Research Proposal
Evaluator Reference
Problem Statement
Many hospitals depend on agency nurses as ways of addressing the persistent shortage of nurses. However, this practice has raised issues about “the consistency and quality, as well as the cost of care provided by temporary staff” (Joint Commission on Accreditation of Health Care Organizations, 2002, p. 1).
Problem Symptoms
Recent studies have also indicated that work environment and management culture contributed to negative quality of care rather than agency nurses (Aiken et al., 2012). On the other hand, other studies have associated the poor quality of care and patient safety outcomes to agency nurses.
There are also issues about the morale of nurses employed by the hospitals and poor relations with the agency nurses (Parsons, 2009). As a result, this literature review seeks to clarify whether usages of agency nurses have negative impacts on the quality patient care within the hospital environment, specifically in failure to rescue, morbidity, and mortality.
Failure to rescue (FTR) refers to cases where caregivers “fail to notice or respond when a patient is dying of preventable complications in a hospital” (Aleccia, 2008, p. 1). Silber and colleagues referred to FTR as “a death after a treatable complication” (Silber et al., 2007, p. 918). The United States’ Agency for Healthcare Research and Quality has recognized data from rates of FTR as crucial indicators of the quality of care and patient safety outcomes.
It shows how nurses are sensitive to quality of care during medical care. Aleccia noted that data from HealthGrades reported that more than “188,000 patients lost their lives to FTR between 2004 and 2006” (Aleccia, 2008, p. 1). Mortality reflects deaths that occurred due to nurse staffing characteristics.
Morbidity showed the increment in complication among inpatients that delayed recovery and discharge when agency nurses administered care. The earlier research concluded that higher rates of agency nurses were mainly “associated with higher rates of mortality, morbidity, and failure to rescue” (Aiken et al., 2012, p. 931).
Research Design
Methodology
This part provides the method of collecting the necessary data to meet research objectives. according to Howe and Eisenhardt, “methodology must be judged by how well it informs research purposes, more than how well it matches a set of conventions” (Howe and Eisenhardt, 1990, p. 2) in the final analysis. Therefore, the aim of the research methodology is to collect data that respond to the research issue, present coherent background assumptions, and to ensure that methods used work well to account for the credibility of the results.
A good research should provide a theoretical frame, scientific design, measurement methods that show reliability and validity, apply appropriate statistical methods of analysis, and generalise findings so that fellow researchers can borrow and learn from the results. Therefore, guiding theory, clear objectives, research methods, confidence in conclusions, and clear implications are useful and ensure that a study meet scientific standards.
This is a quantitative correlational study design. It will use structured questionnaires to gather data from agency nurses. The researcher will generate interview data from questionnaires. The research noted that the number of descriptive studies were many in use of agency nurses. Thus, a correlation study was necessary to establish the association between the use of agency nurses and patient safety outcomes.
The researcher shall ensure that the research design provides legitimacy and validity based on the instrument of measure and the study framework. This method provides an objective way of collecting data because the researcher will present a structured questionnaire to respondents. Thus, the investigator shall observe a scientific approach when designing appropriate data collection questionnaires. Moreover, the researcher would identify potential threats with regard to ethical consideration and minimize them before the study starts (Palmer, 2009, p. 115).
The questionnaire shall have a range of questions, which relate to usages of agency nurses and their impacts on the quality of patient care within the hospital environment, specifically in failure to rescue, morbidity, and mortality.
- How many cases of failure to rescue, morbidity, and mortality were reported when agency nurses were in charge of patients?
- Do agency nurses neglect their roles and engage in actions that affect the quality of health care negatively?
- Does the relationship between agency nurses and nurses directly employed by the hospitals affect the quality of health care outcome?
- Do agency nurses observe the quality of care during their work?
- Do agency nurses affect the quality of health care outcome?
- Are there notable differences between the use of agency nurses and regular nurses with regard to patient outcomes?
Research hypothesis
- H0: There is no relationship between the usages of agency nurses and failure to rescue, morbidity, and mortality
- H1: The usages of agency nurses will result in high rates of failure to rescue, morbidity, and mortality among patients
- H2: The usages of agency nurses will not result in high rates of failure to rescue, morbidity, and mortality among patients
Suitability of the research approach
Correlational study design shall allow the researcher to provide a clear association between the use of agency nurses and patient quality of care outcomes. Thus, the study shall indicator whether there are positive or negative outcomes with regard to failure to rescue, mortality, and morbidity whenever agency nurses were in charge of patients.
