Running head: PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 1

Patient to Nurse Ratio Causes Decline in Outcomes

Jordyn T. Murvihill

Brother Butikofer

NURS 420:02

Brigham Young University- Idaho

PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 2

Patient to Nurse Ratio Causes Decline in Outcomes and Safety

Background

A shortage in nurses caring for patients in the hospital has been a prevalent issue that has

been affecting the patients and nurse’s safety and outcomes. The patient to nurse ratio is

expanding to higher number of patients assigned to one nurse during a shift. According to

Oulton (2016), “A shortage is presented due to a decrease in supply that cannot meet the needs of

an increase in demand.” Nurses are being required to work longer hours due to the lack of

professionals, which is driving them away from the health care setting.

Burnouts in nursing professionals have caused an increase in medication errors and lack

of care towards their patients. Medication errors are a result from trying to balance between the

patients and trying to be more time efficient by gathering all the medications at once for the time

they are due. This then causes them to get mixed up in the hands and pockets of the nurses. Just

like all of the others, nurses tend to get tired especially after working 12 hours shift and when

they are constantly caring for several patients with no breaks, they become less caring. They try

to get their necessities done as fast as they can, so they can take a break, even if it is only a few

minutes. This causes a lack of care and empathy towards their patients by not spending as much

time with them.

Patients are released early from the hospitals due to the short staffing which then has

created more issues and inadequate discharge teaching which further leads to other injury or

illness. Harmon (2016) states, “In the United States, no federal law exists to mandate minimum

nurse-patient staffing ratios at hospitals.” Without this law existing, nurses can have sometime 5

or more patients in their care at one time with many different medical issues. This has caused

tremendous stress on the nurses, patients, and patients families.

PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 3

Significance

With the expounding patient to nurse ratios, this causes a major issue on the safety and

outcomes in the nursing profession on both the nurses and patients. With the increased number

of patients for one nurse, it is leading to a series of difficulties in the care of the patient and

effectiveness of the nurse. Many errors are being made by the nurses such as overlooked issues,

medication errors, underdeveloped relationships between nurses and patients, etc. With a

decreased number of patients per nurse, many of these issues could easily be resolved and the

outcome of the patients would be more desirable and less impactful in the future. Nurses have

made excessive medication errors due to acquiring all their patient’s medications at one time and

putting all of them in their pockets. This then could lead to a confusion in which medication is

for each patient. This is crucial because some medications interact with others and if the nurses

are not cautious enough it can cause extensive medical delays. According to State House News

Service (2017), 87% of nurses reported that they do not have enough time to properly care for

their patients and 73% made medication errors due to the excessive patient assignments.

The lack of care also precedes to the burnout of the nurses by having an excessive

workload, which leads to less and less nurses and more and more patients assigned to each. This

can be an ongoing issue due to the lack of nurses in the workforce. Patients are not being

focused on, on a personal level with the nurse so underlying symptoms and less obvious issues

can be overlooked. Because of this, patients could be sent home early before treating all their

illness and this could lead to a decline in their overall health. This is also an issue due to the lack

of patient beds, so they are being sent home early when they become more stable. The outcomes

and relationships within nurses and patients are declining due to the excessive patient to nurse

ratio in the health care setting.

PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 4

The Theory of Interpersonal Relations

The theory of interpersonal relations by Hildegard Peplau explains that the relationship

that is created between the nurse and the patient will result in the type and efficiency of care that

will be provided. This relationship is founded upon the time spent with the patient and getting to

know them. The patient can only and should only see the nurse through the manner in which she

relates to him as a professional – not as an individual who also has a family, or hobbies or

professional interest (D’Antonio, P., Beeber, L., Sills, G., Naegle, M., 2014). The nurse and

patient can create a relationship that should pertain only to medical needs and trust and not

outside of that.

In the model, there are four phases to developing a successful relationship between the

nurse and the patient: orientation, identification, exploitation, and resolution. Orientation is

where the relationship begins when the patient and the nurse are first introduced. The nurse then

proceeds to meet the patient and identify the needs and problem within this patient. The

relationship is first established here when the patient explains what he or she needs and shares

the expectations they have. Identification phase starts when proper nursing assistance is being

shown to the patient to increase their physical and mental health. This decreases the patients

feeling of helplessness because they are receiving care from a professional based upon their

goals and expectations. The exploitation phase includes the nursing care plan being

implemented for the patient’s needs. The nurse must be able to effectively communicate with

the patient to determine the outcomes of the care that is being put forth. Communication is this

phase is very important to understand and properly deal with the problem. The last phase, the

resolution phase, concludes the relationship between the nurse and the patient. This happens

after proper care has been placed and all goals and expectations have been met from the
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 5

beginning phase. Peplau’s phases of the nurse–patient relationship have been used to teach

nursing students a way to understand the occurrences within the nurse–patient dyad (Deane &

Fain, 2016). The teaching to develop the techniques on Peplau’s theory begins in nursing school

to better achieve that level of communication before starting in the professional field.

In this theory, there are six roles that the nurse can have during the relationship with the

patient: stranger, teacher, counselor, leader, resource person, and surrogate. In a stranger

relationship, the nurse and patient meet for the first and the trust is starting to form. As a teacher,

the nurse is informing the patient on information they should know to increase their knowledge

on the problem. In a counselor relationship, the nurse is able to offer insights and

encouragement based upon the issue to help increase a desire outcome. In a leader relationship,

the nurse helps the patient to increase their responsibilities in reaching their desirable outcomes

through the goals they set. As a resource person, information is being given to the patient based

upon the situation. In a surrogate relationship, the nurse is the patients advocate.

