Impact of Nursing Shortage on fall rates


This study sought to find out the impact of nursing shortage on fall rates.   The paper begins by explaining why the topic was chosen and its importance to nursing discipline. The problem had also been explained in detail including its outline, its background information and some of its possible causes. An in-depth literature review on about thirty sources concerning the topic was conducted. Scholarly articles a detailed discussion of the methodology that was used for the project was presented. The methodology used in this research is divided into six sections: evaluation methods and tools, data integrity, research design, research methods, participants, and permissions. The research keenly considers the challenges expected in a collection of data such as possibilities of errors and the biases involved. Finally, the findings are consolidated, studied once again keenly and analysed accordingly without biases. A detailed summary of the findings will be given and all the research questions will be answered with reference from the findings.


Table of Content

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Abstract………………………………………………………………………………………….. 2

Acknowledgements …………………………………………………………………………………………………………3

Chapter 1: Introduction to the Problem………………………………………………………………………………. 7

Introduction…………………………………………………………………………………………………………. 7

Problem Statement………………………………………………………………………………………………… 9

Research Question……………………………………………………………………….12

Chapter 2: Literature Review………………………………………………………………………………………….. 14

Introduction……………………………………………………………………………………………………….. 14

Shortage of Registered Nurses and Patient Safety………………………………………………….. 15

Understaffing of Nurses………………………………………………………………………………………. 16

High Quality Care………………………………………………………………………..18

Fall Risk Factors………………………………………………………………………….19

Competence of Nurses……………………………………………………………………21

Work Environment………………………………………………………………………22



Chapter 3: Methodology…………………………………………………………………………………………………. 24

Introduction……………………………………………………………………………………………………….. 24

Evaluation Methods and Tools……………………………………………………………………………… 24

Data Integrity…………………………………………………………………………………………………….. 25

Research Design…………………………………………………………………………………………………. 26

Research Methods………………………………………………………………………………………………. 26

Participants………………………………………………………………………………………………………… 27

Permissions………………………………………………………………………………………………………… 28

Chapter 4: Findings…………………………………………………………………………………29

A Data Driven General Summary of the Results…………………………………………29

Data Analysis…………………………………………………………………………….30

Answers to the Research Question Based on Data Analysis…………………………….33




          Chapter 1: Introduction to the Problem


The effectiveness of any institution largely depended on the staff, their quantity as well as quality. The quantity part was still more important because if for example there were a few members of staff who were highly qualified, then the services could most probably be ineffective. A large number of that staff made it easier for them to be able to give more services at a reduced energy than when they were few. This meant that there was a need to have highly qualified staffs in institutions as well as good number that increased the efficiency of that institution. It was crucial for hospitals to have enough medical practitioners like nurses. Shortage of nurses was the lack of enough supply of qualified nurses in the health care field. It was a situation where the demand for nursing professionals exceeded the supply of their services in the health care facility.  The shortage of competent health practitioners including nurses was taken to be one of the principal barriers to effective health systems across countries in the world. Countries all over the world faced serious nursing shortages as they were confronted with increasing health care needs and retreating numbers of nurses. This shortage of nurses was a risky deficiency of qualified nurses who were required to care for patients and the population as a whole. It was worth noting that nursing was a distinctive controlled ground and sovereign occupation whose qualified practitioners saved lives and advanced patient outcomes in extensive assortment of settings (Buerhaus, 2005).

There were a number of reasons as to why this topic was chosen. The patient healthcare has been compromised due to nurse shortages in various hospitals all over the world. This impacted negatively on patient outcome. Reports indicated that many patients were at a high risk of death due to inadequate healthcare as the number of nurses in the hospitals could not meet the patient demand.  First of all, this was because there was reasonable evidence of a shortage according to the quality of services that were offered in hospitals. An increased number of patients who frequented the health facilities for checkups as well as treatment had been witnessed on the one hand, and on the other, little was being done to raise the population of nursing staff that took care of the services in the health facilities. There had been an outward expression of violence by a number of them. Some patients had developed some complications while still in the facilities as compared to their state hitherto. As an example, a number of patients showed stable conditions when they entered the facility, but while still in the facility, the conditions worsened. This had created serious dangers of likeliness of death. This has created a huge problem that needed to be addressed urgently by both the concerned governments as well as the health facility management

In the second place, the attention to the patients was very little in some health facilities. Long queues discouraged many from coming for medical care. Some patients failed to be served because they were last in the long queues and the procession order did not favour them, hence they ended up being discouraged from attending the health facilities. In the same way, some health facilities that had chosen their working hours making them to close at that scheduled time made it hard for some patients to get any medical attention in the stipulated operating hours.

Thirdly, researchers had discovered new diseases and conditions that affected the life of humans. As a result, of course, the population around the globe had been affected adversely because of the numbers that was reported to have these diseases. Some of those diseases were treatable but the increase in the numbers deterred effective services rendered on the patients. This called for an increase of the numbers of nurses that helped in limiting this rise of the number of patients.

The project was quite important to the nursing discipline in several ways. Investigating the problem of the impact of nursing shortage revealed the problems that nurse’s faced in their careers. First, investigating the problem of the impact of the nursing shortage revealed the conditions in our hospitals. Maybe nobody wanted to know if there was any impact in nursing shortage  or whether there was any challenges facing them at all. Secondly, there was some slowness in the government to recruit more nurses. Knowing that there was reluctance in the government helped in contacting as well as addressing the relevant channels on the problem for a rectification. Thirdly, there could be a small number of students enrolling in the nursing colleges, probably in fear of being challenged by the difficulties that they have to bear in the latter days of their career. Knowing these possible challenges to the nursing career was very important to nursing discipline. It helped to prepare myself psychologically for the future or to garner up support to push for the betterment of the carrier to be able to render effective service to the patients in various hospitals in the world. Fourthly, there was an importance to get general information about the current affairs in one’s profession so as to be able to speak right away what one thought was most significant.

