Nursing Leadership and Management Field Experience

C1. Identifying the Problem 

A nurse to patient ratio sets the highest number of patients that can be allocated to a nurse in a single shift. A high nurse to patient ratio means that a nurse is allocated a high number of patients, and a low nurse to patient ratio means that each nurse has a small number of patients during a shift ( Falk & Wallin, 2016 ). At Reston Hospital, the nurse to patient ratio is very high. This is attributed to the high nurse turnover rate in the organization. This harms the quality of care provided, as well as patient safety. The quality of care offered and patient safety is adversely affected when nurses are assigned many patients. As a result, the number of both documentation and medication errors is high in the hospital, and the patient outcomes are poor. According to Falk & Walli (2016), the vigilance of a nurse is important in ensuring delivery of quality and safe care, and therefore, allocating a high number of patients compromises the ability of nurses to offer safe care. Multiple studies show that as the number of patients per nurse increases, events related to patient safety as well as deaths and morbidity increase. 

C2. Describing the Problem 

Nurse staffing is the main concern because of its impact on patient outcomes which are an indicator of the quality of care. Nursing associated outcomes are one of the main indicators of quality of care. Nursing sensitive outcomes include prolonged hospital stays, pneumonia, and mortality within thirty days, and UTIs, among others ( Driscoll et al., 2017 ). Lack of adequate nurse staffing is harmful to patients as it leads to increased prevalence of infections, diseases, errors, as well as patient mortality. Findings from empirical research show that insufficient staffing and increased workload among nurses is dangerous to patients. Several studies conducted in the ICUs found that a high nurse-patient ratio increases the risk of developing medical-related complications for every additional patient on the workload of a nurse above the established ratio of 1:4, the possibility of a patient dying increases by approximately seven percent. In addition, the risk of being readmitted because of pneumonia increases by six percent while that of being readmitted as a result of myocardial infarction increase by nine percent. 

A high nurse to patient ratio is linked to increased rates of adverse patient outcomes. The association between high nurse to patient ratio and the outcomes of patients is caused by a high workload, stress, and burnout among nurses. Burnout is defined as a condition of physiological and psychological fatigue caused by work demands ( Driscoll et al., 2017) . An increase in nurse to patient ratio induces the intention to leave work among nurses. This impact is, in most cases, mediated by burnout and dissatisfaction with work. Burnout leads to loss of staff and consequently leads to poor quality of care. As healthcare providers experience job stressors related to the nurse-patient ratio, the quality of care reduces. 

Nurses with symptoms related to burnout as a result of many patients present more safety risks to their patients. In addition, patients who receive care from nurses who suffer from burnout report reduced satisfaction during the care process and less professionalism from such nurses. The quality of care becomes worse because nurses suffering from burnout have many pressing emotional problems. They are emotionally exhausted, impaired memory and lack adequate attention. This increases the risk of making errors. Moreover, burnout increases the risk of developing an aggressive attitude towards patients and staff, and this may affect patient satisfaction as well as communication between staff, which are important for quality care. The plan aligns with the core role of a nurse executive. It involves leading the nursing team, oversight of the management aspect of patient care, and the making of related administrative decisions aimed to support the goals of the organization. It includes initiatives that enhance patient care and improving the organization and satisfaction of the nursing staff. 

C3. Explanation of Causes 

The high nurse to patient ratio problem in the organization is linked to system and management related challenges. System-related challenges involve the inability of the organization to attract and retain nursing talent. The management challenges include failure of the organization’s management to communicate effectively and manage employee performance. Several factors cause the problem of the high nurse to patient ratio. The most significant contributing factor is reduced nursing staff in the organization because of the high turnover rate. This has led to more nursing workload on the remaining nurses, which has negatively affected the quality of care offered. Resistive organizational inertia and failure to understand change can also be linked to the problem. Nurse leaders and the management in the organization do not appreciate process excellence. The leaders and managers in the organization are comfortable with the way things are done within the nursing teams, and the inefficiencies are ignored. Moreover, the organization has been seeking ways to reduce its budget costs as a result of reimbursement related issues. As a result, when nurses leave, the organization does not replace some of them to cut down on costs involved in hiring and compensation for new nurses. In addition, the management believes that hiring more nurses will further constrain the budget and reduce profit margins. All these factors contribute to a high nurse to patient ratio, which in turn affects the quality of care. 

