Nurse-to-Patient Ratio - Research Proposal Example

? Proposal for a Research Paper on Nurse-to-Patient Ratio Affiliation with more information about affiliation, research grants, conflict of interest and how to contact Creating a Research Project Proposal Introduction: There appears to exist a tendency on the part of healthcare administrators to ignore the aspect of ‘nurse to patient ratios’ when staffing hospitals and other such institutions. Often, the lack of adequate attention to this matter has resulted in the organizations’ inability to extend proper medical care to the patients. On the other hand, there is a general feeling among nurses that increased levels of patient acuity entails delays in providing medical treatment. However, this factor is never considered when nurses are assigned to care for a selected number of patients. Quoting Barbara Blakeney, President, American Nurses Association (ANA), the American Association of Critical Care Nurses (AACN) endorses the fact that inadequate nurse staffing is the primary concern for the nurses and that “when RN care is insufficient, patient safety is compromised and the risk of death is increased” (Nurse-to-Patient Ratios, 2007). Shortage of nurses places extra onus on the available staff and hence seasoned nurses are matriculating away from bedside nursing. This happens primarily because the added tasks needed to be performed are not directly related to patient care. This can be evidenced in the case of Cameroon Diva, a BSN, who states that she wants to quit bedside nursing because in the hospital where she has worked, they had “extreme staff shortage and not enough nursing assistance on the floor” (Diva, 1996). Besides, the frequent changes in computerized charting require nurses to remain near their computers and take their time away from the primary task of patient care. It is a matter of common knowledge that higher patient-to-nurse ratios cause significant physical and mental exhaustion and result in greater job dissatisfaction among nurses. Patient well-being directly correlates to the amount of nursing care a patient receives daily. Therefore, in order to achieve the objective of providing quality patient care, administrators and managers need to ensure that healthcare institutions attain an appropriate level of patient-nurse ratio. Problem Statement: Current policy on Medical-Surgical nursing units across America’s hospitals require that Registered Nurses care for five to six (average of “5.25”) acutely and chronically ill patients in a 12 hour shift (Welton, 2007). Licensed practical nurses also care for 6 to 7 patients during a 12 hour shift. Nurses feel that added tasks take away a considerable portion of their time, which otherwise can be spent on patient care. The diversification in the roles of nurses today, through deployment on other tasks, calls for a closer examination of the need to change the policy pertaining to nurse–to-patient ratios. In this context, the findings of Aiken et al can be perceived as the “primary arguments for setting specific nurse-to-patient staffing ratios” (Welton, 2007). There is a definitive discrepancy between what healthcare administrators believe to be adequate the level of nurse-patient ratio and actual number of patients a nurse is required to care for. This creates impediments in administering proper care to the needy patients, which, in turn, impacts patient mortality rates. Besides, the shortage in staffing also adversely affects the job satisfaction of nurses and, as a consequence, their rate of burnout increases. Purpose of the Study: The purpose of this study is to determine whether there exists a correlation between nurse-to-patient ratios and patient mortality. The number of patients cared for by a single nurse may have better outcomes in terms of length of hospital stay and fewer complications. Additionally, nurses who derive satisfaction from their jobs are less likely to leave their jobs. The study will also investigate the increasing trend of nurse burnout and find out whether this phenomenon is related to the job dissatisfaction of nurses. Significance of the Study: Providing prompt and regular care to the patients is the primary responsibility of all healthcare facilities. However, in order to shoulder this responsibility efficiently and effectively, such organizations should have adequate number of nursing staff. Unfortunately, healthcare managers often ignore this aspect and most of the healthcare facilities are facing shortage of nurses. This results in overstretching of the services of available nurses. As a consequence, patients do not receive proper care, which increases their mortality rates. Besides, the nurses also find their jobs extremely taxing due to which many of them quit the jobs, thus escalating the nurse burnout rates. This problem is significant because nurse-to-patient ratios directly impact the quality of care provided to the patients. On a medical-surgical unit, nurses could be assigned seven patients to care for in a 12 hour shift, without the inclusion of the patient’s acuity level. This practice could