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Short Staffing of Nurses


The understaffing of nurses in medical institutions is becoming a source of constant concern, including the health maintenance of patients in hospital setting. This paper will examine the crisis of understaffing of nurses in Tenet Hospital and its impact on patients. The main purpose of this research is to analyze and qualitatively assess the repercussions of understaffing of nurses on the health of patients. In this research, data was collected with a set of interview questions that examined the issues related to patient safety. A primary analysis of registered nurses (n=284) from the hospital staff were included in the population studied for this research. Data was retrieved from the inpatient nursing floors (n = 7) throughout the hospital.

The response rate of the participants in the primary analysis should be over 70%. After completion of the interview undertaking, each entry response will be added to create a total score for each question. An email survey in the form of an interview shall be undertaken and to assess the key independent variables and intention relationship. Further, so as to identify the chief targets of action, there shall be the performance of a discriminant analysis. This study findings may indicate that the understaffing of nurses have negative effects on the health and care of patients.


Short Staffing of Nurses

Although the research on staffing of nurses has not clarified the point, many believe that lower patient to nurse ratios ultimately reduces the cost of hospitalization by decreasing the length of patients stay and other hospital complications (Steinbrook, 2002; Coffman, Seago & Spetz, 2002). A safe patient to nurse ratio ranges from 4:1 in telemetry care to 5:1 in a medical surgical floor. According to Stone, Clark and Climioti (2004), evidence in all parts of the United States clearly shows the lack of qualified nurses is a major public safety issue that requires a new approach and policy changes. Monitoring and improving the working conditions of nurses are likely to improve the quality of health care by decreasing the incidence of many infectious diseases, assisting in retaining qualified nurses, and encouraging men and women to enter the profession (Stone et. al., 2004). Therefore, improvements should be made in the workforce to enhance these conditions by providing more staffing of nurses. This study shows that short staffing of nurses affects the quality of care by causing more harm than good.


Problem Statement

The understaffing of nurses puts patients at risk for poor patient outcomes such as increased risks of falls and spread of infections. Research has shown that hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections (Stanton, 2004).


Purpose of Study

The purpose of this study is to demonstrate how the care of patients is affected by the shortages of nursing staff. This paper will present the crisis of understaffing of nurses in Tenet Hospital and its impact on patients. According to Fackelmann (2001) many U.S. hospitals have shifted work once done by aides to registered nurses, forcing them to answer phones, transport patients around the hospital and run samples to the laboratory. Researchers say such non-nursing work can leave nurses with little time to check on patients, a trend that can have dire results (Storfjell, 2008). This study seeks to present documented studies and evidence exposing the fact that understaffing of nurses does have a negative impact on patients’ health and care.


Significance of the Study

This paper will present the crisis of understaffing of nurses in Tenet Hospital States and its impact on patients. This study will also attempt to examine nurse staffing to demonstrate that nurses need a patient to nurse ratio and a stable working environment that promotes safe outcomes. This study will benefit nursing students in making the right choices about where to work and what questions to ask in a job interview. Instructors will also benefit by this research in the clinical area because they can show the students about obtaining balance and prioritizing the responsibilities of nursing to prevent burnout. Furthermore, this research will attempt to provide the recommended safe patient to nurse ratio and describe how to balance work as a nurse for the prevention of poor patient outcomes.


Research Questions

  1. Is the short staffing of nurses related to the higher incidence of hospital acquired infections?
  2. Does the shortage of nursing staff increase the risk of falls in patients?
  3. Do nurses have a workload that includes a safe patient to nurse ratio?

Literature Review

To ensure that the research is extensive and all the issues were addressed, a number of education resource databases were used including EBSCO and CINAHL. EBSCO is essentially a global research database service that avails to those who are members (through subscription) a wide range of content in many subjects. The initials EBSCO stands for Elton B Stephens and Company named after the founder, Elton Bryson Stephens. CINAHL, on the other hand, is primarily a resource that avails to those who are members through subscription of a wide range of nursing literature. The initials CINAHL stand for the Cumulative Index to Nursing and Allied Health Literature. The search terms used in this case where nurse understaffing, medical institutions understaffing, nurse understaffing impact, nurse understaffing today, nurse understaffing research, nurse understaffing effects and nurse understaffing patients.


