Impact of Extended Nursing Shift Hours on Quality of Patient Care in Emergency Departments in Australia

This research proposal explores the impact of extended nursing shift hours on the quality of patient care in emergency departments in Australia. It aims to study how long working hours affect the quality of nursing care and provide recommendations to address the issue. The research is significant in devising occupational health and well-being measures for emergency nurses in the Australian healthcare system.

Running head: RESEARCH PROPOSAL
RESEARCH PROPOSAL
Name of the Student
Name of University
Author’s note

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Topic
Impact of extended nursing shift hours or long work hours (overtime) on quality of patient care
in emergency departments in Australia
Introduction
Background of the problem
There are several trends in the hospital use along with the staffing patterns. These trends
have converged in order to generate potentially hazardous conditions, endangering the patients’
safety. High level of the patients’ acuity along with increased rate of admission of the patients
followed by the discharge cycles along with the shortages of the nurses cast a fatal challenge in
order to deliver safe and effective care. The conditions are more severe in the emergency. In
emergency units, admission of the patients can occur at any time in the day and majority of them
are critical. However, there is a lack of systematic data on the trends of the nursing shift hours in
the emergency unit of the Australian healthcare (Weaver et al., 2016). However, study conducted
by Oliveira et al. (2015) stated that schedule shifts might be eight, twelve or at times sixteen
hours per day and might not follow traditional pattern of the working hours as shift can be even
late at night, early in morning and even in the national holidays or in days of national disasters
like flood or storm. This irregularity in the shift timings and working more than 12 hours a day in
the emergency unit is a problem in the nursing profession.
Research question
What are the consequences of extended nursing work hours on quality of care for
emergency nurses workings in Australian clinical setting?

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Research objective
 To study how long working hours affect the quality of nursing care in the emergency unit
of the Australian clinical settings
 To provide recommendations in order to address the issue associated with long working
hours
Significance of the proposal
Proper analysis of the effect of the long working hours on the quality of the nursing care
from the perspective of the nursing professionals will be helpful in devising occupational health
and well-being model for the emergency unit nurses under the Australian healthcare settings
(Sharma et al., 2014)
Theoretical framework of the study
The theoretical framework of the study is based on the COR (Conversation of Resources)
theory. This theory focuses on the relationships between the working conditions and healthcare
professionals’ individual working outcomes. The theory highlights that people are focused on
protecting their resources in order to respond to all kind of demands in the work-place. When the
nurses perceive threats due to the loss of the resources or they fail to receive sufficient pay-off in
response to their hard-work. They tend to lose their valuable resources leading to hamper in the
overall quality of care or the work progress along with increase in the mental well-being and
distress (Van der Heijden et al., 2017).

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Literature Review
Review of the paper
In order to have a detailed insight about the effect of the long working hours on the
quality of nursing professionals, a review of the literature was conducted. The analysis of the
literary papers that are already published online lead to the identification of several new
concerns.
Caruso (2014) conducted a survey among the healthcare workers in order to identify the
wide range of risks associated with the nurse and their quality care in relation to the long shift
hours and poor quality of sleep. The findings of the study highlighted that long shift hours along
with long working hours increases the risk of poor performance in the working hours. The survey
highlighted that the long working hours hamper the quality of sleep of the nursing professionals
leading to fatigue induced errors during the care procurement. The poor quality of sleep also
endangers the nurses in the domain of developing non-communicable diseases and injuries
during commuting. The personal health hazards leads to increase absenteeism at work that
further increases the work pressure on the existing nursing work-force and thereby hampering
the quality of care. One of the main strength of the paper is it highlighted that increased working
hours not only hampers the quality of care but also hampers the physical well-being of the nurses
that further hampers the quality of the care. However, the study has certain limitations that study
is conducted from the perceptions of the healthcare workers and not solely the nurses. Moreover,
the study of the failed to highlight the exact workforce included in the survey.
Attarchi et al. (2014) used self-reported questionnaire followed by statistical analysis was
used in order to evaluate the associations between the long shift hours of the nursing

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professionals and the increase prevalence of the musculoskeletal symptoms. The statistical
analysis highlighted that most common form of the musculoskeletal complications among the
nursing professionals are lower back pain and upper back pain. Other common musculoskeletal
complications include pain in shoulder, wrist, knees, buttocks and ankles. Attarchi et al. (2014)
mainly recommended proper work planning and making of the roster in order to regularize and
reduce the nurse working hours. One of the strength of the study its, the study provide a clear
overview of how the increase in the working hours of the nursing professionals hamper their
physiological health and well-being and leading to increase absenteeism at work. Though Caruso
(2014) also highlighted about poor physiological wellbeing, but the focus was on poor quality of
sleep. Another strength of the study is large sample size. Attarchi et al. (2014) conducted their
study over 454 healthcare workers. Large sample size helped to reduce the chances of getting
biased results. However, they only focused on the nursing professionals of Iran and thus can be
regarded as one of the limitations and results might not be applicable under the global
perspective.
Kunaviktikul et al. (2015) conducted a study over the nursing professionals in Thailand I
order to investigate how the extended working hours (more than 40 hours per week) hampers the
relationship of the nursing professionals with the patients, nurse colleagues and organizational
outcomes. The authors used multistage sampling in order to select 1524 nurses from 90 different
hospitals across Thailand in order to conduct descriptive statistical analysis through logistic
regression. The high sample size along with the selection of the nursing professionals from 90
different hospitals helped in randomization of the sampling and thereby helping to get unbiased
results. The analysis of the results highlighted that extended working hours has a positive
correlation with the patients’ outcomes leading to errors like communication errors, error in