lead to: (a) increased incidences of pressure ulcer development (b) higher mortality rates associated with hospital acquired pneumonia(c) failure to rescue patients whose condition has changed (d) inadequate assessments due to the nurse not having enough time to assess patients properly (e) and (f) burnout on the part of nurses due to the inundation of other nurse related tasks. This can be evidenced from the study conducted by Bonnie M Jennings, which finds that work stress and burnout in health organizations entail “absenteeism and turnover, both of which detract from the quality of care” (Jennings, n.d., p. 1). With the impending healthcare reform the public is expected to have better access to health insurance. As a consequence, hospitals are likely to encounter a dramatic surge in the number of patients. Most patients may be ailing from advanced diseases that require more treatment time and other necessary resources. Hospital authorities will have to increase the nurse-patient ratio in order to accommodate the influx of patients. In this context, there exists another problem that colleges are not turning out enough students to correspond to the rate in which older nurses are retiring or moving onto jobs that are less demanding. By reducing the number of patients that one nurse has to care for, hospital will able to ensure better outcomes as well as higher patient and nurse satisfaction. Nurses will no longer feel the need to move out of bedside care and will be satisfied with the quality of care they provide. Most importantly, the mortality rate of patients with acute medical problems will be brought down more quickly and nursing shortage will be reduced drastically. Nursing could be perceived as the surveillance system of healthcare establishments for early detection of adverse events. Nurse staffing levels influence the timing of problem identification, and timely detection and prompt attention are important in patient rescue. More supportive work environment and better staffing will facilitate a high quality of nursing care, resulting in more favorable nurse and patient outcomes (Nantsupawa et al, 2011). Additionally, Aiken et al. (2010) reports that “each patient added to nurses’ workloads was associated with a 7% increase in mortality following common surgeries, and that nurse burnout and job dissatisfaction, precursors of voluntary turnover, also increased significantly as nurses’ workloads increased” (Aiken et al. 2002, p. 2). Once the nursing administrators and nurse managers across the world become realistic about the problems associated with high patient-to-nurse ratios, the practice of nursing can move forward in practicing holistically as the profession is intended and not segmentally. Research Questions: 1. What is the relationship between higher nurse-to-patient ratio and outcomes in the quality of nursing care? 2. To what extent does the lack of job satisfaction influence nurse burnouts? 3. Does lower nurse-to-patient ratios cause nurse turnover? When the proposed research questions are examined closely and internally rationalized, there are a plethora of positive consequences that could be drawn from these. It is surprising that healthcare administrators and managers fail to appreciate the significance of adequate staffing in providing quality care to the patients. It is high time they recognized the need of maintaining an appropriate nurse-to-patient level to achieve the objectives of providing quality patient care. This will also enable the organization to ensure job satisfaction to the nurses and thereby help to retain them. Literature Review: Nurse-to-patient ratio has become a controversial topic among nurses and administrators. Implementing ratios in hospitals may require strict compliance, which means that the amount of patients assigned to each nurse should not exceed the defined ratio. This could be difficult to mandate every point in time during a shift on every shift. This ratio mandate may have the potential to break regulations when incidentals occur with nurses such as rest room breaks and lunch. For this literature review, articles were retrieved by searching databases such as, SocIndex, EBSCO, ProQuest, Ovid, CINAHL, and Science Direct to ascertain articles pertaining to the stated research question. Combinations of terms and words ‘nurse burnout’, ‘nurse-to-patient ratios’, ‘nurse dissatisfaction’, ‘patient dissatisfaction’, ‘nurse-patient satisfaction’. Five satisfactory articles were found, several of which were excluded due to lack of a defined sample, methodology, data analysis, findings and conclusions. In 2003, Seago, et al conducted a research that found strong evidence that an increase in nursing staff is related to positive patient outcomes, Additionally, she found it difficult to argue against adding more nurses. (p. 66). Little research was found examining the adequacy of nursing staff in United States hospitals. The results indicated that nonrural hospitals have one RN per four to five patients on the day shift, and one RN per five to six patients on the day shift, and one RN per five to six on the