C4. Identification of stakeholders 

Different stakeholders will be involved in project development and implementation. Understanding the role played by stakeholders in a project is essential in ensuring that it succeeds. Each of the stakeholders involved in the project can contribute to either speeding up, slowing down, or total obstruction of the proposed solution plan execution. Some of the stakeholders may not be on the frontline, but they are very important advocates or even change agents. The relevant stakeholders for the proposed project are nurses, nurse managers, management team, the board of directors, and investors. As a result of the different interests presented by each stakeholder group, it is important to manage the project’s stakeholders. The stakeholders’ management process is considered a type of risk management (Pirrozi, 2019). Meeting stakeholders’ expectations will translate into a decreased risk of experiencing negative influences that may affect the plan. The project does not involve a power shift. 

D. Purpose of the Project 

The purpose of the proposed project is to reduce the nurse-patient ratio, thus improve the quality of care provided in the organization. For healthcare to be considered quality, it must be safe, centered on people, effective, efficient, and equitable ( Nantsupawat et al., 2015) . Ensuring quality of care is important to the long term success of healthcare organizations. This is because it has a direct effect on patient outcomes and disease prevention. It can help determine if a healthcare organization is improving, stagnating, or declining, and determine growth opportunities. Today, there are many options that one can seek medical care from. As a result, care quality should be the priority of any healthcare organization. Failure to address quality of care leads to losing patients to competitors in the healthcare industry. Individuals who have a negative experience may share with other people on different forums leading to an organization’s bad reputation. According to Falk & Wallin (2016), nurses with a lower number of patients to care for have the best care outcomes. 

According to Driscoll et al. (2017) , approximately 74 percent of all nurses in California stated that the quality of care improved because of the mandated staffing law. Other studies indicate that a low nurse to patient ratio reduces complaints from both patients and their families as well as reduces horizontal conflicts at the workplace. A low nurse to patient ratio improves satisfaction among patients. Existing evidence indicates that the length of hospital stay among patients is inversely proportional to the number of nursing hours for each patient stay. In addition, there exists a directly proportional relationship between the number of nurses and readmission; in situations where the nurse ratio is beyond four patients for every nurse, the readmission rate increases. A high rate of readmission is considered as an indicator of overall poor health care quality. Also, the cost of managing readmitted patients may not lead to supplemental reimbursement. Existing evidence points to the fact that nurses can sufficiently meet the needs of their patients during their stay in hospitals if they are allocated fewer patients in a shift. 

In addition, a low nurse to patient ratio is associated with a reduction in medication errors and mortality among patients ( Driscoll et al., 2017) . Also, the number of different events that can be prevented, such as pressure ulcers, hospital-acquired infections, falls among patients, and several other health-related complications as a result of being hospitalized, reduce as a result of a low nurse-patient ratio. Fatigue among nurses is also reduced when the nurse to patient ratio is low hence improving patient safety, nurses’ retention, and satisfaction at work. All of these factors contribute to quality care. Therefore, optimal staffing through practices that ensure nurse retention is essential in offering the best possible medical care and receiving the optimal value from nurses. Existing studies support that staffing models that consider nurse to patient ratio offer great benefits. In addition, the hospital could reduce costs and increase its profit margin if the nurse to patient ratio is reduced. This is supported by existing evidence on the relationship between nurse to patient ratio and hospital financial performance. 

In the past years, hospitals have encountered uncertainties related to finances because of reduced reimbursements, increased acuity patients, and increased competition from other organizations in the healthcare industry. As a consequence, healthcare organizations have been looking for ways to decrease the costs they incur in providing care. Based on the fact that nurse compensation and benefits comprise a substantial amount of total healthcare organizations’ costs, they have been reducing the number of nurses as a way of reducing expenses and increase their profit margin. However, studies conducted on this issue indicate that a low nurse-patient ratio contributed to improved outcomes for patients and the nursing staff without negative effects on the financial aspect of a healthcare organization. 