The design study shall provide an opportunity for the researcher to explore a large number of variables in one study (Porter and Carter, 2000; Burns & Grove, 1997). In addition, the investigator shall establish the degree of association between research variables. This study shall also establish a basis for experimental study in the area of focus. However, the researcher shall not draw any conclusion based on the findings. For instance, it will be unwarranted for the researcher to conclude that positive associations between variables are responsible for such outcomes.
In this case, there could be other possible reasons for such relationships because of different factors in the hospital environment. For instance, other factors could be responsible for such outcomes rather than nurse characteristics. The hospital environment, working conditions, and hospital resources may influence the quality of care among patients. Under such circumstances, without accounting for other factors, the obtained association between patient outcomes and the use of agency nurses may lack adequate support. In other words, such factors could be the cause of negative outcomes rather than agency nurses. Thus, some hospital environments may be responsible for negative patient outcomes.
Purpose of the research proposal
The study aims to establish whether usages of agency nurses have negative impacts on the quality patient care within the hospital environment, specifically in failure to rescue, morbidity, and mortality.
Roles and bias of the researcher
Theoretically, the role of the researcher does not exist in this study design. The researcher shall remain detached and impartial to the study. Thus, research participants would be independent from the influence of the researcher. The researcher would attempt to reduce cases of bias by developing a research design that ensures effective data collection and analysis. There are instances of personal bias, which may originate from the researcher’s interests, questionnaire design, and measurements, but the researcher does not have any personal interest in this study. While such personal bias may be difficult to avoid, the researcher shall remain objective to the study.
The researcher would recognize these challenges and ensure that he remains objectives throughout the study process. Moreover, the researcher shall ensure that all elements of the research design and analysis conform to established standards of a quantitative study (Selby et al., 1990). This shall help in reducing potential bias in the study.
The role of the researcher
The role of the researcher shall remain significant in this study. The researcher shall be in charge of locating and identifying hospitals and nurses who would take part in the study. He will identify appropriate data for the study and what information to exclude from the study. The researcher would develop study instruments. He will classify, count, and develop an appropriate statistical model for describing study results. The investigator has clear knowledge of what to expect in the study. Further, the researcher shall design every element of the study before the study begins. These elements will include structured questionnaires and checklist document for data from patient outcome records.
The researcher will record data in the form of numbers and statistics. He will be able to draw inferences and confirm the study hypothesis. However, in all these roles, the researcher shall remain detached.
Researcher detachment
The researcher shall perform the above roles. However, according to quantitative study design, the researcher should remain detached from the study, as well as from research participants. The aim is to observe objectivity of the study. In other words, the researcher shall not attempt to influence any aspect of the study by his feelings, beliefs, and experiences. According to quantitative researchers, issues of bias may arise when the researcher takes an active role in the process.
This implies that the researcher could attempt to sway study outcomes to favor his beliefs and values. Instead, the study outcomes should reflect hard scientific results. Bias in quantitative research normally results in a poor quality study, which researchers do not accept in the field of quantitative research.
Description of the sampling technique
The study will use cluster random sampling method. Random sampling is useful for drawing internal validity. It would assist the researcher to avoid sampling bias in the study. The researcher shall randomly assign subjects to the study. The investigator would perform a successive random sampling. In other words, the researcher will identify many hospitals in the region and apply random simple sampling to select them. Populations for the study would come from the chosen hospitals.
Sampling technique and its appropriateness to the methodology
Random sampling shall eliminate cases of bias in the study. The researcher will apply cluster random sampling because of the large number of hospitals and nurses in the region of the study. Thus, the cluster random sampling will ensure that the researcher selects adequate number of hospitals based on equal chances of representation. These selected hospitals would provide research participants.
Procedure for Cluster Random Sampling
- The researcher will select clusters or groups of hospitals from the State
- From each cluster, researcher will use simple random sampling to select agency nurses who will take part in the study
- The researcher shall use a subset of agency nurses from the hospitals to participate in the study because of their large numbers
- The State shall provide hospital clusters for the study
The researcher shall ensure that all clusters have equal chances of taking part in the study.