night shift. This research was found to be inconclusive because data was collected from one Medical-Surgical nursing unit in 17 hospitals. Additionally, this research should make a differentiation between the Medical-Surgical units. Types of patients, age, gender, and diagnosis are important components to factor into the decision regarding nurse-patient ratios. This research will expand the data collection to include Licensed Practical Nurses, the magnet status of the hospital, the staffed unit size, years in practice, nurse skill mix, and the acuity level of the patients. To accurately determine the outcome of nurse-to-patient outcomes, the length of time that a nurse interacts with a patient is not included nor were the patients’ outcomes documented. Nantsupawat et al. 2011 conducted a predictive correlational design using secondary data analysis of a 2007 Thai nurse survey. The survey was conducted at 13 general and 26 regional hospitals for a total of 39 out of 94 general and regional hospitals in Thailand. This research was limited to those who provided direct care for patients in the study hospital and reported having responsibility for at least one but fewer than 21 patients on their shifts (p. 428). The Likert scale was used to determine job satisfaction and quality of care whereas burnout was measured by using the Maslach Burnout Inventory Human Services Survey. Nurses who cared for 10 or more patients were dissatisfied with their job and experienced high burnout (Nantsupawat et al. 2011). Staffing is a major concern because of its effect on patient safety and quality of care. Adverse outcomes sensitive to nursing care are urinary tract infection, pneumonia, failure to rescue, and extended length of stay. This study will highlight to positive outcomes that is overlooked in other research studies. Improved staffing may lead to a significant reduction in burnout, job dissatisfaction, decreased complaints by patients and families and missed changes in patients’ conditions, however; positives aspects of ratios will be addressed. In a research article by Needleman et al. (2011), the focus was to examine the relationship between lower levels of staffing and increases in patient mortality. Data was retrieved for 2003 to 2006 from electronic data for a sample of 197,961 admissions. Unlike the study conducted by Nantsupawat et al. (2011), this research constructed measures of patient turnover for each shift to include admissions, discharges, and transfers and over an expanded amount of time. The variations that occur on units could make it difficult to enforce ratio mandates when there are fluctuations in patient census. Needleman et al (2011) went further to address the need to have patients reassessed multiple times during a shift in order to revise staffing. In this research, it would be important to point out how unrealistic frequent assignment changes could negatively impact nurses. The constant changing of assignments may lead to fail to rescue a patient if changed mid shift, especially when acuity is not addressed. Finally, Needleman’s research failed to include information on care delivery models, support staff availability, and physical differences of units. Additional research is needed to include patients with a diagnosis that requires closer observation, hospice patients, and do not resuscitate patients, to make this research more valid. Many researches were conducted to determine if there is a relationship between the increase of nurse burnout and nurse job dissatisfaction. Vahey, Aiken, Sloane, Clarke, & Vargas, 2004) research examines the association between nurse burnout and patient satisfaction, and explores whether the factors that account for nurse burnout also account for patient dissatisfaction (p. 57). The characteristics of job-related burnout may be: (1) emotional fatigue, (2) depolarization, (3) reduced interactions, and (4) lack of caring. Coincidentally, this research was conducted in an urban hospital where AIDS (Acquired Immune Deficiency Syndrome) patients are cared for. The sample consisted of RN’s (Registered Nurses) and LPN’s (Licensed Practical Nurses). 820 nurses completed a self-administered questionnaire that addressed hospital and personal characteristics. Of the 722 AIDS patients on the unit, 621 agreed to participate in the survey. After adjustments to patient characteristics, patients on units with higher than average levels of emotional exhaustion among nurses were only half as likely as those on units with lower than average emotional exhaustion to be highly satisfied with their care (Vahey et al., 2004). Biases may be recognized in this research related to the limitations of patient type. In order for this study to be more conclusive, it would be important to include the stages of the patient’s disease and their ability to perform activities of daily living. The assumption is that when a patient is totally dependent upon the nurse to render care, patients may be most appreciative, therefore; patient satisfaction ratings would be higher. This research would include a higher variable of patients to better assess the reasons for nurse burnout and patient satisfaction. O’Mahony (2011) conducted a quantitative study to show how magnet status hospitals may differ in how nurses and patient satisfaction are rated. The study revealed that consequences of burnout include low morale, increased absenteeism due to sickness, decreased effectiveness and productivity, poorer job performance and patient care, and higher staff attrition and turnover (O’Mahony, 2011). This study was completed at a hospital in Ireland that has magnet status, which assumes that nurses at magnet hospitals may be less likely to experience burnout compared to non-magnet hospitals. 