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Qualitative and Quantitive Studies- Final Draft

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Introduction

Intensive care units (ICUs) require more nurses than other healthcare settings because of

the demands of caring for severely ill patients. Patients undergoing acute medical care and

ventilation for serious clinical disorders are looked after in the intensive care unit (ICU). The

majority of these patients are elderly individuals, 65 years of age or older. Concerns with

excessive nursing workloads are more severe in ICUs than in other hospital departments due to

the important and demanding responsibilities ICU nurses conduct daily, both physically and

mentally (Banda et al., 2022). Increased patient acuity and sickness complexity need larger

pharmacological therapies, which invariably correlate with greater physiological and

psychological needs.

The lack of nurses in the ICU has made several issues brought on by the increasing

workload more prevalent, including staff fatigue, increased medical blunders, and subpar care.

Therefore, our study aims to ascertain whether having enough nurses in the intensive care unit

lowers the incidence of medical errors, infections, and stress among patients and nurses.

PICOT Question: In adult patients aged above 65 years undergoing intensive care unit,

does an adequate number of nurses, as compared to a lack of an adequate number of nurses,

reduce medical errors, stress and infections among patients and nurses in the intensive care Unit

for six months?

Background of Studies

The first qualitative study identified for our study is by Banda et al. (2022). Banda and

colleagues (2022) conducted a study In the ICU at Queen Elizabeth Central Hospital to better

understand how nurses assessed the influence of a high nursing workload on patient care.
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Although the Malawian health system has taken some initiatives to reduce excessive nurse

workloads, the study finds that there are still not enough nurses, especially in critical care

settings, due to inadequate prioritizing of critical care. The study aims to understand how a high

nurse workload impacts patients in an intensive care unit (ICU). Knowing the effects of nursing

workload in the ICU is crucial, given the shortage of nurses and the numerous links between

workload, patient safety, and the quality of care.

The second qualitative study identified was by Pazokian and Borhani (2017). Pazokian

and Borhani (2017) sought to convey nurses' perspectives on elements that influence patient

safety. All medical professionals have a responsibility to protect their patients. Nosocomial

infections, decubitus ulcers, prescription errors, bed falls, and operating room burns are just a

few examples of non-safety services that have put a strain on patients and harmed the security of

the healthcare system. Achieving a high standard of safe treatment is the responsibility of all

healthcare professionals, including nurses, because patient safety is a topic that impacts the entire

healthcare community.

The first quantitative study identified for our study is the study by Fagerstrom et al.

(2018). Fagerstrom and associates (2018) used a metric based on the RAFAELA system to

ascertain if patient safety events and patient mortality are connected with daily workload per

nurse (OPC/nurse). The study also compares the estimates to the average patient-to-nurse ratio

(patients/nurses). Numerous studies have revealed that a lack of nurses in hospital-based care

harms outcomes like infections, the inability to perform rescue attempts, and mortality. The

contradicting results show no clear relationship between nursing workload (NWL), mortality,

and other patient outcomes. They also suggest a complex and non-linear relationship between

these variables. Therefore, the study aims to ascertain whether concerns about patient safety and
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mortality are related to a nurse's workload. The study has demonstrated that the risk of

complications and patient death increases when labour conditions exceed the ideal assumption

limit. When considering patient severity and case mix, the patient-to-nurse ratio, a common

method of nurse staffing, may not always be the optimal option (Fagerstrom et al., 2018). Given

this, a recruitment metric based on the putative ideal NWL might be viewed as a creative attempt

to fill a gap in the body of information regarding clinical management and leadership.

The second quantitative study identified is by Nogueira et al. (2017). The second study

by Nogueira and colleagues from 2017 focused on the relationship between nursing care

parameters and the average number of hours spent helping patients in intensive care units

(ICUs). Despite extensive studies on the subject, none has conclusively established the effect of

nurse care hours on the outcomes of ICU patients. The study's objectives were to investigate the

hour ratio—the ratio between the number of nursing care hours provided to patients and the

number of nursing care hours needed by patients—in an intensive care unit (ICU) and to link this

ratio to care indicators evaluated in the unit. The study demonstrates that the ratio of nursing care

hours can describe the incidence of VAP, phlebitis, and unintentional or accidental extubation of

the orotracheal cannula. The clinical outcomes of critically ill patients are impacted by the

control and monitoring procedures used by the nursing team.

How the Articles Support the Nursing Practice Problem

Our study examines whether an adequate number of nurses compared to a lack of

adequate nurses reduces stress and infections, and medical errors among patients aged 65 years

and above and nurses in the intensive care unit for six months. Therefore, the composition of a

PICOT question is: (P) is the adult patients aged 65 years and above, intervention (I) is the

adequate number of nurses, comparison (C) is the lack of an adequate number of nurses, while
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the outcome (O) is reduced medical errors, stress and infections among patients and nurses in

intensive care units.

