Nurse-Patient Ratios and Inpatient Safety Outcomes: Research Proposal, First Draft

Hospitals across the globe continue to grapple with the implications of inadequate nurse staffing, especially in acute care settings where patient safety hinges on timely and attentive nursing interventions. One of the most serious consequences of staffing shortages is the growth in the number of falls among patients. Notably, a fall is a relatively frequent and expensive phenomenon that causes longer stays in the hospital, higher expenses on care, and severe injury. Patient falls not only jeopardize the well-being of patients but they also affect nurse morale, hospital image, and the institutional safety standards: Nurse-Patient Ratios and Inpatient Safety Outcomes: Research Proposal, First Draft.

This research aims to examine whether a reduction in hospitalization fall rates is linked to a nurse-to-patient ratio of 1:4 compared to a ratio higher than 1:6, during a 30-day hospitalization. This emphasis is based on the evidence that shows that nurse workloads impact the rate of falls due to a lack of care, chances, and responsiveness to patient demands. The PICO(T) question that underlies this study is as follows: In hospitalized adult patients, how does a nurse-to-patient ratio of 1:4 compared to a ratio above 1:6 affect patient safety outcomes such as falls within a 30-day hospital stay?

This study is particularly important to hospital administrators, nurse leaders, policymakers, and patients, since it provides information on staffing policy that can reduce harm and enhance the quality of care. The main limitation is the possibility of collecting inconsistent data on fall rates between units due to the existence of reporting differences. However, standardization protocols will be discussed in the method section.

Literature Review

Falls among patients are one of the most frequent adverse events in hospitals. LeLaurin and Shorr (2021) reveal that up to one million hospitalized patients fall every year in the U.S., one-third of whom experience some form of injury. The outcomes of such events include extended hospitalization, readmission, and lifelong disability. Many different fall prevention programs are available, but nurse staffing levels have remained a key factor in relation to falls. The issue of how nurse-to-patient ratios influence fall rates is an urgent and still-current research topic.

The correlation between nursing quality of care staffing and patient outcomes is evident. Twigg et al. (2021) presented the initial quantitative results that demonstrated that with high nurse workload, mortality and adverse events increased, which led to demands for a legal set of staffing ratios. Later, the New York State Nurses Association (2023) showed that each additional patient nurse increased death occurrence during hospitalization by 7%, thereby highlighting the necessity of changing staffing policy and training in the field of nursing.

This focus has been extended throughout recent research. Alanazi et al. (2023) associated missed care, including fall prevention, with poor staffing and burnout. A similar argument is reflected by Pressley and Garside (2023), who discovered that when dealing with workloads that are far beyond their capacity, nurses tend to overlook important safety precautions. Atnafu et al. (2025) reported the same results in Ethiopia, implying that the problem is widespread since the staffing shortage causes gaps in care and safety.

Furthermore, Mctavish and Blain (2024) reported that Canadian hospitals with 1:4 ratios had fewer falls than those exceeding 1:6, urging policy changes. A key debate continues between cost-saving flexibility and mandated safety. Proponents argue that the cost of falls far outweighs staffing expenses. This proposal aligns with that shift, focusing solely on fall rates to contribute more precise evidence to current nursing research and policy discussions.

Theoretical Framework

The proposed study will be guided by the Theory of Human Caring by Jean Watson, which places a focus on a holistic relationship between a nurse and a patient. Watson argued that successful healing cannot be limited to physical care strategies; it is based on proper human interactions that will enhance trust, empathy, and dignity. The theory identifies basic carative factors that include structuring an enabling environment, developing interpersonal relationships, and fostering the well-being of the patient (Afra et al., 2022).

To prevent falls among inpatients, the theory presented by Watson emphasizes the significance of active nursing care that is sensitive to the needs of patients. Nurses have better chances of spending time familiarizing themselves with the emotional and physical needs of patients, detecting fall risks, and acting proactively when their workloads are manageable (as in the case of a 1:4 ratio). On the contrary, high patient volume decreases the chance of such therapeutic instantiation, which can compromise safety. The hypothesis proposed by Watson in her framework refers to the perspective of better staffing that gives nurses room to exercise their full potential, thereby improving patient outcomes, such as fall prevention.