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treating pressure ulcers, and patient medication errors. Increase in the working ours has also been
found to induce hamper in the quality productivity and decrease in the job satisfaction and
thereby increasing the overall level of nurse turn over. However, one of the limitations of the
study is, patient outcome was measured based on self-reported questionnaire and this may
always not reflect the real rate of occurrence of the adverse events (Kunaviktikul et al., 2015).
Problem identified
The main problem identified through the review of literature is long working hour
hampers the physiological well-being of the nurses leading to the development of the
musculoskeletal injury and other injuries during communication due to the lack of adequate
sleep. The increase in the psychological complications leads to increase absenteeism and high
nurse turnover leading to hamper in the quality of care. The review of literature also highlighted
that long working hours are associated with more communication errors and medication error
among the nursing professionals.
Research gap
None of the papers identified so far has been conducted based on the perspective of the
nursing professionals working in the emergency unit of the Australian healthcare system. Having
a detailed perspective of the emergency care nurses in Australia about the increase working
hours and its relation with the quality of the nursing care will help to devise the occupational
mental and physical well-being measures along with proposal for the recruitment of the more
nurse strength. All these initiatives will subsequently led to increase in the quality of care along
with decrease in the length of stay at the hospital.

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Research Design and Methodology
Research methodology is defined as a process for accumulating data (Taylor,
Bogdan&DeVault, 2015). It supports the nature of the question and nature of the evidences
collected (Neuman and Robson, 2014). Authors are of the opinion that is a body of knowledge
that enables the scholars to described and analyse methods (Silverman, 2016).
Research Design
According to Saunders et al. (2015), the research design is presented in the form of
research onion. There are several layers of research opinions which must be considered while
conducting research. According to the different layers of the research opinion, considerations
over numerous concerns must be taken into account (Creswell & Poth, 2017). The following
section explains the several contexts associated with the research onion.

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Figure: Research Onion
(Source: Saunders et al. 2015)
Research philosophy
Research philosophy is defined as the first layer of the research onion it is defined as a
belief about the process of collection of data, data interpretation and analysis (Hughes &
Sharrock, 2016). There is various research philosophies explained in the research onion and
these include epistemology, ontology and axiology (Creswell & Clark, 2017). Each view of the
research philosophy is further associated with different research philosophies and the most
significant among them are positivism, realism, interpretivism and pragmatism. In this research,
the researcher is planning to use pragmatism in order to explore the relationship between the
extended working hours of the emergency unit nursing professionals in Australia and its effect
on the overall quality of nursing care. According to Mayer (2015), pragmatism seeks to take into
account of the lived experiences and will be helpful in understanding actual exhaustion occurs
from long working hours from the perspective of the nursing professionals. Thus pragmatism
research philosophy will offer suitable framework to understand the relationship between the
long working hours and quality of care.
Research approach
The second layer of the research onion is known as research approach. There are two
types of research approach, deductive and inductive. The deductive research approach
concentrates on employing the existing literatures to identify theories and ideas that the
researcher will verify by the use of the data. Alternatively, inductive research approach deals

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with collection of new data and development of new theories based on the results of the data
analysis (Creswell & Clark, 2017). This research will make use of the inductive research
approach in order to collect the data based on the nursing perspectives in order to generate new
set of theories that will help to define the relationships behind increased work pressure and the
quality of nursing care in the emergency department.
Research Strategy and Time Horizon
Research strategy and time horizon is the third and fourth layer of the research (Brannen,
2017). The research strategies are of several types, exploratory, causal and descriptive. This
research will abide by exploratory research strategy. Exploratory research attempts to understand
the problem that has not been studied clearly in order to establish priorities and thereby helping
to design more operational definition to resolve the problem (Brannen, 2017). Thus exploratory
research will help the researcher to explore the problem of poor quality care in the emergency
department under the context of the increased work load.
Research Methods
There are three types of research methods, qualitative, quantitative and mixed methods
(Bryman, 2016). It is often confirmatory and is used to collected test textual data like interviews,
observation, surveys, focus groups and conversational analysis (Robinson, 2014). Here the
qualitative research method will be used to investigate an issue associated to the perceptions
attitudes and views of the interviewees towards work pressure and quality care in emergency
unit. Quantitative research on the other hand is used when relationship between two variables are
measured. Here the participants response are coded, categories and then they are reduced to
numbers that can be manipulated through statistical analysis (Bryman, 2016). Since here the

