Impact of Low Nurse Staffing on Aged Care Patients: A Qualitative and Quantitative Study

This study investigates the impact of low nurse staffing on aged care patients through a qualitative and quantitative approach. The research questions focus on the experiences of nursing staff and the impact of staffing ratios on care delivery. The study aims to provide evidence for the need for adequate staffing levels in aged care facilities.

Running head: ASSIGNMENT 2
Evidence based nursing research
Name of the Student
Name of the University
Author Note

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Introduction
Problem statement- Personal care attendants play a crucial role in aged care facilities
and residential homes. Their work is highly labour intensive and involves effort to improve
the nursing care quality that is delivered to the older patients. Therefore, presence of a good
nurse-to-patient ratio is one of the primary prerequisites for an effective aged care (Brunetto
et al., 2013). The aged care industry is currently facing a crisis due to the fact that the older
adults present in nursing homes are not being given proper treatment and care, which is their
basic right. Shortage of nursing professionals and a lack of skill mix are some of the key
reasons that contribute to this drawback (Chenoweth et al., 2014). Thus, the problem
statement is that aged care nurses and carers suffer burnout due to shortage of staff that leads
to poor health outcomes.
Background- According to reports from the National Staffing Survey, presence of
adequate staffing levels were confirmed by only few of the respondents recruited for the
purpose (AMN Healthcare, 2017). It is generally measured when the nurse-to-population
ratio, nurse-to-patient ratio, the, or job openings demand more nurses than those that are
currently available. This staff shortage is currently being observed in all developing and
developed nations round the world. Furthermore, the healthcare sector in Australia a large
industry and the increased demand for the nursing professionals is pushing the healthcare
sector towards risky situations (Browne et al., 2013). Recent reports state that New South
Wales is on the border of nursing crisis, in addition to south-west Sydney that might soon
face a shattering nurse shortage in immediate future (Abc.net.au, 2018). Appropriate nursing
care is one of the most important aspects of residential aged care and the staff are the primary
targets for making profits and cost-cutting (McGilton et al., 2013). This cost-cutting affects
the resources and staff involved in caring for older patients. Furthermore, reports from the

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department of health and aging also illustrate the presence of weekly earning pay gaps in the
aged care workforce, with a deterioration in the care quality (King et al., 2013).
Qualitative data research question- What are the experiences of nursing staff in aged
care industry with staffing issues and its impact on the resident care?
Quantitative data research question- How does the staff nursing ratio in aged care
impact on the care delivery?
Thesis statement- In this essay I argue that lower nurse staffing creates a negative
impact on older patients in residential care.
Definitions-
 Aged care- Fulfilling special demands and needs exclusive to senior citizens.
 Low nurse staffing- A condition where there exists a demand for nursing
professionals such as, RNs.
 Personal care attendant- Professionals involved in delivering non-medical care to all
patients at their homes
 Residential care facility- facilities that provide support and accommodation to frail
and aged people.
Research justification
Systematic search- Following identification of the key terms and phrases relevant to
both the qualitative and the quantitative research questions, their combination was used along
with several Boolean operators such as, ‘OR’, ‘AND’ and ‘NOT’, for retrieving articles from
the database. Due to absence of adequate articles from the database of the Royal College of
Nursing, MEDLINE, CINAHL, PubMed, InfoRMIT and Google Scholar. The key phrases
were typed in the database in the form of “aged care” AND “staff ratio9”; “geriatric nursing”