Evidence on competition among hospitals indicates that healthcare organizations in competitive markets compete against one another based on quality and other services but not on prices alone. Staffing of nurses is an essential aspect of this type of strategy. Due to the essentiality of nurses in care provision, hospitals need to not only recruit but also effectively retain nurses to have a competitive advantage in the healthcare market. Reducing the nurse-patient ratio will significantly affect the overall financial situation of the organization in a positive way and improve its competitive advantage, considering the high competition in the healthcare industry. A lower nurse to patient ratio has a positive impact on care quality as well as the general profitability of a healthcare organization. 

E. Proposed Solution 

The proposed solution is a nurse retention protocol to ensure a low nurse to patient ratio. Based on the fact that nurse turnover is the underlying cause of a high nurse to patient ratio in the organization, hiring of new nurses alone is not a lasting and adequate solution because more nurses will keep leaving voluntarily as a result of the existing working environment. It should be combined with an effective protocol that ensures nurse retention. The protocol is based on existing evidence. The interventions included in the protocol are autonomy, rewards system, and communication. These three interventions are proposed because they improve job satisfaction, the commitment by the organization, and nurse retention, which ultimately lead to adequate staffing, which is essential for a low nurse to patient ratio. Autonomy is important for nurse retention. Nurses form the largest part of health workers in the present-day healthcare system. It is, therefore important to empower them as well as establish an environment in which they can make decisions and receive support from healthcare organizations (Ogata et al., 2018). The strategies to be executed to establish and enhance autonomy include encouragement from the management to nurses to look for learning experiences in the organization and outside as individuals. By doing so, nurse leaders will be acknowledging the value of more learning and professional development among nurses in the organization. Nurse leaders ought to offer a chance for nurses to share the information they get through their encounters with their colleagues. Moreover, they should be allowed to execute changes in present nursing practice based on the existing evidence. Nurse leaders will be trained in allowing autonomy among nurses as a way of ensuring retention for a lower nurse to patient ratio. Among the strategies to promote autonomy is a provision of time when monthly nursing staff meetings are conducted for learning in-service, resource binders for nurses in-services so that all nursing staff can access them, and provision of a bulletin board placed in the break room to allow nurses place educational information and share with each other. 

Recognizing the value of an employee’s contribution to an organization is important in ensuring retention. Individuals who are not acknowledged often feel that they are not visible, less valued, lack motivation and feel disrespected (Seifi et al., 2017). The majority of the nurses are not satisfied with the recognition offered by employers. Failure to recognize and appreciate their effort in most cases leads to feeling discontented, reduced morale, less productivity, and care outcomes that are not optimal (Seifi et al., 2017). As a result, the quality of care is negatively affected. Insufficient recognition is considered one of the main reasons for nurse turnover and is associated with reduced satisfaction among nurses. Recognition can be tangible or intangible. Intangible rewards include praise, while tangible rewards include money, among others. One of the proposed strategies for recognition for this protocol includes nursing leaders’ acknowledgment of the work well done by nurses. By doing so, nursing leaders will promote a nursing practice environment that is not only positive but also one in which nurses will feel that they are valued as well as appreciated for their work. It will contribute to reduced turnover, which is one of the main reasons for a high nurse to patient ratio in the organization. Also, the commitment of the hospital will increase. 

Nurse leaders can use the internal media within the organization to appreciate the nursing staff or use other means that show recognition. Providing positive feedback is also another strategy proposed in this protocol to ensure nurse retention. Through offering positive feedback, the nurse leaders, as well as the organizational management, will be celebrating the achievements of the nursing staff. As a result, a culture that focuses on celebrating what is done right and not being punitive will be created. Strategies such as the use of handwritten notes can be used to send positive feedback to the nursing staff. In addition, tangible rewards such as money can be combined with the intangible ones in an attempt to show acknowledgment of the nursing staff’s work. 

Communication is another important intervention proposed in this protocol to promote nurse retention. Both communication and being open to feedback are essential elements in all organizations ( Vermeir et al., 2017b). The application of the appropriate tools and strategies in communication is imperative. Nursing leaders may not always have a communication style that is easily understood by other staff. As a result, this may lead to high rates of turnover and subsequently cause a high nurse to patient ratio. Effective communication helps improve satisfaction among employees, as this leads to increased retention. This intervention will require nurse leaders to receive training in communication skills. The ability to communicate effectively and listen to nurses is essential. A nurse leader should be able to listen to what the nursing staff is saying regarding patient care effectively. Being the bedside primary care providers, the better understand patients (Ogata et al., 2018). The ability of nurse leaders to effectively listen to nurses shows a commitment from the organization to employees. It also offers validation of the concerns raised by nurses and sends a message that the hospital’s leadership is committed to the nurses. Apart from training nurse leaders on communication skills, other strategies to be implemented include giving nurses time to raise their concerns during meetings and create a policy that allows access to the management by the nursing staff. 

