Quality of care: Article Review

Quality of care
Quality of care

Quality of care Article Review


 The international agencies and national nursing associations acknowledge the fact that unhealthy working conditions affect the quality of care, employee’s health, and are associated with nurse sensitive patient outcomes. In their article “Hospital magnet status, unit work environment and pressure ulcers,” Ma and Park explored the relationship between the RN environment nurse outcomes (job satisfaction, turnover rates and intent to stay) and patient safety outcomes (pressure ulcers, falls, and quality of care).

The article suggests that the hospital administration  and  nurse leaders should understand the importance of nurse work environments, as it sets  the stage for quality care and provides competitive advantage in current’s  value driven healthcare system (Ma &Park, 2015).

This essay is a critical analysis of Ma & Park article’s that aims to assess if the information improves nursing practice, increases nursing knowledge and understanding on patient safety. The main topics that will be critically analyzed include the article’s research design, data collection, data analysis, findings, discussion and nursing implication.

The research problem and its significance

 Creswell   states that a study’s research problem should be described using an approach that orientates the reader to the research subject (Creswell, 2014; Jaul, 2014).  The article states that better nurse work environments are associated with lower hospital acquired pressure ulcers. Pressure ulcers are critical patient issue because they are associated with prolonged hospital stays, increases patient risks for adverse events and increased consumption of the healthcare costs (Cai, Rahman, & Intrator, 2013; Buttaro et al., 2013, p. 304).

The research problem in this study is the organization’s factors or nurse work environment that negatively influence patient’s outcome, such as increasing HAPU incidence. “The unit-level work environments have major impact on the nurse work environment” (Ma & Sharks, 2015, p.65). The research problem is a focal point of research. It is well stated in this article and generates questions in which the research study aims to address (Stafford & Brower, 2012, p. 11; Suttipong & Sindhu, 2011, p. 373).

The study hypothesizes that nurses play crucial role in preventing pressure ulcers. However, the degree of patient safety is determined by the nurse work place environment, “The organizational factors in work-environments facilitate or constrain the professional nursing practice” (Ma & Parks, 2015, p. 566).  The article evaluates the nursing factors at both the hospital and unit level associated with Hospital acquired pressure ulcers (HAPU).

On the other hand, the significance of a study is the rationale of the study.  The researcher proves to the audience that the research is vital and worth doing it.  For instance, the study indicates that the need to reduce hospital acquired pressure ulcers has gained national attention. “There are approximately 2.5 million pressure ulcers that occur in the USA, and coasts $9.1-11.6 billion (Ma &Sharks, 2015, p. 65).”

 The research design and methods

Richardson-Tench and colleagues state that research design is the overall strategy chosen by the researcher to integrate different components of the study. It should be constructed in a logical manner to ensure that the researcher effectively address the research problem using the appropriate data collection and analysis approach (Melnyk & Fineout-Overholt, 2014; Richardson-Tench et al., 2014).

 The research method is used in this article is qualitative. The research design used in this article is the Cross-sectional observational study of data collected from the National Database of Nursing Quality Indicators (NDNQI). This research design is appropriate for this study because it examines the relationship of exposure and outcome in a defined population at one point in time.

In addition, the research design is inexpensive, less time consuming and provides a good but quick picture of prevalence of the research problem and its outcome. Although appropriate for this study, the main issue with this research design lacks time element making it difficult to determine the temporal relationship between the research problem and the outcome of the proposed intervention (Ma & Sharks, 2015, p.567).

 Data used in this article was collected from NDNQI. The data collected was supplemented with the NDNQI RN survey.  The total participants for RN survey was 33, 845 from 1,381 units in 373 healthcare facilities in 44 States. The inclusion criteria for this survey were nurses who had spent 50% of their time in general units in the hospital within the last three months. The researcher also established measures to ensure reliability of the data collected (Ma & Sharks, 2015, p.566).

Data analysis of the collected data was analyzed using t tests to compare the nurse work environments, staffing levels, HAPU rates and the RN skill mix of the NDQI member hospitals.  Three multilevel logistic regression models were used to estimate the effect of nurse work environment and healthcare facilities management of HAPU. The data analysis used is appropriate for this nature of the study as it provides conclusive comparative analysis (Ma & Sharks, 2015, p.568).

 Findings and their relevance to contemporary nursing policy and practice

 The study findings indicate that improving working environments both at hospital level and unit level results to lower HAPU rates. The data findings presentation in this article  is concise and appropriately used non-textual elements such as table summaries and figures to present data findings effectively.  The data provided is critical in answering the research question. For instance, Magnet hospital units had 21% low odds of having HAPU as compared to the non-magnet hospital.  

