Mar 7, 2019 in Research Proposal

The Quality of Patient Care

Abstract

As evident from the introduction of the legislation on mandatory nurse-to-patient ratio in the United States, it is certain that a low number of nurses in hospitals results in increased risk for the health of patients. Additionally, data from successful mandatory nurse-to-patient ratio implementation in California reveals that there, with proper nurse staffing in hospitals, the level of patient outcome is high. Furthermore, previous assessments concentrated only on a very limited number of outcomes since studies used small hospital samples. As a result, there was little or negligible result relating the number of nurses to the poor patients outcome in hospitals. However, using the mandatory nurse-to-patient ratio as defined in each state, it is evident that the number of nurses, the number of hours per shift, the number of nurses in each shift, and patient health outcomes are directly proportional. Consequently, this paper has focused on evaluating numerous journal articles to ascertain that with proper nursing and nurse shift hours, the health of patients directly improves.

1.0 Introduction

When it comes to the discussion of issues regarding the quality of inpatient healthcare, the assumption is mostly that the workforce is competent to accomplish the task. The assumption of nurses’ workforce being up to the task involves issues of training, numbers, and competency. Although these assumptions are not readily known to the concerned parties, the frontline worker understands the consequences of neglecting issues of nurses’ competency and workforce. Additionally, when nurses are overworked, they get demoralized and this results in unsafe health care conditions.

The main factors attributed to the overworking of hospital nurses are a result of patterns and trends used in nurses staffing. Such patterns and trends result in the creation of potentially dangerous conditions that affect both patient health care and patient safety severely. Additionally, the lack of systematic national data on the tendency concerning the amount of working hours per nurse per day emphasizes the possibility of nurses working longer hours. Furthermore, such long working hours are coupled with little or no breaks and little or negligible recovery time between shifts.

Originally, there were no federal or state regulations that restricted the number of hours a nurse may work voluntarily on any day and within any week. As a result, hospitals have manually made work schedules that have then been attributed to nurses overworking. This paper discusses the issue of quality patient health care and nurses understaffing. The study evaluates factors that contribute to the poor quality care for hospital inpatients in relation to nurses, hindrances to the resolution of quality health care associated with a proper inpatient-to-nurse ratio, and the best practices needed to promote efficient inpatient healthcare.

2.0 Problem Statement/ Research Question (s)

In the American nurse staffing system, there has been a great increase in the workloads for nurses. The four key reasons behind the increase are increased nurses’ demands, inadequate nurse supplies, diminished nurse staffing coupled with increased overtime, and reduction in the patients’ duration of stay. This paper discusses the issue of quality patient health care and nurses understaffing. The study evaluates factors that contribute to the poor quality care for hospital inpatients in relation to nurses, hindrances to the resolution of quality health care associated with a proper inpatient-to-nurse ratio, and the best practices needed to promote efficient inpatient healthcare.

2.1 Literature Review

This section will present an overview of work done previously that provides the required background for the research purposes. It will concentrate on various issues associated with quality patient health care and nurses understaffing. This section will begin with a thorough coverage of quality patient health care and nurses understaffing topics, which will assist in setting the context of this research.

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2.1.1 Factors that influence poor quality of inpatient care in relation to nursing understaffing

According to Weisman, it is important to understand that the deficit being experienced in terms of nurse staffing emerged in the late 1990s. Consequently, Sherenian highlight a high percentage of patients reported dead during their stay in hospital or even shortly after being discharged from hospital, which then urgently necessitates proper nurse ratios. Unfortunately, the issue of nurses understaffing does not seem to have sufficient immediate solution given that the demand for nurses in hospitals cannot be met by the available nurses’ supply. Although the demand for nurses in the United States gradually declined in 2012, the demand rose to exceed the supply with at least 100,000 nurses. Additionally, the demand for nurses was projected to increase with a deficit of about 250,000 registered nurses. The increased shortage in nurses is associated with aging characterizing the population in America in general. The aging population accounts for both the nation’s 1 million nurses and the general population. The implication is that no matter how large the number of young people joining nursing is, the challenge of efficient nurse staffing remains.

With the American hospitals characterized by a high demand for registered nurses, the obvious result is the increase of inpatient-to-nurse ratio. Unfortunately, the increase in the ratio of inpatients to nurses comes with no expected rewards or incentives, but with a need for additional effort. Consequently, the imbalance between nurse efforts and expected rewards results in demoralization and de-motivation. The resulting situation is that of burnout and dissatisfied nurses being subjected to greater workloads caused by patients’ shorter hospital stays; increased standard patient perception; and less resources for support. For patients, the quality of healthcare is poor, hence resulting in poor outcomes.