In addition, the development and execution of a shared governance model and more collaboration are essential in improving communication in the organization. A shared governance model allows participation and is important in improving the quality of care in healthcare organizations. Among how shared governance framework can promote communication is through encouraging the nursing staff to network with others, partner with different units, and offer major positions in committees related to patient care to nurses. The development and execution of clear communication channels by nurse leaders are also essential in enhancing communication within the nursing staff. For communication to be effective, it has to be simple as well as clear. By so doing, the information passed across is well understood, and this is essential in reducing or preventing conflicts that arise as a result of miscommunication. Different communication channels can be used to pass information across. These include meetings, discussions conducted in groups, and electronic mail, among others, as appropriate for the specific situations and the environment. Use of these simple yet important techniques, nurse leaders and the management will make sure that the information given to the nursing staff is clear and easily understandable. Moreover, listening to the nursing staff will make nurses feel satisfied hence improve retention. 

F. Evidence Summary 

Communication 

In their study, Vermeir et al. (2017b) conducted a narrative literature review for work satisfaction with regard to communication satisfaction among nurses in healthcare facilities. According to Vermeir et al. (2017b), effective communication is important for providing high-quality care and ensuring the safety of patients. Lack of effective communication may cause several negative outcomes, among them compromised the safety of patients and discontinuity of the care needed. The medical care field is complex, and the fact that there are limitations related to the actions of human beings requires standardized communication so that members can raise their concerns related to the safety of patients (Vermeir et al., 2017b). Communication contributes to satisfaction and performance at work. There are eight communication dimensions that influence job satisfaction. These dimensions are the communication climate, supervisor’s way of communication, feedback, and the quality of communication media. In addition, horizontal communication, communication at the subordinate level, and the perspective of the organization also influence satisfaction at work. How communication is conducted has an impact on job satisfaction, which in turn impacts turnover among nurses (Vermeir et al., 2017b). 

Low levels of work satisfaction often lead to an increased turnover, which has a negative impact on the quality of care provided. The few available nurses are assigned more patients. Furthermore, organizations incur extra costs when recruiting other nurses. Moreover, there is an adequate shortage of registered nurses; hence it is sometimes difficult to replace the ones who have left. The satisfaction of nurses significantly influences satisfaction among patients. An increase in job satisfaction is directly related to more motivation, and this, in turn, is linked to increased patient satisfaction related to the care given (Vermeir et al., 2017b). In their recommendations, Vermeir et al. (2017b) propose interprofessional education and training on effective and correct methods of communication. Pieces of training and exercises on communication should be conducted in environments that are both simulated and controlled. By ensuring effective communication, nurse retention is improved, leading to a lower nurse to patient ratio. 

In a different article, Vermeir et al. (2017a), conducted a study to examine the relationship that exists between communication, turnover, work satisfaction, and burnout in nurses. They conducted multicenter research involving three hospitals. Questionnaires were used for data collection, and a total of 1,454 nurses participated in the study. Results on communication indicated that all the communication aspects had a significant relationship with job satisfaction (p<.001) (Vermeir et al., 2017a). However, employee relationship was an exemption. Also, all the communication perspectives studied were related to turnover (p<.001). Satisfaction with communication levels was low among the nurses who had the intention to leave. In addition, communication dimensions were related to burnout. Nurses who reported burnout had high levels of communication dissatisfaction. 

The study concludes that various communication dimensions correlate with job satisfaction. Low scores in work and communication satisfaction were linked to a high turnover intention and burnout among the nurses studied. Approximately 25 percent of the participants were indifferent to the issue of the organizational aspect of communication. This represents a specific concern related to the role played by organizations. How a nurse leader, such as a manager communicates, was found to influence job satisfaction and the intention to leave. Satisfaction with a nurse leader communication was found to affect satisfaction and retention positively. The study attributes low communication satisfaction to factors such as slow and cumbersome communication means and structures in organizations and a large distance between the nursing staff and the management. Vermeir et al. (2017a) recommend improvements in different communication dimensions as an effective strategy of communication satisfaction hence improved nurse retention. Such a strategy should be structured in a way that improves communication from the nursing units to the management/administration. 