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author is planning to conduct open ended interview for the nursing process the encryption of the
coded data and subsequent numerical analysis fall outside the scope of the research. Mixed
method approach, make use of both qualitative and quantitative methods in order to collect and
analyse the data. However, here the author will conduct only qualitative interview and hence
mixed method approach is irrelevant under this context.
Study and Target Population
Population is defined as a comprehensive number of components namely items,
organisations and individuals that are required to be measured as the sample of the study (Etikan,
Musa &Alkassim, 2016). For this research, all the nursing professionals who are working in
emergency department of the Australian Healthcare are suitable for the research.
Qualitative Interview Sample Size
The sample size for this research will be 25 nurses having more 3 or more years of
experience of working in the emergency unit in the Australia healthcare, state run, publicly
funded hospital.
Sampling Design Strategy
Sampling is defined as a process of selection of subset cases from the total number of
units for drawing the generalised conclusions for the total body units (Palinkas et al., 2015).
There are different kind of sampling techniques like probability sampling and non-probability
sampling. The sample participants for interview will be selected randomly (probability
sampling). A random sampling plan enables each of the participants equal opportunity to get

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selected in the sample population and thus helping to reduce the chances of the selection bias
(Emerson, 2015).
Questionnaire Development Process
For the development of questionnaire, first attempt will be taken to specify the kind of
information that will be followed by determination of the types of the questions and the number
of questions. The third step includes determination of content of individual items and form of
response (in this case it will be open-ended). The fifth step will be to determine the wording for
each question followed by determination of the sequence of the questions. The seventh question
is determination of the layout along with the physical characteristics of the questions. The last
step is pre-test questionnaire.
Reliability and Validity of the Interview
To examine the reliability and validity of the questionnaire, at first a pilot test will be
conducted over nurse managers with the required knowledge associated with the research
proposal. The nurse manager will be selected randomly and they will be asked to provide their
opinion over the content of the question and to indicate if the question contains any unfair or
uncomfortable wordings within the question. Based on their feedback, the questionnaire will be
modified if required (Noble &Smith,2015).
Procedure for the Collection of Qualitative Data
Data collection is defined as a process of collection of the data from various sources in
order to answer the research question. There are many approaches for data collection and this
include post, telephonic interview, face-to-face interview and internet based survey (Ranney et

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al., 2015). The following research will use semi-structure interview with open ended
questionnaire in order to collect the data for the research. The face-to-face semi-structured
interview will be conducted as per the convenience of the participants within the hospital
premised. This format will allow the researchers to encourage conversation with the participants
and provides the participants the flexibility to illustrate their thought process about the interview
topic (Ranney et al., 2015). The main instrument that will be used for the collection of the
interview data will be audio-recorder.
Ethical Consideration
Informed consent
In order to ease the process of data collection and to abide by the administrative and
ethical guidelines an introductory letter will be obtained from the university under which the
researcher is registered. The letter will discuss the field of research while stating the importance
of the cooperation with the researcher in order to easy the study process. This letter will be
disseminated to the selected hospital authority. After obtaining the permission from the hospital
author another letter will be channelized to the nurses working the emergency unit stating the
scope and purpose of the interview and how their contribution is helpful in improving the
workplace nursing culture. The interest candidates will be given a consent form and one week to
think and given consent. Among the interested candidates who will give consent, 25 nurses will
be selected randomly. Taking consent is an important part of the ethical consideration of the
conducting an interview (Ranney et al., 2014).

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Safety Issue
Before the conduction of the interview, the participants will be informed that there is no
compulsion for them to take part in the interview and they can leave the interview process at any
point of time without any prior notifications. This is guided by the ethical principal of autonomy
(Ranney et al., 2014). Moreover, the consent form will highlight that if the participant feel that
they are not comfortable in answering any part of the question, they can skip that. As per the
ethical considerations, no question of the interview will be offensive. Interview will avoid
personal questions.
Privacy and confidentiality
After the completion of the interview, the recorded audio will be transcribed in a written
format. After the generation of the final official transcript, the transcript will be verified by the
respective interview in order to maintain the ethical guidelines autonomy. If they interviewee
finds any discrepancy in their given interview with that of the transcript then he or she can
challenge the interview and can withdraw his or her name completely from the interview
process. The transcript when confirmed by the interviewee will be devoid of the personal
information like name of the participants and other identification details in order abide by the
ethical principle of privacy. Pseudo names of the interview will be used in order to keep their
identity confidential. The identification details of the interviewee with stored in private folders in
the private computer of the author and the folder will be locked in order to maintain the ethical
principal of confidentiality for the conduction of interview (Ranney et al., 2014).

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Conclusion
The main limitation of the study is lower sample size. Due to time and financial constrain
the author failed to include large sample. The author her will conduct qualitative semi-structured
interview with open-ended questionnaire in order to study the effect of long working hours in the
quality of care under emergency settings of Australian Healthcare. The results will help to frame
occupational health and well-being framework for the nursing professionals in order to improve
the quality of care.

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