A Study Assessing Nurses' Perception of Staffing on Medication Errors

This research proposal investigates the impact of nursing staffing ratios on medication errors in Australian healthcare settings. The study aims to assess nurses' perceptions regarding how staffing levels affect the occurrence of medication errors. The proposal outlines the background of the problem, emphasizing the significance of medication safety and the associated healthcare costs. It includes a clear statement of research questions, the significance of the research, and the theoretical framework based on Henderson's nursing theory. The literature review synthesizes relevant studies on nurse staffing and medication errors, highlighting research gaps. The methodology details the research design (pragmatism), deductive research approach, and data collection methods, including questionnaire development. Ethical considerations, such as confidentiality and informed consent, are also addressed, along with study limitations and implications. The proposal concludes with a summary and references.

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RESEARCH PROPOSAL
Research Proposal
Name of the Student
Name of the University
Author Note

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Table of Contents
Introduction................................................................................................................................4
Background of the problem....................................................................................................4
Clear statement of research questions....................................................................................4
Significance of the research proposal....................................................................................5
Theoretical framework underpinning the study.....................................................................5
Literature review........................................................................................................................5
Research gap..........................................................................................................................9
Methodology..............................................................................................................................9
Research design......................................................................................................................9
Research philosophy..............................................................................................................9
Research approach...............................................................................................................10
Research strategy and time horizon.....................................................................................10
Research methods.................................................................................................................11
Target population and sample size.......................................................................................11
Sampling..............................................................................................................................11
Questionnaire Development Process....................................................................................12
Data collection and analysis.................................................................................................12
Ethical considerations..............................................................................................................12
Confidentiality and data security.........................................................................................12
Inclusion of informed consent..............................................................................................13

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Indication of safety issues....................................................................................................13
Indication or risks to subjects/researchers............................................................................13
Conclusion................................................................................................................................14
Summary..............................................................................................................................14
Study limitations..................................................................................................................14
Study implications................................................................................................................14
References................................................................................................................................15

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Topic: A study to assess the perception of the nurses regarding impact of staffing ratio on
medication error
Introduction
Background of the problem
Medication safety in different areas of the patients’ journey via acute care settings in
the Australian healthcare is a significant healthcare problem. It is estimated that there is
approximately 230, 000 medication-associated hospital admissions occurring per year. This
medication-related hospital admission is increasing the overall healthcare cost in Australia by
AU$1.2 billion (Roughead, Semple& Rosenfeld, 2016). The medication error also increases
adverse drug reactions and at the same the increases the overall duration of stay at the
hospital and thereby decreasing the quality of care and endangering patients’ safety
(Roughead, Semple& Rosenfeld, 2016). Nurses are found as main defaulter behind
medication error. Increased work pressure and extended duty hours are two most cited as
reasons behind medication errors. Thus, proper organization support and co-ordination
between the nursing professionals might help to reduce the work-related stress among the
nurses and promoting professional quality improvement (Sahay, Hutchinson & East, 2015).
Clear statement of research questions
Thus the aim of the research will be to access the perception of the nurses regarding
staffing and its effect on the medication error.
Population (P) Nursing Professionals
Interventions (I) Increased strength of the nursing professionals
Comparison (C) Poor strength of the nursing professionals
Outcomes (O) Improve patients’ safety (decreased medication error)

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Significance of the research proposal
The research proposal will help in understanding how increasing the strength of the
nurses will help to decrease the chances of encountering medication error by decreasing the
work-related stress. Reduction in the medication error will help to increase the overall safety
of patient safety and will help to decrease the cost of care (Sheikh et al., 2017).
Theoretical framework underpinning the study
Nursing theory that aligns with the study is Henderson nursing theory. Virginia
Henderson developed Henderson nursing theoryas she was influenced by her own self-
nursing practice and education. The primary objective of this theory was not to improve or
design any nursing theory but was to identify the unique factors present within the nursing
practice. Henderson while developing the model made three major assumptions, where the
first assumption was that nurses continue to take care of the patient until the patients
independently take care for themselves. The second hypothsis was that nurses devote their
entire time to take care of the patient and the final assumption made by Henderson was that
nurses must have knowledge in both arts and science during their college life (Ahtisham &
Jacoline, 2015). The second assumption coincides with the scope of the research as it is
highlights more time nurses can avail, will be helpful for the patients’ recovery.
Literature review
In order to find the literature gap and to highlight the rational and novel of the
research, a literature review was conducted based on the articles which are published within
the last 10 years. The keywords used for the search of the relevant articles in the electronic
databases (CINHAL and PubMed) include “nurse staffing” OR “nurse to patient ration” AND
“medication error”. The following is a summative literature review based on the relevant
papers extracted during the last 10 years.

