NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

Nursing Practice Concern/Problem

NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

The nursing shortage is a major problem in the USA and the current vacancy rate is at 15% (Gutsan, Patton, Willis & Coustasse, 2018). This has led to increased stress on nurses as the number of patients per nurse has increased. As a result, nurses have to work for longer shifts. In the current situation of COVID-19 crisis, it is evident. Increased work and lower nurse to patient ratio results in burnout in nurses (Chen et al., 2019). This further leads to errors in practice, poor patient satisfaction, poor quality of life, nurse’s intention to leave the job, and disruption in services provided by health care (Torun & Çavuşoğlu, 2018). 

The registered nurse (RN) staffing and national health care retention report from 2016 indicated that nurse to patient ratio in the emergency department (ED) is low. The turnover rate was at 21.1% in 2011, and it increased to 35% in 2016. The hospital separation rate was at 91% due to voluntary termination (Roth, 2017). Increasing turnover rate results in problems such as recruitment, training, and educating new nurses to counter the burnout. However, it takes time and resources to do that (Bakhamis, Paul, Smith & Coustasse, 2019). As a nurse in MSN speciality of nursing education, it is important to find an evidence-based practice (EBP) intervention that addresses the issue of burnout in nurses due to lower nurse to patient ratio.  

NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

PICOT Question

Whether increasing nurse-to-patient ratio and implementing EBP staff scheduling in emergency department reduces burnout in RNs compared to low nurse to patient ratio and non-EBP staff scheduling in two weeks.

Key Stakeholders

Key stakeholders in this EBP are patients, nurses, nurse leaders, nurse administrators, human resource manager, research nurse assistant, a nurse from the informatics field, and statistical assistant. 

Theoretical Framework

Iowa Model of EBP will be used for this EBP project. The framework uses a hierarchical process where stages. The first stage identification of the problem, creating a team for discussion, identifying factors that affect the problem, forming PICOT question based on initial research, collecting, synthesizing, and critiquing the EBP papers from recent publications, and interpreting the results from the papers. This is the first stage. After identifying the problem, the problem will be prioritized based on its effects on nursing, patient outcome, and health care services. Then a team is formed and this team includes nurses from different health care services, leader and coordinator, and other interdisciplinary stakeholders. After that, both external and internal factors that affect the problem will be analyzed. 

NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

Based on the critiquing of literature review, PICOT question will be formed by finding an intervention that is based on significant scientific evidence both statistically and clinically. Then comes the STOP and DECIDE stage where the change is analyzed to see if sufficient evidence is present to implement the change. If the evidence is not sufficient, further review of literature will be conducted else program will be implemented as a pilot EBP change. The change will be applied to smaller units to test their outcome. After that, the results will be evaluated to see if the practice has led to positive change. Then the change will be implemented on a large scale. If the results are not positive or need improvement then further research will be conducted. 

Literature Review

Chen et al. (2019) conducted a cross-sectional investigation study to find the effects of the nurse to patient ratio on nurse’s burnout, intention to leave a job, and satisfaction level. Authors used a self-administered and structured questionnaire to collect data from 1409 RNs working ED between 2013 and 2014. The study used convenience sampling and did not consider the work environment as a study variable. The result highlighted that increase in patient to nurse ratio reduces nurse’s burnout, intention to leave a job, and satisfaction level in nurses. The study has lower generalizability and bias due to the data collection method and study design. 

Dall’Ora, Griffiths, Ball, Simon & Aiken (2015) conducted an observational cross-sectional study on 31,625 RNs from medical units to find the impact of 12-hour shifts on the quality of life and burnout levels in the nurses. Cross-sectional surveys were used to collect data from 12 European countries. The result showed that an increase in 12-hour shifts increases emotional exhaustion, depersonalization, dissatisfaction with the schedule of work, and intention to leave jobs. As the study design uses survey design, biases are present and as a result, the reliability of the result will not be high. 

NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

The study conducted by Qureshi, Purdy, Mohani, & Neumann (2019) used an observational study design with simulation analysis where 252 RNs from the urban academic health care in Canada were recruited. The study used a convenience sample and the participants were subjected to a predictive simulation model to find and predict the correlation between nurse to patient ratio and quality of care, burnout, and workload. Historical and current data was fed into the system. The results highlighted that burnout decreases after increasing nurse to patient ratio as workload decreases and this result in an increase in quality of care. As the study did not gather the data from nurses to understand their perspective, the reliability of the result is dependent upon the accuracy and validity of simulator. 