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AND “staffing pattern”; “aged care nursing” AND “staff stress”. Upon analysing the title and
the abstracts of the articles and determining their full-text eligibility, a total of 10 articles
were retrieved.
Critical discussion- Both the research questions formulated for this investigation are
unique and valid, since no other research on impact of nursing burnout and staffing on health
outcomes of aged patients have ever been conducted in a similar context. The qualitative
research question is relevant to the scope of the research owing to the fact that despite an
increase in awareness of the difficulties encountered by nurses in their workplace, they still
day experience increasing intensities of anxiety. Furthermore, stress has also been identified
as an antecedent that is associated with the interpretation and perceptions of an individual in
response to events that are considered threatening (Roche et al., 2015). Owing to the fact that
stress has been established as a major form of occupational hazard, which creates significant
health problems, the qualitative research aim was in accordance to the primary objective of
the investigation. Aged care nursing is characterised by the presence of a plethora of potential
physical stressors namely, frequent bending and lifting, noisy work environments, changeable
rosters and shifts, and long working hours due to shortage of nursing staff.
Furthermore, less staffing leads to night-shift that subsequently leads to a disruption
in their circadian rhythms, thereby predisposing nurses to illness. Reports have elaborated on
the fact that an estimated 92% of nursing professionals have given statements that confirm
the fact that they are often asked to care for similar residents due to less staff ( Nardi &
Gyurko, 2013). This in turn creates an impact on the daily care that is provided to the elderly
patients in aged care or residential facilities. Additionally, inadequate number of enrolled and
registered nurses result in a compromise in the bathing and feeding of the aged clients.
Moreover, the relevance of the qualitative research questions to existing research can be
illustrated by the fact that other research studies have also identified the impact of

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depersonalisation and emotional exhaustion as a result of burnout on the reduced
accomplishment of nurses and their negative and cynical attitudes towards work. Congruency
of the quantitative research question to the topic of investigation can also be established
based on the importance of an optimal staff-to-patient ratio in healthcare settings (Tubbs-
Cooley et al., 2013).
Legislations have been formulated on the number of nursing staffs that all patients
require in a healthcare setting. This is facilitated by the presence of authorities and
supervisory personnel to ensure presence of immediate availability of nurse as and when
required by any patient. There exist clear evidence that the nurse-to-patient ratio should be
properly maintained, in order to ensure enhanced health outcomes of the service users being
cared for (McHugh, Berez & Small, 2013). A ratio of 1:4 is the minimum nurse-to-patient
ratio that is recommended by the Australian Department of Health, for Level 1 surgical or
acute medical ward in public hospital settings, both during afternoon and morning shifts
(Queensland Health, 2018). Besides, presence of more high acuity clients, as found in an
aged care facility requires the ratio to be lowered, with the aim of delivering safe care to all
patients. The articles extracted for addressing the quantitative research question is in
accordance to previously existing studies due to the fact that presence of adequate staffing
ratio is associated with lower rates of nursing burnout and subsequent improvement in the
health outcome of patients (Cho et al., 2015).
Success of a healthcare organisation in maintaining adequate ratio of nurses to their
clients effectively help in increasing the levels of satisfaction among the service users. This is
a direct manifestation of the fact that proper nurse-to-patient ratio creates deleterious impacts
on both nurse and patient outcomes. In addition, relevance of the quantitative research topic
is can be confirmed by previous findings that have provided evidence for the impact of
burnout on undermining the professional attention and care that nurses give towards their

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clients. Owing to the fact that not much research have been conducted to probe the
association between nurse burnout due to poor nurse-to-patient ratio and the quality of care
provided to aged patients, this research question was formulated.
Approach justification
Qualitative approach- The qualitative research will be based on a narrative research
technique that will help in gaining a deeper understanding of the factors that govern or
underpin the experiences of nursing professionals, which in turn creates an impact on
delivery of healthcare services. The narrative research will enable the process of exploring
the significance of the action of nursing professionals. The narrative research strategy will
primarily focus on spoken words of the nurses working in aged or residential care facilities.
The primary advantage of this approach can be attributed to the fact that the research will
help in providing an explanation of the situation that involves real life problem of nursing
shortage and its impact (Aliyu et al., 2014). The research will be set out in accordance to the
validation provided by the audience. Regardless of its support for drawing conclusions, the
approach is imperative in this context due to its merits of providing an individual
interpretation of the topic being investigated. However, one major weaknesses of the
narrative approach is its linguistically subjective nature that might create difficulties in
accessing the responses in some objective manner.
The central premise of this non-positivist research design is that all efforts will be
taken to gain a sound understanding of the phenomenon being investigated (nursing
experience with staffing issues in aged care) in depth. This will be primarily facilitated by
taking attempts to explore uncertain answers such as, ‘Why?’ ‘What?’ and ‘How?’ (Dubois &
Gadde, 2014). Phenomenological studies oppose that these understandings might result with
the use of different methods, apart from measurements, unlike positivist approach that is