Problem statement

The roles played by the nurses included critical activities such as monitoring, wound dressing, and general ward care and active roles in administration and ward management. Organizations are not the only ones that allude to a scarcity of health personnel and the nursing profession more specifically. From a general perspective, when there were so many patients demanding services from few nurses there was usually a resulting degradation of hospital care. These places uncalled for strain on hospital staff and increased the risk of preventable conditions making headway in life threatening stages for patients. Qualified nurses who had withdrawn from the profession ended up returning to work after nursing ratios are less than the international standards. As Knight (2000) points even though clearly identifying shortages of nurses in general, as well as particular shortages at the professional nurse level in the health care system, it is, however, very difficult to quantify if there is a shortage or not the only way one can define if there is a shortage is if the health services identify what is their need.

In recent years there was a significant increase in nurse shortages and this had an impact on the system of health care delivery. Many of the hospitals lacked registered nurses. The shortages were as a result of increased registered nurse utilization due to the increased demand of registered nurses to meet the increased patient and hospital demand. The shortage of nurses presented a big problem in the nurses’ quality work, the patient care quality as well as the time nurses spent taking care of the patients. Nurses reported dissatisfaction as well as emotional exhaustion due to much workload. They had more patients to attend to which increased their workload. This resulted to high nurse turnover thus leaving many of the hospitals without adequate nurses thus compromising the patient safety. Lack of registered nurses continued to impact negatively on the patient care. It also undermined the achievement of health care set goals in many of the hospitals. This resulted in poor patient outcomes due to a few nurses attending many patients making the nurses to have minimal time that the nurses spent with the patients. As more patients were taken to hospitals, the workload of the few nurses increased thus they became incapacitated, thus the survival rates of the patients decreased due to inadequate quality care that they got from the hospitals. Nurse shortages in hospitals have therefore put many of the patients in danger as there were more deaths reported due to either neglect or failure to get appropriate diagnosis and treatment. It is therefore important for the governments and the hospital managements come up with strategies and policies that can address the issue of nurse shortages (American Association of Colleges of Nursing, 2012).

There is a direct need for elimination of the nursing shortage. The primary contributing factors to the nursing shortage which if the shortage is not addressed it will only aggravate the situation include high patient-to-nurse ratios resulting in nurse exhaustion, burnout, job discontent, diminished patient safety, and the perception of nurses is all part of a vicious cycle that compromise the overall health care delivery system. There is emerging nurse shortages due to multiple factors such as the demographic changes which affect the demand. Nurses report greater job dissatisfaction and emotional exhaustion when they are responsible for more patients than they can safely care for (Subedar, 2006).

The shortage of registered nurses renders the profession not well staffed due to low enrolment. There has been a decrease in admissions into nursing schools due to the decreasing number of nursing educators. In addition, the ages of the faculties continue to climb; higher compensation can be found elsewhere luring potential educators away from teaching (Hall, 2003). The problem is exuberated further by the fact that RNs are approaching retirement age and the nursing occupation faces difficulties attracting new candidates and retaining the existing workforce. Furthermore, widened patient-to-nurse staffing ratios are associated with higher mortality rates, greater incidences of medical complications and errors, lower job satisfaction, and more burnout among nurses. The rising attrition rates have also contributed to the shortage of not only the experienced nurses but also the new ones (Buerhaus, 2005).

The combination of a high disease burden, ageing nurses, and possible maladministration of public hospital funds leads to increase in disease burden since the care offered is not taken seriously. As the disease burden increases, more people become dependent on hospitals and nurses’ workload becomes heavier. The nurse/patient ratio ultimately determines nurses’ workload, job satisfaction and effectiveness of care. This ratio also closely correlates with mortality rates in hospitals. Nurse/patient ratios in hospitals are akin to teacher/learner ratios in schools. The higher the number of learners to each teacher, the more unpleasant the school becomes for both groups.

A number of solutions have been offered so as to attempt to curb the rising problem of the patient falls. Firstly, the employment of temporary nurses within the health care facilities would effectively reduce the load that is carried by the overall number of nurses, while still not unnecessarily outing too much strain on the facilities’’ budget. However, the number of the temporary nurses that are hired have to be within a given limit as this would have the reverse effect if this limit is over-exceeded (Gay et al., 2009). A second solution is the encouragement of the nurses to spend more time with their patients as this would reduce the occurrence of unmonitored patient incidents and deterioration. However, this has to be coupled with an increase in the number of nurses within the healthcare facility, which would even out the ratio of nurses to patients and reduce the strain on the nurses. Finally, the employment of more permanent nurses within the health care facilities would effectively increase the amount of care offered to the patients, thereby reducing the fallout rates of the patients.

Research Question(s)

The study was aimed at exploring the effects of the shortage of nurses within the healthcare industry and the results that this had on the increase in the number of patient fall rates. As such, the study sought to respond to the following research question.

What is the impact of nursing shortage on fall rates?

Definition of terms

AACN – American Association of College of Nursing

CINAHL – Cumulative Index to Nursing and Allied Health Literature

CNA – Certified Nursing Assistant

ICU – Intensive Care Unit

IRB – Institutional Review Board

RN – Registered Nurses

VHINL – Virginia Henderson International Nursing Library



Recent evidence suggests that the availability of nurses in large numbers will inevitably lead to better patient outcomes if other factors remain constant despite the cost incurred by long-term care providers in the increasing of nurse staffing. Furthermore, fewer patients per nurse is associated with fewer adverse outcomes. Staff shortages will also create some quality challenges and unexpected costs in the long run. There is a more likely trade-off decisions the management is willing to make either in investing in their staff (termed as the current turnover asset) or on other quality-improvement decisions.