The purpose of the study conducted by Arkin, Lee, McDonald, & Hernandez (2015) on 2917 RNs was to find the impact of the varying nurse to patient ratio on the patient mortality who had an aortic valve replacement. A cross-sectional observational study was conducted where EHR data and survey design were used as data collection method. It was found that there were 20% more deaths when nurse to patient ratio was 1/10 compared to 1/6. This highlight that increases in nurse to patient ratio reduces the mortality rate. The limitation of the study was bias and causation. 

Kleinpell, Ward, Kelse, Mollenkopf, & Houghton (2015) conducted a descriptive study on the 433 participants where 222 nurse practitioners (NPs) and 211 physicians to find the correlation between nurse to patient ratio, factors that influence the ratio, care provided, and work pressure. To collect the data, a web-based online survey was conducted. As a result, bias, lower generalizability, and failing to explain causation limitations were present. The result showed that inflow of patients, work pressure, the severity of care, and schedule affected the nurse to patient ratio and work pressure. 

A prospective study on 136 RNs from the Pediatric unit was conducted by Tubbs-Cooley, Mara, Carle, Mark, & Picker (2019) to find the correlation between the missed care, workload, and staffing in the NICU unit. Self-reporting after each shift and questionnaires were used to collect the data that included missed care count and nurse workload. It was found that an increased number of infants per nurse led to increase in 34% of missed care events. The study did not use a randomized control trial. This results in bias and poor causality. 

NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

Leigh, Markis, Josif, & Romano (2015) used the difference in differences study method to analyze whether the law of California on the nurse to patient ratio results in lower occupational injury, increase in quality of life, and quality of care. The data from the US Bureau of Labor Statistics and the California Employment Development Department was used, which included RNs and licensed practical nurses (LPNs). The study found that the law led to 55.7 less occupational injuries and lower number of illnesses per 10,000 nurses. The study has limitations such as assumptions were made, the short-term search conducted, standards of errors were not eliminated, and data might have a bias. 

A cross-sectional study was conducted on 510 Chinese RNs where Liu & Aungsuroch (2017) aimed to find the relationship between nurse to patient ratio, burnout, work environment, job satisfaction, quality of care, and intention to leave the job. Questionnaires were used to collect the data. It was found that lower nurse to patient ratio results in burnout, work pressure, intention to leave the job, poor quality care, and lower job satisfaction. The study did not consider nurses who left health care due to burnout. 

Tawfik et al. (2020) conducted a repeated-measures observational study on 276,054 infants and 397 nurses to evaluate the effects of staffing deviation on patient’s outcome by using a nurse staffing prediction model. The data was collected from EHRs, self-reporting, and questionnaire. The result showed that 35% variations in nurse staffing were observed and this resulted in higher infections in infants due to increased workload on the nurses. This highlight that poor staffing results in increased burnout and poor-quality care. 

Rushton, Batcheller, Schroeder, & Donohue (2015) conducted a cross-sectional study on 114 RNs who were working in a high-intensity workplace. The study aimed to create a 2-phase plan to reduce burnout and increase resilience by evaluating the impact of the high-intensity workplace on resilience and burnout in nurses. The study used questionnaires and six survey tools to collect the data. As a result, bias was present and generalizability was low. The result highlighted that there was an increase in fatigue and burnout levels due to an increase in the number of patients per nurse. Nurses in the work settings such as ED face such issues, and it was important to find interventions to counter the issues relating to burnout, nurse staffing, intention to leave the job, poor-quality care, and quality of life. 

NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

Data Collection Methods

Questionnaires, semi-structured interview and perceived stress scale (PSS) tool will be used to collect the data related to the nurse’s perception and experience. Self-reported error form will be provided to calculate the errors. Two groups will be formed. One will be the control group and others will be the experiment group. The data will be collected before and after the intervention. The process will be continued for two weeks and if needed data will be collected again to compare the outcome before and after increasing nurse to patient ratio. 