The impact of a heavy workload in intensive care units is examined in the first qualitative

study by Banda and colleagues (2022). Banda et al.'s (2022) comparison use a high nursing

workload comparable to our PICOT question's comparison (C). The interventions in both studies

—Banda and the associates' study from 2022 and our study—are the same: an adequate number

of nurses.

The intervention (I) and comparison (C) of the PICOT question were slightly different in

the second qualitative article by Pazokian and Borhani (2017). Patient-centred care and

organizational-based characteristics served as the study's intervention (I), whereas non-patient-

centred care served as the comparator (C). Nevertheless, our study's intervention—sufficient

staffing—is one of the organizational-based characteristics considered. Additionally, Pazokian

and Borhani's (2017) study compares non-patients-centred care influenced by staffing.

The first quantitative article by Fagerstrom and colleagues (2018) seeks to ascertain

whether workload-related concerns for nurses are related to patient safety and mortality issues.

The article's PICOT question is comparable to ours, but ours is focused on patients over 65 in the

intensive care unit. In contrast, the article is focused on all hospital departments. In contrast to

the intervention of our proposed study, the study by Fagerstrom et al. (2018) comparison is a

high workload ascribed to a lack of an appropriate number of nurses. In contrast, the intervention

of our proposed study is a low workload attributed to an adequate number of nurses.

In the second quantitative article by Nogueira and colleagues (2017), the ratio of nursing

care hours to nursing care indicator data is emphasized. The ideal nurse-to-patient ratios in
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intensive care units (ICUs) will be influenced by several factors, including the number of nursing

hours dedicated to patient care in those facilities. The study's intervention is the average number

of hours spent providing care, and its control group is nursing care measures. The effectiveness

and safety of the hospital's nursing care will be monitored with the help of indicators.

Method of Studies

Purposive sampling was utilized in the first qualitative study by Banda and colleagues

(2022) to choose study participants based on how long they had worked at the hospital. In-depth

interviews were used to gather the information. Purposive sampling has several benefits,

including being the most time- and money-efficient technique (Andrade, 2021). However, it is

susceptible to judgmental blunders (Andrade, 2021). The reliability of the data is increased via

in-depth interviews. Nevertheless, the information gathered will probably be biased by the

interviewer.

Purposive sampling was also employed by Pazokian and Borhani (2017) to determine the

research participants in their subsequent qualitative study. Semi-structured interviews were used

to gather the qualitative data. Semi-structured interviews have the benefit of fostering greater

interaction between the participant and the researcher. However, it may induce bias because it

tempts the researcher to pose probing inquiries.

The first quantitative study by Nogueira and associates (2017) used pre-existing data

from the electronic records system, while Fagerstrom and associates (2018) used observational

methods to gather the study's data. Generalized linear models were employed during the analysis.

One benefit of observational research and using existing data is that it is a straightforward and

hassle-free method of gathering data. While utilizing current data entails visiting the
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organization's database and retrieving the necessary data, observation studies occur in natural

settings. However, using observational research is a slow and expensive process. On the other

hand, as it could not accurately reflect the organization's current state, existing data is subject to

prejudice. Additionally, sampling bias can affect existing data.

Results of Studies

The perceived impacts of a heavy nurse workload on patient care were highlighted in a

study conducted by Banda Associates in 2022. The nurses discussed how a high workload

affected the patients on the ward, particularly how patient care and safety were compromised.

The nurses discussed how a high workload affected the patients on the ward, particularly how

patient care and safety were compromised. The implications of a heavy nursing load on nurses'

physical and mental health and their ability to function were also mentioned by nurses as

impacting patient safety. There is a need for concerted efforts from the government, healthcare

organizations, and nurse management to discuss ways of reducing nurse workloads and

evaluating the quality of nursing care in the ICU to promote patient safety.

Additionally, the findings of the study conducted by Pazokian and Borhani (2017)

showed that the intricacy of patient-centred care makes it challenging to implement in practice.

Because of this, it is critical for providing quality care and setting the bar on healthcare that

nurses receive training that emphasizes patient engagement and participation. Additionally, the

executive director needs to hire enough skilled workers and modernize the buildings and

equipment for therapeutic services to be effective.

In the Nogueira et al. (2017) study, 1,717 patients were involved. The average NAS

(Nursing Activities Score) rating was 54.87. The average hour ratio, which measures the
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discrepancy between the patient's total nursing care hours required and hours received, was 0.87.

The incidence of phlebitis and ventilator-associated pneumonia and the hour ratio were

significantly positively correlated, meaning that the incidence of phlebitis and ventilator-

associated pneumonia was lower the higher the hour ratio. Nursing staffing must be modified

since the number of hours spent providing care influences patient outcomes.

According to the study findings by Fagerstrom et al. (2018), the adjusted chances of a

patient safety event when OPC/nurse was above the supposed optimal quantity were 1.24 (95%

CI 1.08 to 1.42) and 0.79 (95% CI 0.67 to 0.93) if it was below the alleged optimal level—

compared to the patient/nurse categorization, models generated using the RAFAELA

classification approach often exhibited larger effect sizes, greater statistical power, and better

model fit. At the same time, the difference was not very significant. Decision analysis used to

evaluate net benefits did not provide clear guidance on which action to favour. The study's

results demonstrated a connection between a nurse's daily workload and patient safety incidents

and death.