Hoi, Ismail and Onge (2010) reported that a workload measurement system is critical for identifying nurse staffing needs for safe care and for justifying nursing resource allocation as a cost conscious healthcare environment. Nineteen wards were observed over a period of one week on day shifts with the use of regression modeling (Hoi et al., 2010).   The results indicated nursing time required for a low-acuity ward increased from 90.5 to 177.1 hours per day (Hoi et al., 2010). This indicated that in a rapidly changing work environment, workload measurement systems should be reviewed periodically. The WIMS (Wireless Integrated Microsystems) was developed as a potential methodology for measuring staffing needs (Hoi et al., 2010) The nursing workforce is confronted with the challenge of meeting competing demands as hospital activity and client acuity are reported to have increased during the 20th century (Buchan, 1997). With the use of a measuring system, one can calculate the appropriate patient ratio required for the improvement of safety for the clients (Hoi et al., 2010).

The study done by Tervo, Kiviniemi and Partenen (2009), was to assess the relationship between patient-to nurse ratios and outcomes. Although there is a growing body of evidence showing that higher levels of registered nurse staffing are linked to better outcomes, it was still unclear how nurse staffing produced these effects (Tervo et al., 2009). A survey of data of nurses (n = 854) in 46 inpatient units at five university hospitals in Finland was used to create a Bayesian Network (BN) model of connections between the variables (Tervo et al., 2009). The BN model showed that the quality of nursing care is influenced by multifaceted work environment measures (Tervo et al., 2009).


A study conducted by Andrews, Burr and Bushy (2011), showed the narrative analysis of comments provided by 106 staff nurses working in a medical-surgical setting. The result of the study suggested that nurses feel that the work environment neither empowers them to act effectively on behalf of their patients nor enhances their self-concept, leading to compromised quality of care (Andrews et al., 2011). Recommendations are offered to enhance nurses' professional self-concept through staff development and policy changes (Andrews et al., 2011). There is an urgent need for substantive changes aimed at lowering the patient to nurse ratio as this will go a long way to enhance patient outcomes.


Lucero, Lake and Aiken (2009) conducted a study to describe registered nurses’ reports of unmet care needs and to examine the variation of nursing care quality across hospitals through a mail survey. A total of 2,008 nurses responded with results to show that across hospitals, there was a wide range in the proportion of nurses who reported leaving nursing care needs uncompleted (Lucero et al., 2009). After controlling for nurses’ demographic information, they found statistically significant variations in the quality of nursing care across hospitals (Lucero et al., 2009). The study showed the differences in nursing care quality across hospitals appear to be closely associated with variations in the quality of care environments (Lucero et al., 2009).



Literature Review Table








Aiken L.H., Clarke S.P., Sloane D.M., Sochalski J.A., Busse R., Clarke H., Giovannetti P., Hunt J., Rafferty A.M. & Shamian J. (2001) Nurses’ reports on hospital care in five countries. Medical News, [20] (3), 43–53.

To assess the variation in patient safety across hospitals and explore whether nurse staffing may be associated with safety.



5,388 nursing units in 636 hospitals.

A cross-sectional observational study using 2004 NDNQI data.



National Database of Nursing Quality Indicators (NDNQI) using an analytic file of monthly observations



Nursing staff hours and hospital Magnet status were significantly associated with the fall rate (Aiken, Clark, Sloan, Sochalski, Busse, Giovannetti, Hunt, Rafferty & Shamian, 2001).


According to the evidence in the study, there are two mechanisms for enhancing patient safety: becoming or emulating a Magnet hospital, or adjusting staffing patterns at the unit level (Aiken, Clark, Sloan, Sochalski, Busse, Giovannetti, Hunt, Rafferty & Shamian, 2001).


Andrews, D., Burr, J. & Busy A. (2011). Nurses' self-concept and perceived quality of care: a narrative analysis. Journal of Nursing Care Quality, 26(1): 69-77








To explore the comments of staff nurses to gain meaning of their experiences.

308 registered nurses caring for adult patients on medical-surgical units.


Written comments in a pre-printed one page with 15 questions.

This study suggest that nurses who feel that the work environment neither empowers them to act effectively on behalf of their patients nor enhances their self-concept may lead to compromised patient care quality (Andrews, Burr, Busy, 2011).