As the data will be collected periodically before and after the intervention, one-way ANOVA analysis will be used to compare the variance and mean of groups. The PSS scale score will be used to analyze the burnout levels in the nurses. The data will be compared with pre and post paired t-test. The SPSS 24.0 software suite will be used to perform these analyses. The significance of intervention will be analyzed based on the correlation value between the groups and PSS scale results. 

NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

Expected Outcomes

The expected outcomes based on hypotheses are: burnout in nurses reduce with increase in nurse to patient ratio; patient and nurse’s satisfaction level will increase; error rate will decrease; intentions to leave job will decrease; turnover rate will decrease and quality of nurse’s life will increase.  


Arkin, N., Lee, P., McDonald, K., & Hernandez-Boussard, T. (2015). The association of nurse-to-patient ratio with mortality and preventable complications following aortic valve replacement. Journal Of Cardiac Surgery29(2), 141-148. doi: 10.1111/jocs.12284

Bakhamis, L., Paul, D., Smith, H., & Coustasse, A. (2019). Still an epidemic. The Health Care Manager38(1), 3-10. doi: 10.1097/hcm.0000000000000243

Chen, Y., Guo, Y., Chin, W., Cheng, N., Ho, J., & Shiao, J. (2019). Patient–nurse ratio is related to nurses’ intention to leave their job through mediating factors of burnout and job dissatisfaction. International Journal Of Environmental Research And Public Health16(23), 4801. doi: 10.3390/ijerph16234801

Chen, Y., Guo, Y., Chin, W., Cheng, N., Ho, J., & Shiao, J. (2019). Patient–nurse ratio is related to nurses’ intention to leave their job through mediating factors of burnout and job dissatisfaction. International Journal Of Environmental Research And Public Health16(23), 4801. doi: 10.3390/ijerph16234801

Dall’Ora, C., Griffiths, P., Ball, J., Simon, M., & Aiken, L. (2015). Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ Open5(9), e008331. doi: 10.1136/bmjopen-2015-008331

NR 505 Week 7 Evidence-Based Practice Project Proposal Outline

Gutsan, E., Patton, J., Willis, W., & Coustasse, A. (2018). Burnout syndrome and nurse-to-patient ratio in the workplace. Marshall Digital Scholar196(01).

Kleinpell, R., Ward, N., Kelso, L., Mollenkopf, F., & Houghton, D. (2015). Provider to patient ratios for nurse practitioners and physician assistants in critical care units. American Journal Of Critical Care24(3), e16-e21. doi: 10.4037/ajcc2015274

Leigh, J., Markis, C., Iosif, A., & Romano, P. (2015). California’s nurse-to-patient ratio law and occupational injury. International Archives Of Occupational And Environmental Health88(4), 477-484. doi: 10.1007/s00420-014-0977-y

Liu, Y., & Aungsuroch, Y. (2017). Factors influencing nurse-assessed quality nursing care: A cross-sectional study in hospitals. Journal Of Advanced Nursing74(4), 935-945. doi: 10.1111/jan.13507

Qureshi, S., Purdy, N., Mohani, A., & Neumann, W. (2019). Predicting the effect of nurse–patient ratio on nurse workload and care quality using discrete event simulation. Journal Of Nursing Management27(5), 971-980. doi: 10.1111/jonm.12757

Roth, B. (2017). Correlation among competency, patient safety and nurse turnover rates?. Retrieved 10 July 2020, from,91.1%25%20of%20all%20hospital%20separations.

Rushton, C., Batcheller, J., Schroeder, K., & Donohue, P. (2015). Burnout and resilience among nurses practicing in high-intensity settings. American Journal Of Critical Care24(5), 412-420. doi: 10.4037/ajcc2015291

Tawfik, D., Profit, J., Lake, E., Liu, J., Sanders, L., & Phibbs, C. (2020). Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit. Health Services Research55(2), 190-200. doi: 10.1111/1475-6773.13249

Torun, T., & Çavuşoğlu, H. (2018). Examining burnout and job satisfaction of nurses working in pediatric units. Journal Of Education And Research In Nursing. doi: 10.5222/head.2018.071

Tubbs-Cooley, H., Mara, C., Carle, A., Mark, B., & Pickler, R. (2019). Association of nurse workload with missed nursing care in the neonatal intensive care unit. JAMA Pediatrics173(1), 44. doi: 10.1001/jamapediatrics.2018.3619

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