EBP Change Process: Enhancing Patient Safety with Optimal Ratios

This report outlines an Evidence-Based Practice (EBP) change process focusing on the nurse-to-patient ratio and its impact on patient safety, utilizing the ACE Star Model of Knowledge Transformation. It begins with the discovery phase, identifying the issue of inadequate nurse staffing levels and its potential to compromise patient safety. The summary phase includes a PICOT question addressing whether an appropriate nurse-to-patient ratio increases patient safety in clinical settings. A systematic review from the Cochrane Database supports the need for change, highlighting the correlation between nurse staffing levels and inpatient mortality. The translation phase discusses care standards, practice guidelines, and stakeholder roles in the change process. The implementation phase details the process for gaining permission, educating staff, and outlining a timeline for the change process trial. Finally, the evaluation phase describes how the outcomes of the trial will be reported and the next steps for implementing the change process information into practice, including monitoring the results and ensuring timely implementation.

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Week 6 Assignment: EBP Change Process form
ACE Star Model of Knowledge Transformation
Star Point 1: Discovery (Identify topic and practice issue)
Identify the topic and the nursing practice issue related to this topic. (This MUST involve a nursing
practice issue.)
This paper would focus on the topic of patient safety and the effective ness of proper nurse to patient ratio
to enhance the patient safety.
Briefly describe your rationale for your topic selection. Include the scope of the issue/problem.
Rationale
In the past few years there had been an increasing needs for the registered nurses in the hospitals due to
the high acuity of the patients and the shorter lengths of the patient stay in the hospitals. The safety and
the quality of the patient care is directly related to the hospital staffing and the experience of the nursing
workforce (McGahan et al., 2012).
In many of the clinical settings it has been noticed that the inpatient working condition has deteriorated as
the hospitals are not keeping up with the rising demands of the nurses (Cho et al., 2015). A constant nurse
vigilance at the bedside is necessary to ensure patient safety. There are several seminal studies that have
documented the increased risk of the patient safety events, the mortality and morbidity as the number of
patients increases (Aiken et al., 2012).
It is the nurse to patient ratio that is only one aspect of the relationship between the nursing workload and
the safety of the patient. Low nurse –to patient ratio has been associated with increased stress workload
and interruptions and the risk of burnout due to the involvement in the medical errors or the exposure to
any disruptive behavior (You et al., 2013).
Scope of research
The scope of research includes researches about the appropriate nurse to patient ratios supported by the
federal laws to ensure the safety of the patient.

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Star Point 2: Summary (Evidence to support need for a change)
Describe the practice problem in your own words and formulate your PICOT question.
The main practice problem of this assignment is the nurse –to patient ratio and its effectiveness in
enhancing the patient safety.
PICO – Does appropriate nurse- to patient relationship increases patients safety in clinical settings.
P- Hospital inpatients
I (interventions)- Proper nurse to patient ratio.
C (comparison)- shortage of staffing
O (Outcome)- Patient safety
List the systematic review chosen from the Cochrane Database of Systematic Reviews from the
Chamberlain library. Type the complete APA reference for the systematic review selected.
Shekelle, P. G. (2013). Nurse–patient ratios as a patient safety strategy: a systematic review. Annals of
Internal Medicine, 158(5_Part_2), 404-409.
List and briefly describe other sources used for data and information. List any other optional scholarly
source used as a supplement to the systematic review.
Electronic search has been conducted to find relevant papers and data has been collected from
government websites.
List of the important websites:-
https://www.nmc.org.uk/about-us/policy/position-statements/safe-staffing-guidelines/
https://www.nmc.org.uk/globalassets/sitedocuments/press/safe-staffing-position-statement.pdf