74% of the nurses the 86 nurses who were asked to take part in the study returned completed forms. Most of them are female and educated to degree level between the ages of 35-40. Nursing concerns in the study related to autonomy, work environment, view of administration, and nurse-physician relationships. Additionally, nurses feel that overcrowding in the ED and lack of resources to complete tasks which may have caused the turnover rate to be 40%. Subsequent research in this area would be warranted to assess nurse burn out in other areas of magnet hospitals. With a high turnover rate, this research may lack validity. The time in practice should be a criterion for participation because a new nurse may not be experiencing the same problems as older nurses. Moreover, Dunton, Gajewski, Klaus, & Pierson (2007) find that “Federal and state governments, insurers, regulators, and health care providers are implementing health care-indicator initiatives to promote improvement in health care quality. Additionally, quality incentive programs for hospitals, generally known as pay-for-performance or value-based purchasing, are focused exclusively on medical outcomes. Hospitals demonstrating good outcomes and efficient health care practices receive incentives, such as higher reimbursement rates, than hospitals with lesser performance” (Dunton et al. 2007, para 2). In conclusion, the significance of this study relates to nurse-to-patient ratio which has a profound impact on how well the public is cared for, how nurses view their job in terms of adequacy in rendering safe care and overall satisfaction with their jobs. The researcher proposes to conduct this study thoroughly as its findings will enlighten policy makers, administrators and nurse managers. Thus, hospital authorities may not ignore the aspect of adequate staffing, which entails poor patient outcomes as well as nurse burnouts and turnover. By adequately staffing healthcare establishments, the authorities will be able to ensure that patients receive quality care, which is the primary objective of these organizations, apart from helping in retaining dedicated nursing care providers. Theoretical Framework: This research is primarily based on 3 hypotheses as under, about which the researcher has conducted retailed literature review: Hypothesis-1: A higher nurse to- patient ratio will produce better outcomes both in terms of quality nursing care and nurse retention. Existing studies on nurse to patient ratio indicate that in most healthcare facilities, nurse-to-patient ratio is very low. Shortage of staffing is a major concern in all hospitals, as has been evidenced through the current literature review. As a result, extra onus is being placed on the existing nurses and their services always remain overstretched. This, in turn, has entailed in a large number of nurses migrating from bedside care and taking up other jobs. Providing bedside care is a tremendously demanding job, which causes considerable physical and mental stress on the nurses. The studies conducted by Welton (2007) claim that an RN has to care for an average of 5.25 patients who are acutely and chronically ill, on a 12 hours shift. This appears much more than a nurse can handle, if one keeps the quality of care in view. Thus, it transpires that shortage of staffing in most of the hospitals has resulted in compromising the quality of care being provided to patients. The article “Nurse to Patient Ratios” (2007) clearly establishes this fact and claims that in sufficient RN care compromises patient safety and increases the risk of death. Hypothesis-2: The second theory this research upholds is that job satisfaction plays a key role in nurse burnout. It is a matter of common knowledge that job satisfaction is a crucial element for any employ to be stress-free. It is imperative that they work in a comfortable environment. In this context, the study by Nantsupawat et al 2011 is relevant. This survey finds that “nurses who cared for 10 or more patients are dissatisfied with their job and experienced high burn out” (Nantsupawat, 2011). Thus, a major part of the literature, reviewed during the course of this research, has validated the hypothesis that job satisfaction plays a crucial role in nurse burnout. Existing literature also supports the belief that dissatisfaction with the job is a major element for nurse burnout. Hypothesis 3: The third premise for the research study is that lower nurse-to-patient