Critical Nursing Shortage in the Healthcare Workplace

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27.06.2022
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CHAPTER ONE: THE PROBLEM

Research Problem

The research problem of this study relates to the critical nursing shortage in the healthcare workplace in the United States. However, the shortage experienced in nursing is not exclusive to the US problem, but a serious healthcare issue that affects nearly all other countries globally (Bleich, 2011; Hellerawa & Adambarage, 2015). It is important to note that nurses are the mainstay of any healthcare system and their job assignments are always manifold and very complex. Therefore, nursing shortages adversely impact healthcare systems whenever they occur. A nursing shortage refers to the primary discrepancy that occurs in the supply and demand. The shortage is credited to availability, qualifications, willingness to work, and demographics.

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Problem Background

In the United States alone, it is estimated that there are 3 million-plus licensed Registered Nurses, with nearly 2.6 million-plus of those nurses currently in the working force. The number translates to less than 1 percent of the U.S’ population. Besides, the Bureau of Labor Statistics (2015) reported that between 2010 and 2020, the need for registered nurses was expected to rise from 2,737,400 to 3,449,000; indicating an increase of 26 percent. Therefore, the U.S is projected to encounter a deficit of approximately 1 million needed nurses. The increase in the need for nurses, particularly registered nurses, is attributed to the aging of the baby-boomer generation (U.S DHHS, 2014). There is a surge in the number of baby-boomers who are turning 65, a rate that is nearly 10,000 persons each day resulting in 79 million senior citizens or 26 percent of the entire US population which therefore increases the need for nurses to provide health care for this aging population (Barry, 2010).

The causes of the nursing shortage are varied, complex, and sweeping. Even though a number of factors exacerbate the problem, a major difference in today’s shortage can be attributed to a disparity in issues of supply and demand. In the past, either an increase in demand or decrease in supply served as the major contributing factor (Berry & Curry, 2012). However, currently both factors reportedly contribute in equal terms. The other difference is that shortages of other health professions as well as supporting staff occur at the same time as the shortage of nurses, further complicating the problem.

Nurse’s role within the health care sector is important in the early detection of and treatment of illnesses (Bleich, 2011). Moreover, since nurses have the proper training and spend their working lives around patients, they can notice the various illnesses’ signs and then offer a timely intervention. It is clear, therefore, that nurses help in saving the lives of patients. The level to which nurses are effective in monitoring the health of a patient throughout depends on how many nurses are available to work (Balducci, Cecchin & Fraccaroli, 2012). For instance, a higher ration of nurses and patient is associated with some significant reduction in unwanted health outcomes like hospital-acquired infections such as pneumonia and urinary tract infections (Bobay, Yakusheva & Weiss, 2011). Also, higher nursing staff levels have their association with patient-risk adjusted mortality, reduced medical complications-related risks, improved quality care, nurses’ improved health through lower risks of possible injuries or absenteeism. In sum, the higher the number of nurses the better the outcomes, care quality and nurses satisfaction. Higher educational levels among nurses also result in better patient outcomes (National Council of State Boards of Nursing, 2016).

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There are a number of factors that have been reported to contribute to the increased demand for the services offered by nurses. First, there is the aging population. It is projected that by 2050, the number of senior citizens around the globe will exceed that of the younger generations. Additional major factors include globalization, a growing private sector, as well as high public trust in nurses. These factors have generated an increased demand for nurses who are considered the main entry point to health services (Autrey, Howard & Wech, 2013). Furthermore, shorter hospital stays as well as complex diseases have resulted in increased acuteness of care. Increased demand is coupled by a decreased supply of nurses. The major reasons for the decreased supply include an aging nursing workforce and shrinking applicant pool. Another reason is unfavorable work environments which include heavy workloads, violence, burnout, stress, wage disparities, inadequate supply of support staff, little involvement in decision making, and health human resources approaches which do not support self-sufficiency (Toh, Ang & Devi, 2012).