Ethical Considerations

One of the ethical considerations in research is informed consent. The informed consent

of the study participants must be obtained. The right to protection of a participant is represented

by informed consent. Additionally, it guarantees the maintenance of their freedom. Protecting

data integrity is the second ethical rule. The privacy and confidentiality of study participants

should be protected. The data should not be accessible to outside parties. All four articles

adhered to the two ethical considerations in research. The two quantitative articles distributed

informed consent before collecting the data. Moreover, all four articles ensured that the data used

in the analysis was secured: Anonymity of the data was preserved.

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Outcome Comparison

Our expected outcome for our PICOT question is that the study results will show that in

adult patients over 65 years undergoing intensive care unit, an adequate number of nurses

reduces medical errors, stress and infections among patients and nurses in the intensive care unit

for six months. The selected studies supported the expected outcomes: Nogueira and the

associates' (2017) results showed an association between the number of hours spent providing

care and patient outcomes. The number of staff influences the number of hours spent providing

care.

Furthermore, the study by Fagerstrom and colleagues (2018) showed an association

between workload and patient safety. Staff workload is affected by the number of staff in a

facility. Besides, Pazokian and Borhani (2017) emphasized hiring enough qualified employees,

while Banda and the associates (2022) described some of the effects of the heavy workload,

including decreased patient safety and care.

Proposed Evidence-Based Practice Change

The nursing practice problem identified is the lack of adequate staff in the intensive care

units. The intensive care unit (ICU) is the hospital section most vulnerable to unfavourable

incidents. Over 20% of ICU patients, particularly those 65 years and older, reportedly

experienced some form of negative incident (Nogueira et al., 2017). Therefore, the PICOT

question was developed to examine whether inadequate staff in the ICU units affects the quality

of care. The qualitative and quantitive research articles were identified so that the study's

outcome could be compared to the previous research findings to determine whether the research
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findings would be consistent with previous findings. Furthermore, analysis of previous studies

helps identify and address the gap in the ongoing research.

The studies have demonstrated the correlation between proper staffing numbers in ICUs

and better patient outcomes, lower mortality rates, fewer problems, and higher patient

satisfaction. In order to solve the issue of insufficient staffing, it has been determined that team-

based care implementation and suitable nurse staffing models are successful techniques. Team-

based care includes inter-professional collaboration, task delegation and role clarity (Will et al.,

2019). Nurse staffing models include adjusting the nurse-to-patient ratio, enhancing flexibility in

staffing, staffing considerations and workload monitoring (Butler et al., 2019).

Conclusion

All four studies demonstrated that the likelihood of complications and patient death

increases when work conditions exceed the ideal assumption threshold. Positive patient

outcomes are the result of daily workload monitoring for nurses. Therefore, We can conclude

that having enough nurses minimizes stress, medical errors, and infections among patients and

nurses in the ICU over six months. The ICU may improve teamwork, improve patient care

outcomes, increase nurse job satisfaction, and address the issue of understaffing by implementing

evidence-based practices that include team-based care and suitable nurse staffing models.

References

Andrade, C. (2021). The inconvenient truth about convenience and purposive samples. Indian

Journal of Psychological Medicine, 43(1), 86–88.

https://journals.sagepub.com/doi/pdf/10.1177/0253717620977000
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Banda, Z., Simbota, M., & Mula, C. (2022). Nurses’ perceptions on the effects of high nursing

workload on patient care in an intensive care unit of a referral hospital in Malawi: a

qualitative study. BMC nursing, 21(1), 136.

https://link.springer.com/article/10.1186/s12912-022-00918-x

Butler, M., Schultz, T. J., Halligan, P., Sheridan, A., Kinsman, L., Rotter, T., & Drennan, J.

(2019). Hospital nurse‐staffing models and patient‐and staff‐related outcomes. Cochrane

Database of Systematic Reviews, (4).

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007019.pub3/abstract

Fagerström, L., Kinnunen, M., & Saarela, J. (2018). Nursing workload, patient safety incidents

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https://bmjopen.bmj.com/content/8/4/e016367.abstract

Hasan, N., Rana, R. U., Chowdhury, S., Dola, A. J., & Rony, M. K. K. (2021). Ethical

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(JNRPSP) 2799–1210, 1(01), 1–4.

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F. M. T., & Laus, A. M. (2017). Effect of nursing care hours on the outcomes of

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https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0188241

Pazokian, M., & Borhani, F. (2017). Nurses’ perspectives on factors affecting patient safety: A

qualitative study. Evidence-Based Care, 7(3), 76-81.

https://ebcj.mums.ac.ir/http:/ebcj.mums.ac.ir/article_9382.html
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Will, K. K., Johnson, M. L., & Lamb, G. (2019). Team-based care and patient satisfaction in the

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