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Integrative Review Paper

Alexis Williams

Bon Secours Memorial College of Nursing

NUR 4322 Nursing Research

Professor Holowaychuk, RN, Associate Clinical Professor

April 23, 2022

“I pledge…”
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Abstract

Purpose: The purpose of this review is identifying the effect of decreased staffing on the patient-to-

patient disease transmission compared with appropriate staffing. Background: Due to a recent influx of

hardships in healthcare, nursing staff have suffered tremendously leaving most units globally

understaffed. Ultimately, this led to unsafe practices such as unsafe patient to nursing staff ratios.

Design and Search methods: This is an integrative review of three articles that support the selected

PICOT question. The three articles were selected during a google search from sources such as PubMed

and ScienceDirect. These articles are peer reviewed articles using either a qualitative or quantitative

research style. The involvement is completely voluntarily, and information was conducted through

surveys and observation. Results and Findings: Staffing deficits have been linked to lower survival rates

and higher transmission rates in the hospital setting. Studies have shown that hygiene practice were

commonly skipped and could have been the cause of disease transmission from patient to patient as

registered nurses went from room to room providing patient care. Higher staff to patient ratios have

been linked to more hospital acquired infections increasing strain on nurses. Limitations: The West

article used cross sectional data which limits the causality of the claims. Implication for Practice: The

results from this review support that staffing deficits have a negative impact on disease transmission

during a patient’s hospital stay. Recommendations for Future Research: Future Research should

discover the specific correlations with decreased staffing and overall mortality of patients in acute

settings.
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Integrative Review of the Literature

The purpose of this review is identifying the effect of decreased staffing on the patient-to-

patient disease transmission compared with appropriate staffing. Since the recent pandemic, staffing in

the hospital, primarily with registered nurses has decreased significantly due to the high risk of disease

transmission amongst each other as well as the increased workload. This has had a negative impact on

nurse’s mental health as well as compliance. Concepts such as infection control has fallen behind in

importance due to decreased focus and overwhelming patient assignments. Healthy staffing ratios are

constantly being ignored along with safety concerns. Patients are ultimately the ones suffering due to

negligence of patient care well as increased negative patient outcomes because of decreased staffing.

Although there are plenty of reasons to why more individuals are contracting illnesses during

their hospital stay, registered nurses are ultimately the biggest risk. Since nurses are constantly in and

out of rooms, they hold significant risk when it comes to patient-to-patient disease transmission.

Therefore, infection control practices are extremely vital when it comes to nurses performing patient

care in between patients.

Design and Search Methods

This research design is an integrative review. The search for research criteria was conducted

with google search engine which led me to sources such as PubMed and ScienceDirect. The terms that

were used to search consisted of ‘intensive care units’, ‘nurse staffing’, ‘medical staffing’, ‘mortality’,

‘observational studies’, ‘infection control’, and ‘workload’. While searching these terms, 48,780 results

from PubMed and 182,123 from ScienceDirect. This ensure that this is a very popular topic with loads of

available literature. Despite the large number of search results, the articles then had to be further

limited to peer reviewed, nursing journal articles, in English, and within a specific time frame. This

ensured validity and met the given criteria.

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The articles were selected because they pertained to the PICOT question, “For registered nurses in an

acute care setting, what is the effect of decreased staffing on the patient-to-patient disease transmission

compared with appropriate staffing?” The articles have been reviewed fully to insure validity of content

and its significance. For that purpose, some articles have been excluded due to them not meeting the

given criteria and not provided content needed to support my PICOT question.

Findings and Results

West found that nursing surveillance was by far the most important component in positive

patient outcomes (West, 2014). With nursing staff deficits this makes this extremely difficult for the

nurse. If the nurse is constantly struggling to spend the appropriate time needed for each patient due to

an impossible workload this leaves opportunity for mistakes, accidents, and even disease transmission.

This study found that the lack of time to allocate to each patient outside of medication administration,

vitals, and blood glucose checks has often led to negative patient outcomes including mortality. Low

staffing levels leaves patient vulnerable to disease transmission and negligence of care. These results

also support that disease transmission is heavily influenced by inappropriate staffing ratios in

comparison to appropriate ratios.