Moreover, though nursing is a profession for people with unique and selfless passion to take care of others, it is both physically and mentally demanding. Due to the challenging quality of the nursing work, it has resulted in high job-dissatisfaction rates, increased stress, and high turnover rate (Demir & Rodwell, 2012). Nursing has been ranked as one of the ten least satisfying professions in the United States. Due to its reputation, nursing has thus become less attractive to the younger generations resulting in a nursing population that is aging fast. Older nurses continually become less physically able to execute their tasks with their age, and employed nurses further feel the burden of the nursing shortage by taking longer work hours as well as more patients. Physical fatigue is constantly reported among nurses working for longer hours as well as extended shifts Nurses who work 12 hours shifts have been reported to have higher levels of fatigue than those who work 8-hour or 9-hour shifts. Similarly, nurses who work 9-hour shifts have been reported as being more fatigued than nurses who work 8-hour shift (Jacky, 2011). Extended shifts, overtime as well as additional shifts also increase the working time for nurses while shortening the time available for nurses to rest and recover from work. The circadian cycle is disturbed through insufficient sleep or poor sleep quality and results in sleepiness and fatigue, which increase rates of nursing staff leaving the nursing profession (Jacky, 2011).

The continued growth of healthcare operations and services have become more complex, and the resulting effects will become immense in terms of future healthcare designs. Increasing recruitment, retention, enhanced job satisfaction as well as efficiency of the people already working in the field requires the creation of supportive, high performing working environments. In sum, if nurses are less exhausted both physically and mentally, they are able to provide better and safer service care for patients.

Study Purpose

The key objectives include:

1. To identify whether a critical nursing shortage influences workload

2. To recognize if workload significantly relates to the quality of patient, care, satisfaction level of nurses and work-related stress.

3. To investigate the effect of the number of staff on the quality of patient and the extent to which nurses as satisfied with their job.

Significance of Study

As in most countries, nurses form a major percentage of the US health sector’s personnel and is among the largest components of healthcare service population across the world. With its important role in promoting health care, it is necessary to examine how this nursing shortage affects job outcomes. The discussion on the relationship between workload, patient care and stress level can make it possible to understand the effects of the nursing shortage on the work of nurses. Besides, both job satisfaction and work stress are helpful in revealing how nursing shortage impacts on any healthcare setting. Therefore, the significance of the current study will be in its ability to provide an extensive data to nurse educators, professional nurses, as well as nurse administrators regarding the factors that have been responsible for shortages witnessed in many healthcare settings in the US.

Research Questions

1. To what extent does the current critical nursing shortage influences workload?

2. To what extent does workload significantly relate to the quality of patient care, satisfaction and work-related stress?

3. What is the relationship between the number of staff and quality of patient and job satisfaction?

Limitations

The researcher intends to seek out study participants (in this case, nurses) who speak English fluently. However, it is possible that language barrier issues may occur during data collection. This may happen in cases where the nurses selected for the study cannot speak English or where questionnaires may need to be translated into their native languages. This would pose a significant challenge in data collection.

The other possible limitation that may be encountered in this study involves literature on the study topic subject that does not have significant data or lacks consistency in the study variables. Literature that suffers from significant data inadequacy may prevent the study from achieving its study objectives. Current and relevant documents with studies on only parts of the area of interest may limit the study.

Another possible source of limitation is source credibility. During the data collection process, it will be important to check how consistent and cohesive the data is. Credibility will be achieved if the data from multiple sources results in the same confirmation. Therefore, in case the data for this becomes inconclusive, it may affect content analysis.

Moreover, the study will be limited to a small area within the US. Therefore, the resulting data may not provide a true representation of possible factors that could be causing critical nursing shortage in the US more broadly. In particular, different regions in the US could could have different causes that explain their nursing shortages; therefore, a general assumption may not be appropriate.

Delimitations

One delimitation imposed by the study design is the sample size, which will affect the ability to generalize the findings of the research to settings as well as populations that are particularly different from settings as well as populations included in the research study. Indeed, this study will be limited to a specific number of nurses. Secondly, this study will be limited to nurses who have work experience of six months or more. Thirdly, the nurses to be included will only be those who work in Miami. The delimitations have been used to narrow the scope of the study.

Definitions of Terms

Nurse shortage: The inadequacy of the number of nurses in providing high quality care based on the existing professional standards.

Job satisfaction: The degree to which individuals feel positive about their jobs.

Work stress: Harmful physical and psychological experiences that individuals endure resulting from work demands or pressures matched to knowledge and abilities which test the ability to cope.

Nurses: Persons who are registered or certified to provide care for the sick either in private or public clinics, hospitals as well as other healthcare facilities.

A registered nurse is a nurse who has completed and obtained post-secondary skills or university degree training and has passed his or her licensing examination in order to earn the title.

Access Plan

The findings’ presentation will take place in seminars and conferences for peer examination and appraising. Presenting the work before peers will be an opportunity to learn about the areas where possible amendments could have been needed. Furthermore, the seminars will be an appropriate channel for disseminating the findings for implementation.

