NURS 3600 Nursing Research

Literature Review Matrix

Name: Sarah Hunt
AUTHOR
, TITLE,
JOURNA
L

YEA
R

McHugh,
M. D.,
Carthon,
M. B.,
Sloane,
D. M.,
Wu, E.,
Kelly, L.,
Aiken, L.
H.

2012

Impact of
nurse
staffing
mandate
s on
safetynet
hospitals
: lessons

METHOD
& DESIGN

This study
used a
time-series
design with
Annual
Hospital
Disclosure
data files
from the
California
Office of
Statewide
Health
Planning
and
Developme
nt (OSHPD)
for the
years 1998
to 2007 to

STUDY
PURPOS
E
The
purpose
of the
article
chosen
for the
systemati
c review
was to
explore
the
differenti
al effect
of
California'
s staffing
mandate
on safetynet and
non-

VARIABLES
(Omit if a qualitative
study)
Depende Independe
nt
nt
Qualitativ
e Study

SUBJECTS
Numb
er
173
hospita
ls

RESULTS

Characteristi
Sample
cs
Method
California
28 (16%)
hospitals from met
1998 to 2007
criteria for
safety-net
hospital.

California's
mandate
improved
staffing for all
hospitals,
including
On
safety-net
average,
hospitals.
the safety- Furthermore,
net
improvement
hospitals
did not come
had more
at the cost of a
beds and
reduced skill
were more mix, as was
likely to
feared.
be
teaching
institution
s. All the
city or

COMMENTS*

Alternative and
more targeted
designs,
however, might
yield further
improvement for
safety-net
hospitals and
reduce potential
disparities in the
staffing and skill
mix of safety-net
and non-safetynet hospitals.
One drawback of
their research is
they stated there
is potential that a
more targeted

from
California
Milbank
Quarterly

Needlem 2011
an, J.,
Buerhaus
, P.,
Pankratz,
S.,

assess
differences
in the
effect of
California's
mandate
on staffing
outcomes
in safetynet and
non-safetynet
hospitals.

The study
examined
the
association
between
mortality

safety-net
hospitals;
essentiall
y
examinin
g how
safe
staffing
effects
patient
outcomes
. This ties
into the
proposed
clinical
question:
Are
patients
more at
risk with
higher
nurse-topatient
ratios?
Crosssectional
studies of
hospitallevel
administr

county
hospitals
in the
sample
were
considere
d to be
safety-net
hospitals.

approach would
show further
disparities
between safetynet and nonsafety-net
hospitals.

The study
cited 63
different
and
separate
studies/
articles to
draw a
conclusion
.

Types of
unit
Patient
numbers

Day shift,
night shift,
evening
shift
Number of

197,96
1
admissi
ons
and
176,69

Large tertiary
academic
medical
centers.

The
samples
were
approved
by the
institution

Staffing by
RNs was within
8 hours of the
target level for
84% of shifts,
and patient

Good variety of
samples from
various hospitals.
In this
retrospective

Leibson,
C. L.,
Stevens,
S. R.,
Harris,
M.
Nurse
staffing
and
inpatient
hospital
mortality
New
England
journal of
medicine

and patient
exposure
to nursing
shifts
during
which
staffing by
RNs was 8
hours or
more
below the
staffing
target. It
also
examined
the
association
between
mortality
and high
patient
turnover
owing to
admissions
, transfers,
and
discharges.
It used Cox
proportiona
l-hazards

ative data Length of

have
shifts
shown an
associatio
n
between
lower
levels of
staffing of
registere
d nurses
(RNs) and
increased
patient
mortality.
However,
such
studies
have
been
criticized
because
they have
not
shown a
direct link
between
the level
of staffing
and

shifts
Age
Sex

6
nursing
shifts in
43
hospita
ls.

al review
board at
each
collaborati
ng
institution.
Data were
obtained
from a
tertiary
academic
medical
center
with
trained
local data
specialists
who
constructe
d the
analytic
data set.
Members
of the
research
team
jointly
provided
direction
and

turnover was
within 1 SD of
the day-shift
mean for 93%
of shifts.
Overall
mortality was
61% of the
expected rate
for similar
patients on the
basis of
modified
diagnosisrelated groups.
There was a
significant
association
between
increased
mortality and
increased
exposure to
unit shifts
during which
staffing by RNs
was 8 hours or
more below
the target
level.

observational
study, staffing of
RNs below target
levels was
associated with
increased
mortality, which
reinforces the
need to match
staffing with
patients needs
for nursing care.

