Qualitative Research Critique on Nursing Workload and Patient Outcomes in NICU

This research critique analyzes the relationship between nursing workload or nurse-to-patient ratios and the results in NICU patients by conducting a systematic review. The study aims to enhance patient safety, low death rates and reduced cases of nurse burn out. The study findings have several implications to nursing.

Running head: Research Critique 1
Qualitative Research Critique
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Research Critique 2
Background of the study
Negative outcomes in the adult intensive care unit (ICU) in addition to death are linked with
nursing workload and higher patient-to- nurse ratios (Needleman, Buerhaus, Mattke, Stewart,
& Zelevinsky, 2002; Needleman et al., 2011). There is a scarce of studies on the impacts of
nurse staffing in the neonatal ICUs (NICUs), yet the British Association of Perinatal
Medicine 2005 report indicated that just two percent of the NICUs in the UK met the
standard approvals in staffing (Redshaw & Hamilton, 2005). Existing research on the
association between staffing and nursing results such as mortality are inconsistent (Hamilton,
Redshaw & Tarnow-Mordi, 2006; Grandi, González, & Meritano, 2010; Pillay, Nightingale,
Owen, Kirby, & Spencer, 2011). A proper understanding of the relationship between nursing
workload or nurse-to-patient ratios and outcomes of neonatal cases is significant towards
enhancing patient safety, low death rates and reduced cases of nurse burn out (Aiken et al.,
2002). Thus, this forms the research gap in the study.
The study is significant because a thorough comprehension of the link between nursing
workload or nurse-to-patient ratio will impact several elements of clinical practices,
organization of units, public policy, patient quality care, and decreased nurse burn out (Leiter
& Maslach, 2009).
The study aims at ascertaining the association between nursing workload or nurse-to-patient
ratios and the results in NICU patients by conducting a systematic review.
The inferred research question of the study include:
1. What is the relationship between nurse-to-patient ratios or work load and the results in
NICU patients?

Research Critique 3
The purpose and research questions of the study were relevant to the research problem since
both aimed at finding out whether nursing workload or nurse-to-patient ratios were linked to
results in NICU patients.
Method of study
The qualitative approaches used were best suited to achieve the objective of the study for
various reasons. The researches searched medical library databases using specific terms, such
as neonatal and staffing, workload and infant, or staffing and infant among others. These
search terms were also relevant to the study topic and objective. The eligibility of the studies
were also carried out.
The qualitative methods used in the study were the most appropriate to respond to the study
questions because the data was extracted using STROBE, which is a standardised data
collection tool (Von Elm et al., 2007). This implies that only the most appropriate studies
were included in the analysis.
The authors cited the adverse outcomes in addition to mortality rates in the mature (ICU) as
the perspective from which they designed their research. Additionally, the authors cited the
British Association of Perinatal Medicine report in which just two percent of NICUs of UK
met standard requirements. The conflicting nature of studies on the association between
staffing and results were also cited as the basis of developing the study.
The researchers cited both quantitative and qualitative studies associated the purpose of the
study. These were cited as part of the perspective upon which the study was developed which
included contradicting outcomes and findings from previous studies on the research topic.
Other types of literature included in the article are British Association of Perinatal Medicine
2005 report.

Research Critique 4
The study cited 16 references published between 1990 and 2010. A lot of weaknesses were
associated with the available studies, of which the authors provided an extensive evaluation
of the same. Majority of the studies did not indicate how missing data was handled or provide
any information on how they dealt with evident sources of bias in the data. Most
significantly, of all the studies included in the review, none of them indicated whether their
data collection and analysis tool was reliable or valid. All the studies had varying report on
the definition of nurse-to-patient ratio and varying cut offs were applied to distinguish
between ‘low’ and ‘high’ ratios. The nurse-to-patient ratio definition adopted by most of the
reviewed studies is that which integrated measures of the severity of the patients’ sickness.
The literature review did not provide in depth information to lay the foundational argument of
the study. For instance the study cited 13 references in laying the background of the study but
there were no comprehensive information or critique provided for the cited references.
Additionally, the study did not develop any framework from the study findings.
Results of the study
Six independent studies were included in the review. The outcomes of all the studies reported
19,570 infants that were nursed for in the NICUs between 1996 and 2007 in South America,
USA, UK and Australia. Extremely underweight infants were reported in three studies, two
studies reported that all infants were registered to the NICU, and one research reported
averagely preterm infants. Four studies reported mortality prior to being cleared from the
NICU comparative to nurse-to-patient ratios as a primary outcome. One study associated
lower nurse-to- patient ratio with lower death rate, and suggested that low handling of
severely delicate infants may finally result to better to outcomes (Callaghan, Cartwright,
O’rourke, & Davies, 2003) whereas, three studies linked it with higher mortality rate. Some
others attributed the adverse outcomes to the presence of unqualified caregivers which is as a