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The study conducted by Duffield et al. (2011) stated that improper nurse staffing, high
workload extended work pressure and unstable nurse unit is linked to negative patents’
outcome. Negative patients’ outcome covered in this longitudinal, mixed method study
includes accidental fall and medication error. The study though conducted with the primary
data but mainly focused on the data published with the last 5 years thus failed to provide a
comprehensive overview of the prevailing scenario in healthcare. But the study helped in
understanding that there is an inversely proportional relationship between improper nurse
staffing and negative patients’ outcome. Flynn et al. (2012) study showed that a supportive
environment increases error interception practices. These interception practices have a
determining role in decreasing the medication error. The study mainly highlighted the
importance of the supportive environment like proper training, availability of resources or
proper leadership. However, the study failed to highlighted if increasing the nurse strength or
decreasing the nurse to patient’s ratio is one of the important parameter for reducing the
medication error. Moreover, the study also used non-experimental design and thus can be
considered as one the limitations of the study. The follow-up done was for 8 months and this
further decrease the overall sample size. Frith et al. (2012) in used a retrospective study
design for the analysis of the secondary data with an aim to ascertain the relationship with
nurse staffing and occurrence of the mediation errors. Thus, the scope of the study coincided
directly with the scope of this research proposal. Frith et al. (2012) mainly used data from one
hospital (31,080 patients’ observation). However, the same size was large but selection of
data from one hospital restricted the generalization of the overall data. The study however
highlighted that increasing the number of the RN pr decreasing the working hours of the RN
helps to reduce the rate of medication error. However, Mark and Belyea (2009) failed to
highlight any cross-sectional or longitudinal association with the nurse staffing and the
reduction in the medication error. Thus both the studies, Mark and Belyea (2009) and Frith et

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al. (2012) produced conflicting data during tenure of 3 years. Chang and Mark (2011)
stressed on the importance of the learning climate over in decreasing the chance of the
medication error. However, it failed to relate whether increasing the nurse strength helps to
promote a learning climate within the healthcare organization. But stated that with increase in
nursing staffs, the effective interaction is promoted facilitating exchange of information and
skills to avoid medication errors. The observation study conducted by Valentin et al. (2009)
highlighted parenteral medication errors during administration stage are frequent and has a
serious safety problem in the intensive care units of the hospitals. Increase in the nurse
strength helps to reduce the odds ratio of the occurrence of the parenteral medication error by
increasing the presence of basic monitoring. The increase in nursing strength also increases
the routine checks of the nurses and thus assisting to reduce the chances of the medication
error. However, the study also stated that increase in the nursing strength leads to more
frequent change in the nurses in the shift timings. There are chances of gap in communication
during change of shift nurses (problem in the clinical handover) and thus increasing the
chances of the medication errors. Holden et al. (2011) highlighted in their cross-sectional
survey that increase in the nursing workload helps to decrease the work-pressure over the
nurses and thus helping to reduce the chances of the medication error under the paediatric
healthcare settings. According to Moss et al., (2016), healthcare professionals are completely
burnout due to excess workload known as burnout syndrome (BOS) and this condition is
particularly common in the people who take care of the critically ill patients. The researcher
had explained the potential reason of this syndrome that is due to lack of balance between the
personal characteristics and organizational factors of the employees that directly influence the
psychological health and well-being of the various critical care nurses, healthcare providers
and physicians world-wide. The harmful consequences of this syndrome were also explained
by the researcher that included decreased patient satisfaction, reduced quality of patient care