Chapma
n, S. A.,
Spetz, J.,
Seago, J.
A.,
Kaiser, J.,
Dower,
C. J.,
Herrera,
C Pliet,
C. O.
How
have
mandate
d nurse

2009

models in
the
analyses
with
adjustment
for
characteris
tics of
patients
and
hospital
units.

individual
patient
experienc
es and
have not
included
sufficient
statistical
controls.

This article
presents
an analysis
of
qualitative
data from
interviews
with
healthcare
leaders
about the
impact of
nurse
staffing
ratios.

In 1999,
California
became
the first
state to
pass
legislatio
n
mandatin
g
minimum
nurse-topatient
ratios.
Regulatio
ns

oversight
of the
analysis,
wrote the
manuscrip
t, and
made the
decision to
submit the
manuscrip
t for
publicatio
n.
Qualitativ
e Study

Twelve
hospita
ls with
23
hospita
ls
leaders
.

Twenty
hospitals
(including
public, not-forprofit, and forprofit
institutions)
representing
major
geographic
regions of
California
were
approached.

Twelve
hospitals
agreed to
participate
. There
were
semistruct
ured inperson
and
telephone
interviews
conducted
with 23
hospital
leaders.

Several key
themes
emerged from
the analysis.
Most hospitals
found it
difficult and
expensive to
find more RNs
to hire to meet
the ratios.
Meeting the
staffing
requirements
on all units, at
all times, was

Further research
should continue
to monitor
patient outcomes
as other states
consider similar
ratio regulations.
Results of this
study will be
useful to
healthcare
managers
searching for
ways to reduce
unnecessary
administrative

staffing
ratios
affected
hospitals
?
Perspecti
ves from
California
hospital
leaders.
Journal of
healthcar
e
manage
ment

detailing
specific
ratios by
type of
hospital
unit were
released
in 2002,
with
phased-in
implemen
tation
beginning
in 2004
and
complete
d in 2008.
These
ratios
were
implemen
ted at a
time of
severe
registere
d nurse
(RN)
shortage
in the
state and

challenging
and had
negative
impacts, such
as a backlog of
patients in the
emergency
department
and a decrease
of other
ancillary staff.
Hospital
leaders do not
believe that
ratios have
had an impact
on patient
quality of care.
Findings
related to
nurse
satisfaction
were mixed.
Increased RN
staffing
improved
satisfaction
with patient
workload, but
dissatisfaction

costs while
continuing to
maintain the
level of
administrative
activities
required for the
provision of safe,
effective, highquality care.

Harringto 2012
n, C.,
Choinier,
J.,
Goldman

a
worsenin
g
financial
position
for many
hospitals.
This
article
presents
an
analysis
of
qualitativ
e data
from
interview
s with
healthcar
e leaders
about the
impact of
nurse
staffing
ratios
The study
This
used
study was
descriptive designed
information to collect
on staffing and

with issues of
decisionmaking control
(e.g., decisions
on when best
to take a meal
break) were
taken out of
the nurse's
hands to meet
ratio
requirements.

Not a
quantitati
ve
research
study.

Not
mentio
ned.

Six different
countries.