In order to understand burnout and job dissatisfaction for nurses, organizational stressors within their work environment are crucial. When working within the hospital, nurses deserve to work in environments that accommodate advanced autonomy and control; proper relationships between physicians and nurses; and provision of administrative support for healthcare. During their stay, patients use elements like an art of care, physical environment, availability, and trust to determine their overall satisfaction with the hospital care. Signs of nurses’ burnout therefore indicate that the nurse is emotionally exhausted, depersonalized, and linked to minimized personal achievements. In order to improve their situations, nurses move to hospitals with better work conditions and nurse-to-inpatient ratios. Such failed nurse retention affects the quality of care offered to patients.

2.1.2 Barriers to the resolution of the attainment of efficient patient quality care

Registered nurses have long recognized the need for more emphasis on staffing issues. Staffing concerns influences on the safety of both patient and nurse and there is a very strong association between adequate ratios of nurse-to-patient and the attainment of safe outcomes for patients. Additionally, finding an optional nurse-to-patient ratio is a challenge nationally and this has been associated with the increase in patient acuity, shortened stays in hospitals, increased complications with patients, reduced satisfaction for patients, high job satisfaction, and nurse retention.

According to Schwartzhoffer, staffing levels are highly influenced by numerous forces. One of the chief forces is budgetary considerations. In addition, nursing is affected by the local market and labor markets. Depending on the budgetary needs of a hospital institution, the number of nurses hired is affected. In this case, when a hospital institution has high budgetary considerations, the number of nurses hired is high and the capability to meet the required nurse to patient ratio is low. Nonetheless, the lower the budget consideration, the less a hospital institution is likely to hire more nurses, thereby jeopardizing the mandatory nurse-to-patient ratios. Furthermore, when the labor market is characterized by a high demand for nurses, hiring new nurses means paying more money to them and this also reduces the number of nurses being hired.

Another barrier to quality nursing care is the category of the care needs for different patients. For each patient, several factors affect the quality of care they receive and these include resources available in their families, capability to provide self-care, the complexity of the status of health for the patient, and the co-morbid conditions of the patient medically. Consequently, the implications are that some patients are more vulnerable to poor quality of care, especially in instances when there is nurses’ shortage. For instance, patients with little family resources are likely to experience very high acuity and shorter hospital stays given that few nurses available only attend longer to patients with a high capability. This means that no matter how sick the patient is, their financial resources or capabilities deter them from receiving quality nursing care.

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The lack of proper assessment and intervention execution of nurse-related care also hinders the provision of optimized patient outcomes and increases the vulnerability of experiencing adverse effects. When there are few nurses guarded by very lax assessment programs, the impact is that the nurses tend to fail in their observation of proper nursing standards and protocols. Consequently, patients tend to experience poor quality care that could have been prevented.

2.1.3 Best practices for effective patient care

The best way to achieve high quality patient care is to ensure proper nurse-to-patient ratio. In the United States, the nurse-to-patient ratio is left to the states to decide. This is because proper nurse-to-patient ratio has to take into consideration population in the area. Some population demographics considered in the decision of patient-to-nurse ratio are age and size. In populations where most people are old, proper nurse staffing has to consider safety and risk assessment of the patients among other factors. Furthermore, observing proper nurse staffing should be coupled with conventional nurse assessment and evaluations to ensure that all the laid down nurses’ practice standards are observed. When nurses understand the results expected from their work, they are obliged to ensure that each patient assigned to them is provided with the highest quality of care. Effective patient care implies observing fair risk assessments and implementing proper risk mitigation policies, promoting reasonable shift levels, and implementing frequent nurse burnout assessment tests to ensure that nurses are not distressed when offering patient care.

2.2 Research design and Rationale

The study uses qualitative research design as a way of offering a comprehensive picture of all elements of the study. In order to understand the relationship between nurse-to-patient ratio and the quality of patient healthcare outcome, this paper will use description and explanation research design. The main focus of this research design will be to evaluate the current situation that is contributing to the low level of patients’ healthcare quality. Next, explanation and description section will focus on exploring the reasons why there is low quality patient healthcare outcome. Through the use of descriptive research, the level of nurse understaffing will be examined and correlated with the findings of evaluating the level of patient healthcare quality. This will be done to demonstrate existence of healthcare understaffing problems and competent findings used to challenge the low speed at which most states are deploying the mandatory nurse-to-patient ratio. For each state, the set nurse-to-patient ratio is dependent on the population. Using population to determine the number of patients per nurse per shift will be evident in the amount of healthcare quality polarization over time. Consequently, the explanatory research will be used to understand reasons why such deterioration in patient healthcare is happening.

Good understanding of the relationship between nurses-to-inpatient ratio and the quality of patient healthcare outcomes rests on a strong understanding of the current situation to lay a strong foundation for new knowledge. The implication here is that through research it is possible to establish new knowledge, modify existing knowledge, or emphasize the need to embrace the recommended knowledge. In order to offer competent quality of healthcare to patients, a health care institution has to be aware of the number of patients each nurse should attend to during every shift.