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and job turnover. The researcher had also highlighted prevalence factor, diagnostic criteria,
causative factor and bad effect of burnout syndrome (BOS). The development of burnout
syndrome was bad and the influence was affecting the overall health condition of the health
care professional that was harmful for both patient and health care professional the patient
outcome was reduced due to excess workload on the healthcare providers. According to
Nightingale et al., (2018), there is a relationship between the caring behaviour of the health
arte professional and the emotional intelligence of the health care professional. The
researcher had highlighted different factors that impact the relationship between the
emotional intelligence and the caring behaviour of the healthcare professionals. An
integrative study design was used by the researcher to conduct the study. Different data
sources were used such as Psych info, CINAHL Plus, Medline, Social Sciences Citation
Index, Scopus and Science Citation Index and this resources were filtered from the
publication year that was in between 1995 to 2017. The study involved both quantitative and
qualitative study that included the knowledge of relationship between the emotional
intelligence and the caring behavior of the healthcare professionals. Three primary healthcare
professionals were identified in the study that included physicians, nurse leaders and nurses.
The nurse’s emotional intelligence were associate with both emotional and physical caring
and in case of physicians and nursing leader the emotional intelligence was less relevant.
Hence, the study gave a detail insight about developing emotionalintelligence among nurses
that will exhibit positive impact on the caring behavior of the healthcare professionals and
assist the patient with better health outcome. According Scanlon et al., (2016), the concept of
quantitative occupational stress risk assessment (OSRA was highlighted that is evaluated to
understand the influence of lifestyle under health promotion (HP) and the consequence of the
stress that result in the development of risk factor for the nursing staff. The concept of
perceived stress was defined and the effect on registered nurse due to the excess stress. The

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researcher had also highlighted the risk factors that were responsible for excess stress among
the nursing staff like lack of staff support and treatment facilities, poor job satisfaction and
bad employee health.
Research gap
Though there are literary articles that showed a relationship with positive
relationships with the nursing strength and decrease in the medication errors, but majority of
the research were either observational studies or conducted over any particular hospitals or
hospital. The lacked the generalization of the data. Moreover, none of the research conducted
so far have studied the perception of the nurses over increasing the nursing strength and
reduction of the medication error. Opinion coming from the nurses will help to bring an
effective organizational change. Thus, this research proposal is novel.
Methodology
Research design
The research design is used to highlight the steps used for the conducting the research
starting from the process of data collection data synthesis and analysis (Saunders et al.,
2015).
Research philosophy
It helps to highlight the underlying concept behind the collection and interpretation of
data (Hughes &Sharrock, 2016). Positivism, realism, interpretivism and pragmatism are
common research philosophies used in the research (Creswell & Clark, 2017). In this
research, the author will use pragmatism as the main research philosophy. It will help to
establish and explore the relationship between the poor strength of the nursing profession in
the hospital unit and encountering medication errors during the duty hours. Pragmatism seeks

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to establish relationship based on the lived experience (Mayer, 2015). Thus, it will be helpful
to use the experience to nurses to describe how increase in nursing stress helps them to
concentrate on their work and to avoid medication error.
Research approach
Deductive and inductive are two types of research approaches commonly used in
research. In this research, the author will use deductive research approach. Through deductive
research approach, existing literatures will be used to identify theories and prevailing ides
that will be subsequently verified by the research with the use of the data collected in the
research. Inductive research approach is not suitable for the study as it deals with generation
of new theory by the use data represented in the research (Creswell & Clark, 2017).
Research strategy and time horizon
Exploratory, causal and descriptive are three main research strategies. This research
will employ descriptive research strategy(Brannen, 2017). This research strategy will help to
validate and to explain the research hypothesis over the specific group of population. Here
the research hypothesis is increase in nurse population or staffing will help to reduce the
medication error. Deductive research approach thought popular was opted but because it
helps to analyse the problem that has not been studied before in order to set the priority
(Bryman, 2016). However, the problem of medication error has been studied before
extensively thus deductive research approach is not suitable for this research. The time
horizon will be cross-sectional study. It is a kind of observation study that analyse the data
over a particular subset of population during a single point of time and not during multiple
interval like the longitudinal studies (Brannen, 2017).