Nurses who report higher levels of job satisfaction also report higher levels of autonomy, participation in decision making, and collaboration

(Andrews, Burr, Busy, 2011).

Berlan, A., Berensten, S., & Gundersen, D. (2009). Hospital-acquired infections and patient safety. Nordic journal of Nursing research & clinical studies, 29(1), 33-37.

To examine the thoughts and


of the critical care nurses in regard to hospital-acquired infections and patient safety


Berensten & Gundersen, 2009).


23 advanced nurses with training in anesthesia,


and surgery care.

Descriptive by

qualitative analysis.

Focus group interviews.

The findings show that respect for hygiene protocols becomes reduced over time and this affects patient

Safety (Berlan, Berenstein, Gundersen, 2009).

Busy and stressful work environment can is an issue when having to adhere to the hospitals protocols.


Borkowski, N., Amann, R., Song, S., & Weiss, C. (2007). Nurses’ intent to leave the profession: issues related to gender, ethnicity, and education level. Health Care Management Review, 32(2), 160-167



To explore issues relating to the nursing shortage.

284 nurses


Electronic survey designed as a two step approach.


Heavy workload and management leadership styles are predictors or significant influences for nurses' intent to stay with or leave an organization (Borkowski, Amann, Song, & Weiss, 2007).

Short staffing   of nurses are associated with unsafe conditions in hospitals across the United


Geiger, J., Trinkoff, A., & Rogers, V. (2011). The impact of work schedules, home and work demands on

self-reported sleep in registered nurses. Journal of Occupational and Environmental Medicine, 53(3), 303-307.

To explore the relationship of work schedules to self reported restless and inadequate sleep in a large population-based sample of registered nurses (Geiger, Trinkoff, Rogers, 2011).




(n = 2246)












Non- experimental correlational











Cross-sectional mailed survey












Odds of inadequate and restless sleep showed a clear dose effect for adversity of work schedule, even when adjusted for age and home demands (Geiger, Trinkoff, Rogers, 2011).



Current scheduling practices and high work demands negatively impact nurses' sleep and may be partially explained by exposure to work demands

(Geiger, Trinkoff, Rogers, 2011).





Hertting, A., Nilsson, K., Theorell, T., & Larsson, U. (2004). Downsizing and reorganization: demands, challenges and ambiguity for registered nurses. Journal of advanced nursing, 45(2),145-154



To explore registered nurses' experiences of psychosocial 'stressors' and 'motivators', and how they handled their work situations, following a period of personnel reductions and ongoing reorganization

(Hertting, Nilsson,

Theorell, & Larsson, 2004).

14 nurses followed for one year.

Explanatory research using interview questions.

Audio taped interviews.

Five themes are in relation to nurses' perceived stressors, motivators, and coping options. (Hertting, Nilsson,

Theorell, & Larsson, 2004).




The study demonstrated that the well-being of nurses depends on being an equal/parallel health professional in a comprehensive team that shares knowledge and improves collaborative care of patients

(Hertting, Nilsson,

Theorell, & Larsson, 2004).



Hoi, S., Ismail, N. & Ong, L. (2010). Determining nurse staffing needs: the workload intensity measurement system. Journal of Nursing Management, (18), 44–53,



To develop a prototype nursing workload intensity measurement system.



Nineteen wards were observed over a period of one week day shifts in a 1500-bed acute care hospital involving 500 nurses.

A descriptive observation survey adopting a work sampling technique.


questionnaire survey



The nursing time required per day for each activity

was compared with the derived activity time in the current study (Hoi, Ismail & Ong, 2010).

In order to properly identify nursing staffing needs, a workload measurement system is highly recommended to assure safe patient care.

Lucero, R., Lake, E. and Aiken, L. (2009). Variations in nursing care quality across hospitals.   Journal of Advanced Nursing, 65(11), 2299-2310


To describe registered nurses’ reports of unmet nursing care needs and examine the variation of nursing care quality across hospitals.




1999 nurses















Secondary analysis of a 2008 survey of registered nurses.











Mailed questionnaire survey













Across hospitals there was a wide range in the proportion of

nurses that reported leaving each nursing care need undone (Lucero, Lake, Aiken, 2009).



Differences in nursing care quality across hospitals appear to be associated with variations in the quality of care environments

(Lucero, Lake, Aiken, 2009).