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https://www.evidence.nhs.uk/search?q=Nurse%20patient%20Ratio
Briefly summarize the main findings (in your own words) from the systematic review and the strength of
the evidence.
This paper had reviewed the evidence about the nursing staffing ratios and the in-hospital death through
September 2012. From 550 studies, 87 articles have been chosen and 15 new studies that augmented the
existing two reviews were selected from the studies. The strongest evidence supporting the relationship
between the nurse staffing level and a decreased inpatient mortality. None of the studies have reported
any serious harm in increasing the nurse staffing (Shekelle, 2013).
The cross sectional studies in the intensive care unit and the post-surgical settings has supported a causal
relationship between increased staffing level and decreased patient mortality. Two relevant systematic
reviews has been included to assess the benefits and risks of increasing the staffing levels. Lower rates of
nosocomial infections, pulmonary failure, failure to rescue, unplanned intubation were related to higher
RN staffing (Shekelle, 2013).
Some of the limitations that can be perceived form the literature review is that the review was restricted to
studies that used the hospital related mortality as the outcome. There was a lack of rigorous evaluation,
low response rates to the surveys that collect explanatory variables.
Outline one or two evidence-based solutions you will consider for the trial project.
One of the important evidence based solution to manage the nurse staffing for managing the nurse- to
patient ratio are restricting the unsafe floating of the nurse staffs. Temporary trained nurses will be
appointed to check the health outcomes of the patient (Cho et al., 2015). A detailed orientation and the
competence level of the staffs should be assessed before assigning a nurse to a clinical area. Any
temporary nursing professionals appointed should also get the same orientation and the competency
determination as the permanent staffs.
Another evidence based intervention is to develop a patient classification system and additional nursing
staffs should be added to the minimum ratio based on the documented classification system
Star Point 3: Translation (Action Plan)

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Identify care standards, practice guidelines, or protocols that may be in place to support your intervention
planning (These may come from your organization or from the other sources listed in your Summary
section in Star Point 2).
1. One of the safe staffing guidelines has been given by the Nursing and the midwifery Council of
United Kingdom. As per the guidelines, the nurse to –patient ratio in the critical care unit should
be 1.2 or less and the nurse –to patient ratio in an emergency department should be 1:4 or less at
all times that the patients are receiving the treatment. Secondly all the nursing staffs should be
registered with the NMC to practice as the nurse or the midwife (NMC, 2014).
2. The NICE guidelines for the hospital staffing capacity and capability. Again the National Quality
Board’s (NQB) guidance can also be followed to deliver the right staff, with the desired skills for
delivering the patient care. NICE has also published guidelines on the safe maternity staffing for
the maternity settings (National Institute for Health and Care excellence, 2017).
List your stakeholders (by title and not names; include yourself) and describe their roles and
responsibilities in the change process (no more than 5).
Appropriate staffing is a collective accountability of the executive teams and the boards.
Main stakeholders – The registered nurses who are working in the inpatient setting. Then can identify the
workload or the unmet needs of the patient or any problem arising due to less workforce.
The doctors- They can identify if any medical errors have occurred due to shortage of nursing staffs.
The clinical manager/ clinical officer- The clinical mangers would validate the needs of the nurses in the
inpatient ward.
The hospital board- The hospital board is responsible for assessing the registration and the qualification
of the recruited nurses.
Being a nurse, I should be able to point out the unmet needs or the adverse outcomes of shortage of the
nursing staffs.
What specifically is the nursing role in the change process?

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Being a nurse, it is important to identify the adverse outcomes for inappropriate nurse to patient ratio.
They will help to develop the patient classification system. Secondly it is also necessary to assess the
stress and the burnout caused to the nurses due to excessive patient load.
List your stakeholders by position titles (charge nurse, pharmacist, etc.).-Why are the members chosen
(stakeholders) important to your project?
The leader nurses – to identify the gaps and unmet needs of the patients due to nurse shortage.
The medical managers- To assess the qualification of the newly appointed staffs.
The operational heads – for analyzing the cost
What type of cost analysis will be needed prior to a trial? Who needs to be involved with this?
Cost analysis should be made for recruiting new temporary staffs with the numbers of days for which the
trial has to be conducted. The cost required for providing training to the new staffs.
Star Point 4: Implementation
Describe the process for gaining permission to plan and begin a trial. Is there a specific group,
committee, or nurse leaders involved?
In order to begin trial, it is first necessary to seek permission from the governing body, the ethics
committee and the temporary nurse participants. Consent form should be signed before the conduction of
the trial.

