome of the patient?

Articles and the Nursing Practice Issues
            All these articles are concerned with the healthcare problem of nurse staffing and how it influences outcomes and will therefore be critical in addressing the PICOT question. In the first article, the relationship between nurse staffing and the quality and safety of care is investigated. The second article attempts to answer the PICOT question by analyzing nurse staffing as a sign of a bigger issue in healthcare by relating it to hospital infections and medical faults. The third article involves the effect of the size of an ICU workforce and how that impacts on the chances of survival for critically ill patients. Additionally, it examines how nurses’ workload impact on patient outcomes. The study attempts to answer the question of whether adequate staffing of healthcare workers in the ICU can improve mortality rates especially nurses since they spend the most time with these patients and may be best placed to spot early warning signs of the progression of an illness. Finally, the last study investigates the amount of care hours a patient gets versus the amount of care hours required per patient and compares that to numerous patient health indicators in order to evaluate the link between nurse and patient workload to patient survival. The interventions used in the articles include nurse to patient ratios, patient safety factors, staffing levels, nurse workloads, work environment and nurse training. This closely ties in with the intervention in our PICOT question which is adequate nurse staffing. The comparison groups are patients in ICUs and other hospital units. All the studies described above have all the parameters needed for the PICOT question. The only difference is the methods used to analyze the relationships investigated, the interventions and control groups used in order to answer the research questions.

Methods
            In the first two articles (Pazokian & Borhani, 2017) and (van Oostveen et al., 2015), the researchers employed a qualitative design to the study. The first article used semi-structured interviews lasting between 30 to 45 minutes from 32 nurses. A data-rich sample was achieved by using purposive sampling in the nurse recruitment. In the second study, the researchers used focus groups and interviewed different healthcare experts in numerous fields of practice. Qualitative research allows for more detailed assessment of issues in the research question. By using responses from healthcare experts, the two qualitative studies provide further insight into the perspectives, experiences and attitudes of the population being addressed in the research question. The only setback to this method is that focus groups and conducting interviews can be time consuming. Additionally, it may be difficult for the researcher to discern the link between the variables used in the study (Grove et al., 2014). The third and fourth articles, (West et al., 2014) and (Nogueira et al., 2017) are both quantitative studies. Statistical controls were used to identify links between the variables used in the studies through observational means. One study gathered data from National Research Centers in the countries where the studies were carried out while the other utilized clinical surveys. Since the measurements in both these studies are objective rather than subjective, the results are more valid and reliable. The drawback from this type of research methodology is that it may overlook the perspectives and experiences of the respondents especially in highly controlled environments (Rahman, 2016).

Results
            The first study concluded that inadequate nurse staffing was a symptom of a larger healthcare issue that needed addressing (van Oostveen et al., 2015). Nurses lack autonomy and power and hence may not be free to ask administrators to hire additional nurses. Additionally, organizational aspects, mainly staffing had an impact on patient care quality and safety (Pazokian & Borhani, 2017). A high nurse to patient ration contributed to inferior patient care. Finally, optimum staffing led to more nurse satisfaction and safety. The results from these studies can be applied to improve patient outcomes. The most effective strategy to achieve this is to lower the nurse-to-patient ratios. The third study concluded that patients’ chances of survival increase when there are more nurses (West et al., 2014). Disregarding patient acuity, there were no discernible changes in clinical staff influence. The final study scored the mean nursing activity at 54.87. The infection rate in hospitals was lower with a lesser nurse workload (Nogueira et al., 2017). These findings back the need for suitable staffing of nurses. Consequently, these interventions can be implemented in healthcare facilities to improve patient outcomes.

Ethical Considerations
            Consent to participate in research should be granted by the participants of the study as was in the case with the studies where a letter to grant permission was obtained before carrying out the study. An ethics committee is also needed to approve the study and this was the case in the second study (Pazokian & Borhani, 2017). The other two studied did not discuss the ethics considered in undertaking the research.