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primarily concerned with providing answers to questions as ‘How much?’ or ‘How many?’
(Oliver, Nesbit & Kelly, 2013). Thus, the key feature that influenced adoption of this
approach is the fact that it emphasises on viewing social reality through interpretation by the
concerned individual based on the ideological positions that are held by him/her.
This non-positivist approach will be marked by three different social schools of
thought namely, ethnomethodology, phenomenology, and symbolic interactionism. All of
them would highlight human interaction with the phenomena occurring in their daily lives,
thereby giving qualitative suggestions to social inquiry. The methodology would comprise of
a focus design group that would facilitate the investigation of the view and experiences of the
nursing professionals working in residential care homes, regarding their staffing and its
subsequent impact on their work. The focus group will involve an ordered discussion with
selected set of persons to gain facts about their opinions and experiences of working in aged
care with the persistent staffing issues. The purpose of focus group methodology is to attain a
qualitative information from the predetermined number of nurses (Krueger & Casey, 2014).
This will help to concentrate on the observations and words of the nurses, to express their
situation and reality in the present day context. The participants for the focus group will
comprise of 90 registered and enrolled nurses (45 each), selected across 10 different
aged/residential care units, in and around the district. Selection of the participants will be
done based on convenience sampling. They will be organised into nine groups, containing 10
nursing professionals each. Each group will be asked questions related to their feelings of
being a nurse, feelings about aged care in general, staffing issues faced by them (if any),
experiences that they find enjoyable, impacts of staffing issues on their work, their worries
and stress, and expectations (Stewart & Shamdasani, 2014).
Immediate debriefing of the interactions that were recorded during the focus group
will be followed by transcribing them verbatim, and noting down significant non-verbal

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behaviour. The responses will be coded based on different levels from 1 to 3 (Ormston et al.,
2014). These will directly help in examination of the data according to each line, comparing
them and eventually describing the psychological process being investigated. This coding
will lead to the emergence of a range of themes from the point of view of the recruited
nurses, thereby providing an explanation for the research question.
Quantitative approach- The quantitative research design will be a cross-sectional
study that will focus on measuring the outcome of low nurse-to-patient ratio on delivery of
services in aged care facility. The research will be primarily based on a positivist approach
that relies on scientific evidence such as statistics and experiments for revealing the true
nature of operation of the society. The information derived from this approach will
interpreted with the help of logic and reasoning. Thus, the positivism will rely on the
utilisation of factual knowledge that will be obtained through observation and measurements
that are reliable and trustworthy. Positivism generally depends on quantifying observations,
thereby leading to statistical analysis (Larkin, Begley & Devane, 2014). This will be
completely in accordance to the view that knowledge can be generated through experiences.
The use of this approach can also be justified based on its ontological and atomistic view of
the world in the form of observable and discrete elements that have been found to interact in
a regular and determined manner. Some of the principles of positivism that the quantitative
research will focus on the assumption that there exist no difference between logic related to
inquiry across science. In addition, the approach also assumes that the research should be
empirically observable to the senses.
The cross-sectional design of the quantitative research will involve collection of data
from the entire nurse population, at one point in time, with the aim of assessing the
relationship between poor staffing ratio and its impact (O'Donnell, Kramar & Dyball, 2013).
It will provide a snapshot of the effects that poor nurse-to-patient ratio have on delivery of

