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The search for resources from online databases is very hectic work especially if the search involves obtaining background information. Through the use of PICO or Problem, Intervention, Comparison, and Outcome questions, the search can be narrowed down using keywords and other limitations. The current paper discusses the process of obtaining literature from online databases for the PICO Question: What is the effectiveness of implementing the mandatory nurse-to-inpatient ratios on healthcare quality in hospitals in the United States?

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Database Search for Relevant Literature


For a long time, poor nurse-to-patient ratios in hospitals have been associated with poor patient care quality. Based on the needs assessment of the chosen population, the following questions about the population, intervention, comparison and Outcome or PICO were developed .

Problem statement: What is the relationship between mandatory nurse-to-patients ratios and the quality of patient care, nurses’ burn out, and the effects on the nurse work environment on the quality of general healthcare in the United States.

PICO Question: What is the effectiveness of implementing the mandatory nurse-to-inpatient ratios on healthcare quality in hospitals in the United States?

P – All the registered nurses-to-inpatient ratios working in hospital environments

I – Follow-up program regarding the quality indicators for mandatory nurse-to-inpatient ratios implementation

C – Compared to current requirements for nursing practice, the quality of patient care should be provided for every patient by every nurse during their shifts in a hospital setting. Evidence from across numerous research have proved that with proper observation of mandatory nurse-to-patient ratios in hospitals, low nurse enrollment in hospitals has been identified as the highest contributor to poor patient care quality and nursing issues associated with burnout and poor work environment.

O – Efficient quality of patient care provision has been monitored closely over the last few years as notable deterioration has been identified in errors in medical service and medication; increased patient complications, increased mortality; increased nurses burnout; and poor nurse retention and job satisfaction among others. In order to provide standardized requirements for efficient care provision, a federal regulation is in place, 42 Code of Federal Regulations, that calls for hospitals certified to take part in Medicare to enroll adequate licensed registered nurses, licensed practical nurses, and other professional to provide to all patients the needed nursing care. Furthermore, the states have been provided with the Registered Nurse Staffing such that the staffing done within their states is appropriate to safely meet the needs of the patients.

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Process of narrowing down PICO search and limitations

After framing the research question, the right approach is needed to locate, assess, and evaluate the available evidence. The search strategy can be done using background information or foreground information. Background information offers the best way to identify general information about the PICO question. However, with properly planned search strategy, the search of evidence for the PICO question mostly deals with foreground information search that is narrowed. The result is relevant abstracts, books or full articles that are filtered and with applied limitations.

The first step in the search for the database articles for the PICO question was through the use of background information. In this case, the background information was unfiltered information that led to a wide pool of journal articles. Furthermore, the strategy of using the background information only enabled me to answer a general background question on the topic of impacts of nurse understaffing, and burnout and nurses. As a result, the sources for general background question were numerous and included book entries, chapters and appendices in books, monographs and review articles. To locate the overview of nurses and burnout, the Bobcat Library was a convenient and valid source of books. Access Medicine database was also a source of important textbooks for information on nurses’ burnout. For relevant journal articles, US National Library of Medicine or NLM offered journal articles from Pubmed citations and so is the American Psychological Association. Another important database was The Cochrane Library which rendered numerous journal articles on high quality evidence for health care.

Foreground questions look for evidence to answer request for nursing information associated to a particular patient, an involvement or therapy. At this point, the PICO aspects assist in focusing the foreground question. P – Poor nurse-patient ratio in hospitals, I– mandatory nurse-to-inpatient ratio, C – no nurse-patient ratio, but addressing nurse burnout in hospitals, and O – Improved patient health care quality.

In order to narrow the background information search results, several strategies came into play. First, the search involved selecting topic terms that were more specific. For instance, instead of using “impacts of nurse understaffing”, “burnout and nurses” was used.

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“Nursing PICO Project Help”

When foreground information search is used at PubMed under US National Library of Medicine or NLM, the search can be limited by defining search categories and scope, medical genetics and other filtering information. Filtration or use of limits for different databases differ and include, filtration by publication types; dates of publication; and filtration by topic category. When research results are filtered through database limits, the filtration included selecting case studies, news articles, systematic reviews, editorials and clinical trials among others.

Such form of filtration ensures that the retrieved research offers high level evidence since only rigorous methodology was used. When the research involves using only the most recent literature, the most appropriate way is to use date of publication limits on the topic. The form of limitation was available in Bobcat library and APA library. Another common filtration method is limit by age group which is very useful especially in limiting the set of results by a given age group that is relevant for the topic and it eliminates the need to include limiting keywords. In this database review, there was no need to limit the search results by age, although, such limitation is vital for other research topics. Finally, the set of search results was sort by peer-reviewed articles or other subsets of the topic that may be available especially in PubMed, Bobcat and Access Medicine sites. However, there is another form of database filtration that involves the use of “full text” or “full text available” was avoided because using this form of limitation meant that the search results were further limited to just articles available from individual service. For instance, Bobcat which is available in New York University full text link biases the research results and not narrowing them.

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Frustrations and Successes

Although, libraries contain relevant and valid primary sources of information, searching for information is an uphill task. When searching for the right sources to fit into my PICO question, there were several frustrations. The most common was that of that of no results found for my keywords. It meant that I had to paraphrase my topic, use online libraries to search for synonyms to offer the best results. For some databases, the attempts to get the right resources from the database were too many as I kept experimenting the best and easiest way out.

Another frustration was on databases that could not offer any search tools unless one was a registered member with a login username and password. Such requirement made the search process to be characterized by a very long and tedious path of accessing the database. The login requirement meant that I had to spend additional time searching since I had little competence in using interactive retrieval system. The interactive retrieval system was different from one digital library to the other which meant that I faced strange searching environment for every library.

Despite the presence of help systems in most of the digital libraries, it was not easy identifying where the kind of help I needed was to be found. The fact that even finding help from the online database was hard meant that the level of frustration increased.

However, there were several successes when searching articles in online databases. The major success was when I realized that I did not have to search for the exact words in the research topic just as they were. Nonetheless, by shuffling or replacing the words with others, I managed to obtain very relevant materials. In addition, I learnt that each database had its own unique features that made the search easier. Features like basic searches, advanced searches, limits, filters, and controlled vocabularies were of significant assistance in searching for the right articles.


When searching for articles in online databases, PICO questions play a critical role because the PICO question enables one to define a research question that is then used to formulate a search strategy. Through the search strategy, it is then possible to use library features to narrow down the search and only concentrate on the most relevant resources.

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