Outcomes Comparison
            The expected outcome from the PICOT question is that the more nurses in a healthcare setting the better the quality and safety of care and patient outcomes. Several clinical issues can be linked to understaffing as a result of inadequate care (Glette et al., 2017). Consequently, the PICOT question can be used to address to improve patient outcomes and reduce medical mistakes and infection rates. For example, the infection rates of phlebitis decreased with an increase in the hours of treatment received by paitents (West et al., 2014). The outcomes discussed in all the articles are consistent with the hypothesis posed by the PICOT question.

Evidence-Based Practice
            The PICOT question addresses the link between nurse staffing and the safety and quality of patient care. The research articles use different methodologies and variables to investigate this question. As a result, each study concludes that in one way or another, having optimum staffing levels leads to better patient outcomes, nurse and patient satisfaction, reduced infections, workloads, medication errors and ultimately facilitates improves healthcare quality and patient safety as posed by the PICOT question. Implementing this evidence-based practice may prove difficult because of the difference in working environments. In a small hospital or clinic, the resources available may limit this intervention. However, the same may be achieved by having proper human resource strategies for the recruitment and retention of nurses. Additionally, workforce planning strategies and workload support tools may help an understaffed hospital (Burton et al., 2016).

Conclusion
            Optimum nurse staffing is a crucial aspect of nursing and the healthcare system as a whole. Nurse staffing levels influence the nursing practice in delivering and maintaining safe and quality patient care. The appropriate staffing levels are rarely met due to difficult working conditions and resources available. However, evidence has proved that increasing the number of nurses in a healthcare facility is linked to better patient outcomes and improves patient and staff satisfaction as well as better care quality and patient safety. Healthcare organizations should therefore strive to achieve adequate staffing levels using evidence-based practices.

References

Aiken, L., Cerón, C., Simonetti, M., Lake, E., Galiano, A., & Garbarini, A. et al. (2018). HOSPITAL NURSE STAFFING AND PATIENT OUTCOMES. Revista Médica Clínica Las Condes, 29(3), 322-327. https://doi.org/10.1016/j.rmclc.2018.04.011

Burton, C., Rycroft-Malone, J., Williams, L., Davies, S., McBride, A., & Hall, B. et al. (2016). Managers’ use of nursing workforce planning and deployment technologies: protocol for a realist synthesis of implementation and impact: Table 1. BMJ Open, 6(8), e013645. https://doi.org/10.1136/bmjopen-2016-013645

Glette, M., Aase, K., & Wiig, S. (2017). The Relationship between Understaffing of Nurses and Patient Safety in Hospitals—A Literature Review with Thematic Analysis. Open Journal Of Nursing, 07(12), 1387-1429. https://doi.org/10.4236/ojn.2017.712100

Grove, S., Burns, N., Gray, J., & Burns, N. (2014). Understanding nursing research (6th ed.). Saunders.

Nogueira, T., Menegueti, M., Perdoná, G., Auxiliadora-Martins, M., Fugulin, F., & Laus, A. (2017). Effect of nursing care hours on the outcomes of Intensive Care assistance. PLOS ONE, 12(11), e0188241. https://doi.org/10.1371/journal.pone.0188241

Pazokian, M., & Borhani, F. (2017). Nurses’ Perspectives on Factors Affecting Patient Safety: A Qualitative Study. Evidence Based Care Journal, 7(3), 76-81. https://doi.org/10.22038/EBCJ.2017.24174.1520

Rahman, M. (2016). The Advantages and Disadvantages of Using Qualitative and Quantitative Approaches and Methods in Language “Testing and Assessment” Research: A Literature Review. Journal Of Education And Learning, 6(1), 102. https://doi.org/10.5539/jel.v6n1p102

van Oostveen, C., Mathijssen, E., & Vermeulen, H. (2015). Nurse staffing issues are just the tip of the iceberg: A qualitative study about nurses’ perceptions of nurse staffing. International Journal Of Nursing Studies, 52(8), 1300-1309. https://doi.org/10.1016/j.ijnurstu.2015.04.002

West, E., Barron, D., Harrison, D., Rafferty, A., Rowan, K., & Sanderson, C. (2014). Nurse staffing, medical staffing and mortality in Intensive Care: An observational study. International Journal Of Nursing Studies, 51(5), 781-794. https://doi.org/10.1016/j.ijnurstu.2014.02.007