According to the second article, they found a very relevant correlation between staffing deficits

and heavy workload with HAI acquisitions that are attributed to non-compliance with infection control

practices (Kong et al., 2012). This study concluded that high nurse to patient ratios lead to lower

adherence to infection control policies which therefore increased HAI transmission. MRSA acquisitions

were likely acquired due to the lack of this adherence.

Patient Safety

Three of the studies provided support of how infection control was lacking adherence in

situations where disease transmission was higher than normal due to staffing deficits and decreased

time available for patient care. This puts patient safety at risk and provides an environment for
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pathogens to roam and bacteria to grow. Since nurses navigate hourly from room to room performing

patient care activities, lacking infection control adherence can be a serious issue and the germs on our

hands alone can create a reservoir for illness. Infection control is extremely vital and stricken adherence

could possibly be what is necessary to combat the high numbers of disease acquisitions along with some

other much needed changes.

The article by Kong displayed how lack of hand hygiene alone contributed to the increase in

MRSA transmission in a hospital in Brisbane, Queensland, Australia ICU (Kong et al., 2012). The overall

effect of a heavy workload led to decreased infection control policy adherence putting patients who

didn’t original have a MRSA infection at risk for acquiring one during their hospital stay. Despite the

limitations, this direct correlation has been proven to a universal issue due to staffing deficits all over.

Kong’s sample was not explicitly stated but the study reported 61 new MRSA infections in 51 weeks with

a cross validation analysis of 0.46 using laboratory surveillance and cross validation. This research article

was a quantitative study.

In the second article published by West, this study also mentioned how lack of surveillance

influenced patient mortality. Lack of monitoring the patient allows infection and bacteria to grow as

well. If a patient doesn’t receive the proper care necessary, infection transmission will follow. West’s

article was a quantitative, cross-sectional article that surveyed 65 ICUs which included 38,168 patients.

This study was conducted in Wales and Northern Ireland using the intensive Care National Audit and

Research Centre Case Mix Programme that audits patient outcomes in England ICUs. The method of

data collection was multivariable using multilevel logistic regression. The hospital mortality rate resulted

in the study was 0.90.

The article by Shuldham mentions the increased occurrence of pressure sores, patient falls, and

increased incidence of DVTs (Shuldham. 2008). All these conditions make the patient more susceptible

to disease transmission and increase their chances of HAI especially when infection control practices
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aren’t being followed. Heavy workloads not only prevent the patient from receiving proper care, but it

increases their risk of disease transmission therefore increasing mortality. This article displayed

quantitative research with a sample of 23, 192 adults and 2,315 children. This study used previous

acquired data to examine the relationship of nurse staffing and patient outcomes. The study was

conducted in a tertiary cardio-respiratory NHS Trust in England which included two hospitals over 12

months.

Patient Mortality

Three of my articles provided support of the increased mortality that comes with nursing staff

deficits. Staffing deficits universally have been negatively impacted patient outcomes and most of the

time result in death. Disease transmission and HAIs are claiming the lives of patients every moment due

to lack of infection control practice adherence, increased workload, and lack of nursing surveillance.

Although all three of these correlates with one another, patients overall are constantly being diagnosed

with new infections following their admission into hospital units and some will not make it to discharge

unfortunately.

The article by West stresses the overall importance of surveillance and how important it is with

patient mortality. (West, 2014). This article proposed that increasing staffing including staff other than

registered nurses could potentially yield disease transmission and patient mortality. Negative outcomes

are commonly the result of negligence in some form when it comes to patient care and/or infection

control practices. Increasing clinical staff could prevent these occurrences by increasing surveillance

therefore increasing adherence and providing more surveillance.

The article carefully monitors MRSA acquisitions that were concluded to be acquired due to

non-compliance with infection practices due to heavy workloads (Kong et al., 2012). Kong’s results

suggest that creating a reservoir for pathogens is the likely result when nurses are understaffed and

overwhelmed with their patient load. Infection control practices are ultimately in line to prevent these
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types of situations but if non-compliance occurs, HAIs are extremely common and tedious. In most

cases, they overall increase patient mortality.