ChapterLiterature Review


The research was conducted from a number of sources that proved to have accurate information about the topic. The authors of the research articles presented enough evidence for their arguments to be persuasive and supported the information by actual facts that resulted from actual studies. The research began by mentioning the objective of the study and how the study was important in this practice, the results of the study and how important it was to the concerned parties.

A shortage in the number of nurses in several facilities of health care negatively influenced the outcome of patients as well as the standard of the care that was given to patients. This shortage caused a rise in fall rates in many health facilities since patients got substandard care. The ratio of nurses to patients in the healthcare facilities was far from reaching the stipulated range because the nurses were compelled to give care to many patients. This literature review was built on six main themes that addressed the issue of shortage of nurses and an increase in fall rates. The first theme of the literature review explained why shortage of registered nurses compromised the safety of patients putting the patients at risk of falling. The second theme was that understaffing increased the chances of negative outcomes in the hospitals predisposing patients to fall. The third theme concerned the need to consider the nurse-to-patient ratio in developing and implementation of staffing policies as an important aspect of reducing fall rates. The fourth theme concerned the consequences of poor quality care that resulted from understaffing that included increased fall rates and high mortality rates. The fifth theme concerned fall risk factors such as age and severity of the sickness. The six themes concerned the competence of nurses and the importance of good work environments as motivating factors that enhanced quality of care and reduce fall rates among patients.

Shortage of Registered Nurses and Patient Safety

Bruce et al (2010) investigated the relationship that exists between the number of nurses who are registered and the safety of patients in a health care facility. They specifically examined the effect of a shortage of registered nurses on fall rate. The study revealed that the use of temporary registered nurses results to poor outcomes among patients as indicated by the constant increase in patient falls. Such an increase, according to the study, is closely associated with substandard care that patients get whenever there is an inadequate number of registered nurses in a health facility. This study indicated that increasing the number registered nurses enhanced patients’ care and this translates into a reduction in decrease in fall rates. In facilities that have an adequate number of nurses, nurses have adequate time to attend to patients. This was revealed in a study that was carried out by Creswick et al (2011). In their study, Creswick et al (2011) analysed the time that is spent with patients and the effect it has on the outcome of patients. The time that nurses take with patients, as this study revealed, is positively correlated with the patients’ outcome. In those cases where nurses spend a longer time with patients, there are usually very minimal chances that patient falls will be reported. The patients will, therefore, not be among the increasing statistics of fall rates. The time taken is part of the care that is given to the patients and that many patients require. The authors have suggested that the time spent with the patients, has some effects on the patients. In this case, increasing the number of registered nurses in a health facility enhances the safety of patients since the nurses get adequate time to attend the patients. Whenever adequate nurses are hired to attend to patients in a health facility, some people may wonder whether the quality of the services offered is enhanced. Katya et al (2002) sought to investigate this issue. In their study, Katya et al (2002) carried out an investigation on how the number of nurses in a hospital affected the standard of care given to patients. In their investigation, it was revealed that increasing the number of nurses to match with the number of patients improved the standard of care given to patients because the nurses are not under pressure to execute their duties. As this study revealed, nurses can only serve the patients without haste if they are adequate to cater for all the patients present in the facility.

Understaffing of Nurses

People who visit health facilities expect the outcomes of the therapy or treatment that they get will be positive. They usually have high expectations of improvement of their wellness and assurances of support and continued care from the nurses. This has however not been the case as many patients continued to report negative outcomes that can be associated with inadequate or lack of proper care by nurses. One of these studies was conducted by Jawad et al (2003) who sought to find out the connection between the number of nurses in facilities that provide health care and the outcome of patients. The study also sought to find out whether the ratio of nurses to patients in hospitals has a considerable influence on patient falls. The study revealed that the number of nurses in healthcare facilities and the patient outcome were positively correlated. This means that the largest number of negative outcomes among patients was reported in health care facilities that had inadequate number of nurses as compared to the need of their services that is usually defined by the number of patients present. A similar study was conducted by Diane (2004) whose aim was to investigate how nurse staffing affects the patient outcomes. In this study, it was revealed that nurse staffing reduces the patient falls. The results of the study indicated that patient outcomes are highly influenced by staffing where healthcare facilities with adequate number of nurses to match with the need for their services reported more positive outcomes among patients. The issue of understaffing is, therefore, a major threat to the provision of quality care among patients. The negative effects of nurse shortages have been manifested in the increasing negative outcomes in those facilities that lack an adequate number of nurses. This was clearly revealed in a research that was conducted by Lau et al (2009). In this research, Lau et al (2009) sought to examine how nurse shortages in healthcare facilities impacts on patient outcomes and patient care. According to the findings of this research, positive patient outcomes are increased whenever there is an adequate nurse staffing and this is revealed by increased patient falls whenever nurse shortages are reported. The need for increasing positive outcomes brings about the issue of staffing policies that healthcare facilities should adopt to reverse the increasing fall rates. Understaffing compromises the security of patients besides increasing the number of negative outcomes that are reported in healthcare facilities. Many studies show that the staffing levels of nurses contribute to the adverse outcomes of patients in a hospital setting such as increased fall rates. Evidence on this issue is well documented in numerous studies that have been conducted on the same. McGahan, Kucharski, and Coyer (2012) carried out a study whose aim was to review the literature published in the past ten years examining the association between staffing levels of nurses and mortality incidences in addition to morbidity among adults’ patients in intensive care unit (ICU). The study involved literature search since the year 2002 up to 2011 using Cumulative Index to Nursing and Allied Health Literature (CINAHL), the database in Australia and Medline. The literature review included 19 articles. The results from these studies showed that the increase of nurse staffing resulted to a decrease in adverse events and increase in patient safety in terms of patient fall prevention. Similarly, Di, Christine, Peter and Patricia (2010), conducted another research review that sought to investigate the link between nurse stuffing and patient outcomes. The study method involved the use of electronic search for articles using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline as well as Journals @ OVID. The results showed that there was a decline of 3 to 12 per cent adverse outcomes as well as 16 percent mortality risk reduction regarding surgical patients due to increased staffing of registered nurses. It is evident that nurse-staffing improvement is an investment that is cost effective but the health policy-advisors have not yet appreciated it in the health system. Every policy response, according to this research, should acknowledge the importance of patient safety and the need to reduce fall rate by spelling out the measures that should be taken if the number of patients increases or high turnover rate is reported among nurses in a healthcare facility. The policymakers should make sure that there are adequate registered nurses who are able to guarantee the patient safety by reducing fall rates.