Data were
collected
from
Internet
searches

The study
found wide
variations in
both nurse
staffing

Lacked
information on
actual statistics
and numbers.
Was a vague

, M.,
Jacobsen
, F. F.,
Lloyd, L.,
McGrego
r, M
Szebehel
y, M.
Nursing
home
staffing
standard
s and
staffing
levels in
six
countries
.

regulations
and
policies as
well as
actual
staffing
levels for
registered
nurses,
licensed
nurses,
and
nursing
assistants
across
states,
provinces,
regions,
and
countries.

compare
nurse
staffing
standards
and
staffing
levels in
six
counties:
the
United
States,
Canada,
England,
Germany,
Norway,
and
Sweden.

A
prospectiv

To
evaluate

of staffing
regulation
s and
policies
along with
statistical
data on
actual
staffing
from
reports
and
document
s. Staffing
data were
converted
to hours
per
resident
day to
facilitate
compariso
ns across
countries.

Journal of
nursing
scholars
hip.

Meyer,
2009
R., Wang,

Care
providers

Comorbidity

Six
hospita

Canadian
hospitals in

Crosssecti
onal data

standards and
actual staffing
levels within
and across
countries,
although
comparisons
were difficult
to make due to
differences in
measuring
staffing, the
vagueness of
standards, and
limited
availability of
actual staffing
data. Both the
standards and
levels in most
countries
(except
Norway and
Sweden) were
lower than the
recommended
levels by
experts.
The findings
indicate that

research article.
Findings
demonstrate the
need for further
attention to
nurse staffing
standards and
levels in order to
assure the
quality of nursing
home care.
A high quality of
nursing home
care requires
adequate levels
of nurse staffing,
and nurse
staffing
standards have
been shown to
improve staffing
levels.

This study adds

to a growing

S., Li, X.,

Thomson
, D.,
OBrienPallas, L.
Evaluatio
n of a
patient
care
delivery
model:
patient
outcome
s in
acute
cardiac
care.
Journal of
nursing
scholars
hip.

e,
correlation
al design
with crosssectional
and
longitudina
l
component
s was
conducted
in
Canadian
cardiac
and
cardiovasc
ular care
inpatient
units.
Data were
collected
from
multiple
sources.
Hierarchica
l linear
modeling
was used
to examine

the
influence
of nurse
staffing
and work
environm
ent
variables
on
patient
outcomes
by testing
a
conceptu
al model

Canadian
hospitals
Unit
types
Number
of beds

Mental
health
status on
admission
Number of
days care
was
provided

ls.

Ontario and
New
Brunswick
that met the
inclusion
criteria (i.e.,
high volumes
of patients in
the cardiac
case mix
groups of
interest), four
were teaching
hospitals.

were
collected
either at
the
beginning
of the
study or
when
patients
were
discharge
d;
repeated
data,
either
daily or at
two time
points
between
admission
and
discharge,
were
collected
during a
6-month
data
collection
period
between

patient
outcomes are
influenced not
only by patient
and nurse
characteristics,
but also by
organizational
staffing
practices.
Organizations
that manage
the complexity
of work
conditions and
target staffing
utilization
levels between
80% and 88%
at the unit
level can
optimize
patient
outcomes.

body of evidence
that
improvements in
patient outcomes
are influenced by
multiple and
interrelated
staffing and work
environment
factors. The
results of this
study suggest
that nurses' work
performance is
enhanced when
staffing practices
related to job
security and
satisfaction,
nurse autonomy,
overtime, shift
changes, and RN
and full-time
staffing
complements are
appropriate.
Relates to my
patients because
I worked on a

relationshi
ps among
variables.

Twigg,
D.,
Duffield,
C.,
Thompso
n, P. L.,
Rapley,
P.
The

2010

An
electronic
search of
articles
published
in English
using the
Cumulative
Index to
Nursing

This
Not a
article
quantitati
provides
ve study.
a
comprehe
nsive
review of
the
research
linking

This
N/A
was a
compre
hensive
review
with no
statistic
al
number
s

February
and
December
2002.
Ethical
approval
was
received
from the
University
of Toronto
and
hospital
sites.
Patient
and nurse
consents
were
obtained
on site.
Cumulativ
e Index to
Nursing
and Allied
Health
Literature
(CINAHL),
Journals @
OVID and
Medline

cardiac unit and

recently
transitioned to
ICU.