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2.3 Role and Bias of Researcher

In this research, the nurse will have the role of assessing the need associated with planning how to offer high quality patient care and ensuring that the nurses are not subjected to overworking, fatigue, and stress, which increases incidents of absenteeism. Further, the researcher will ensure that all factors needed to understand the impact of nurses understaffing and the poor quality of patient healthcare outcome are well understood. The researcher will use the scores obtained, interpret them, and define any recommendation needed to amend the situation. Using descriptive statistics, the research scores will be analyzed and results will be interpreted and generalized for the United States of America population. During data collection, the researcher will also be expected to listen, think, ask probing questions, and focus on generating a deep conversation level with the participant.

In this qualitative research, the researcher is expected to be personally involved in every aspect of the research process since every decision will be founded on personal grounds. Since this role comes with lots of complexity, the researcher is bound to be biased in the techniques used to collect data, character of the data, and processing and presentation of data. Since the technique used in data collection will be face-to-face interviews, the aspect of the lack of anonymity will arise and this may deteriorate the relationship between the research and the respondents, as well as affect the loyalty of the researcher to the respondents. Additionally, the researcher uses their empathy to have the respondents tell their story and protect them from other researchers. In the end, the researcher might arrive at conclusions that may be unfair or disloyal to the respondent, hence resulting in a faulty or wrong data analysis. Furthermore, qualitative research involves less number of respondents compared to quantitative research and this would mean that the researcher’s influence on the interviewee is very high.

2.4 Sampling Techniques

In this research, the study population is all nurses working in public healthcare facilities within the United States. The employees are registered nurses working with these public healthcare institutions whether as ordinary employees, managers, or healthcare executives. Since it is not possible to study the entire nurse population, the study focuses on a subset of the population collected randomly from two institutions. One of the institutions complies with the mandatory nurse-to-inpatient ratio while the other is characterized by a high level of nurse understaffing. The sample of nurses used in this study is not the primary source of information, but an effort to understand and explain certain facet of nurses staffing.

2.5 Participants

For this study, participants must meet several requirements to qualify. The participants must:

  • Hold the United States citizenship
  • Be employed by a US public health facility
  • Be a registered nurse and currently working
  • Hold an ordinary employee or healthcare executive position

2.6 Data Collection Methods

Data collection will involve case studies and face-to-face interviews that will include questions on:

  • Job satisfaction
  • Organizational commitment to improve nurse staffing
  • Condition of work environment
  • Nurses’ fatigue and stress levels
  • Nurses’ turnover rate or intention to leave

2.7 Instruments

The instruments used in this study will be interview guides to collect data on the factors affecting nurses’ performance, the stay of patients in hospitals, and the quality of patient care outcomes. The procedure will involve engaging each of the nurses in an interview, collecting field notes, and using observations to collect as much data as possible. The findings will be used to confirm the recommendations from case studies and make conclusions.

2.8 Research Procedure

Randomly selected participants will be obtained from two institutions. One of the institutions complies with the mandatory nurse-to-inpatient ratio while the other is characterized by a high level of nurse understaffing. Private one-on-one interviews will be conducted with each participant whereby they will be expected to answer questions relating to the research topic. The researcher will listen, think, ask probing questions, and focus on generating a deep conversation level with the participant. The sample of nurses used in this study is not the primary source of information, but an effort to understand and explain certain facet of nurses staffing. Therefore, more information will also be obtained from relevant literature.

2.9 Data Analysis

Data obtained from the participants will be analyzed using descriptive statistics. Data obtained from the relevant literature will be analyzed through the principle of triangulation to increase the validity of the study conclusions. Triangulation is a technique used in qualitative research and it concerns the cross-checking of multiple data collection procedures and data sources to examine the extent to which all evidence converge.

3.0 Conclusion

Nurses’ understaffing is associated with work stress that does not only result in errors, but also results in more pressure on the nurses, thereby jeopardizing lives of the patients. In order to handle the issue of understaffing, the United States Congress passed nurse-to-patient ratio intended to deal with the number of patients each nurse handles each shift and unit. In order to understand the need for proper nurse-to-patient ratio, the success of the California State is compared with other states that have not complied with the mandate.

Although financial constraints and other factors affect the presence of proper nurse staffing, each hospital must consider relevance of need assessment for the community being served in order to ensure that proper patient and nurses’ health care is promoted. The data obtained should then be used to determine the nurse staffing levels needed and the best way to attain nurse staffing goal.

In building my next research proposal, I would try to use a mixed research method or quantitative research method as it is easier to build a research proposal using the two methods other than the qualitative technique. The components that were most challenging to write about include the research design and rationale, research procedure, and data analysis. In particular, data analysis section for a qualitative study is very hard to write. There is only one part of the proposal that intrigued me most and that is the literature review section. A lot of information was available and therefore this part was easier to write. This proposal is very useful as it highlights a critical component of the nursing profession. I plan to use this proposal to conduct a study in future that will determine relevant steps to be taken by the government to improve nurse-to-patient ratio.

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