Evaluator Reference
Research participants for the study will be agency nurses. They shall consist of agency nurses from different backgrounds, age, race, and ethnicity. This will reflect the diverse health care setting of the US. The researcher considered junior nurses as those below 40 years of age while nurses above 40 years were senior nurses. The education level of researcher participants would be baccalaureate or higher degree qualifications.
There will be two types of research instruments for the study. First, the researcher shall gather data using structured questionnaires from research participants. Second, the research will collect information from patient outcome records by using a checklist. The researcher shall use the collected data to make confirm the study hypothesis and make inferences.
Target audience or participants
The study targets agency nurses.
Age
All registered agency nurses of any age are eligible for the study. The researcher will use variations in age of agency nurses to indicate patient outcomes. In this regard, the researcher shall consider agency nurses less than 40 years of age as junior nurses, whereas nurses above 40 years shall fall in the category of senior nurses.
Number of participants
The researcher will gather data from several agency nurses and hospitals. Thus, reducing effects of sampling on the survey is important for the study findings. The researcher shall not collect data from the entire population. Therefore, the researcher will select a sample from the entire population randomly. Results from the study would be useful for drawing inferences about the entire population.
Population size = 300
Error to tolerate = 5%
Confidence Level = 95%
The researcher used a Web-based application to calculate and determine that the number of research participants as 168.
The estimated response rate will be 80 percent. Thus, the researcher shall target 210 research participants in order to get 168 responses.
Gender
Both male and female nurses shall take part in the study.
Ethnicity
The researcher shall not restrict agency nurses based on their ethnicity, race, national, or state of origin. Instead, the researcher aims at inclusion in order to reflect diversity in American populations.
Economic situation
The study assumes that all nurses are in the same economic situation.
Education level
The study shall interview both agency nurses with a baccalaureate or higher degree qualifications. This is necessary to understand whether differences in qualifications also affected patient outcomes among agency nurses.
Data collection methods
The researcher shall use structured questionnaires to gather information for the study. A questionnaire will have a number of questions presented to research participants in order to gain required information on the usage of agency nurses and patient outcomes.
The investigator would ensure that he carefully constructs and administers questionnaires for drawing general inferences from the results. In this context, the researcher shall pay special attention to type of questions, order of questions, scaling, and format of the questionnaire. In order to guarantee effectiveness of the questionnaire, the researcher will conduct a pretest with a subset of the target population.
The researcher understands challenges inherent in the process of developing questionnaires. The study instrument would be a closed ended questionnaire. In other words, respondents will only respond based on the provided options and scales. The researcher will use Likert scale, Yes/No, and multiple questions to develop the instrument.
The researcher will be able to reach a large number of agency nurses by using e-mail. This method also offers simple processes of developing, coding, and interpreting the results. Moreover, this form of data collection instrument is standardized. Therefore, all respondents shall respond to the same questions asked in a similar manner. This would ensure that the study instruments are reliable. It will also enable the researcher to gather data about sensitive information like failure to rescue, morbidity, and mortality from participants who would wish not to respondent in the presence of others or face-to-face with the investigator.
However, one major drawback to a structured questionnaire is that the researcher would not be able to explore respondents’ opinions about complex issues in the hospital environment.
Instruments to be used for data collection
The researcher shall use structured questionnaires for data collection from research participants.
He will also review patient outcome records for purposes of making a comparison between regular and agency nurses. For patient outcome records, the researcher shall use a table (checklist) to collect data and comments about failure to rescue, mortality, and morbidity in cases where both agency nurses and regular nurses were in charge of patients. The data for the study will be from 2008 to 2012.
The researcher shall establish a rapport with the hospital staff who keeps patient outcome records. The data requested are sensitive in nature to the hospital and patient. Thus, the researcher must ensure that he only collects relevant data to the study. He will not gather any personal information related to any patient.
Data to collect through the instruments or methods
The researcher shall gather data related to patient outcomes and background information about research participants through study instruments. He will review patient outcome records for specific data related to morbidity, mortality, and failure to rescue for a given period. This is necessary because some participants may not provide relevant information about sensitive information. Thus, records would be the best source of secondary information for the study.
