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Nursing Schedule and Patient Mortality Study Critique Research Paper

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The report has an apt title indicating the study population (nurses) and variables of work schedule, staffing, and patient mortality (Trinkoff et al., 2011). Overall, the title communicates the gist of the research in a clear and succinct manner to the reader.

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The abstract is presented in five distinct subsections – background, objective, methods, results, and discussion. It begins with a brief background on how nurse staffing relates with patient mortality followed by a clear study objective, i.e., to evaluate the relationship between unfavorable work schedules and patient outcomes. A clear summary of the methods used is given, which entails quantitative data on key indicators drawn from a survey of 633 RNs in various hospitals. The results of the research and a brief discussion that highlights the effect of nurse schedules on mortality are also included. Overall, the abstract is clear and concise.

Statement of the Problem

The research problem is clearly stated and easily identifiable – low patient outcomes due to nurse fatigue related to unfavorable schedules. Further, the findings and supporting data from previous research are used to build a cogent argument for the study. The studies reviewed indicate that “nurse fatigue, turnover, errors, and emotional exhaustion” are more likely to arise in extended shifts (12 hours) than in normal ones (8 hours) (Trinkoff et al., 2011, p. 1).

These factors impact the quality of nursing care and patient outcomes. The significance of the research problem to nursing is that favorable work schedules improve the quality of nursing care, translating into better patient outcomes. There is a great flow or fit between the research problem and the paradigm (balance theory) and study methods, which guarantees results validity (Polit & Beck, 2012). The quantitative approach was appropriate since the study’s objective was to determine the relationship between unfavorable work schedules and high inpatient mortality rates.

Hypothesis or Research Questions

The research hypothesis is explicitly stated at the end of the introduction. However, no research questions are given. The justification for the absence of research questions is also lacking. The wording of the hypothesis is appropriate as it clearly specifies the key variables, i.e., “adverse work schedules and mortality rates”, as well as the study population – nurses (Trinkoff et al., 2011, p. 2). The preceding paragraphs review research findings related to work schedules, fatigue, and sleep deprivation and tie them to performance deficits in nurses. Further, the conceptual framework, which is grounded in the balance theory, ties aspects of the nurse work environment with patient outcomes.

Literature Review

The literature review is embedded in the introduction and involves studies published between 1989 and 2010. Since the article’s publication year is 2011, the literature review is relatively current and up-to-date. It includes mainly primary sources drawn from nursing journals. The review involves an integrated synthesis of evidence on nurse work schedules and mortality rates. According to Jaidka, Khoo, and Na (2013), a critical and objective analysis of different studies in a logical structure is the goal of literature synthesis on the topic. In this article, the review involves varied sources examining various aspects of the nurse work environment. The gap identified in research forms the basis for the new study.

Conceptual/Theoretical Framework

The conceptual framework briefly describes the key concepts of “nurse work environment, performance, and patient outcomes” related to the study (Trinkoff et al., 2011, p. 2). However, the definitions are not detailed enough to capture the variables. Additionally, a conceptual map is lacking. The study provides an appropriate rationale for the choice of the conceptual framework, which is that human factors in nursing environment influence performance, which affects clinical outcomes.

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Protection of Human Rights

It is not clear if appropriate procedures were employed to protect the subjects. However, the 2004 Nurses Work-life and Health survey involved mailed questionnaires that tend to be unobtrusive to the respondents (Roush, 2015). The participants’ identities and addresses came from their respective hospitals in Illinois and North Carolina and are not revealed in the article. In addition, participants unwilling to participate were free not to return the questionnaires. It is not clear if the research went through an IRB/ethical review. The study design does not seem to minimize risks to participants as it involves repeat data collection. Self-reports of work schedules and demands appears to maximize benefits to participants.

Research Design

In terms of rigor, the research design (cross-sectional) seems adequate for the purpose of this study. It involved a three-wave longitudinal study with a random initial sample of 5,000 drawn from 71 hospitals in two states (Trinkoff et al., 2011). Appropriate comparisons were made between the study hospitals in terms of RN shift hours and staffing and mortality data in wave 1-3. However, the number of data collection points is not clear. It is also not stated if blinding was used or the questionnaire pretested for possible biases prior to mailing. The attrition rate was low (85% and 86% response rate in wave 1 and 2, respectively) due to follow-ups by the researchers.