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Describe the plan for educating the staff about the change process trial and how they will be impacted or
asked to participate.
A two days session can be taken involving the old nursing staffs to enquire about the staffing problems
and issues arising out of the problems. Education will also be provided regarding the change process trial
and the rationale behind the trial.
They will be informed that this change process trial can help them as their workload will get distributed if
new temporary nursing staffs are recruited for the trial.
Outline the implementation timeline for the change process (start time/end time, what steps are to occur
along the timeline).
Week 1 Week
2
Week
3
Week4 Week
5
Week
6
Week
7
Week
8
Week
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Enquiry about
the nursing
workload

Detecting the
adverse
outcomes due


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to less
staffing
Consent from
the
participants

Recruiting the
participants

Trial   
Measurement
of the
outcomes

Dissemination
of the practice
 
List the measurable outcomes based on the PICOT. How will these be measured?
The measurable outcomes are- Patient safety, mortality and job satisfaction.
The patient safety outcomes can be measured by tallying the patient mortality rate or the fall rate with the
previous data before the conduction of the trial. Job satisfaction can be measured by the using a
questionnaire before and after the trial.
What forms, if any, might be used for recording purposes during the pilot change process. Describe.

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Standard operating procedures and logbooks can be used for the recording.
What resources are available to staff (include yourself) during the change pilot?
Guidelines and protocols, withdrawal forms to withdraw from the study.
Will there be meetings of certain stakeholders throughout the trial? If so, who and when will they meet?
In order to improve the nurse patient staff ratio, a constant interaction has to be made between the
operational heads and the head nurses while recruiting staffs as per the competency levels to have an
understanding of the qualifications or the skills required in nursing.
Star Point 5: Evaluation
How will you report the outcomes of the trial?
The report of the trial can be disseminated by bringing the issue in online forums or by spreading the
news through the publication of newsletters.
What would be the next steps for the use of the change process information?
The final step would be to monitor that the result of the trial are implemented to practice as soon as
possible within the mentioned time frame.

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References
Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., ... &
Tishelman, C. (2012). Patient safety, satisfaction, and quality of hospital care: cross
sectional surveys of nurses and patients in 12 countries in Europe and the United
States. Bmj, 344, e1717.
Cho, E., Sloane, D. M., Kim, E. Y., Kim, S., Choi, M., Yoo, I. Y., ... & Aiken, L. H. (2015).
Effects of nurse staffing, work environments, and education on patient mortality: an
observational study. International journal of nursing studies, 52(2), 535-542.
McGahan, M., Kucharski, G., Coyer, F., & Paper, W. A. B. N. R. (2012). Nurse staffing levels
and the incidence of mortality and morbidity in the adult intensive care unit: a literature
review. Australian Critical Care, 25(2), 64-77.
National Institute for Health and Care excellence, (2017). Access date: 17.2.2019. Retrieved
from: https://www.nmc.org.uk/about-us/policy/position-statements/safe-staffing-
guidelines/
NMC, (2014). Nurse- to patient ratio .Access date: 17.2.2019. Retrieved
from:https://www.nmc.org.uk/globalassets/sitedocuments/press/safe-staffing-position-
statement.pdf
Shekelle, P. G. (2013). Nurse–patient ratios as a patient safety strategy: a systematic
review. Annals of Internal Medicine, 158(5_Part_2), 404-409.

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Sun, B. C., Hsia, R. Y., Weiss, R. E., Zingmond, D., Liang, L. J., Han, W., ... & Asch, S. M.
(2013). Effect of emergency department crowding on outcomes of admitted
patients. Annals of emergency medicine, 61(6), 605-611.
You, L. M., Aiken, L. H., Sloane, D. M., Liu, K., He, G. P., Hu, Y., ... & Shang, S. M. (2013).
Hospital nursing, care quality, and patient satisfaction: cross-sectional surveys of nurses
and patients in hospitals in China and Europe. International journal of nursing
studies, 50(2), 154-161.