Mark, B. & Belyea, M. (2009). Nurse staffing and medication errors: cross sectional or longitudinal relationships? Research in nursing and health, 32, 18-30.

To examine the relationship between change in nurse staffing and medication errors.

284 nursing units and a total 1,892 nurses.



Non-experimental, causal modeling design.






284 nursing units in 145 hospitals.


When RN proportion exceeded, medication errors increased (Mark & Belyea, 2009).

It demonstrated a significant


between a higher proportion of professional

nurses on the

nursing staff and

lower rates of medication errors (Mark & Belyea, 2009).


Palfi, I., Nemeth, K., Kerekes, Z., Kallai, J., & Betlehem, J. (2008). The role of burnout among nurses.

International journal of nursing practice, 14(1),19-25


To explore the occurrence of burnout among nurses in health and social institutions, to reveal the connections between burnout and socio demographic factors, and to learn its extent in different types of care.

805 registered


Correlational design.

Survey was a one-off, represent-tative sample with 805 question-naires processed

Burnout is twice as high among intensive care nurses (10.7%) than among long-term care nurses (3.6%), and the least is among active ward nurses (0.6%) (Palfi, Nemeth, Kerekes, Kallai, & Betlehem



Prevention by providing safe staffing, could save health-care workers from burnout and leaving the job independently

(Palfi, Nemeth, Kerekes, Kallai, & Betlehem




Ruggiero, J. (2005). Health work variable, and job satisfaction among nurses. JONA, 35(5), 254-263.




To explore the relationships and relative contributions of selected work (stress, work load, weekends off), shift worker health (sleep, depression), and demographic variables (age, number of individuals needing care after work) to job satisfaction.


247 critical care nurses.

Dillman Tailored Design Method of survey research was used to recruit participants and collect data.


There were no significant differences in these variables among self-defined day, night, and rotating shift nurses. Hierarchical regression analyses indicated that more weekends off per month and less depression and emotional stress contributed significantly to job satisfaction in nurses (Ruggiero, 2005).

Improvements in scheduling and interventions designed to reduce depression and emotional stress may help to improve job satisfaction in nurses and aid in nurse recruitment and retention (Ruggiero, 2005).




Stelina, P., Groves, M., & Paffor, L. (2005). Managing medication errors – a qualitative study. Medsurg nursing, 14(3), 174-178.

To forge a more intense

understanding of how nurses

experience making or being

involved in medication errors

1,384 nurses

Descriptive design

using qualitative analysis.

A 16-item

Liker survey.

Analysis of the participants

response revealed three key themes: time is on our side, context counts, and reliance on systems (Stelina, Groves,   & Paffor, 2005).

Medication errors occur most when a nurse has a heavy load of patient care to provide (Stelina, Groves, & Paffor, 2005).



Storfjell, J., Omoike, O., &   Ohlson, S. (2008). The balancing act: patient care time verses cost. JONA, 38(5), 244-249.




To determine the time the nurses spend with their patients.

11,400 patient-days per unit across the 14 units consisting of general medicine, ortho-pedics, telemetry, and general surgery.

Observational design.

An activity-based costing approach was used in 14 medical-surgical nursing units to study nursing activities and their related costs.

Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psycho-social support

(Storfjell, Omoike, &   Ohlson, 2008).

Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psychosocial support Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psycho-social support

(Storfjell, Omoike, &   Ohlson, 2008).


Tervo, T., Kiviniemi, V. and Partanen, P. (2009). Nurse staffing levels and nursing outcomes: a Bayesian analysis of Finnish-registered nurse survey data. Journal of Nursing Management,

37 (8)



To assess the relationship between patient-to- nurse ratios and the nursing outcomes.

Registered nurses

(n = 854) in 46 inpatient units at five university



A survey of data

The nursing care is influenced

by multiple work environment measures (Tervo, T., Kiviniemi, V. and Partanen, P., 2009).

Literature provides evidence that higher levels of nurse staffing are linked to improved patient outcomes (Tervo, T., Kiviniemi, V. and Partanen, P., 2009).

Unruh, L., Joseph, L., & Strickland, M. (2007). Nurse absenteeism and workload: negative effect on restraint use, incident reports and mortality. Journal of advance nursing, 60(6), 673-81.



To assess the impact of nurse absenteeism on the quality of patient care.