Reward System 

Numerous studies indicate that recognizing and rewarding the effort and contribution of employees significantly reduces voluntary turnover. There exists a common idea that rewarding as well as recognizing employees is usually an expensive initiative to undertake. However, research shows that it is not a must for rewards to be expensive. Compare to the costs incurred in replacing nurses who have left and the effect on quality and safety of care as well as the profitability of an organization, rewarding and recognizing the nursing staff is not expensive. In their study, Kurnat-Thoma et al. (2017) identified compensation and benefits as one of the factors that reduce annual healthcare facility and nursing staff turnover. A program comprising different elements among them recognition for new hires was implemented to determine its effectiveness in reducing turnover rates among new hires. From the study’s results, the turnover rates reduced from 18.2 percent to 11.9 percent in the participating hospital. Decisions related to compensation and recognizing employees are some of the essential decisions that an organization can make to reduce the rates of voluntary turnover among employees. According to Peltokorpi et al. (2015), most organizations across the United States have an established reward for a performance plan intending to retain employees. This has proved effective in the efforts of these organizations to reduce voluntary turnover among employees. 

According to Kurnat-Thoma et al. (2017), study participants acknowledged the fact that rewards and recognition are important for retention. Compensation packages comprise of salaries and various benefits such as employee professional development and rewards either in monetary or non-monetary forms. In the study, employees were willing to remain in their organization if their work was recognized through performance rewards. The recognition can be done on a monthly basis or a quarterly plan depending on an organization. According to Kundu & Mor (2017), when the performance of an employee is outstanding, she/she should be recognized with a tangible or intangible reward such as being recognized throughout the organization or a bonus. By doing so, an organization can retain productive employees. 

When employees felt that their work was being valued, their performance and satisfaction increased, and they felt motivated to continue performing well (Kundu & Mor, 2017). Moreover, an opportunity for training or professional development increases the length of the period an employee remains in his/her position. When employees receive training for professional and career development purposes, they acquire new skills and can pursue better opportunities with better pay in an organization. This has a positive impact on the retention of employees. Lack of an opportunity to advance can increase the possibility of an employee leaving an organization. Besides the studies presented in this literature review, other multiple studies provide evidence showing that recognizing employees through compensation and rewards have a positive influence on employees’ retention, even among nurses. 

Nurse Autonomy 

Autonomy refers to the extent of self-determination needed for an individual to have real psychological empowerment. Autonomy in the context of nursing leadership is the power to act. The concept of autonomy involves several precursors before a person becomes sovereign. The major aspects of autonomy include knowledge, the ability for self-determination, rational thinking, being accountable, and the urge to act. Labrague et al. (2018) conducted a study to examine the extent of professional autonomy among nurses, its predicting factors, and outcomes. One hundred and sixty-six participants from the nursing profession were recruited for the study. Among the factors assessed were autonomy, burnout, satisfaction, performance, turnover intention, and work-related stress. From the study’s findings, the strong predictors of autonomy identified were education as well as hospital bed capacity (Labrague et al., 2018). In addition, autonomy was found to have a positive impact on different job-related outcomes, among them satisfaction, commitment and retention. According to Labrague et al. (2018), nurses with increased autonomy levels perform better, are satisfied, and are committed to their work. 

The positive results of autonomy include improved job satisfaction, more commitment to one’s roles and duties, retention of position, better relationships at work, and improved work efficiency. According to Labrague et al. (2018), autonomy is an important factor in ensuring a healthy work environment. It makes staff happy and reduces their intentions of leaving. Moreover, autonomy is associated with ideas of dignity, and in situations where autonomy does not exist, nurses tend to feel that their dignity and respect towards them is destroyed. As a result, they are demoralized. Therefore, job satisfaction decreases, and this causes them to quit their jobs. Autonomy is essential for employee engagement, and employers should give their employees some amount of autonomy that aligns with organization goals and organizational culture. Labrague et al. (2018) propose sufficient support, training, and various policies that promote autonomy among nurses to ensure their retention. 