Methodology

Design and Approach

The proposed study will use a retrospective, quantitative, and comparative research design to examine the correlation between the nurse-to-patient ratio and the rate of inpatient falls in the adult medical-surgical unit. This non-experimental method is appropriate for studying the existing data in local hospitals; moreover, it allows for comparing the level of staffing and reducing ethical and practical limitations. To ensure reliability and consistency in data points, the analysis will be on the events of falls recorded during a continuous 30-day hospitalization.

Population and Sample

Individuals admitted to adult medical-surgical units in three large urban acute care hospitals within the last year, aged 18 or older, will be the study population. Units will be stratified into two groups depending on their average nurse-to-patient ratios using stratified sampling. Group A will consist of units having a ratio of 1:4. In contrast, Group B will consist of units having a ratio of above 1:6.

The minimum sample size per group will be 300 records of patients to limit the possibility of insufficient statistical power and the inability to generalize the results. To help assure sample consistency, patients admitted to specialty areas like intensive care and maternity units will be dropped, as these units will have different staffing patterns and different levels of acuity that may confound the key analysis.

Recruitment and Data Access

There will be no active recruitment of patients, and secondary analysis of existing records will be carried out. Institutional approval will be obtained through the quality assurance department of each hospital. The identified data, such as the nurse staffing log, fall incidents report, and patient length of stay, will be provided.

Data Collection and Measurement

Standardized hospital incident reporting systems will be used to identify fall events, which will be confined to falls verified with internal audits. The level of nurse staffing will be retrieved in the form of official shift rosters. The nurse-to-patient ratio is the independent variable, whereas the rate of fall per 1,000 patient-days is the dependent variable.

Instrument Validity and Reliability

To increase data reliability and ensure data integrity, the data will be cross-verified with electronic health records (EHRs) and internal audit logs. The fall logs employed are standardized and generally accepted as a functional measure of patient protection results.

Ethical Considerations

The study is eligible to be reviewed using expedited IRB because no patient identifiers will be used. All participating institutions will still be able to grant full ethical approval. Information will be confidential, and data will be stored safely, password-protected, and reported as aggregated.

Timeline

Activity	Time Frame
Obtain IRB approval and hospital permissions	Weeks 1–4 (Month 1)
Retrieve and validate data	Weeks 5–12 (Months 2–3)
Analyze data and generate findings	Weeks 13–15 (Month 4)
Prepare and finalize the study report	Weeks 16 (Month 4)
Total Duration	4 Months

Conclusion

The proposed study aims to investigate the effectiveness of nurse staffing ratios on the occurrence of inpatient falls, which is an acute and preventable issue in patient safety. Based on the theory of human caring by Jean Watson, the research hopes to measure the safety of staffing practices, specifically a 1:4 ratio, in reducing falls in hospitalized adults. The proposed study, by being specific, also provides actionable data that would be crucial in promoting policy changes and improving nursing practice accordingly. The evidence will have empirical backing of staffing reforms with a focus on both patient safety and nurse well-being, resulting in improved goals of quality care and evidence-based nursing leadership.

References

Afra, L. G., Hajbaghery, M. A., & Dianati, M. (2022). Human caring: A concept analysis. Journal of Caring Sciences, 11(4), 246–254. https://doi.org/10.34172/jcs.2022.21

Alanazi, F. K., Lapkin, S., Molloy, L. J., & Sim, J. (2023). The impact of safety culture, quality of care, missed care, and nurse staffing on patient falls: A multisource association study. Journal of Clinical Nursing, 32(19-20). https://doi.org/10.1111/jocn.16792

Atnafu, A., Teshale, G., Dellie, E., & Park, Y. S. (2025). Exploring health system challenges and gaps for crisis response in Ethiopia: A scoping review of publications and reports from 2020-2024. BMC Health Services Research, 25(1). https://doi.org/10.1186/s12913-025-13084-y

LeLaurin, J. H., & Shorr, R. I. (2021). Preventing falls in hospitalized patients. Clinics in Geriatric Medicine, 35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007

Mctavish, C., & Blain, A. (2024). Nurse-patient ratios: Current evidence report. Canadian Federation of Nurses Unions. https://nursesunions.ca/wp-content/uploads/2024/11/NPR-Full-Report-Final-01Nov24.pdf