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Research methods
There are three types of research methods namely qualitative, quantitative and mixed
method. Here the researcher will use qualitative research methods in order to analyse the
textual data that will be collected through interview. Quantitative research method was
avoided was it help to establish the statistical relationship between the two variables
(Bryman, 2016). Since only qualitative data will be collected in the research, mixed method
is avoided as it deals with analysis of both qualitative and quantitative data (Creswell &Poth,
2017).
Target population and sample size
The nursing professionals are the main target population of this research as
highlighted in the PICO questions. Registered nursing professionals who have more than 1
year of experience under the Australian Healthcare system (hospitals) will be selected for the
study (interview process). The sample size of the conduction of the interview will be 25
nurses working in state and privately run hospitals in Australia.
Sampling
The sampling is a process of selection of the sub-set of population from the pool of
population. There are two types of sampling, probability and non-probability sampling
(Etikan, Musa &Alkassim, 2016). Here the researcher will non-probability sampling as the
sample size is small. However, probability is sampling that use random selection of the
candidates in the study population is more unbiased in comparison to non-probability
sampling (Emerson, 2015).
Questionnaire Development Process
Questionnaire development was done based on the information gathered from the
review of literature. This will be followed by specifying the pattern of the questionnaire used

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in conduction of interview. The third step will involve selection of the wording used in the
questionnaire that will help to extract the required excerpts from the nurses. The reliability
and the validity of the interview will be determined by conducting a pilot test over the nurse
managers selected randomly. Their feedbacks will be used to modify the questionnaire
further (Noble & Smith, 2015).
Data collection and analysis
The data collection will be done through face-to-face interview conducted with the
help to the open-ended questionnaire. Telephonic and email based interview are other modes
of data collection in qualitative interview (Ranney et al., 2015). However, in order to study
the emotions and reactions of the nurses, face-to-face interview mode was selected for data
collection. The data of the interview will be recorded in the audio-recorder. Thematic data
analysis will be. The recorded interview will be transformed in to written format and themes
will be generated from significant statement of the interview (Neuman& Robson 2014).
Ethical considerations
Confidentiality and data security
In order to ensure privacy and confidentiality of the data, the name and other personal
identification details of the participants of the interview will be kept confidential. The name
of the participants will not be used anywhere in the research. During the generation of written
transcript, the transcriptionist will be nit aware of name of participants. The name and other
details will be kept secured in the computer of the first author and the folder will be password
protected.

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Inclusion of informed consent
At first 50 prospective candidates will be selected for state and private run hospitals in
Australia (the hospital that will given consent to conduct an interview over their registered
nursing professionals). Each of the 50 selected candidates will be forwarded with a letter
(informed consent letter) in their official email address. The letter will contain the scope and
the purpose of the interview and the duration of the interview. The letter will also highlight
that no objectionable questions will be used in the interview process and they can leave the
interview during any time without any notice placed beforehand. The first 25 nurses who
revert back to the mail giving the consent will be selected for the interview process. Ranney
et al. (2015) stated that preservation of the autonomy of the participants of the interview is
the main purpose of the taking the informed consent.
Indication of safety issues
In order to ensure the safety of the overall process of conduction of the interview, the
date and the time of the interview will be schedule as per the convenience of the nursing
professionals selected as interviewee. This will help to upheld the ethics of autonomy. The
interview will be devoid of objectionable questions that might hamper the dignity of the
interviewee.
Indication or risks to subjects/researchers
Since do direct interventions is applied over the nurses or patients or the selected
target population of the interview, there is no threat of risk. Interview will be conducted
during the recess time of the nurses as per their consent in order to avoid the generation of
further stress during their duty hours.

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Conclusion
Summary
In summary, it can be said that this qualitative interview based study will tend to
focus on the opinion of the nurses regarding how increasing the nurse to patients’ ratio helps
to decrease the overall chances of medication errors.
Study limitations
One of the limitations of the study is the sample size. The interview will be conducted
over 25 nurses only selected from the state and privately run hospitals. The small sample size
will help to prevent the generalization of the data (Ranney et al., 2015). Moreover, the study
will use non-probability sampling for the selection of the target population and this can be
regarded as other limitations of the study as it will increase the chances of the selection bias
(Ranney et al., 2015).
Study implications
The implications of the study is, if positive association is found with the nursing
staffing and medication error then it will help to bring a change in the healthcare
organisational practice. This change in practice will help to improve the overall health
outcomes by improving patients’ safety and decreasing the overall cost of care. The results
will also help to highlight how the occupation health and well-being like reduction of the
workload, work stress and extended shift hours helps to bring a positive change in the nursing
environment. This reference will help in effective human resource planning in the nursing
profession. The resources will be divided based on the patients’ strength in different units of
the hospitals like emergency units that has maximum flow of the patients during any time of
the day will have maximum nursing strength to manage the care process accordingly.

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