72 nurses

Retro-spective study design.

Monthly data from incident reports and staffing records in six inpatient units for 2004 were analyzed.




Absenteeism alone may not be a strong factor in lowering quality, but the combination of high registered nurse absenteeism and high patient load (Tervo, T., Kiviniemi, V. and Partanen, P., 2009).


Low staffing contributes to high absenteeism (Tervo, T., Kiviniemi, V. and Partanen, P., 2009).



In summary, research has demonstrated through numerous studies that it is unsafe for nurses to have responsibilities that are demanding and unrealistic to complete. The nurse’s role has been regarded as stress-filled based upon the physical labor, human suffering, work hours, staffing, and interpersonal relationships that are central to the work nurses do (Jennings, 2007). Nevertheless, nurses continue to work under these conditions, even if it affects their health. All the articles demonstrated the effects that an unnecessary and heavy workload has on nursing care.


Theoretical Framework

The effect of stress in the nursing workforce is a cause for concern. Under the humanistic nursing theory, Kleiman (2005) proposed that the importance of an individualized relationship with the patient is central to providing high quality nursing care. Paterson and Zderad (2008) point out that a nurse is aware of self and others:

Nursing embraces more than a benevolent technically competent subject-object one-way relationship, but is guided by a nurse in behalf of another. Rather it dictates that nursing is a responsible, transactional relationship whose meaningfulness demands conceptualization which is essentially founded on a nurse's existential awareness of self and others (Para. 1).

The theory of Karasek’s model on demand-control was used for this study related to its discussion of stress. Karasek’s (1979) model suggests that two factors produce job stress, job demand and control. He proposed that the combination of high work demands and low control results in “high strains” that result in a variety of health problems (Landy & Conte, 2010, p. 21). This theory is relevant to the workload a nurse has in conjunction with providing patient care. Stress is a factor a nurse faces daily when providing care for his or her patients and completing the demands of their workplace.



There are a few limitations that might affect the results of the study. One of them is the fear a nurse may have about losing their job for being honest about his or her workload on the interview. Therefore, a nurse may be hesitant to participate. Not everyone believes that participation in a study is anonymous and may be less than honest in completing the questions.

A potential issue with the sample population is the usage of only a group from one hospital to represent all nurses worldwide. There is no other sample population used to compare the results, or to rule out other factors involved pursuant to logistical and resource considerations. For example, the pediatric and labor floor was also excluded as a result of their unwillingness to participate in the study thereby bringing about a weakness in this study.



Studied and Sample Population

This research took into consideration the registered nurses from Tenet Hospital’s upper six floors. The total number of those nurses who were approached for the research was 284. The nurses in this case have a total of two weeks to complete the emailed interview questions. It is, however, important to note that the original number of those who were to participate in the interview was 300. Nevertheless, out of the 300 participants, only the indicated 284 agreed to participate. In this case, it is important to note that the study population was sourced from both part timers and full timers. All the mailed (284) interviews were received. However, we had to return 12, which were incomplete and two, which were unclear i.e. contained significant errors and in that regard, they could not be expected to reflect the true nature of the research. They were received back shortly.


The Procedure of Data Collection

In regard to the authorization of the interview questionnaire, all the relevant authorities were contacted including the management of Tenet Hospital as well as a host of other regulatory authorities. It was only after all the required permission was accessed that the collection of data proceeded. In this case, we identified a contact person in Tenet Hospital, who was responsible for the actual distribution of the submission of the interviews (see Appendix B) to study participants. It is important to note that the signed informed consent was received from each nursing floor. The consent was in a manila envelope (brown in color). Further, there was the posting of the research purpose on each nursing floor of the hospital.


The researcher will come by each department every afternoon to open box and collect the signed consents. In order to provide privacy, the researcher will be the only one with the key to open the box. The time for the completion of the questionnaire is 25 minutes, and it is due on the 14th day from the day of submission. When it comes to the mailed interview questions, the range could go from asking the satisfactory level of their workplace to the changes that need to be made on under staffing.