High Quality Care

The issue of quality care in healthcare facilities should be approached in many dimensions. Increasing number of nurses where patients are many is just but one measure that policymakers should consider. Whether increasing the number of nurses is a sufficient measure to curb the increasing fall rates in healthcare facilities is a matter that has generated debate among researchers. One may wonder whether such a move alters the standards of healthcare that nurses should provide. Silber et al (2007) conducted a study on the shortage of nurses and its consequence on the safety of patients, the standards of the care given, as well as mortality rate among patients. The study revealed that hospitals with few nurses and high number of patients have more cases of medical errors and vice versa. The patient mortality, for example, is high and there are more patient falls. A low number of nurses, therefore, determines the care given to patients as well as their safety. In yet another study Wilt et al (2007) examined the issue of staffing as well as the care quality that is provided to patients. In their inquiry, they found out that nurse shortages have highly influenced the health care quality and this has led to higher fall rates. According to the researchers, nurse staffing influences the quality of the patients’ care implying that nurse shortage results to negative patient outcomes such as increased fall rates and even deaths.

Fall Risk Factors

Even though high quality care is important for all patients, many people have raised questions about whether some patients deserve more care than others. This question on the disproportionate provision of health care among patients received a boost when the issue of age and severity of sickness was raised. The issue of fall risk factors among patients and its impact cannot, however, be wished away. This issue has prompted many researchers to find out these fall risk factors where factors such as age, gender, diagnosis or severity of the sickness, time of day, physical factors, and environmental factors have been investigated. According to Rapp at el (2012), falls as well as falls related to injuries are among the leading problems in aged-care facilities. The aim of this study was to offer descriptive data regarding the falls within nursing homes. This study did a prospective recording on all falls for a period of one year covering the entire residents in Bavaria. Five hundred and twenty-eight nursing homes were involved in the study. The researchers used a standardized form to capture all incidences of reported falls. The standardized form included a code for facility identification, date, sex, age, needed care degree, time, sex, fall location and activities that brought the fall. In estimating the total person-years that were exposed as well as to calculate the fall rates, the researchers used data explaining the home-bed capacities as well as levels of occupancy. The residents needed care degree determined the stratification of all analyses. The researchers recorded at least seventy thousand falls in the course of 42,843 person-years. There was a higher fall rate in men as compared to women. The men fall rate was 2.18 per person-year while that of women was 1.49 per person-year. Fall risk varied by the care-needed degree whereby reduced fall risks were observed in the least as well as the highest categories of care. Almost 75 percent of the total fall rates happened at residential rooms or in bathrooms while 22 percent of the falls happen within common areas. Walking constituted to 36 percent of the falls while transfers consisted to 41 percent of the falls. In the course of the day, there was varied fall risk. Many of the falls were witnessed between 10 am up to midday as well as between 2 pm up to 8 pm. This study concluded that the varying patterns of fall risks in particular groups might assist to target measures of prevention. In yet another study, Jeniffer (2004) investigated the difference in preventing patient falls between the old and other patients. It was revealed that fall rates among the aged and its severity is higher as compared to younger patients. It was also revealed that there is a possibility of utilizing the nursing staff to lessen the patient falls. The study revealed that increasing the number of nurses can help to reduce patient falls especially among the old. In a similar study, Penoyer (2010) points out that there is a high correlation between staffing of nurses and the patient outcomes among critically ill patients. Critically ill patients require healthcare facilities to increase the number of competent nurses in order to improve healthcare quality. Majority of such patients have very minimal chances of survival when they fall. The main aim of this study was to evaluate the literature related to nurse staffing and the patient outcomes in ICU. The study used annotated review method where literature review of the key nursing as well as medical literature concerning the staffing of nurses as well as patient outcomes since 1998 up to 2008 was reviewed. A total of twenty-six studies were reviewed. The study results showed that a decrease in nurse staffing led to adverse patient outcomes in ICU patients. This review shows that it is important for hospital stakeholders to understand the need for nurse staffing in the ICU patient in order to be able to make decisive decisions concerning the nurse provision resources in the hospital. In yet another study, Liang, Chen, Lee, and Huang (2012) investigated the association between staffing of nurses and the patient mortality in acute-care hospitals in Taiwan. The study involved a stratified random sampling method where the researchers selected 108 wards from thirty-two Taiwan hospitals. A longitudinal panel survey was used to obtain data whereby a questionnaire that consisted of ward characteristics, patient demographics, patient outcomes, nursing manpower, and hospital characteristics was used. For statistical analysis, the study used mixed effect logit technique to determine the association between staffing of nurses as well as patient mortality. The results of this study demonstrated a strong relation between staffing of nurses as well as patient mortality in acute-care hospitals. The study findings are consistent with results from other similar studies. It is evident in the study that when the nurses have high nursing hours in acute-care hospitals, reduced patient fall rates are reported.

