Quality of Healthcare System in South Korea

Quantitative Research Article: Cho, E., Chin, D., Kim, S., & Hong, O. (2016). The Relationships of Nurse Staffing Level and Work Environment with Patient Adverse Events. Journal of Nursing Scholarship

Question 1

The authors describe the research problem in the article’s introduction section. In this section, the authors note that the South Korean healthcare system continues to deliver significantly poorer quality of healthcare despite notable development in other areas such as increased access to hospital care, increased investment in hospitals, and advanced medical technologies. Compared to other OECD countries such as Canada, nurses in South Korea report poorer quality of patient care.

In the literature review section, the authors explore available evidence on the identified research problem. Through this review of literature, the authors establish that although there is strong evidence describing the association between patient outcome and nurse staffing levels, such studies have mostly been conducted in Europe and the United States. As such, there lacks empirical evidence on whether or not the association between patient outcome and nurse staffing levels exist in South Korean hospitals. Under the “Methods” section, the authors the range of methodologies employed in the study. The study collected three key types of data which included nurse survey data, hospital discharge data, and facility data.

Data analysis for the study focused mainly on analysis of descriptive statistics. Through this analysis, the researchers aimed to examine: nurse staffing level and working environment; the incidence of adverse events; and characteristics of nurses and hospitals. In their conclusion, the authors established that there is a significant association between nurse staffing level and nurse work environment, on one hand, and patient adverse events on the other hand. This conclusion was consistent with earlier studies that had identified an association between inadequate nurse staffing levels and patient adverse events.

Question 2

As earlier noted the introduction section largely focuses on describing the research’s problem and as such provides little evidence to support the researchers’ conclusion. The literature review section, however, provides strong evidence for the researchers’ conclusion. Similar to the study’s conclusion, available literature supports the observation that there is a significant association between nurse staffing levels and patient adverse events. It can also be noted that the evidence provided under the methodology section supports the researchers’ conclusion. To ensure an improvement on previous evidence, the current study controlled for nurse, hospital, and patient characteristics. The use of multilevel ordinal logistic regression in data analysis was equally significant to the researchers’ findings. Through this data analysis approach, the researchers were able to control for nurse and hospital characteristics when exploring the relationship between nurse staffing level and patient adverse events.

Question 3

Although the article does not describe in detail all the measures taken to protect subjects, there is significant evidence that the researchers took some measures. Among these measures included ensuring that nurses completed questionnaires provided privately. In addition to this, participating nurses were provided with envelopes in which to place the completed questionnaires and the envelopes dropped in locked boxes placed at each of the of participating hospitals. This approach protected the identity of participating nurses. It can also be noted that the data generated by the researchers contains no personally identifiable information. By removing all personally identifiable information, the researchers ensured the study posed no privacy harm to participants.

Despite the above measures, the study does not describe in detail how recruitment of subjects was conducted. More importantly, the article does not indicate whether approval from an Institutional Board Review (IRB) was obtained. Another important aspect relating to protection of human subjects that is not covered by the article is whether informed consent was obtained from participants. Specifically, the article does not indicate whether participating nurses were adequately informed about the nature and purpose of the study during recruitment. Overall, the researchers should have comprehensively factored all ethical considerations associated with human subjects’ research and provide evidence of the same in the article.

Question 4

The study by Cho et al. (2016) contains several identifiable strengths and limitations. One of the main strengths of the study relates to the use of randomly selected data set obtained from large sample sizes. At 92%, the response rate of the study could also be identified as an equally significant positive that enhanced the reliability of the findings. With such a high response rate, the researchers were surer the findings of the study represented the entire target population. The fact that the study controlled for nurse, hospital, and patient characteristics is another important positive. By controlling for the three variables, the researchers ensured the influence of these variables’ characteristics on the association of nurse staffing level and patient adverse outcomes was adequately considered.

Despite the above strengths, the study has several limitations key among them being the cross-sectional nature of the data used. Since the study relied on cross-sectional data to test its hypothesis, its results cannot be reliably used to describe a causal relationship among the three main constructs: nurse staffing level; nurse work environment; and patient adverse events. The fact the study used self-report survey to obtain data on outcomes and covariates could also be identified as a limitation. Specifically, difficulties in recalling coupled with reporting bias could have influenced the adverse patient events reported by nurses. In this regard, the prevalence of adverse patient events might have been overestimated or underestimated as there lacked objective measurement of this variable. Another limitation of the study relates to the use of hospital discharge data of surgical patients as the only source of data on patient characteristics adjustment. This limitation could have significant effect on the generalizability of the study’s findings.