The reliability will be measured by comparing the answers from nurses working in different departments and establishing validity of the answers. Validity describes the extent to which a tool actually measures what it was designed to measure (Burns & Grove, 2005). In face validity, the appearance of the capability in the instrument is to propose a number that it has the means to provide in the results. Although this method does not provide strong substantiation of validity, it is a useful contributor to the process (Polit & Beck, 2008). The results will reflect the total of nurses in agreement with each interview question. Some of the questions in the interview that can be asked and subsequently accommodated are in the emailed interview.



The design used in this research was qualitative. This approach was used because we intended to get the world view on the issues the research was about. In this context we assumed that there was no reality on the issues at hand and that the reality was only based on perceptions that are different persons and they are bound to change over a period of time. We did not restrict what we knew on the research because it should only have meaning within a given situation. The purpose of the qualitative research was to form new figures and build new theories.


We got outside of any existing theories that explain the phenomenon of interest. We had open mind to new ideas which emerged through the abstract thinking process of the researcher during the personal experiences of the research process.


Ihde (1977) in this book Experimental phenomenology: An introduction discussed that the area of formation of new ideas and forms in relation to human visual perception. He discovered that one of the important strategies in switching from one view of a drawing to another was by changing of the focus.Ihde noted that a new reconstruction tends to be considered odd at first and unnatural; it attains stability and naturalness after a while. The same can come true if we change our ideas about the practice of nursing.


Nursing is known to have a strong base. There comes an historical view of such phenomena as illness, patients, nursing care and its effects and health. Views on long held beliefs are introduced in this discipline very early. For instance for some time now the nurse perceive patients to be passive and unable to take care of its responsibility. Now patients are more often perceived as participating in their care and responsible for their health.The qualitative research approach helped us get a process by which we could examine a phenomenon outside of common belief.


In the research we examined many dimensions of the nursing field and formed new ideas. We changed the normal perceptions as we observed the present ones. The reconstruction was used as a means of organizing data. We worked hard to maintain our rigor in our study by trying to be consistent in adhering to the philosophies of the approach we used. We tried to get away from older ideas which came as a result of poor developed methods. Other problems which we did our best to avoid were having inadequate time spent on the collection of data, poor observations and failure in giving of considerations to the data that was observed.


The main approach of the qualitative study we used was the phenomenology approach.This is the approach that the philosophical movement is dedicated to describe the experience structures as they present them selves to consciousness, without recourse to theory assumptions from other fields like natural sciences.This approach is both a philosophy and method of research. The purpose of using the phenomenological research was to describe the experiences the nurses had. This is because they are lived in phenomenological terms.The nurses were viewed to integral to the environment. The focus was on how the nurses interpreted the experiences the got from their duties and their views of the usual phenomena in their discipline.



The setting is in the Tenet Hospital of Hialeah, Florida, located in the main express way of Palmetto. There are a total of six floors in the hospital and 228 nurses working that will be approached for their participation in the interview. It includes four unit areas with a total of 104 nurses and two types of patients that who are taken care of daily.Each questionnaire will have a number imprinted at the top right corner, starting with the number 100 created with the Remark office Optical Map Recognition (OMR) software.


Protection of Human Subjects

The Institutional Review Board (IRB) is charged with protecting the rights and welfare of people involved in research (NHRMC, 2010, p.1). This is a committee that is charged with the review, approval as well as monitoring of behavioral research undertakings which have the human subjects as its participants. There is a review process that must be submitted prior to starting the investigation of the study involved. Reviews in this case include exempt and non-exempt. In the scenario presented herein, I will utilize exempt reviews. This is essentially because the study in this case essentially concerns itself with an issue that occurs under the regular nursing setting.

Interview questions will be made up of questions related to the problems and effects of nurse understaffing in Tenet Hospital. For all the subjects, the information they avail through the set of interview questions will be kept confidential. This is an important assurance aimed at ensuring that all participants take part in the study undertaking without having to fear a disclosure of any kind in the future in regard to the contents of the interview. Hence in that regard, all the completed forms will be delivered in a sealed envelope and participants are under no obligation to have their names or any form of identification in the forms. This is where the relevance of the number identifier comes in.


The participants will be informed via a letter of information with an attached consent to fill out. A copy of the letter will be posted in the bulletin of the nurse’s lounge. The researcher will hand it out to the nurses every morning from Monday through Friday at 8:00 am when they arrive at the floor. Their identity will be protected because the interview questions will be received anonymously with only a number identifier.


Data Analyzing Strategies

To ensure tha

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