Population and Sample

The study gives a detailed description of the population and sample (633 nurses). A random sampling technique was used, which helped enhance the sample’s representativeness. Sampling biases were minimized through mailing a large number of questionnaires (4,229) to eligible RNs in the two states to obtain an adequate sample size. However, the use of teaching hospitals may have increased sampling bias. It is not clear if power analysis was utilized.

Data Collection and Measurement

Conceptual and operational definitions are not clearly stated. The researchers only state that data were collected in three areas: work schedule, staffing, and mortality (Trinkoff et al., 2011). Operational definitions such as shift hours and conceptual operations, e.g., RN, are not stated. It is possible that through data collection, the authors will develop these definitions. The operationalization of the key variables involved a survey/questionnaire form.

The justification given is that the survey involved a specific pretested instrument, the Nurses Work-life and Health Study. The specific instruments from which the work schedule – Standard Shiftwork Index – and staffing and mortality data were obtained seem appropriate given that they capture the study variables. The study’s evidence for data reliability relates to expert review of the instruments to ascertain their content validity.


The intervention involved 633 RNs. The three-wave survey was rigorous in terms of participant selection (random) and implementation. Initially, 4,229 RNs received surveys with a majority of those who responded receiving further surveys (2,624). Intervention fidelity lies in the standardized nature of the surveys. Bias was minimized by avoiding monetary incentives. Well-trained staff was involved in data collection.

Data Analysis

In the results section, the analysis was done to test the study’s hypothesis. It involved an analysis of the characteristics of the hospitals and participants – work schedule – using principle coordinate analysis (PCA) (Trinkoff et al., 2011). The statistical methods seem appropriate for this study. The descriptive analysis and PCA were appropriate to obtain the mean and SD of the data as well as linearly uncorrelated variables (eight components) (Nieswiadomy, 2011).

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The extraneous effect due to confounding variables was minimized by using standardized and specific survey questions (Wilkes & Jackson, 2013). The specific scales used eliminated the possibility of contradictory interpretations that cause Type I error or Type II error. The intention-to-treat analysis was not done since only those who returned the survey were included. It is not stated if there were problems of missing data and how they were addressed.


The statistical significance, effect size, and confidence intervals (95%) are summarized in four tables. The findings are summarized in four detailed tables. Their presentation can support a meta-analytic study on the topic and EBP interventions aimed at reducing patient mortality.

Interpretation of the Findings

The study’s findings are explained in the context of four previous studies. One of the causal inferences justified is that “long hours affect performance” due to nurse fatigue (Trinkoff et al., 2011, p. 4). The interpretations are grounded in the results and literature. The limitations are clearly stated and are related to sampling and measurement problems. The issue of limited generalizability of the findings is ascribed to the use of teaching hospitals only.


The stated study implications for clinical practice include shorter workdays, regular breaks/naps for staff nurses, and deployment of fatigue risk-management programs. These implications appear reasonable and complete.

Global Issues

The article is well written and structured logically. The results and discussion sections involve adequate details to support critical analysis. However, a CONSORT flow chart to capture participant flow is lacking. The findings are clear and readily accessible to RNs.

Researcher Credibility

The presentation and articulation of issues shows that expert researchers conducted the study. Further, the lead authors are professors of nursing. This increases the user’s confidence in the findings and their interpretations.

Summary Assessment

Overall, the study findings seem valid and reliable given the scientific rigor involved. I have confidence in the study’s findings. Evidently, the study’s findings contribute to quality nursing care through favorable work schedules that prevent nurse fatigue and poor performance.


Jaidka, K., Khoo, C., & Na, J. C. (2013). Literature review writing: How information is selected and transformed. Aslib Proceedings, 65(3), 303-325. Web.

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Nieswiadomy, R. M. (2011). Foundations of nursing research (6th ed.). Upper Saddle River, NJ: Pearson Education.

Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

Roush, K. (2015). A nurse’s step-by-step guide to writing your dissertation or capstone. Indianapolis, IN: Sigma Theta Tau International.

Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1), 1-8. Web.

Wilkes, L., & Jackson, D. (2013). Enabling research cultures in nursing: Insights from a multidisciplinary group of experienced researchers. Nurse researcher, 20(4), 28-34. Web.

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