Research Critique 5
result of attempting to boost nurse to patient ratio. Additionally, the astonishing outcomes
may be as a result of the incapability to measure workload in addition to ratios.
The study findings have several implications to nursing. A startling figure of 19,570 infants
that were nursed for the NICUs within a range of eleven years shows the demanding nature of
the nursing profession. The demanding nature of the work requires that nurses to also offer
better quality care, but this is restricted by the nurse-to-patient ratios thus affecting the quality
of nursing care. Furthermore, the decision to include unqualified caregivers as a strategy to
meet the standard nurse-to-patient ratio leads to adverse outcomes including death and
comprises the professionalism of nursing.
The findings of the study provides additional knowledge to nursing in various ways. It is
clear from the study that there is need for a standardised and approved tool to measure
workload is required due to difficulty to measure workload and absence of credible, legal
measures of neonatal nursing workload. The technique has to be cognizant of the variations
in unit group in varying nations and be valid to be used in NICUs of varying sizes and acuity
stages. The findings of the study affect all areas of nursing and shows the need for additional
research in ascertaining the aspects that can optimise the value of neonatal nursing care
instead of just determining specific workload that can comfortably be dealt with by a nurse.
Ethical considerations
There is no indication whether the research was sanctioned by any Institutional Review
Board, except for the disclosure statement of no conflict of interest worth of disclosure, and
the acknowledgements to the authors who provided supplementary data and contribution.
Conclusion

Research Critique 6
The study to find out the impact of workload or nurse-to-patient outcome in the NICU is
significant for the nursing profession for it determines the quality of care provided by nurses
and affects the NICU outcome.
Increased mortality rate in the ICU is associated with nursing workload and increased patient-
to-nurse ratio. However, the specific influence of staffing on the results in the NICU is not
clear. The findings indicate that nursing workload affect the results of NICU, but there is
need for further research on this topic since extant studies are faced with several weaknesses,
making it difficult to rely on their conclusions. This calls for further research into the aspects
that can optimize the nursing care quality as opposed to focusing on the specific workload
that a nurse can effectively handle.

Research Critique 7
References
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital
nurse staffing and patient mortality, nurse burnout, and job
dissatisfaction. Jama, 288(16), 1987-1993.
Callaghan, L. A., Cartwright, D. W., O’rourke, P., & Davies, M. W. (2003). Infant to staff
ratios and risk of mortality in very low birthweight infants. Archives of Disease in
Childhood-Fetal and Neonatal Edition, 88(2), F94-F97.
Grandi, C., González, A., & Meritano, J. (2010). Patient volume, medical and nursing
staffing and its relationship with risk-adjusted outcomes of VLBW infants in 15
Neocosur neonatal network NICUs. Archivos argentinos de pediatría, 108(6), 499-
510.
Hamilton, K. E. S., Redshaw, M. E., & Tarnow-Mordi, W. (2006). Nurse staffing in relation
to risk-adjusted mortality in neonatal care. Archives of Disease in Childhood-Fetal
and Neonatal Edition.
Leiter, M. P., & Maslach, C. (2009). Nurse turnover: the mediating role of burnout. Journal
of nursing management, 17(3), 331-339.
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-
staffing levels and the quality of care in hospitals. New England Journal of
Medicine, 346(22), 1715-1722.
Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M.

Research Critique 8
(2011). Nurse staffing and inpatient hospital mortality. New England Journal of
Medicine, 364(11), 1037-1045.
Pillay, T., Nightingale, P., Owen, S., Kirby, D., & Spencer, A. (2011). Neonatal nurse
staffing and delivery of clinical care in the SSBC Newborn Network. Archives of
Disease in Childhood-Fetal and Neonatal Edition, fetalneonatal-2011.
Redshaw, M., & Hamilton, K. (2005). A survey of current neonatal unit organisation and
policy. National Perinatal Epidemiology Unit.
Von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., Vandenbroucke, J. P.,
& Strobe Initiative. (2007). The Strengthening the Reporting of Observational Studies
in Epidemiology (STROBE) statement: guidelines for reporting observational
studies. PLoS medicine, 4(10), e296.