Insert data from patient outcome records for the period: 2008 to 2012
Validity
The researcher will structure data collection instruments in a manner that allows inferences to be possible. Thus, it will be possible to evaluate the main research question of the study. The researcher would observe “internal validity, use reliable and valid measurements and review, perform appropriate analysis of the data (statistical validity), and make appropriate inductive inferences about the pattern of results to be able to draw conclusions about its practical and theoretical implications – external validity” (Steinberg, Bringle, and Williams, 2010, p. 39). Research instruments shall measure what they were designed to measure.
Thus, research instruments will only measure specific issues in usages of agency nurses and patient outcomes in a hospital environment. The researcher will review the instrument with colleagues to ensure that the instruments conform to content validity. He will also ensure that the instrument accounts for all areas of the study. The researcher shall compare results with past studies in order to establish associations. In construct validity, the researcher would conduct a correlation coefficient test to determine validity. High correlation coefficient would mean that instruments are valid.
Reliability
A good research instrument should provide consistent scores. A test procedure for reliability involves testing for coefficient, which would be in a numerical summary. Researchers have observed that several forms of reliability exist, and they all have impacts on the general reliability of the study instrument and collected information. Reliability is a significant precondition for validity. This is critical for the study because an instrument can be reliable, but not valid. Thus, a reliable study instrument must also be valid.
The researcher shall compare results with results obtained from pre-test. This is like test-retest reliability. Thus, a reliable study instrument should provide related outcomes when research variables are the same. The researcher will also conduct Chronbach’s alpha test to determine reliability.
Research procedure
The primary objective of a correlational research study is to establish association among variables in the study. The initial stage of the research involved a systematic review of possible research problems for the study. The researcher decided to pursue usages of agency nurses and patient outcomes. The steps for the study are as follow (Majeed and Awan, 2011, p. 62):
- The researcher identified the study problem as usages of agency nurses and patient outcomes
- The researcher noted that some studies have associated the usages of agency nurses with high rates of failure to rescue, morbidity, and mortality
- The researcher conducted a literature review of past studies in order to identify what other scholars have done in usages of agency nurses and failure to rescue, morbidity, and mortality as indicators of patient outcomes
- The researcher designed quantitative study approach for the research
- Data collection instruments for the study would be structured questionnaires and a checklist document to capture data from the patient outcome records
- The researcher targeted agency nurses in this study
- The investigator shall send structured questionnaires to agency nurses
- He will also review patient outcome records for cases of failure to rescue, mortality, and morbidity
- Data analysis will involve descriptive analysis and logistic regression
The researcher shall identify all data suitable for tabulation and those for charts, graphs, frequency tables, percentage distribution, and inferences
- There would be analysis of data and drawing of inferences by answering the research question through inferential techniques and correlation coefficient
- The process shall show how agency nurses (independent variables) correlate with failure to rescue, morbidity, and mortality (dependent variables)
- Quantification of results shall show differences in frequencies
- Results shall be precise and set stage for experimental studies
- The researcher shall write the final report based on study outcomes and inferences
Data Analysis
The researcher used SPSS version 17 for data analysis (Pallant, 2005). This provided a good chance for the researcher to analyse qualitative data after coding. Data analysis would involve the use of both descriptive and logistic regression. Data for correlation between variables would mainly consist of descriptive statistics. For instance, correlation tests would show whether the use of agency nurses correlate with patient outcomes. It would show whether such relationships are positive or negative. In addition, descriptive statistics would indicate the extent of such relationships.
Descriptive statistics shall provide basic features of information collected for the study. In other words, we would obtain summaries and measures about data collected. For instance, the researcher will describe mean and median to show the central tendency and mode of data to identify the most common measurement in collected data.
Such data are useful for making inference. The standard deviation, coefficient of variance and variance shall show any dispersion in analyzed data. Any calculated value would assist the researcher to understand deviation of values from the mean range. The researcher shall also know normality in the data through tests for skewness and Kurtosis. Most statistical techniques assume that distributions of scores on dependent variables are normal. In this case, a normal distribution represents a symmetrical, bell-shaped curve, which has the greatest frequency of scores in the middle, with smaller frequencies towards the extremes (Gravetter and Wallnau, 2000).
Skewness tests for instrument normality indicate the tilt or lack of it in distribution of respondents (Kline, 1986). These are right and left skewness whereby right skew are common. Some authors have argued that skew should have a range of +2 to -2 to indicate normal distribution. However, others statisticians apply a stringent rule of + 1 to – 1 to assess normality of instruments. There are several statistical techniques that the researcher can use for making assumptions about the data collected.