Competence of Nurses

Competence of nurses and their morale in the practice of nursing is also an important aspect to consider while examining the issue of fall rates. According to Butler at el (2011), nurse staffing is highly linked to organizational outcomes, staff related outcomes as well as patient outcomes. Butler carried out a study to determine the nurse staffing effects on patients as well as staff related outcomes. The study search strategy involved Cochrane/EPOC resources like EPOC Specialized Register, DARE and CENTRAL. It also used PubMed, generic search engines, British Library, CAB Health, Virginia Henderson International Nursing Library (VHINL), Joanna Briggs Institute database, and global theses database. The researchers carried out trials that were randomly controlled as well as clinically controlled prior and after the studies. The participants included nurses as well as patients in a hospital setting. The study included any patient or nurse related outcome objective measures. Seven reviewers who were working independently in pairs to obtain relevant data from the relevant studies collected the data. The study identified 6,202 articles that were relevant to the review. Each article was thoroughly examined and important details obtained whereby researchers chose 15 articles that were the most relevant. The review showed that increase in the number of nursing specialists led to shorter stays in the hospital, reduction in cases of pressure ulcers, as well as reduction of fall rates. This study also suggested that support staffs who are specialized may highly affect the patient outcomes besides reducing fall rates. It was also found out that primary nursing as well as self-scheduling nursing may decrease the staff turnover. The results of this study suggested that some nurse staffing interventions improve patient outcomes where competent nurses revitalize the working force among nurses. The morale of nurses is not only determined by their competence in executing their roles but also by the state of their working environment.

Work Environment

Nancy (2010) did a research to examine how the work environment affects the patient outcomes. Work environments that are poor results to negative patient outcome such as patient fall and high mortality rates. This study is important as it assist in understanding the effects of nurse shortages on patient outcome. There are no limitations in this study therefore the health providers, governments, nurses as well as students can use it when making decision concerning nurse staffing. The findings of this study reveal that patient outcomes are affected by the work environment.

Summary of current Best practice

There is a significant difference in outcome observed in high and low staffed institutions. An immense mass of data suggests that adverse outcomes will be experienced in low staffed institutions relative to those which are high staffed. Despite the lack of guaranteed improved outcomes with increasing staffing alone, it will be wise and even cautious to adjust the level of staffs in the frequency of outcomes sensitive to the number of staffs.


Rising fall rate was a big problem in many healthcare facilities. This literature review raised several issues relating to fall rates. One of the issues raised concerns the effects of nurse shortage in healthcare facilities and how nurse shortage caused some medical errors such as patient fall. Another issue concerned the importance of policy response in dealing with staffing issues in healthcare facilities. The review indicated that substituting those registered nurses with semiskilled nurses or health practitioners resulted to adverse patient outcomes including increased fall rates. The review highlighted the trend found on many of other studies that linked increased staffing of nurses to the decline in fall rates. It was evident from the review that the times spent with patients and patient outcomes were positively correlated. In this regard, one of the reasons why nurses took little time with patients resulted to increased fall rates were clearly identified as understaffing. It was also clearly demonstrated why there was great need to hire more nurses in health care institutions that were understaffed. An insight in the use of nurse-to-patient ratio had been identified as a good measure of knowing where there was understaffing and how to prevent falls among patients with special attention to elderly and those people who were critically ill. The review also showed the importance of strengthening nursing profession and enhancing quality of services through adequate staffing as the best way of reducing fall rates. The review identified some of the consequences of fall-physical injuries as increased mortality rates and longer stays in hospitals that had led to dire financial impact. Since understaffing was identified as the greatest barrier to implementation of fall prevention strategies, the review identified staffing as the best fall prevention strategy.

Chapter 3: Methodology


            This chapter provided an overview of the methodology that was used both in the qualitative and quantitative study.  The chapter was divided into six sections: evaluation methods and tools, data integrity, research design, research methods, participants, and permissions.

Evaluation Methods and Tools

The researcher evaluated this research project by conducting a formative evaluation (Sharma & Petosa, 2014). In this case, the researcher asked the participants to complete an evaluation during the period of conducting the research. This helped in adjusting to the newly emerging needs that would arise in the course of the research. In collecting the feedback, the researcher monitored the timelines for the project. Whether the project reached all those participants targeted, the number of participants that was expected to participate, and whether there were adjustments that were required were other issues that the evaluation captured.   The evaluation process helped in documenting whether health interventions in the nursing field was of the required quality. This evaluation also described the outcomes of the intervention implementation. The evaluation results provided data on all the intervention components and the patients. Ensuring that the study met all the required standards guaranteed the quality of the study.

The use of formative evaluation allowed the researcher to collect rapid and meaningful diagnostic feedback in this study. The tool that the researcher used in this formative evaluation was the feedback loop. The researcher completed this tool in the course of the study. This tool drew lessons that readers were expected to learn from the study’s outcome metrics through an iterative basis. It involved the collection of social indicators as well as analysing them regularly and with rigour (Bradshaw, Bradshaw, & Lowenstein, 2007).