New York State Nurses Association. (2023). Research shows safe staffing saves lives. New York State Nurses Association. https://www.nysna.org/resources/research-shows-safe-staffing-saves-lives

Pressley, C., & Garside, J. (2023). Safeguarding the retention of nurses: A systematic review on determinants of nurses’ intentions to stay. Nursing Open, 10(5), 2842–2858. https://doi.org/10.1002/nop2.1588

Twigg, D. E., Whitehead, L., Doleman, G., & El‐Zaemey, S. (2021). The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review. Journal of Advanced Nursing, 77(12). https://doi.org/10.1111/jan.14909

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Research Proposal, First-Draft
Purpose: Start your research proposal.

Use the instructor feedback from the Identifying the PICO(T) or Research Question and the Identifying the Nursing Theoretical Framework to complete this draft. Failure to use instructor feedback will result in deducted points. —– (Teacher’s feedback: Great job! Thank you for quantifying your ratios! This is a great topic.

For the purpose of this course, if you find it is easier to focus on evaluating just one of the patient safety measures, you can do that. However, if you would prefer to report on all three, that is fine. Just be mindful that you will need to prepare to present details about how each of those outcomes will be defined and measured in your proposal.

I look forward to seeing your proposal! Resource articles should be 5 years or less) Please refer to order #60766

Assignment Instructions

• Compile your research proposal.
• Develop a methodology for how you will carry out this proposal.
• Write no more than seven (7) pages. Please use APA 7th edition. Your reference and title pages do not count in the page limit. Papers that exceed seven (7) pages will be scored as zero.
• Include each of these components in the paper to receive full credit (Note: These components should serve as the outline & headings for your paper.)
  • Title Page:
    • Follow APA guidelines. Links to an external site.
    • Make your title succinct and to the point.
  • Introduction (Including the Problem Statement & PICO(T) or research questions):
    • Write 1-2 well-constructed paragraphs.
    • State the problem and give it context.
    • Explain the significance and purpose of your research.
    • State your hypothesis or PICO(T)/ research question(s). — PICOT Question: In hospitalized adult patients, how does a nurse-to-patient ratio of 1:4 compared to a ratio above 1:6 affect patient safety outcomes such as falls within a 30 day hospital stay?
    • Mention potential problems or pitfalls.
    • Specify for whom the research is relevant.
      

      Nurse-Patient Ratios and Inpatient Safety Outcomes: Research Proposal, First Draft

  • Literature Review (Background):
    • Review the Module 3 LibGuideLinks to an external site. on how to write a literature review
    • Include recent and pertinent data on your phenomenon of interest.
    • Provide relevant history and statistics.
    • Include seminal works and recent developments.
    • Discuss debates or developments in nursing, healthcare, or nursing education.
  • Theoretical Framework:
    • Use the instructor feedback and compiled information from the Identifying the Nursing Theoretical Framework to write this portion of the paper.
    • You may also refer to the Toolkit in Chapter 6 of your textbook for theories and conceptual frameworks.
  • Methodology:
    • Describe the research design and data measurement methods.
    • Detail participant selection and sampling methods.
    • State the number of subjects needed and how they will be recruited.
    • Discuss the reliability and validity of instruments used, if any.
    • Mention any ethical considerations and discuss how informed consent will be obtained if needed.
    • Outline the research procedure and estimated timeline, as appropriate.
  • Conclusion
  • Reference page

Formatting and Submission:

• Format your paper according to APA guidelinesLinks to an external site..
• The paper should be no more than seven (7) pages, excluding the title and reference pages.
• Proofread your work before submission.
• Direct quotes should be avoided.
• All papers are submitted to TurnItIn for Plagiarism and AI detection. If your score exceeds 25%, the paper will not be graded. You (the student) are responsible for reviewing the TurnItIn score before the due date. You may resubmit as many times as needed before the assignment due date.

Resources:

• Refer to the course LibGuide for guidance on writing a literature review.
• Contact your class librarian for assistance with database searching and writing a literature review.

Evaluation:

• Refer to the grading rubric for how this assignment will be evaluated.