Similar findings are presented by Asefeh (2017) in their descriptive cross-sectional quantitative study whose aim was to describe various factors such as job satisfaction and how they are associated with turnover intention and transition. The results of the study showed that turnover intent was significantly affected by more professional autonomy (p=.001). Therefore, a work environment that promotes professional autonomy was found to improve registered nurses’ retention. For professional autonomy to exist, collaboration and allowing nurse practitioners to practice to the maximum of their skills based on education and roles are required. Retention was found to improve as a result of increased satisfaction caused by autonomy among nurses. 

G. Implementation Plan 

G1. Plan of action 

G2. Timeline 

G3. Resources and Personnel 

All the above mentioned resources will be required for protocol development and implementation facilitation. 

G4. Change Theory 

Kurt Lewin’s theory of change will be used for change implementation in the proposed protocol. This theory involves three stages, which are unfreezing, changing, and refreezing (Muldoon, 2018). According to Lewin, the change process involves creating an idea that change is required. After creating the need for a change, the next step entails moving towards the expected or desired state, and the final step involves making firm the newly acquired behavior and make it the norm of an organization. The three stages will be applied in the process of the project implementation process. Most people are naturally resistant to changes. The unfreezing step aims to raise awareness of the current situation and how the situation is a hindrance to an organization (Muldoon, 2018). The old ways of doing things, how individuals think, the existing processes/procedures, and the structure of an organization is assessed to prove to employees and other relevant stakeholders in the organization that a change is required. 

In the unfreezing stage, the current situation of the organization will be presented to all the relevant stakeholders and the need to change the situation. Currently, there is a high nurse to patient ratio because of high nurse turnover, and this has negatively affected the quality of care in the organization. Nurses in the organization experience burnout as a result of increased workload, and this has caused dissatisfaction among patients. As a consequence, the organization’s financial performance has reduced because patients prefer other healthcare facilities that offer quality care. There is a need to improve nurse retention if quality care is to be offered. By presenting the problem, its impact, and solutions to the manager and the other relevant stakeholders, a need for change will be created. During this stage of unfreezing, communication is vital to ensure that employees and stakeholders who may resist the change are aware of the change, the reasons for the change, and how it will impact them (Muldoon, 2018). 

After unfreezing people, they can start moving. According to Lewin, change involves transition into the new state (Muldoon, 2018). This step will involve the implementation of the proposed protocol. The change becomes real at this point. All the actions to be implemented to increase employee retention will be implemented in this stage. Among the actions to be implemented is communication training, implementation of a rewards system, training on autonomy, execution of autonomy promotion strategies such as resource binders, among other activities. It is a period that is usually characterized by uncertainty, and it is considered the hardest step. New behaviors will be learned, and processes as well as how the nursing staff think will change. Communication and support are also vital in this step as employees develop familiarity with the change. Also, it will be essential to continue reminding the nursing staff of the reasons behind the change and the benefits it will cause once execution is complete. 

After change implementation, the change will be reinforced, stabilized, and solidified in the refreezing stage. The changes made are embraced and refrozen as the new way of doing things in an organization (Muldoon, 2018). This step is critical because it helps prevent individuals from going back to their past ways of doing things or thinking. Effort should be made to ensure that the change made is not lost and that it becomes a part of an organization’s culture. Monitoring and impact evaluation will be conducted to determine if the change is being sustained. Acknowledgment from the management and nurse leaders will help reinforce the change. The refreezing stage will involve implementation of the rewards system to help ensure that the new behavior is reinforced in the organization’s culture. 

G5. Barriers to Implementation 

Both financial support and resistance to change could be potential barriers as well as hindrances to project completion. Financial support is the most likely barrier to the implementation of the protocol. The project will require finances to cover costs for different resources that will be required. In addition, some of the proposed interventions in the protocol, such as a rewards system, will require the organization to set aside some money for monetary rewards such as bonuses and staff training for professional development. This might a challenge considering the declining financial situation of the organization. In order to mitigate the problem, financial assistance will be sought beforehand to ensure that the financial costs for protocol planning and development are met. In addition, the proposal will be presented to the stakeholders early to allow adequate time for financial planning. Another challenge would be resistance to change. To mitigate this challenge, adequate buy in will be ensured through creating a need for change, effective communication, and a through explanation of the proposed solution and its benefits to all the stakeholders. 

References 

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