Data integrity

In order to maintain the integrity of data, the following measures were taken.  All the notes that were collected during the time of data collection were kept in order to account for everything that occurred.   That helped in the reconstruction and justification of the research findings. Those notes contained crucial information about methods that worked and observations as well as project’s progress. Personal notebook also accompanied the notes. The researcher   noted all errors by use of a consistent system to ensure that data was neither altered nor damaged.  The researcher also recorded any change to the data including the changes that was done and the date these changes were made. Any relevant information was also recorded. Since printed questionnaires were used in data collection, the data were converted to an electronic format where a system of double entry was used to minimize the rates of incorrect entry. In this case, there was no data entry clerk because the researcher keyed in the data into an SPSS software program. After data entry, a data crosscheck was conducted to identify any inconsistency and remedy it. The data was then stored properly for future reference. Proper storage allowed other researchers to evaluate or even use the research results in the future (Clinical tools Inc., 2006). In this study, the researcher bore the responsibility to store any information collected.

Research design

This research took a week to complete. The researcher conducted interviews to collect data on attitudes, concerns, feelings, values, and nursing interests and issued out questionnaires. Such a design helped in explaining all the current conditions by using numerous subjects with a keen interest in their in their intrinsic expression that helped in describing the entire phenomenon of increased fall rates in the nursing home. Some of the questions that the researcher asked the Director of Nursing included the following.

  • What is the ratio of nurse to patient during day shift, evening shift and night shift?
  • What is the ratio of Certified Nursing Assistant (CNA) to patient on each shift?

Fullerton, Severino, Brogan, and Thompson (2003) successfully used this design to conduct an investigation to delineate behaviour, knowledge as well as skills that characterized the competency domain among educated midwives. Just as in the case of this study, the data that Fullerton et al (2003) collected using stratified random sampling was quantitative data involving 214 participants. The same design was used in a study that Haberman et al (1993) conducted successfully to find out the perception of bone marrow transplantation survivors. In this study, 125 adult participants were involved. The study was large and used several designs that included cross-sectional, mailed survey, and descriptive design. The study accommodates huge sample sizes, guarantees results’ generalizability, besides being easy to administer.

Research methods

As earlier noted, the data that was collected in this study was both qualitatively and quantitatively. As a result, qualitative and quantitative research methods were used. There are numerous types of qualitative research methods. This study involved the use of only one method, which is the phenomenology type of qualitative research methods. This research method involved selection of participants who narrated the incidences of fall rates in the effort to investigate their causes and effects in the nursing home. In other words, the phenomenon under study in the increasing fall rates in nursing home. The participant’s experience was interpreted as captured in the interview that was conducted.

This method was adopted because it was the most appropriate since it was applied to numerous experiences. It was also used to examine a wide range of perspectives for all the participants that were identified for the research as well as their lengthy experiences.


The participants of the study were the members of the healthcare industry within a given nursing home (nurses and other staff members) together with the patients visiting the healthcare institutions within the period of the research. Stratified random sampling method was used, only educated patients who had managed to successfully complete their high school educations from all gender, race and economic status were selected. This was because some of the questions that were asked during the study required some educational background information, with the implication that they would not be effectively handled if they were given to individuals with a poor educational background.

The participants’ ages ranged from twenty to eighty years old. The genders of the participants were both male and female. Individuals who participated in the survey were from any ethnicity and race. The survey did not discriminate on the economic situation of the participants. This was because the information that was needed for the survey did not depend on the economic situation of the individuals who gave the answers to the questions (Jackson, 2008). Because of the nature of the sampling technique, the respondent pool was expected to have a mixed demographic and gender inclination, which did not necessarily alter the nature of the results collected by the study.


In order to obtain the required permission to conduct the research in the nursing home, the researcher contacted the Director of Nursing who assisted me in getting the Institutional Review Board (IRB) approval. The following process was followed in acquiring the IRB approval.  First, the researcher completed the NIH Web- based Training Course “protecting Research Participants”.     The researcher then reviewed all the current guidance as well as policies. The researcher then created   a RASCAL proposal that formed my IRB application. This application was accompanied by my research description, questionnaires that the researcher intended to use in the data collection process, consent form, and assessment form. The researcher was then given permission by the Director of Nursing to carry out the research in the nursing home. The consent of the patients who were identified to participate in the study was also sought where patients were issued with consent forms to fill. All the potential risks as well as the discomforts that were believed to occur were properly explained to the patients.   Attached, is a copy of the University IRB application form that was presented to the capstone committee chairperson for approval. Also attached is a copy of the informed consent form template that was filled by all participants.


In this chapter, the purpose was to describe the methodology used in this research, give a detailed explanation of the sample selected addressing their traits, measures taken to maintain integrity by the use of computer software’s. The data were collected and analysed from different patients in health care’s after the research was approved by the IRB

Chapter 4: Findings

The results of my project were presented and organized in the form of a report that was accompanied by graphs. The graphs acted as visual aids that accompanied the detailed and comprehensive report.

A data-driven general summary statement of the results

Increasing fall rates were a clear sign that the quality of services provided by the nurses was compromised. One of the main explanations was the job dissatisfaction and huge nurse workloads. As a result, nurse workloads should be decreased in order to improve the safety of the patients. Nurse-to-patient ratio was used to measure the number of patients that a single nurse attended to at any one particular time. For instance, a 1:5 or 0.2 nurse-to-patients ratio meant that one nurse was attending 6 patients at one particular time within a specific unit in a nursing home. Increasing the nurse-to-patient ratio meant that more nurses were available to attend to the patients. This implied that the higher the value of nurse-to-patient ratio, the better. The recommended nurse-to-patient ratio differs from one department to another (Lang et al, 2004). These ratios also vary from one state to another. Data on nurse-to-patient ratio (in decimal) was compared with that of fall rates. The following were the results of my project. Nurse shortage was defined as a situation when the nurse-to-patient ratio was low since one nurse was attending more patients than expected.