The logistic regression would enable the researcher to explore how well a “set of variables explains the categorical dependent variable” (Pallant, 2005). The approach would allow the researcher to test for categorical outcomes in two or more categories. These variables would be either categorical or continuous, or they may consist of both outcomes.
Logistic regression would show the adequacy of variables by exploring their suitability (Pallant, 2005). The approach would account for the relative significance of study variables and their association. Logistic regression would provide “a summary of the accuracy of the classification of cases based on the mode, allowing the calculation of the sensitivity and specificity of the model and the positive and negative predictive values” (Pallant, 2005, p. 163). This method of data analysis would not make any assumption about the scores of variables.
Ethical issues
The investigator shall follow all guidelines of ethics in research as Beauchamp and Childress indicated (Beauchamp and Childress, 2001). The University will provide ethical guidelines for this study and ensure that the study is not bias and would not harm research subjects. In addition, the researcher would obtain written consent of all study participants before the start of the study (Pimple, 2006). Overall, the researcher would:
- respect autonomy of choices of respondents
- Confidentiality
- Protect all respondents
- No personal data would be collected in the study
- Research participants would be free to withdraw from the study at anytime
- The researcher would observe professional code of ethics as the University provides
- The participants will understand the purpose of the study
- No human subject would suffer any harm in the study
References
Aiken, H., Shang, J., Xue Y., and Sloane, M. (2012). Hospital Use of Agency-Employed Supplemental Nurses and Patient Mortality and Failure to Rescue. Health Services Research. Web.
Aleccia, J. (2008). Before Code Blue: Who’s minding the patient? Web.
Beauchamp, T., & Childress, F. (2001). Principles of biomedical ethics. New York, NY: Oxford University Press.
Burns, N., & Grove, S. K. (1997). The practice of nursing research (3rd ed.). Philadelphia: Saunders.
Gravetter, F., and Wallnau, B. (2000). Statistics for the behavioral sciences (5th ed.). Belmont, CA: Wadsworth.
Howe, K. R., & Eisenhardt, M. (1990). Standards for qualitative and quantitative research: A prolegomenon. Educational Researcher, 19(4), 2-9.
Joint Commission on Accreditation of Health Care Organizations. (2002). Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Web.
Kline, P. (1986). A handbook of test construction. New York: Methuen.
Majeed, A., and Awan, N. (2011). Procedures for Developing a Medical Research Study. Journal of Rawalpindi Medical College, 15(1), 62-64.
Pallant, J. (2005). SPSS Survival Manual. Sydney: Ligare.
Palmer, J. A. (2009). Nursing Research Understanding the Basics. Plastic Surgical Nursing, 29(2), 115-121.
Parsons, J. (2009). Agency nurses – whats the problem? Web.
Pimple, K. (2006). Protection of human subjects in non-biomedical research: A tutorial. Web.
Porter, S., and Carter, D. (2000). Common terms and concepts in research. In D. Cormack (Ed.), The Research Process in Nursing (4th ed.). (pp. 17-28). Oxford: Blackwell Science.
Selby, M., Gentry, N., Riportella-Muller, R., Quade, D., Legault, C., and Monahan, K. (1990). Evaluation of sampling methods in research reported in selected clinical nursing journals: implications for nursing practice. Journal of Professional Nursing, 6(2), 76-85.
Silber, H., Romano, S., Rosen, K., Wang, Y., Even-Shoshan, O., and Volpp, G. (2007). Failure-to-Rescue: comparing definitions to measure quality of care. Medical Care, 45(10), 918-925.
Steinberg, K., Bringle, R., and Williams, M. (2010). Service-learning research primer. Scotts Valley, CA: National Service-Learning Clearinghouse.
Appendix
Research Questions
- How many cases of failure to rescue, morbidity, and mortality were reported when agency nurses were in charge of patients?
- Do agency nurses neglect their roles and engage in actions that affect the quality of health care negatively?
- Does the relationship between agency nurses and nurses directly employed by the hospitals affect the quality of health care outcome?
- Do agency nurses observe the quality of care during their work?
- Do agency nurses affect the quality of health care outcome?
- Are there notable differences between the use of agency nurses and regular nurses with regard to patient outcomes?