Peer Feedback: Grading the Evidence

Identifying Level 1 Evidence

Throughout the literature review process for my evidence-based practice question, “In adult patients in acute care settings at St. Michael’s Medical Center, how does improving nurse-patient ratios compared to current practice affect patient safety outcomes (such as falls, pressure ulcers and medication errors) over 6 months?” I focused heavily on identifying Level 1 evidence: Peer Feedback: Grading the Evidence.

This included randomized controlled trials and high-quality prospective studies. Two studies, one by Dietermann et al. (2021) and another by McHugh et al. (2021), stood out as exemplary Level 1 sources. Dietermann et al. (2021) used multilevel regression across European hospitals to reveal significant reductions in mortality and pressure ulcers with better staffing, while McHugh et al. (2021) examined U.S. hospitals before and after ratio legislation, noting substantial decreases in mortality, readmissions, and medication errors. These studies were pivotal because they provided robust, generalizable findings with high internal validity and strong statistical power.

Role of the PICOT in Evidence Identification

My PICOT question significantly facilitated the evidence search. The clearly defined population (adult patients in acute care), intervention (improved staffing ratios), comparison (current practice), and outcome (patient safety metrics) helped generate specific and targeted search terms like “nurse-patient ratio,” “acute care,” “patient safety outcomes,” “mortality,” “pressure ulcers,” and “medication errors.” These terms aligned well with database filters in CINAHL, PubMed, and Embase, enabling efficient identification of relevant Level 1 studies. The structured nature of the PICOT question streamlined the selection process and improved the relevance of retrieved articles.

Challenges and Nature of Evidence Found

Although Level 1 evidence was accessible, there were limitations. Randomized controlled trials on staffing were scarce due to ethical and logistical concerns. Instead, I relied on prospective observational studies and large-scale panel data, which still qualified as Level 1 under Johns Hopkins’ classification.

I supplemented this with Level II and III studies to provide depth, particularly qualitative insights into nurse perspectives on burnout and care rationing (Banda et al., 2022). Overall, the evidence base was robust and consistent, affirming that improved staffing ratios enhance patient safety outcomes.

References

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). https://doi.org/10.1186/s12912-022-00918-x

Dietermann, K., Winter, V., Schneider, U., & Schreyögg, J. (2021). The impact of nurse staffing levels on nursing-sensitive patient outcomes: A multilevel regression approach. The European Journal of Health Economics, 22(5), 833–846. https://doi.org/10.1007/s10198-021-01292-2

McHugh, M., Aiken, L., Sloane, D., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of hospitals. The Lancet, 397(10288), 1905–1913. https://doi.org/10.1016/S0140-6736(21)00768-6

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WK 10 8114 Blog: PEER FEEDBACK: GRADING THE EVIDENCE
For this Blog, you will share your experiences grading the evidence to address the practice question you selected for the Literature Review Assignment you are currently working on. This Blog is due by Day 7 of this week (Week 10).

This Blog is a unique opportunity to receive valuable feedback from your colleagues, which you can then incorporate to improve your Assignment. By the end of the week, please reflect upon the feedback you received, and then apply whatever you find valuable as you work toward completing your Literature Review Assignment.

To Prepare

• Continue working on your Literature Review Assignment, which is due Day 7 of Week 10.
• Reflect on your experiences identifying Level 1 evidence to address your practice question.
• Consider if and how your PICOT assisted you in identifying search terms to identify Level 1 evidence.
• Reflect on whether or not you had difficulty finding Level 1 evidence and why.

Note: Not all practice questions lend themselves to systematic reviews or experimental research, thus they may vary in terms of the applicability of Level 1 evidence.

Peer Feedback: Grading the Evidence