Among the key information that the research sought to get in the process of data collection included the following. First, it sought to find out what was the ratio of nurse to patient during day shift, evening shift and night shift. In response to this question, the research found out that the nursing home had 1 nurse for 17 patients dayshift translating to a ratio of 1:17. In the evening shift, 1 nurse had 22 patients translating to a ratio of 1:22. During the night shift, 1 nurse had 32 patients and this translated to a ratio of 1:32. I also sought to know what was the ratio of Certified Nursing Assistant (CNA) to patient on each shift was. The information obtained was that 1 CNA had 10 patients’ day shift, 15 patients’ evening shift, and 28 patients night shift. The information also revealed that fall rates were reported when the number of patients increased.

Data analysis

The data was analysed by running a regression analysis that generated the graphs in figure 1 and 2 below.

Figure 1: Fall rates and nurse-to patient ratios

The graph above represented fall rates in the vertical axis and nurse-to-patient ratio in the horizontal axis. The graph indicated that fall rates and nurse-to-patient ratio are inversely related. An increase in the nursing shortage was depicted by a decrease in nurse-to-patient ratio because the denominator that represented the number of patients under one nurse increased. In this case, the value of y (fall rates) decreased as that of x (nurse-to-patient ratio) increased. It implied that nurse shortages increased when the denominator (patients) was too large or when the nurse-to-patient ratio was minimal. As indicated in the graph above, fall rates dropped as the nurse-to-patient ratio increased implying that fall rates decreased when nurse shortages decreased. One can, therefore, conclude that nursing shortage increases fall rates. This relationship was confirmed by taking the reciprocal of nurse-to-patient ratio that gave the value of shortage of nurses. The graphs below indicated the resultant relationship.

Figure 2: fall rates and nursing shortages


The graph above showed that fall rates and shortage of nurses were positively related. As the nurse shortage increased, fall rates increased and vice versa.

In the two graphs above, the only way to reverse the trend was by altering the number of nurses. The patients who visited the nursing home cannot be limited or fixed because these were people who visited the health facility to seek for medical attention. Fixing the number of patients meant that some patients would be turned away even when they were in urgent need of medical attention. Such a move is unethical and unacceptable in the field of nursing where all patients must be attended for the sake of saving lives. Since the employer determined the number of nurses, they could be limited depending on the available resources. Fixing the number of nurses as the number of patients continued to increase meant that the nurses’ workload increased.   The need to take care of increased number of patients meant that nurses were overworked and the quality of the services in the nursing home was negatively affected. The management of the nursing home would, therefore, monitor the trend of patients within any particular period and decide whether to increase the number of nurses or not. Since an increase in fall rates signified a decrease in the quality of services provided by the nurses due to high level of workload, the management of the nursing home could intervene by hiring more nurses and retaining them.

The answers to the research questions based on data analysis

The study results revealed that high fall rates were reported during the night shift when the nurse patient ratio was 1:32. Important to note was the fact that the CNA-to-patient ratio during the night shifts was also 1:28. This indicated that nurses were overworked during the night shifts since they were supposed to take care of more patients that the other times of the day. The high number of patients who were attended to by a limited number of nurses during the night shifts was therefore the main cause of the increased number of fall rates that were reported.


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Appendix 1: Informed consent form template

Masters Degree


What is the impact of nursing shortage on fall rates?




You are invited to participate in a research project being conducted by researchers from xxxxxx is conducting research to determine whether the shortages of nurses in health care facilities increase the incident of patient fall rates. Several studies have previously linked poor staffing levels on certain health care facility units and adverse patient outcomes such as high fall rates. The purpose of this research is to test whether the shortage of nurses in health care facilities increases the incidence of fall rates among patients. Students will participate in a curriculum, which encompasses a succinct description of the effective nursing procedures, as well as proper nursing levels within healthcare institutions. This curriculum will also entail an examination of ways of reducing patient fall rates, as well as strategies to enhance nurse staffing in these institutions. The research will be conducted in health care institution and will take the span of one week to complete. The research will focus primarily on a nursing home facility that offers residential care for people in need of constant nursing care, but are prone to significant deficiencies with various activities of everyday life. All students will be expected to participate fully in all forms of routine classroom activities in order to complete the course effectively. The participants will be required to conduct interviews and apply questionnaires to gather pertinent information regarding the impact of nurse shortages on increasing fall rates. Participants will be required to perform these activities, in addition to regular involvement in, the curricular activities. Confidentiality will be maintained, records will only be seen by the researcher, and that all data that is reported will be aggregated. When individual or case studies are conducted as surety of anonymity must be indicated.

Participants are expected to participate in any regular classroom instruction but may choose to voluntarily participate or withdraw from video or audio taping and interviews. Participants may withdraw at any time from non-regular classroom instruction and will not be penalized for non-participation.

Participants and their legal guardians can contact the researcher via phone or email. My phone number is XXXX and my email address is xxxxxxxx

Participants and legal guardians have a right to the results of the study. In signing this informed consent, participants and legal guardians agree to participate in the research

Signature on Participant Signature of Legal Guardian




Typed/Printed Name Typed/Printed Name






Appendix 2: Application for approval of research project


Institutional Review Board

Application for Approval of Research Project

Directions to the candidate: Please complete each portion of this application, attach necessary documentation, and click submit.


Student ID Number:

Title of prospectus: What is the impact of nursing shortage on fall rates?

Capstone committee chairperson:

Degree/Discipline-MSN Education Specialization

  1. Describe the research method (s) to be utilized in this study. Include research question (s) as well as an explanation of the need for human subject participants.

