Journal Critique

Introduction
For decades, taxpayers and policymakers have demanded better and quality healthcare. According to Kim and Bae (2018), to meet these needs, two strategies have been applied. One is allowing the public to report the quality of care for specific health institutions to create awareness and help consumers make informed choices. The other one is paying for performance, which targets healthcare institutions and entices them through incentives to provide better results. As a continuing effort, evaluations also indicate that nurse-staffing level is an important factor in the delivery of quality care. Studies carried out in the United States, Canada, Australia, and New Zealand show that lower levels of hospital nurse staffing have a close relationship with adverse outcomes. Consistently, the retrospective observational study “relationship between nurse staffing level and adult nursing-sensitive outcomes in tertiary hospitals of Korea” was carried out to examine the relationship between nurse staffing levels and health outcomes for adult medical and surgical inpatients in Korea.
Research Problem and Significance (400 words)
Recently, South Korea has been experiencing an increase of chronic diseases due to the rapid growth of its aging population. According to Cho, Chin, and Kim (2015), despite the huge investments made towards improving their healthcare system, the Korean health system continues to deliver significantly low-quality care. Nurses represent a larger population of the hospital staff delivering the highest volume of direct care to patients. Consistently, studies indicate that nurse staffing level play a critically significant role in the patient health outcomes. Literature published in connection with studies performed in the United States, Canada, Australia, and New Zealand indicates that nurse staffing directly affects patient outcomes (Kim & Bae, 2018). Better patient to nurse staffing ratios were associated with lower mortality rates and better health outcomes. However, although there is strong evidence linking nurse staffing with improved patient outcomes, little is known about the significant association of nurse staffing with patient outcomes in Korea. In fact, as Kim and Bae note, three previous studies have assessed the relationship between nurse staffing and healthcare outcomes, but they were limited to surgical patients and acute stroke patients. Therefore, the study seeks to explore the relationship between nurse staffing level and adult medical and surgical inpatients. More specifically, the study seeks to understand the status of Nursing-sensitive outcomes using Korean HIRA reimbursement data. The paper also seeks to compare the incidence of NSOs rate with nurse staffing grades and explore the relationship between NSOs and nurse staffing levels.
Previous studies indicate that high levels of nurse staffing have a positive impact on the quality of care delivered in healthcare facilities. It is also evident that lower number of nurses has a negative impact on patient health outcomes and mortality rates. The study, not only identifies the nursing-sensitive outcomes but also provides additional evidence to support the relationship between higher nurse staffing and improved health outcomes. Ideally, as Kim and Bae note, nursing-sensitive outcomes are indicators of patient health status and reflect the nursing staff activities. Accordingly, the indicators are significant in monitoring the quality of nursing care, although it should correspond with patient acuity and healthcare facility for accurate comparisons.
Research Design and Methods
In research, one of the most basic choices that researchers encounter is the use of qualitative or quantitative methods or mixed methods. According to Creswell (2014), qualitative, quantitative or mixed methods are research designs that determine the methods of data collection used and analysis. The procedure involves making several decisions to ensure that the research is comprehensive and useful. Undeniably, the approaches are not as discrete as they appear; more specifically, they represent different ends of a continuum. Additionally, it is also important to explore the difference between qualitative and quantitative research to understand the research design and methods used in the study. To start with, qualitative research is represented by words and uses open-ended questions. On the other hand, quantitative research is framed using numbers and uses a close-ended question to test for the hypotheses. Consistently, the article is an observational study and used qualitative research methods to explore the relationship between nurse staffing levels and patient health outcomes. The authors extracted data from the 2012 and 2014 HIRA databases containing inpatient and outpatient electronic data of healthcare practices in Korea. Among the information extracted include age, sex, at least 30 diagnoses, operations and procedures performed on a patient, emergency room services, as well as ICU admission. The inclusion criteria considered patient data from 19 years and above and who were admitted to tertiary hospitals between 2013 and 2014. The study did not consider patients without nationwide identification numbers, because it would have compromised the calculation of comorbidity scores. Data was measured using the nurse staffing levels and assigned grades one to seven. The grades were determined by the ratio of beds to registered nurses present in the general wards. To determine the nursing-sensitive outcomes, the study defined a denominator, numerator, and exclusion criteria to calculate incidences for every 12 NSOs indicators. Notably, the research used the SAS® 9.4 to calculate descriptive statistics such as standard deviation, mean, and frequency among others. The study used Chi-squared test, Student’s t-test, and ANOVA to measure the differences in proportions. Multiple logistic regression was to examine the relationship between nurse staffing and NSOs.
Findings
The results of the study were divided into three segments. The first outlined the distribution of patient and hospital characteristics and highlighted the number of adults medical and surgical inpatients. The second part outlined the incidences of nine NSOs for all the patients and found it to be 0.86 – 2.84 percent. The third represented the results of the relationship between nurse staffing levels and NSOs after adjusting both patient and hospital. The fourth represented the adjusted NSO incidence rate against nurse staffing grade.
Virtually, as Kim and Bae (2018) notes, when the number of staff is low, underreporting is likely to occur. However, the research used health administrative data from tertiary hospitals, presumed to have an adequate workforce and thus more reliable. Consistently, the study found a significant association between higher nurse staffing and the rate of eleven NSOs. The findings are in line with previous studies as outlined by the authors. Nonetheless, Kim et al., also note that the relationship between nurse staffing and patient health outcomes can be affected by the source of data.
Relevance to Contemporary Nursing Policy and Practice
Research indicates that healthcare facilities with adequate nurse staffing levels have better patient health outcomes (McHugh, Berez, & Small, 2013). Staffing outcomes research has relevance for nursing policies and practice. More precisely, the research indicates that lower nurse staffing levels affect the delivery of quality care. Thus, this information helps managers and hospital administrators understand the significance of adequate nurse staffing. To the nursing practice, McHugh and Ma (2014) notes that the availability of adequate staffing has the potential to eliminate issues such as burnout, job dissatisfaction, and high nurse turnover.
Conclusion
For several decades, researchers have reported the positive relationship between higher nurse staffing levels and patient health outcomes. In the United States, Canada, Australia, and New Zealand, the studies have been comprehensive. However, for Korea, it was not clear the correlation between nurse staffing and patient health outcomes. The study presents a comprehensive study and a clear analysis of the relationship between nurse staffing and health outcomes. Proposals for future studies include further investigation into the topic using the same methods used in the study.

References
Cho, E., Chin, D. L., Kim, S., & Hong, O. (2016). The Relationships of Nurse Staffing Level and Work Environment With Patient Adverse Events. Journal of Nursing Scholarship, 48(1), 74-82.
Croswell, J. (2014). Research design: qualitative, quantitative, and mixed methods approaches. London: Sage Publications Ltd.
Kim, C.-G., & Bae, K.-S. (2018). Relationship between nurse staffing level and adult nursing-sensitive outcomes in tertiary hospitals of Korea: Retrospective observational study. International Journal of Nursing Studies, 80, 155-164.
McHugh, M. D., & Ma, C. (2014). Wage, work environment, and staffing: effects on nurse outcomes. Policy, Politics & Nursing Practice, 15(3-4), 72-80.
McHugh, M. D., Berez, J., & Small, D. S. (2013). Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Affairs, 32(10), 1740-1747.

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