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healthcare services to older adults. This cross-sectional study will have an analytical design
that will investigate the correlation between the nursing impact and shortage of nursing
personnel. This study will be representative of the entire population of nurses.
The quantitative research design will seek to explore whether there exists any
association between poor nurse staffing and missed care or mortality of older adults present
in residential and/or aged care facilities (Kalisch & Xie, 2014). The method will encompass
use of administrative data survey of nursing professionals and aged patients. Information will
be collected from an estimated 50 hospitals that will be provided by public data and the
administrators. Data collection will establish an association between staff in each unit/shift
and the needs of patient per shift, thereby measuring the delivered care quality (de Veer et al.,
2013). The patient data will be based on 200 patients, aged more than 60 years who have
been admitted to aged care or residential living facilities 2018 onwards. The major outcome
measure will be mortality and adverse health outcomes of the aged patients. This will be
measured with the use of data on discharge related status, length of hospitalisation,
comorbidities and patient death. Missed care evaluation will comprise of assessing nurse
surveys that focused on patient surveillance, pain management, hygiene, and comprehensive
care. Surveys that asked questions on the staff number involved in delivering direct care to
the older patients, and the number of clients that they had to look after will also be included
in the analysis. A random intercept models and generalized estimation approach will be
adopted to examine the association between the variables of interest. The Bayesian method
will also be put to use for construction of this model.
Comparison- Gatekeepers refer to healthcare professionals, characteristically
physicians or nurses, having initial encounters with patient, thereby having the responsibility
of controlling the entry of the patient into healthcare system (Ritchie et al., 2013). Nurses are
responsible for maintaining, negotiating and restoring emergency care services by using their

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gatekeeping roles (Hegney, Eley & Francis, 2013). Owing to the fact that the nursing
professionals have often been identified as the gatekeepers of patient health and safety,
conducting a qualitative research would be the best approach in this scenario (Aiken et al.,
2014). Ethical concerns related to the focus group are that it would require an approval from
the research committee in addition to permission from the hospital administration from which
the nurses will be recruited (Scott & Garner, 2013). In addition, all the nurses will have to be
provided an information on the design and objective of the study, followed by obtaining a
written consent for the interviews (Tuttas, 2015). Some ethical concerns related to the cross-
sectional study are that it will require proper maintenance of the confidentiality and
anonymity of the patient and nurse data. Thus, the advantages of focus groups in providing
detailed information on the personal and group opinions of nurses on the research question
and the opportunity to seek proper clarification make it the best approach for the research.
Conclusion
Thus, it can be concluded that the qualitative research will be the best approach for
gathering information on nurse’s experience in relation to shortage of staffing and its
subsequent effect on health status of older patients. Categorising the information obtained
from the focus group into specific themes and patterns will help in reporting the findings and
providing an exact explanation of the perceptions and attitudes that nursing professionals
hold regarding the workforce shortage problems. This will provide an opportunity to disclose
the perceptions that nurses hold, in setting where they can be validated. Some of the major
disadvantages associated with a cross-sectional approach are that it is extremely difficult to
govern whether an outcome followed a particular event in time, or vice versa. These studies
are primarily useful for determining the prevalence of certain diseases or behaviour among
individuals in a target population. However, ethical issues might arise when certain medical
or occupational records are utilised for a purpose for which consent was not taken.

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Individuals or their public representatives should normally be told that their data
might be used in epidemiological studies, and what means of protecting confidentiality are
provided. Consent is often not required for the use of publicly available information, although
there might be discrepancies in regards to what information is viewed as public. However, it
becomes imperative to reduce and/or eliminate disclosure of any such personally sensitive
information. Lack of satisfactory staff on specific nursing units such as, aged care and
residential care facilities is a challenging situation that is commonly faced by nursing
professionals and managers. There are several legal implications associated with
inadequate staffing levels that pose a risk to the health and safety of all patients. Aged care
nurses cover an assortment of obligations during each shift. These nurses have the duty of
administering medications to the older patients and/or residents, in addition to observing each
patient that they are in charge of. Moreover, their responsibilities also encompass changing of
dressings, checking their patient's vital signs and liaising with the concerned physicians. The
heavy workload of aged care nurses is therefore a major challenge that is attributed to
increased demand for nursing professionals, their inadequate supply, increased overtime due
to reduced staffing and a reduction in the length of stay of patients.
Therefore, heavy nursing workload will create an adverse effect on patient safety.
This in turn will threaten job satisfaction of the nurses and, as a result, lead to increased
turnover and shortage. Hence, there is a need to improve aged patient by increasing the
number of nursing personnel in residential units or subsequently lessening the number of
older patients assigned to the nurses. A comparison of the qualitative and quantitative
research approach suggests that the qualitative approach will be less time consuming, feasible
and will provide a wider range of information on the research question.

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