ratios increase patient mortality. Besides, this research also encompasses the hypothesis that lower nurse-to-patient ratios have caused a large amount of nurse turnover. Bedside care, as discussed earlier, necessitates a lot of physical exertion by the nurse. Moreover, it also mentally stresses the care giver when she has to attend a large number of patients. When a nurse is allocated the care of an unreasonable number of patients, she may not be able to provide the required quality of care to all the patients. As a result, the quality of care gets compromised. This, in turn, affects patient safety and increases their morality. Electronic data, pertaining to 2003-2006, indicates that in many instances, patients had to be reassessed multiple times during a shift. This entails the risk of failure “to rescue the patient if changed mid-shift, especially when acuity is not addressed” (Needleman et al. 2011). Under such circumstances, shortage of nurses, stemming from lower nurse-to-patient ratio, may compromise patient safety and enhance the chances of their mortality. On the flip side, lower nurse-to-patient ratios also force nurses to leave their job in search of less stressful options, thereby increasing nurse turnover. The evidences available in the existing literature support and validate all the three hypothesis proposed by this researcher. The research has been conducted within these theoretical frameworks for establishing the premise of this research. Limitations: The main limitation for a research study of this magnitude derives from the fact that the variables in this case cannot be measured on a uniform scale. For example, the role of a nurse, having to care for five patients in a maternity ward, differs from that of another working in an emergency ward. Thus, quantifying the element of additional work a nurse has to perform, as a result of lower nurse-to-patient ratio, becomes extremely difficult. Though the correlation among shortage of staff, quality of care, nurse burnout and turn over as well as patient mortality rate is easily recognizable, obtaining quantitative data to support each claim will be a difficult task. In many case, though nurses and health care managers are aware of the shortfall in the quality of care, they may not readily acknowledge this fact or admit it to an interviewer. However, the researcher feels confident that even by working within this limitation, she will be able to elicit information that will help in deducing reliable results. Methodology: There are two types of popular methodologies that this researcher can use viz. Quantitative Methodology and Qualitative Methodology. Another option is to use the recently emerging trend of Mixed Methodology. For obtaining certain data, for instance, in terms of the number of hospitals taken as samples, number of patients being attended by nurses in these hospitals during specific duty hours, volume of nurse burnouts and turnovers etc, quantitative methodology will be appropriate. However, to ascertain the level of quality of care, nurse job satisfaction etc, the researcher will have to resort to qualitative methodology. Therefore, it appears that mixed methodology will be the most appropriate approach for conducting this research. However, the researcher intends to keep an open mind and remain flexible so that as the research progresses, data collection will be done using the appropriate methodology as the situation demands. Research Design: The research design primarily concerns with the methods of collection of data and an explication of the structure of the research. In order to obtain relevant information relating to the research questions, the researcher will resort to three main methods: Direct Interviews, Questionnaires, and Literature Review. The researcher proposes to personally visit healthcare facilities to conduct interviews with healthcare managers, administrators, nurses and, where possible, patients. This will facilitate ample information for the research in terms of staff shortage, nurses’ job satisfaction as well as the level of patient satisfaction. The healthcare managers will also be able to provide data relating to nurse turnovers and how it affects the quality of patient care they provide. The researcher also expects, through this process, to elicit information on how lower nurse-to-patient ratios impact patient mortality by analyzing data relating to nurse-to-patient ratios in these facilities. Information relating to research questions will also be obtained by designing appropriate questionnaires. Questionnaires will be distributed among healthcare administrators and nurses. Once the researcher compiles the information, the same will be analyzed using the appropriate statistical tools. Based on the result of the data analysis, the researcher will draw up the finding and results and endorse suitable recommendations. Settings: The primary research will be conducted within the settings of the hospital premises, which are selected as samples. Interviews will be conducted in the location, which will be convenient to the sample population. Questionnaire will be sent through electronic mail or by post, after ascertaining the preference of the interviewer through telephone calls. For secondary data collection, including literature review, the researcher will utilize public libraries and college libraries. Compilation and related work will be done in own resources including home and/or college. Sample Population: To generate information relating to the theoretical frame work of research questions, the researcher will need to interview hospital administrators, managers, nurses and, where feasible, patients. The researcher proposes to interview at least five samples from the first category, which will include different hospital authorities. 