There are several limitations noted in this study. To start with, participation of hospitals in NDNQI is voluntary, which indicates overrepresentation or underrepresentation of hospitals with certain characteristics. Secondly, the study omitted some specific information such as ethnicity, socioeconomic status and other co-morbidities that could introduce residual confounding effects. In addition, patient level information in most of quality indicators is limited.

Despite the limitations, the study findings are consistent with the previous studies that better nurse work environments is associated with lower hospital acquired pressure ulcers, lower readmission rated and a higher overall rating.  The nursing implication of this study is that it improves the understanding of work environments in relation to patient’s outcomes (Guihan et al., 2016, Matsuo, Oie, & Furukawa, 2013).

The quality of care is influenced by the nurse work environment characteristics such as the administrative support, nurse-physician relations and nurse resource adequacy.  Effective nurse work environments are established through better communication, team work between the healthcare providers and higher autonomy/practice control.

Nurses in such types of environments are less likely to suffer from burnout or express intent to quit their jobs, but are likely to function efficiently, deliver superior quality of care that ultimately improves patient’s overall outcome (Demarre et al., 2014, p. 392; Singh et al., 2015, p.7; Neilson et al., 2014, p. 21).


Critical appraisal is important process as if facilitates a thorough understanding of the research study in order to establish the study strengths and weaknesses and to evaluate the quality, and if the study’s strength is effective and appropriate for its use in the reader’s practice. This study generates new ideas that will help improve the quality of care and patient safety and quality of care in nursing practice. The study findings in this study facilitate the understanding the link between organizational environments and the patient outcomes. This study highlights the effectiveness of unit-specific quality improvement initiatives in today’s highly specialized care.


Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.

Cai, S., Rahman, M., & Intrator, O. (2013). Obesity and Pressure Ulcers Among Nursing Home Residents. Medical Care, 1. http://dx.doi.org/10.1097/mlr.0b013e3182881cb0

Creswell, J. W. (2014). A concise introduction to mixed methods research. Sage Publications.

Demarre, L., Verhaeghe, S., Van Hecke, A., Clays, E., Grypdonck, M., & Beeckman, D. (2014). Factors predicting the development of pressure ulcers in an at-risk population who receive standardized preventive care: secondary analyses of a multicentre randomised controlled trial. J Adv Nurs, 71(2), 391-403. http://dx.doi.org/10.1111/jan.12497

Guihan, M., Murphy, D., Rogers, T., Parachuri, R., SAE Richardson, M., Lee, K., & Bates-Jensen, B. (2016). Documentation of preventive care for pressure ulcers initiated during annual evaluations in SCI. The Journal Of Spinal Cord Medicine, 160204031040002. http://dx.doi.org/10.1080/10790268.2015.1114225

Jaul, E. (2014). Multidisciplinary and comprehensive approaches to optimal management of chronic pressure ulcers in the elderly. Chronic Wound Care Management And Research, 3. http://dx.doi.org/10.2147/cwcmr.s44809

Matsuo, M., Oie, S., & Furukawa, H. (2013). Contamination of blood pressure cuffs by methicillin-resistant Staphylococcus aureus and preventive measures. Irish Journal Of Medical Science, 182(4), 707-709. http://dx.doi.org/10.1007/s11845-013-0961-7

Ma, C., & Park, S. H. (2015). Hospital Magnet status, unit work environment, and pressure ulcers. Journal of Nursing Scholarship, 47(6), 565-573. 

Melnyk, B., & Fineout-Overholt, E. (2014).Evidence-based practice in nursing & healthcare: A guide to best practice, 3rd Edition. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins

Neilson, J., Avital, L., Willock, J., & Broad, N. (2014). Using a national guideline to prevent and manage pressure ulcers. Nursing Management – UK, 21(2), 18-21

Richardson-Tench, M., Taylor, B., Kermode, S., & Roberts, K. (2014). Research in nursing: Evidence for best practice (5th ed.). Cengage Learning Australia: South Melbourne.

Singh, R., Dhayal, R., Sehgal, P., & Rohilla, R. (2015). To Evaluate Antimicrobial Properties of Platelet Rich Plasma and Source of Colonization in Pressure Ulcers in Spinal Injury Patients. Ulcers, 2015, 1-7. http://dx.doi.org/10.1155/2015/749585

Stafford, A., & Brower, J. (2012). Letʼs get comfortable. Nursing Management (Springhouse), 43(9), 10-12. http://dx.doi.org/10.1097/01.numa.0000418777.69056.f7

Suttipong, C., & Sindhu, S. (2011). Predicting factors of pressure ulcers in older Thai stroke patients living in urban communities. Journal Of Clinical Nursing, 21(3-4), 372-379. http://dx.doi.org/10.1111/j.1365-2702.2011.03889.x

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