Additionally, the findings of this research will be posted online on the university’s website. It is apparent that different people from academia and non-academia access the university’s website for different kinds of information. It is expected that the different groups that access the website, particularly stakeholders in the nursing profession, will find this information and implement it in their practice where appropriate. This research will also be available on other internet platforms such as the Google search engine which will make it available to worldwide audiences.

Chapter Summary

This chapter enables the reader to develop a good understanding of the study. Through the study background and the problem statement, the reader is able to gain a proper understanding of the informed decision of the researcher to undertake a study on this particular topic. It identifies the objectives of the study and the research questions which will guide the collection of data to make it possible for the objectives to be met. The chapter ushers the reader to the second chapter, which presents a thorough review of the relevant literature.

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CHAPTER TWO: REVIEW OF THE LITERATURE

Introduction

The section presents a review of literature materials that are relevant to the topic of discussion. In particular, it will assess, summarize, classify, compare and evaluate information. Since the researcher could not include all of the relevant materials, she considered only the most relevant, current and reliable materials. Therefore, such sites as Wikipedia.com and about.com were not included in the study as they would not enhance its reliability. As a way of ensuring relevance, the researcher limited the sources to those dealing with such direct topics such as critical nursing shortage, work load and its relationship to quality load healthcare and stress, as well as the relationship between the number of staff and job satisfaction. The chapter will therefore be helpful in gaining more insight on the topic of critical nursing shortages in the healthcare workplace from previous studies.

Trends of Critical Nursing Shortage in the Society

The health care environment is ever changing, and the demand for nurses is on the rise. Currently, there is pressure for clinical practices to take place in a lean and efficient manner because of shrinking reimbursement, increased utilization and regulations put in place by oversight bodies (Hofler & Thomas, 2016). The AACN (2014), in the factsheet for shortage in nursing, reports that the U.S is expected to experience a shortage of registered nurses as Baby Boomers age and the need for health care grows. The report further indicates that nursing schools throughout the US are struggling to expand their capacities, further compounding the problem. The report quotes the findings of the Bureau of Labor Statistics (2015), which showed that registered nursing is listed as one of the top occupations through 2022, but the shortage of this group of healthcare professionals is projected to spread across the US between 2009 and 2030.

Harrington and Heidkamp (2013) in their brief report predict that by 2050, 19.5 million American workers will be aged 65 years or older, representing approximately 19 percent of the total U.S. workforce. The report also showed that the individuals in the workforce who are 65 years or older is projected to grow by 75 percent while those in the workforce between 25 and 54 years will only grow by 2 percent. One-third of the U.S workforce was expected to be 50 years or older by 2016, and the group is expected to reach 115 million by 2020 (Heidkamp, Mabe & DeGraaf, 2012).

In another study, Juraschek, Zhang, Ranganathan and Lin (2012) relied on projected changes in population size and age to develop demand and supply models in forecasting the registered nurse job shortage in the 50 states. The authors expect that by 2030, the states that are projected to have the largest shortages of registered nurses will include California, Florida, and Texas while the states expected to have the largest shortage ratios will be New Mexico, Arizona, and Nevada. The forecasts in the study indicate that shortages of registered nurses will become worse within the next two decades. The shortages will be due to high demand ratio that is coupled with a decreasing supply. The study identified many factors that affect demand including age both for the nursing workforce and patient populations, economic recession and health care reform law.

Cox, Willis and Coustasse (2014) identify several issues that arise with an aging workforce such as the increase retirement of these skilled nurses. The authors list exhaustion and chronic diseases as some of the major stressors that aging nursing workforces still have to deal with in the workplace. Insufficient staffing is also identified in the study as a major cause of nursing shortage. The study further identifies decreased staffing of nurses due to their high turnover as well as retirement, which make it difficult for existing nurse to effectively provide quality patient care. Parker, Lazenby and Brown (2013) recognize nursing as a stressful career because of the complexity of the health care environment, acuity of patients as well as advancement of technology and increasing demand for accountability in meeting patient safety and quality needs. The researchers further found that nurses who feel safe and supported in their clinical environments report decreased moral distress and increased job satisfaction.