Discussion and Implications for Practice

The research articles used for this integrative review illustrate the cause and effect that nursing

deficits has on disease transmission. Since recent events, nurse staffing within the hospitals has

decreased tremendously leaving a lot of units short staffed, overworked, and forced to take larger

workloads. Although this poses a huge safety risk, management lacks control due to the increasing

number of hospital admissions. It has been concluded through research that the main cause of this is

noncompliance with infection control practices. Lack of adherence to these policies creates a reservoir

for bacteria to growth and diseases to spread. Hand hygiene is the number one way to reduced HAI and

lack of is the number one way to increase disease transmission, later increasing mortality.

Clarification of this mechanism was obtained through research while in search of answers to this

PICOT question, “For registered nurses in an acute care setting, what is the effect of decreased staffing

on the patient-to-patient disease transmission compared with appropriate staffing?” Numerous articles

were located that contained a series of both qualitative and quantitative research that contributed

highly to this question of interest. The commonality between the studies is that all of them found a

distinct correlation between staffing deficits and negative patient outcomes. The difference between

them mostly included the data methods, location, and overall effects. In some cases, the disease or

infection of concern varied but overall, the sources combine summed up negative patient outcomes

with disease transmission.

The implication of these findings concludes that the increase of disease transmission for patients

during their hospital stay is directly related to staffing deficits and increasing staffing could have a

positive impact on lowering these numbers. Although this isn’t exactly an easy task, improving nursing

to patient ratios temporarily to lessen the workload could also benefit patient outcomes as well as
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increasing other clinical staff. Overall decreased staff leads to higher disease transmission which

increases patient mortality in acute settings and to change this more staff is needed. Future Research

should discover the specific correlations with decreased staffing and overall mortality of patients in

acute settings.

Limitations

This article limits the data collected and could have benefited greatly from a longitudinal study that

showed the data over time. The data was also somewhat outdated. Another limitation is that since the

Article by Kong specifically focuses on MRSA the validity of this source lacks credibility due to MRSA

infections that can colonize for years even after the initial infection. MRSA could have been transmitted

previous at different times and on different units. Another limitation of both studies is that the samples

collected weren’t large enough to guarantee validity and were in one hospital unit.

Value to Practice

In summary, disease transmission has been an increasing obstacle in hospitals globally due to decreased

staffing of registered nurses. Nurses are forced to take on heavier workloads than the safe requirement

and infection control practice adherence has decreased significantly along with surveillance. Research

findings conclude that increasing staffing is vital to decreasing disease transmission. This research

provides the necessary support for the selected PICOT question, “For registered nurses in an acute care

setting, what is the effect of decreased staffing on the patient-to-patient disease transmission compared

with appropriate staffing?” The findings support the need for adequate staffing in improving patient

outcomes and provided the necessary changes that need to be implemented to improve disease

transmission and patient mortality rates.

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References

Kong F., Cook D., Paterson DL., Whitby M., Clements A.C., (2012). Do staffing and workload levels influence the

risk of new acquisitions of meticillin-resistant Staphylococcus aureus in a well-resourced intensive care

unit? J Hosp Infect. 2012 Apr;80(4):331-9. doi: 10.1016/j.jhin.2011.10.008.

Sasichay-Akkadechanunt T, Scalzi CC, Jawad A.F., The relationship between nurse staffing and patient outcomes.

J Nurs Adm. 2003 Sep;33(9):478-85. doi: 10.1097/00005110-200309000-00008.