Question 5

The evidence from the study has significant influence on nursing practice. Firstly, the study’s findings provide evidence on the association of nurse staffing level and patient adverse events in South Korea. Notably, there lacked such evidence before the study by Cho et al. (2016). With the evidence available now, nursing practice in the country is expected to use this information to design interventions for overcoming barriers related to nurse staffing shortage. Considering the quality of health care is best described by patient outcomes, evidence from the study is likely to drive need for policy change in the South Korean health care sector with a strong focus on increasing opportunities for health care organizations to increase their nurse staffing levels.

Qualitative Research Article: 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: 1300-1309.

Question 1

The researchers use the introductions section to provide an overview of the issue of nurse staffing level and patient outcome. A brief review of literature on this area indicates that while nurse staffing level should match perfectly with the demand for care and positively influence patient outcomes, nurses have reported that current staffing levels are not adequate to provide to guarantee high-quality care. The literature review section of the article is incorporated as part of the introduction section and advances the authors’ discussion of the association of nurse staffing level and patient outcomes. The authors also use this section to describe the concepts of nurse-to-patient ratios (NPR) and patient classification systems (PCS) as applied in the Netherlands’ healthcare sector.

The study used a descriptive phenomenological approach as part of its research methodology. The choice of this approach was based on the need to reduce the likelihood of participants presenting their individual experiences. Interviews were the study’s main method of data collection. Data analysis for the study employed Colaizzi’s analytic method and used MAXQDA version 11. Data analysis involved first transcribing audios recorded in interviews and grouping them into meaningful segments. The transcribed data was then coded to and clustered into themes for easier analysis. In their findings, the researchers noted three key themes central to nurses’ experiences with nurse staffing: nursing behavior; autonomy; and authority. Based on these findings, the researchers concluded there are other significant issues relating to the position of nurses and nurse staffing is only but the “tip of the iceberg.”

Question 2

The evidence presented in most sections of the article appears to support the researchers’ conclusion. In the introduction and literature review sections, the authors note that past studies have identified nurse staffing as a significant issue facing nursing practice. The authors’ conclusion not only supports this earlier observation but also advances it by providing evidence for more issues facing the profession. . It can also be noted that the evidence provided under the methodology section supports the researchers’ conclusion. By using a mode familiar with nurses, the researchers were able to obtain data on nurses’ perceptions of nurse staffing in a way that reduced the likelihood of participants providing personal experiences.

Question 3

One of the strategies used by the researchers to ensure protection of human subjects is informing all participants about the aim of the study. This ensured that all nurses taking part in the study knew its aim and purpose before committing. Additionally, participants gave oral consent before committing to take part in the study. Permission was also obtained from participants before every session that involved audio-recording. The researchers further assured participants that all personally identifiable information would not be published and this protected the confidentiality of participating nurses. To ensure this, the researchers saved data obtained from participants under identification numbers. The study was approved by an Institutional Board Review (IRB) – Academic Medical Center, Amsterdam, Netherlands. The board, however, determined the study did not need ethical approval since it had no significant effect on the wellbeing of nurses and patients.

Question 4

One of the strengths of the study is its use of the Lippitt model for Managing Complex Change which most participating nurses were familiar with. By using the model as the underlying framework for data collection, the researchers were able to obtain the desired insight from nurses on their perceptions of changes in nurse staffing. The fact the quality of the interviewer’s technique was assessed after the first interview could also be identified as another positive of this study. By involving the services of an interviewing expert, the study ensured that interviews were conducted appropriate and this protected the quality of data obtained.

Despite the above strengths, there are several limitations that could be noted in the study. Firstly, the researchers focused on only one health care institution and this could have hindered the generalizability of the findings. Specifically, focusing on one hospital means the findings can only be generalized only to similar hospitals located in the Netherlands. Secondly, the fact the researchers once worked in the hospital in which the study was conducted could have influenced data collection. In view of this, the reliability of the data collected could have been positively or negatively influenced by the researchers’ role.

Question 5

The study by Oostveen et al. (2015) has notable benefits to nursing practice. Firstly, evidence from the study indicates that while the positioning of nurses is crucial, nurses continue to face challenges in regard to their contribution to the issue of nurse staffing. Specifically, the study points out lack of authority and autonomy in decision-making as the single most significant barrier facing nurses. The study further notes that nurses are hindered by lack of appropriate communication skills especially in regard to use of evidence to guide arguments on the association of nurse staffing level and adverse patient outcomes.

Going forward, nurses can be expected to use the findings of this study to identify and exploit opportunities for improving their communication skills. Health care organizations can also be expected to use this evidence to guide policies aimed at providing opportunities for nurses to exercise authority in nurse staffing decision-making processes.