Holdren, Paul III and Coustasse (2015) conducted a literature analysis to examine how the effects of burnout syndrome can cause nursing shortage. The results of the analysis indicated that poor work environments as well as an increased nurse-to-patient ratio have resulted in significant burnout in hospital nurses. Nurses’ experiences of burnout syndrome are emotional exhaustion, depersonalization as well as reduced personal accomplishment that directly influence their work. The symptoms of burnout often contribute to nursing shortage, which create a vicious cycle of burnout and nursing shortages. Stress emanating from the physical work environment, ambiguities in roles, and management significantly increases the level of nurses’ emotional exhaustion. The study identifies other factors such as age, job status, educational level as well as workload of patient-to-nurse ratios as significantly contributing to burnout syndrome that is associated with nursing shortages. The analysts conclude that when burnout syndrome is lessened, nurses develop a renewed passion and devotion to jobs which then eliminate nursing shortage while allowing hospitals to save money and increase quality of patient care.

Bragg and Bonner (2014) conducted a study to explore the reasons why registered nurses resign from hospitals in rural communities. The study, using grounded theory methods, gathered data from participants working in rural hospitals using semi-structured interviews. The findings revealed that whenever nurses and organizational values are not aligned, conflicts occur for nurses about how to perform nursing that is aligned to professional values and integrity. However, resignations occur whenever nurses are unable to realign their personal values to changed organizational values such as service structures, centralized budgets and resources, tiresome hierarchies and management structures that hinder communication and decision making, out-dated and ineffective operating systems, bullying, inefficient and inexperienced staff, lack of correctness and share vision as responsible for nursing shortages (Bragg & Bonner, 2014; Koh, 2016).

Bakr (2012) examined the impact of nursing shortage on quality care. The study was prompted by the realization that nurses, which form the largest group among professionals working to provide health care, have undergone significant alterations with respect to their work. The study identified various factors contributing to nursing shortage including personal factors, educational factors, organizational factors, and social factors.

Flinkman, Isopahkala-Bouret and Salantera (2013) conducted a qualitative case study to investigate in detail why young nurses are leaving the nursing profession and reeducating themselves to new careers. The investigators found that nursing as a career choice is characterized by demanding work schedules, poor practice in some environments and certain bad tendencies to stereotype the career. The study outcome revealed that there was a shift towards perceptions when it came to the understanding of how turnover process contributes to nursing shortage eventually.

A review by Lartey, Cummings and Profetto-McGrath (2014) sought to determine the effectiveness of strategies that have been used to retain registered nurses. The study was conducted on the premise that the expected nursing shortage if not resolved would affect job satisfaction, healthcare costs, as well as quality of care offered to patients. The investigators claimed that retaining experienced nurses had the potential of helping to lessen the shortage, enhancing knowledge transfer, and enhancing the provision of quality care to patients. The investigators found from their study that team work as well as individually targeted strategies that include mentoring, thorough orientation, and increased job satisfaction are some of the factors that may help to retain nurses and prevent potential nursing shortages.

Hellerawa and Adambarage (2015) carried out another study aimed at investigating the impacts that nursing shortage has on the nurses’ job satisfaction, quality of patient care, as well as work stress. Using explanatory research design, the researchers were able to analyze data from questionnaires to find a positive correlation between reduced workload and high quality patient care provided. On the other hand, quality of patient care reduced whenever there was increased workload. In addition, the investigators found a positive correlation between emotional intelligence and workload and work stress. The study concluded that nursing shortages influence employee workload, which in the end affects the quality of patient care. Nurses’ emotional intelligence is reported as moderating factor for job outcomes of nurses.

Durano (2014) examines nursing shortage from the perspective of inflows and outflows. This investigator claims that the factors contributing to the shortage are multifaceted, particularly in developed society where low inflows of entrants into the profession predominates similar to high outflow of people that are leaving the workforce. The author reports that low inflow is the result of fewer younger people entering into the profession, particularly at a time when there are wider professional opportunities that are available for young people. The negative perceptions regarding the working conditions in the nursing profession as well as low social value attributed to it negatively affects recruitment. The study further recorded that nurses opt to leave their profession because of rates of high turnover, since many nurses do retire from active employment. Nurses are often leaving their jobs before reaching the retirement age due the existing challenging working conditions (Durano, 2014).

Relevance

Only relevant literature materials have been used. First, the materials are mostly peer-reviewed journals meaning they contain information that can be considered reputable. All the materials used were recently published; therefore, they provide up-to-date information. Indeed, nearly all of the articles were published within the last five years. Secondly, the articles provide information regarding the topic of discussion which is crucial in supporting and anchoring the study.