Shuldham, C., Parkin, C., Firouzi, A., Roughton, M., & Lau-Walker, M. (2008). The relationship between nurse

staffing and patient outcomes: A case study. International Journal of Nursing Studies.

https://www.sciencedirect.com/science/article/abs/pii/S0020748908001697

West E, Barron DN, Harrison D, Rafferty AM, Rowan K, Sanderson C. (2014). Nurse staffing, medical staffing, and

mortality in Intensive Care: An observational study. Int J Nurs Stud. 2014 May, 51(5):781-94. doi:

10.1016/j.ijnurstu.2014.02.007
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Appendix

APA Citation of article West E, Barron DN, Harrison D, Rafferty AM,

Rowan K, Sanderson C. Nurse staffing, medical

staffing and mortality in Intensive Care: An

observational study. Int J Nurs Stud. 2014

May;51(5):781-94. doi:

10.1016/j.ijnurstu.2014.02.007. Epub 2014 Feb

27. PMID: 24636667.

Background/Problem

Statement This study closely investigates the

relationship between staffing levels and

workload and patient survival rates. The

study is intended to find out if the size of

the workforce which includes the staff

has an overall impact on the survival

chances of critically ill patients. In

addition, the study also explores if high

workloads contribute to high mortality in

these patients regarding other factors.

Research Design (i.e. Quantitative, cross sectional, retrospective

qualitative, quantitative) risk adjusted observational study,

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Specific Design (i.e. ethnography

Phenomenology,

Experimental)

Philosophical

Underpinnings (for

qualitative designs only)

Sample (size, type, Voluntary participation

sampling method) The Intensive Care National Audit and

Geographical location Research Centre Case Mix Programme :
Setting of the Study National clinical audit of patient outcomes

from ICUs in England , Wales and Northern

Ireland; 65 ICUs surveyed

38,168 patients

Observational study

Type of Data Collected Major independent variables studied:

(Major Variables Studied- number of nurses per bed; number of

independent, dependent
consultant national half days; intensivist;
and their definitions), if
support staff; workload variables. Other
appropriate
variables included proportion of beds in the

ICU that were occupied at the time of each

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patient admission; how seriously ill the

present patients were in occupied beds;

average length of stay in hours; admissions

to the unit, per bed per day; and number of

transfers in from another unit.

Method of Data Multivariable, audit of previous files

Collection/Measurement

Tools (i.e. BP cuff, Visual

analog scale, Beck

Depression Index)

Data Analysis (ex.

Statistical tests used (linear multilevel logistic regression

regression, paired t-tests,

etc.) or Content/Thematic

analysis.

NOT software [i.e. NUD*st

or SPSS or SAS])

Themes generated/ No explicit themes just variables (stated in

statistical significance previous section), Correlation between the

ICU and hospital mortality rates was 0.90

Findings (describes major The study found that controlling patient

findings in the article) characteristics, workload of the unit, and

having higher numbers of nurses per bed

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were associated with higher survival rates.

Therefore, this concluded that higher

workloads were associated with higher

mortality.

Value to Practice based This study provided evidence that higher

on PICOT Question workloads have been linked to higher

(describe how findings mortality rates which in relation shows that
relate to the PICOT
higher workloads have shown an overall
question)
decrease in patient outcomes which can be

a major contributing factor to increased

transmission of transmissible diseases like

COVID-19 since staff to patient ratios are

extremely out of range.

APA Citation of article Kong F, Cook D, Paterson DL, Whitby M,

Clements AC. Do staffing and workload levels

influence the risk of new acquisitions of

meticillin-resistant Staphylococcus aureus in a

well-resourced intensive care unit? J Hosp Infect.

2012 Apr;80(4):331-9. doi:

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10.1016/j.jhin.2011.10.008. Epub 2011 Nov 25.

PMID: 22119567.

Background/Problem Decreased staffing and increased

Statement workloads have been linked to increased

transmissions of MRSA in ICU units. This

study analysis this theory and provides a

clearer picture of why. The study focuses

on finding the overall impact and

relationship between staffing deficits and

new hospital acquired infections.

Research Design (i.e. Quantitative, triangulation, logistic

qualitative, quantitative) regression

Specific Design (i.e.

Phenomenology,

Experimental)

Philosophical

Underpinnings (for

qualitative designs only)

Sample (size, type,

sampling method) Study took place in the ICU of the Princess

Geographical location Alexandra Hospital which has 796 beds and

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Setting of the Study is located in Brisbane, Queensland,

Australia from January 1, 2003, to

December 31 2007.

no sample size given

Type of Data Collected Probability of new MRSA acquisitions

(Major Variables Studied-

independent, dependent

and their definitions), if

appropriate

Method of Data Cross validation

Collection/Measurement

Tools (i.e. BP cuff, Visual

analog scale, Beck

Depression Index)

Data Analysis (ex.