Robust
evidence
exists
nationally and
internationally
that links
nurse staffing
to patient
outcomes.
Recent meta-

No primary
research
completed by the
authors of this
article
An appropriate
policy response
demands that
the evidence that

impact of
nurses
on
patient
morbidit
y and
mortality
the
need for
a policy
change
in
response
to the
nursing
shortage.

and Allied
Health
Literature
(CINAHL),
Journals @
OVID and
Medline
was
undertaken
.

Australia
n health
review.

Zhu, X.,
You, L.,

2012

The study
was

nurse
staffing
to patient
outcomes
at a time
of
growing
shortages
,
highlighti
ng that a
policy
response
based on
substituti
ng
registere
d nurses
with
lower
skilled
workers
may have
adverse
effects on
patient
outcomes
.
The
purpose

identifi
ed.

Qualitativ
e Study

181
hospita

was
undertake
n.

All of the
eight

Four-stage
sampling

analyses have
found that
there was a 312% reduction
in adverse
outcomes and
a 16%
reduction in
the risk of
mortality in
surgical
patients with
higher
registered
nurse staffing.
Evidence
confirms that
improvements
in nurse
staffing is a
costeffective
investment for
the health
system but
this is not fully
appreciated by
health policy
advisors.
The adjusted
joint effects of

patient safety is
linked to nurse
staffing be
recognized.
Policy makers
must ensure
there are
sufficient
registered nurses
to guarantee
patient safety.

The study
recommends

Zhen, J.,
Liu, K.,
Fang, J.
Nurse
staffing
levels
make a
differenc
e on
patient
outcome
s: a
multisite
study in
Chinese
hospitals
.
Journal of
nursing
scholars
hip.

conducted
in 181
hospitals
across all
of the eight
economic
zones in
mainland
China
using a
four-stage
sampling
design. Two
instrument
s, the
China
Nurse
Survey and
the patient
satisfaction
measurem
ent from
the
Hospital
Consumer
Assessmen
t of
Healthcare
Providers
and

of this
study is
to
examine
the
relationsh
ip
between
nurse
staffing
and
patient
outcomes
in
hospitals
in
mainland
China.

ls

economic
zones in
mainland
China.

design.
Two
instrumen
ts, the
China
Nurse
Survey
and the
patient
satisfactio
n
measurem
ent from
the
Hospital
Consumer
Assessme
nt of
Healthcar
e
Providers
and
Systems,
were
employed
in data
collection.
In this
article,
7,802

nurse staffing
on patient
outcomes from
logistic
regression
analyses
showed that
more nursing
staff per
patient had
statistically
significant
positive effects
on all
necessary
nursing care,
nurses' reports
of quality of
care, their
confidence on
patients' selfcare ability on
discharge from
the hospital,
patient
adverse
events, as well
as patients'
report of
satisfaction.

that the nurseto-patient ratio

on medical and
surgical units in
Chinese hospitals
be increased to
at least 0.5-0.6
so as to secure
patient safety
and the quality of
health services.
Chinese
population, but
relates to
patients in
America.

Systems,
were
employed
in data
collection.
In this
article,
7,802
nurse
surveys
and 5,430
patient
surveys
from 600
medical
and
surgical
units were
analyzed.

nurse
surveys
and 5,430
patient
surveys
from 600
medical
and
surgical
units were
analyzed.

When the
nurse-to
-patient ratio
(total number
of nurses on all
shifts on the
unit divided by
total number
of patients
who stay on
the unit)
increased to
the 0.5-<0.6
category, most
patient
outcomes were
significantly
improved,
considering
hospital and
patient factors
and nurse skill
mix in the
logistic
regression
models.
The findings
provide
evidence on

Hayes,
N., Ball,
J.
Achievin
g safe
staffing
for older
people in
hospital.
Nursing

2012

Two
surveys of
RCN
members
working on
older
people's
wards in
NHS
hospitals in
the UK
were

Hospitals
provide
care for
older
people
who are
the
frailest,
most
acutely ill
and have
the most

Qualitativ
e Study

158
hospita
ls in
the UK.