The research methods to be utilized will be interviews, field notes, and focus groups. The research question is: What relationship exists between nursing shortage and patient fall rates? The research will appreciate the need for human subject participants to offer first-hand knowledge regarding the research issue.

  1. Describe the research procedures (s) to be employed in this study. Research procedures must include methods used to collect and analyze data.

The data collection techniques to be used will include observing, interviewing (including the use of focus groups), administering questionnaires,  and the use of field notes to document my observation. The researcher will analyze data through coding, use of computer software (for example, ethnography), and summarizing of data. Coding will be used for interview data. Ethnography will deal with the analysis of text data where graphs and flow charts will be used to present data. Summarizing will be done for audio and visual recordings. The filled questionnaires and other interview instruments that comprises of comments and information by the patients, Director of nursing, and nurses will be critically analyzed. This process will involve the researcher going through each and every questionnaire or interview sheet and pick on unique and high frequency information so as to build a data.

  1. Describe the use of any data collection tool (s) your study will employ. Attach any applicable documents to this application.

The method of data collection will be interviews, administering questionnaires, observation, and the use of field notes.

  1. Describe the human subject participant population. Include the following information: age, gender, physical or developmental disabilities, and any relationship to the researcher.
  1. The human subject participation population encompassed in this research will be residents of a nursing home facility, nurses and the Director of Nursing. These residents of the nursing home who form the bulk of this research’s participants include young adults with mental or physical disabilities and the elderly. The facility’s records indicate that these patients are aged between 22 and 68 years. This population includes both male and female patients, some of whom also receive occupational, physical, and other forms of rehabilitative therapies following the incident of illness or an accident. Notably, a small percentage of the nursing home’s resident population includes people with special needs, for instance, Alzheimer patients. Therefore, the human participant population of this research consists of individuals with mental, developmental disabilities. With regard to physical abilities, most patients in the health care facility were incapacitated by illness, accidents or old age. Nurses and, the Director of Will your population include any members of vulnerable or protected populations such as: pregnant women, children, prisoners, residents of a facility such as a nursing home or group home, individuals with mental or emotional disabilities, non-English speakers, individuals at or above the age of 65, traumatized individuals, economically disadvantaged individuals, employees of the researcher, or students of the researcher? If so, provide justification for the inclusion of this population in this study and describe how you will mitigate any potential conflicts of interest as well as provide for full informed consent of such participants.

The population will consist of people considered as vulnerable of protected members of population, which include residents of a nursing home as well as people above the age of 65 years. The human subject population will also consist of traumatized individuals who were victims of accidents that caused mental or physical incapacitation. The research will also involve economically disadvantaged individuals since it will be conducted in a governmental institution that provides residential care to all persons regardless of their economic standing. The researcher will provide full, informed consent of all participants by educating them on the research undertakings, as well as the purpose of the research. The researcher will obtain full, informed consent from family members of patients with mental disabilities. This informed consent will entail a concise assurance that participants’ information will be handled with utmost confidentiality and professionalism. The researcher will mitigate any potential conflicts by ensuring that all participants are aware of their rights with regard to pulling out of the research participant list. Participants will be informed additionally by signing the xxx university informed consent form prior to starting this research.

  1. If your population includes children under the age of 18, identify whether your study poses only minimal risk, greater than minimal risk but with a benefit to participants, or greater than minimal risk but with no benefit to participants.

None of the participants are under age 18

  1. Describe the steps you will take to minimize any risk to participants in your study.
  1. The researcher will be responsible for conducting sound research consistent with moral and legal requirements. This includes, among others, acquiring and properly documenting informed consent of participants. The researcher will minimize the incident of risk to participants by monitoring participants to detect harm by using clear-headed judgment to deter risk and modify research procedures to eradicate immediate risks. The researcher will minimize risks to study participants through implementation of a sound research design. This includes making sure that the autonomy of study participants is maximized, ensuring that benefits to study participants are maximized, and study risks are minimized. Participants will be fully informed of the intent and reasons for the research. Each participant will be fully informed of the benefits and risks of the study. Describe the steps you will take to ensure anonymity and /or confidentiality of research participants and collected data. If participants will not partake in the study in an anonymous and /or confidential manner, discuss why this type research design is necessary.

The researcher will guarantee participant’s anonymity by concealing their identities in all documents used during and resulting from research undertaking. The researcher will also assure human study participants of utmost confidentiality by restraining the number of persons with the right to access information offered by the study participants. The researcher will respect the right to privacy and anonymity by taking care to decide whether or not to record sensitive participant information. The researcher will take proper precautions to protect participant data confidentiality. For example, the researcher will remove any names, as well as other forms of information from which outsiders can infer identities such as location of the nursing home. No names will be recorded.

  1. Discuss the procedures you will employ to gain informed consent of participants in your study. Informed consent typically consists of a form signed by participants. Such documentation informs potential participants of the following
  • Description of the nature of the research study in lay terms;
  • The identity of the researcher;
  • Expected nature and duration of the participant’s involvement in the study;
  • Statement that participation is voluntary and can be terminated by the participant at any time without penalty;
  • Description of reasonably foreseeable risks and benefits;
  • Description of confidentiality procedures;
  • Disclosure of potential conflicts of interests; and
  • Parental consent (i.e. informed assent) for participants who are under 18 years of age.

Attach a copy of informed consent documentation you will utilize. You may submit the same document you utilized in your capstone prospectus.


  1. If your research study requires access to members of organizations, agencies, school districts, etc., please attach an official letter of permission from the institution(s) where you will conduct your research.

Attached approval letter from the Director of the Nursing Home facility





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