Effects on Quality of Service and Economy

The shortage of nurses is associated with work overloads, higher job-related burnout as well as dissatisfaction, resulting in a major shift from the profession (Aiken, Sloane, Bruyneel, Van den Heede, & Sermeus, 2013). The intention to leave the profession even in the developed nations such as the US remains high (Aiken et al., 2013). The poor-conditions of work that characterize nursing jobs include the fact that one nurse has to attend to many patients or low staff engaged, working for long hours, changing schedules, work overloads, no appreciation, shift work, new policies and low pay. Nurses have reported that as a result of high pressures to accomplish work in health care environments that are characterized by shortage nursing, nurses have had to take mandatory overtime, skip meals and do non-clinical jobs which results in them spending less time with patients. The net result is poor employee outcomes. Poor working conditions as well as job dissatisfaction among nurses result in burnout, absenteeism, as well as high turnover, particularly among the qualified nurses.

It is evident that nursing workload affects the time that a nurse can allocate to various tasks. In fact, under a heavy workload, nurses may lack sufficient time to perform their tasks, particularly those that have a directly affect patient safety. Notably, heavy workloads influence the decisions that nurses make when performing their various procedures. Likewise, heavy workloads have the potential of reducing the duration that nurses take to collaborate and communicate with physicians, hence affecting the quality of collaborations between physicians and nurses. A heavy workload may lead to poor nurse-patient communication.

High workload remains a major stressor for nurses in various settings including ICUs. Among the negative emotional effects that heavy nursing workload can cause include anger, cynicism, as well as emotional exhaustion. Nurses who experience distress and burnout are less likely to perform their duties effectively and efficiently due to reduced cognitive and physical resources; the less-than-optimal performance has the potential of affecting patient care as well as safety.

There is a relationship between working conditions such as high workload, and job dissatisfaction. Often, job dissatisfaction of nurses may lead to turnover, poor job performance, low morale and absenteeism; creating a vicious cycle of undesired effects of shortages. The effects have high cost implications for healthcare systems because they threaten patient care quality as well as organizational effectiveness. Furthermore, high turnover rates can lead to higher costs for health providers because of the need to continually recruit, train new staffs, increase overtime as well as use of temporary agency staffs as a way of filling the gaps that are left by departing staff. The other costs associated with turnover are low efficiency among the newly employed, reduced morale among the staff and deteriorating productivity.

A heavy nursing workload is related to suboptimal patient care and may lead to reduced patient satisfaction. It has been reported that nurse-staffing levels have significant effects on nursing-sensitive patient outcomes. That is to say, there is a strong correlation between lower nurse staffing levels and higher rates of pneumonia. Similarly, nursing shortages have been shown to have significant impact on hospital acquired infections. For instance, medical patients reportedly have higher number of hours of care per day by registered nurses due to lower urinary tract infections.

Workload is a factor that contributes to errors, which have been categorized as slips, lapses or execution errors, as well as knowledge or mistakes and errors. Whenever nurses have high workloads, they are more likely to see a reduction in the ability to focus on the critical tasks that require critical safety, resulting in conditions that are error prone and unsafe for patient care provision.

The inability to improve nurse retention or increasing turnover due to nursing shortage can have a significant negative impact for the nation’s employers. The inability to fill vacant nursing positions or failure to plan how to alleviate future nursing shortages can also be detrimental structures. Furthermore, noting that the decreased advanced practice nurses and increasing the scope of practice restrictions may not help in addressing current and future needs of the population, there is need for effective measures to help solve the problem of shortages in nurses.

Chapter Summary

The section has given in-depth of the various literature materials used in this study. The writer successfully carried out and presented the assessment, summary, classification, comparison and evaluation of information. The researcher has also given insights on inclusion exclusion criteria of past studies. Its conclusion, ushers us to the methodology chapter where the researcher will discuss how, where, and what issues of the research study.

CHAPTER THREE: METHODOLOGY

Introduction to Research Design

This chapter analyzes the various strategies to aid in collecting data and the identification of study participants as well as how the analysis and reporting of findings will be done. The study participants will be the individuals from whom the primary data will be gather to achieve study objectives. The method (s) of data collection to be used will be those that capture important themes that the investigator intends to achieve in the study. Data analysis and reporting will be vital in highlighting the findings of the study.