Elderly
members
from NHS
hospitals in
the UK.

Two
surveys of
RCN
members
working
on older
people's
wards in
NHS
hospitals
in the UK
were

how
inadequate
nurse staffing
might result in
missed but
needed
nursing care
and negative
patient
outcomes,
while better
staffing levels
could be an
effective
strategy for
improving
patient
outcomes.
Sixty six per
cent (n=158)
of respondents
said there
were generally
not enough
RNs to meet
patient needs.
Many of their
comments
illustrate the
reality of

older
people.

carried out
in August
to
September
2011 and
October
2011.
King's
College
London
undertook
the survey
design and
analysis.
An email
invitation
to
complete
the survey
was sent to
125,062
RCN
members
drawn from
the
membershi
p database
and
excluding
those

complex
needs,
yet older
people's
wards in
many
hospitals
are
poorly
staffed.
The Royal
College of
Nursing
(2012)
has
published
summary
guidance
and
recomme
ndations
on safe
staffing
for older
people's
wards.
The
guidance
and
recomme

carried
out in
August to
Septembe
r 2011
and
October
2011.
King's
College
London
undertook
the survey
design
and
analysis.
An email
invitation
to
complete
the survey
was sent
to
125,062
RCN
members
drawn
from the
membersh
ip

striving to
meet the
complex needs
of patients
when staffing
levels are not
adequate: 'The
skill mix
doesn't allow
for enough
time to be
given to the
basic care
needs of the
patients. With
one RN often
in charge of 12
patients, her
time is spent
doing drug
rounds and
intravenous
infusions
therefore there
is no time left
for proper
patient
assessment.

whose
details
indicated
that they
were
unlikely to
work with
older
people in
NHS
hospitals. A
series of
focus
groups
with front
line nurses
working on
wards in
six
hospitals in
England
and Wales
and
workshops
and
discussions
with
invited
expert
gerontologi

ndations
were
develope
d as part
of a
project
that
explored
staffing
and
factors
underpin
ning good
quality
nursing
care for
older
people in
hospital.
This
article
presents
further
data from
the
project
exploring
the
relationsh

database
and
excluding
those
whose
details
indicated
that they
were
unlikely to
work with
older
people in
NHS
hospitals.
A series of
focus
groups
with front
line
nurses
working
on wards
in six
hospitals
in England
and Wales
and
workshops
and

cal nurses
across the
UK were
also
carried out.

ip
between
staffing
levels
and care
delivery,
as well as
staff
views on
the
adequacy
of staffing
and
approach
es to
workforce
planning
at ward
level. It
also
explores
the
practical
implicatio
ns for
nurses
working
on older
people's
wards.

discussion
s with
invited
expert
gerontolog
ical nurses
across the
UK were
also
carried
out.

*Include under Comments anything that may be of interest to you in the article, would be helpful in considering whether contributes to
answering your clinical question, or to application of the research findings to your practice; e.g. Small sample size, no race info. Subjects
very unlike my patients. Innovative intervention, not sure if my manager would go for it.
Now that you have summarized the articles you obtained, please answer the following questions:
1. Does the evidence answer your clinical question? There was ample amount of research to answer my question about how safe staffing
highly influences patient outcomes. However, it would be better on my part to search more quantitative studies along with qualitative
studies.
2. If the evidence answered your clinical question, what is the answer? My questions was answered, and the research indicates it is very
important for safe staffing so as not to compromise patient outcomes.
3. If the evidence did not answer your clinical question, what are your next steps? Although my question was answered and confirmed my
ideas about safe staffing, my next step is to further investigate studies related to quantitative research rather than just qualitative
research.