Statistical tests used (linear Statistical analysis was used to link different

regression, paired t-tests, sources and data management in Microsoft

etc.) or Content/Thematic access using laboratory surveillance. Multi-
analysis.
variate forward stepwise logistic regression
NOT software [i.e. NUD*st
analysis was done to link the exposure and
or SPSS or SAS])
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colonization/infection.

Themes generated/ Sixty-one MRSA acquisitions were identified

statistical significance in 51 weeks. The cross-validation analysis

was 0.46 and lacked the ability to predict

weeks that the MRSA acquisitions occurred

but overall showed an increase.

Findings (describes major This study found that in contrast with other

findings in the article) research that staffing deficits and heavy

workloads have been linked to HAI in

hospitals which is attributed to non-

compliance with infection control practices.

These findings concluded that high nurse to

patient ratios lead to lower levels of

adherence to infection control policies which

therefore increase transmission.

Value to Practice based The study’s results can help with useful

on PICOT Question practices that could overall improve patient care

(describe how findings but doesn’t go beyond that. I do not think this

relate to the PICOT article would be beneficial to my research for my

question) picot question because it lacks credibility and

trustworthiness. The results ultimately are not

relevant due to lack of these factors.

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APA Citation of article Monjazebi F, dolabi SE, Tabarestani ND,

Moradian G, Jamaati H, Peimani M. Journey

of Nursing in COVID-19 Crisis: A Qualitative

Study. Journal of Patient Experience.

January 2021. doi:10.1177/2374373521989917

Background/Problem

Statement The study explored nurses’ and nursing

staffs’ experiences with caring for

COVID-19 patients in a hospital located in

Iran in 2019. The fight to eradicate this

illness at the start of the pandemic posed

many complications and challenges for

ICU units. This study outlines the

supportive treatment barriers that nurses

struggle with before the introduction of

vaccinations was available.

Research Design (i.e. Qualitative content analysis,

qualitative, quantitative) phenomenology

Specific Design (i.e.

Phenomenology,
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Experimental)

Philosophical

Underpinnings (for

qualitative designs only)

Sample (size, type,

sampling method)

Geographical location Purposive Sampling method with maximum

Setting of the Study variability: eighteen interviews and five field

notes were gathered from nurses, head

nurses, and clinical supervisors employed in

Masih-e Daneshvari Hospital in Iran from

February 20, 2019 to April 23, 2020.

Type of Data Collected Nurses and nursing staff experiences with

(Major Variables Studied- giving care to COVID-19 patients

independent, dependent

and their definitions), if

appropriate

Method of Data Interviews, voice recordings using open

Collection/Measurement questions with open-ended and interpretable

Tools (i.e. BP cuff, Visual answers; co-constructive questions
analog scale, Beck
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Depression Index)

Data Analysis (ex.

Statistical tests used (linear Data analyzed with conventional content

regression, paired t-tests, analysis. Data and analysis done

etc.) or Content/Thematic simultaneously. Semantic units were distilled
analysis.
from participants’ expressions as primary
NOT software [i.e. NUD*st
codes
or SPSS or SAS])

Themes generated/ Twelve categories/themes and five major

statistical significance categories : Security in Caregiving; Healing

hands, Empty hands; Mental and Physical

Problems; Multiple Feelings; and Self-

Reassurance.

Findings (describes major Found that caring for COVID-19 patients

findings in the article) was complex and interrelated within

physical, mental, and emotional aspects.

This study found that nurses’ experiences

and feelings modified gradually overtime,

and they developed deeper feelings with

caregiving as well as other aspects of

nursing care.

Value to Practice based The article relates to my picot question

on PICOT Question because it provides themes of the

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(describe how findings experiences of real nursing staff and caring

relate to the PICOT for COVID-19 patients. This study gives me

question)
insight on the issues that these nurses

experienced as well as barriers. This

provides a starting point on reform in

assessing the issues in the present

pandemic which could be leading factors in

increased transmission.