20 to 30nurses and 5 to 10 patients will also be interviewed for obtaining relevant information. In addition, questionnaires will be sent to another five healthcare administrators and 30 nurses to elicit information relating to the research hypotheses. Protection of Human Subjects: The researcher will apprise the sample population that any information they provide will be handled with discretion and used solely for the purpose of this particular research only. They will also be assured of absolute confidentially of the information they part with. Instruments & Materials: The instruments and materials will initially be pooled from own resources. However, the researcher will make efforts to find any interested parties to sponsor the funding for the research. Following are the main resources that will be required for this research: i. Desktop/Laptop Computer ii. Tape Recorder iii. Audio Cassettes iv. Stationary including computer paraphernalia Data Collection Procedures: The participants in the interview will be briefed about the objectives of the research as well as its hypotheses and requested to express their genuine responses to each questions. The researcher will take note of all variants where it is significant. For instance, if a nurse attends to only 3-4 patients in a duty schedule, her response to questions relating to job stress will be different from one who caters for 5-6 patients. The response of each segment of the respondents will be recorded, compared and suitable inference endorsed for analytical purposes later. Similarly, the primary data inferences drawn will be compared with what would be deduced from secondary data, including literature review, and suitable conclusions drawn after defailed discussions. Data Analysis Strategies: The information gleaned as above will be analyzed using appropriate statistical tools for both quantitative and qualitative data. Reference List Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J., & Smith, H. L. (2010). Implications of the California Nurse Staffing Mandate for Other States. Health Services Research. 45(4), 904-921. doi:10.1111/j.1475-6773.2010.01114. Retrieved from http://www.nursing.upenn.edu/chopr/Documents/Aiken.2010.CaliforniaStaffingRatios.pdf Diva, C. (1996). No More Bedside Nursing, I Quit. Allnurses.com. Retrieved from http://allnurses.com/first-year-after/no-more-bedside-120488.html Dunton, N., Gajewski, B., Klaus, S., & Pierson, B. (2007). The Relationship of Nursing Workforce Characteristics to Patient Outcomes. Online Journal of Issues in Nursing, 12 (3), 7. Retrieved from http://www.medscape.com/viewarticle/569394 Jennings, B. M. (n.d). Chapter 26: Work Stress and Burnout Among Nurses: Role of the Work Environment and Working Conditions. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/JenningsB_WEWCN.pdf Nantsupawat, A., Srisuphan, W., Kunaviktikul, W., Wichaikhum, O., Aungsuroch, Y., & Aiken, L. H. (2011). Impact of Nurse Work Environment and Staffing on Hospital Nurse and Quality of are in Thailand. Journal of Nursing Scholarship, 43(4), 426-432. doi:10.1111/j.1547-5069.2011.01419.x. Print. Needleman et al. (2011). Nurse Staffing and Inpatient Hospital Mortality. The New England Journal of Medicine. 364(11), 1037-1045. Print. Nurse-To-Patient Ratios, (2007). American Association of Critical-Care Nurses. Retrieved from http://www.aacn.org/wd/practice/content/nurse-staffing-ratio.pcms?menu=practice O’Mahony, N. (2011). Nurse Burnout and the Working Environment. Emergency Nurse. 19(5), 30-37. Retrieved from http://web.ebscohost.com.southuniversity.libproxy.edmc.edu/ehost/pdfviewer/pdfviewer?vid=3&hid=107&sid=3a2dc473-d5c8-4d49-9bb0-249c294c04b9%40sessionmgr104 Seago, J. A., Spetz, J., Coffman, J., Rosenoff, E., & ONeil, E. (2003). Minimum Staffing Ratios: The California Workforce Initiative Survey. Nursing Economics. 21(2), 65-70. Retrieved from http://search.proquest.com/docview/230477018?accountid=87314 Vahey, D., Aiken, L., Sloane, D., Clarke, S., & Vargas, D. (2004). Nurse Burnout and Patient Satisfaction. Medical care. 42(2), 57-66. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14734943 Welton, J. M. (2007). Mandatory Hospital Nurse to Patient Staffing Ratios: The Argument for and Against Mandatory Nurse-to-Patient Staffing Ratios. The Online Journal of Issues in Nursing. American Nurses Association, Inc. Retrieved from http://www.medscape.com/viewarticle/569391_4 Read More