Methodology

The methodology will be a mixed design study with both qualitative and quantitative strategies for data analysis will be used in this study. Mixed method of research involves collecting, analyzing and integrating quantitative approaches like surveys with qualitative approaches like interviews (Creswell, 2013). The approach is superior to cases where only either one of the methods is used. Therefore, the mixed design method was chosen because it will enable the investigator to analyze numerical data qualitatively and to identify important themes for the study qualitatively. Using the two methods will allow the investigator to have a comprehensive evaluation of data that will be available. By mixing qualitative and quantitative research and data, the investigator will gain a better depth and breadth of understanding and validation, while balancing the weaknesses that are characteristic of using each approach by itself. In this way, the mixed method design is advantageous in providing strengths that balance weaknesses of either qualitative research. The methodology provides a more complete and comprehensive understanding the research problem than each of the methods. Also, the method provides an approach for developing better and context specific instruments. Finally, this methodology was chosen because it will allow for better explanation on the findings and how causal processes work.

Description of Participants

This study will be conducted in three healthcare facilities in the United States; one outpatient clinic that provides various nursing care services and two in-patient units within hospitals providing comprehensive care. Only full-time registered nurses working in inpatient and outpatient facilities will be eligible to participate in the study. Furthermore, the registered nurses who will be expected to participate will be those who have six months of total work experience or more. The participants will be both male and female nurses. The number of study participants expected to take place in the study is 278.

Access of Permissions

Before the commencement of the study, the researcher will have to seek to have the study approved by the university’s review board. The investigator will also present the proposal to the board to determine if the activities of the research would be considered to constitute human participant research. Secondly, the board will be expected to review, approve, and require modifications so as to secure approval for this research. In addition, as required by the board, information will be given to the research participants as part of informed consent according to appropriate laws, regulations, as well as international standards. In case the IRB may require that additional information be given to the study participants, particularly where the board deems that the information would add to the protection of the rights or welfare of participants. The investigator looks forward to the IRB notifying him/her in writing regarding the decision to approve the research study.

Apart from seeking permission from the university’s institutional review board, the investigator will seek the consent of the management of the three hospitals to survey their nursing personnel. Furthermore, the investigator intends to make a personal request to the nurses to participate in the research. The participants will be told that participation in the investigation is voluntary; therefore, any of the registered nurses are free to decide whether or not they would like to take part. Besides, the participants will be told that they can stop participating in the research at any time, particularly where they believe that their rights are being violated. Also, all the participants will be given consent forms to fill before the commencement of data collection. Finally, the participants will be asked to fill in the forms to affirm that they have agreed, without coercion, to take part in the study.

Data Collection Method

Anonymous questionnaire forms as well as information sheets will be distributed to the registered nurses in the facilities where the study will be conducted. The questionnaire forms will be distributed in nursing staff work areas from where the registered nurses can pick them with ease. Furthermore, drop boxes will be provided in all the facilities for the participants to drop off their duly completed questionnaires. The use of questionnaires is considered appropriate because it is a cheaper means of data collection method. Just as important, the use of questionnaires will save the investigator’s time because he will not need to be present as the registered nurses are completing the forms. The use of anonymous questionnaires will serve to conceal the identity of the study participants and to prevent possible victimization by colleagues or the management. Questionnaires are useful for this study because they are practical, provide speedy results, are scalable, allow scientific analysis and predictions, allow user anonymity, can be filled without pressure, and cover all aspects of the study topic. Apart from the questionnaires, the investigator will also interview some of the study participants in order to gauge their perception regarding nursing shortage. Among the themes or factors to be considered when constructing the questionnaires or conducting the interviews will be; job dissatisfaction, work stress, workload, patient care and quality which are all factors that are associated with nursing shortage (American Association of College of Nurses, 2012). The use of interviews will be important because they provide accurate screening, capture verbal and non-verbal queues of the respondents, allows the interviewer to keep focus on the interview, and capture emotions and behaviors of the respondents.

Methodological Assumptions

The investigator assumes that all of the registered nurses that will be taking part in the study have the ability to read and write in fluent English. The questionnaires will be constructed in English which is the most commonly spoken language in the US. Similarly, the investigator assumes that the participants will complete the questionnaires with utmost truth. Finally, the investigator assumes that the methods used will enable the collection of pertinent data needed to achieve the study objectives.

Data Processing and Analysis

The investigator will analyze collected data using SPSS version 16. Quantitative analysis will be used for information from the questionnaires while qualitative analysis will be conduced for information gathered through the interviews. In addition, the SPPS will be used in calculating variances and for regression analysis. Finally, the interviews will be coded to identify common themes arising from the various interviewees.

Chapter Summary

The chapter has analyzed the various strategies proposed to be used to aid in collecting data and the identification of study participants. It also presents how the analysis and reporting of findings will be done, assumptions that will be made as well as issues to do which ethical considerations like how to treat confidential issues. The chapter marks the end of the proposal and ushers the reader into the results and findings chapter.

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