Link Between The Theory of Interpersonal Relations and Nurse to Patient Ratios

Due to the increase of patient to nurse ratio within hospitals, there is a decrease of

interpersonal relations. The theory of interpersonal relations relates to the problem of a decrease

in patient outcomes and safety due to the increased number of patients per one nurse because the

nurses do not have enough time to create these relationships with their patients. It takes time and

effort for the nurse to be able to create these relationships. A patient will open up to the nurse if

they feel like there is a connection and tell them more about past issue or current issues they are

facing that might interfere with their health while in the hospital. This is where it is very

important to create that relationship with each patient to have the desirable outcome in the end to

meet the patient’s needs. The nurse uses the nurse-patient relationship to assess the patient’s
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 6

psychological, emotional, and spiritual needs with learned communication skills, personal

strengths, and an understanding of human behavior (Senn, 2013). With an increase within the

relationships between the nurse and the patient, the outcomes of the patient will be more

successful and less impactful in the future.

With the nurses being required to acquire more patients during their shift, this can also

cause them to feel burnt out and tired from constantly on their feet between each one of their

patients. This also affects the interpersonal relationships they create with each patient. They

may be too tired to care to create one or they may just want to get everything done they need to

as fast as they can, so they can eventually have a break. In this case, according to Peplau’s

theory, the identification phase could be interrupted. The rest of the phases are then not able to

be achieved causing a fall in the relationship. In the identification phase, without proper

communication and time the problem could not be identified and resolved, therefore not being

able to reach the exploitation phase.

Research Methods

There will be a positive relationship between the increased number of patients assigned to

a nurse and the decrease in interpersonal relations that lead to decreased patient outcome in the

end. Interpersonal relations with a healthcare setting increase the patient’s outcome based upon

goals that were set by both the patient and the nurse initially. Patients are in a vulnerable state

and the trust resides with the nurse, so that initial trust and relationship is important to see

progression in the health of the patient. The theory of interpersonal relation by Hildegard Peplau

indicates that the increased relationship between the nurse and patient will result in more

efficient care. With the more patients a nurse has, that time they get to build a relationship with

each patient is decreased and the efficiency of the care will decrease as well.
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 7

Research Design

In this research, a quantitative correlational design will be used to collect data to

determine if there is a relationship between these two key concepts in nursing. Quantitative

research is using a systematic process to collect numerical data based upon the research being

conducted. This is used to look at the relationship between the given variables in a study. There

are four types of quantitative research that are used to collect data: descriptive, correlational,

experimental, and quasi-experimental. Correlation research involves the systematic investigation

of relationships between or among variables (Grove, Gray, & Burns, 2015). This will determine

the type of relationship: a positive correlation, negative correlation, or if there is no correlation

between the two variables at all. It is also of an indication of the strength between the two

variables: strong, moderate or weak. For this research, this design was selected because it will

determine if the reason for decreased patient outcomes is due to the decreased relationship

between nurses and patient because of the increased number of patients each nurse is caring for

or vice versa. In a correlational study, the relationship between the two will also be determined if

there is a strong correlation between them or weak.

Research Population

In the research study, all nurses in south eastern Idaho will be included. This is will

provide the results to the area and be able to be collected in a more organized approach rather

than to a bigger population. As well, as all the nurses on the medical/surgical floors in the

hospitals in the area. With only collecting on the medical/ surgical floors, there is a much

broader spectrum of patients with many different medical needs rather to a specific floor with

similar medical attention. Full-time nurses will also only be used in this study for the purpose of
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 8

a consistent number of patients. With a full-time nurse, they will generally have around the same

number of patients a week.

For this study, nurses that have graduated within the last 3 years will be excluded.

Nurses caring for patients under the age of 18 will be excluded from the study because they are

minors and the parents will be making the decisions for them. Nurses caring for patients that are

diagnosed with brain disorders such as dementia, Alzheimer’s, brain trauma, or any other type of

illness that causes the patient to not be fully coherent of what is going on will be excluded from

the study. Those that will be included in this study will be those that have had more than 3 years

of experience in nursing in the southeastern Idaho area and are working full time on the

medical/surgical floor. In this study, there will be approximately 200 participates for all over

southeastern Idaho.

Methods and Measurements

Prior to conducting the research, approval will be needed from the Institutional Review

Board. The purpose of this is to protect the rights of the subjects used in this research. To

conduct research for this study, a survey will be offered to all the medical/surgical nurses in

southeastern Idaho that meet the criteria. There will be an incentive offered of a $20 gift card to

amazon for those that participate. The nurses will be anonymous in this study to protect

themselves and remain confidential. In the survey, it will ask how many patients the nurse was

carrying for on a particular day. It will also ask the outcome of the patients, depending on the

patient’s goal for that day. The outcome will be graded on a scale of 0-2, 0 meaning the goal

was no achieved, 1 meaning the goal was achieve partially and 2 meaning the goal for that day

was achieved. The relationship between the nurse and all the patients will be rated on a scale of

0 meaning no relationship to a 10 meaning a strong relationship. The data collected will then be
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 9

interpreted depending on the outcome of the patients that day and the relationship with each one

of those patients include the number of patients the nurse was caring for at one time during that

shift. A scatter chart will then be used using the data collected to determine if there is a positive,

negative, or no relationship at all between the data.

Ethical Considerations

In this study, nurses are at risk for no confidentiality within the study and for their

answers to be used against them and questioned. The ethical considerations in this study that

have been made noted is the nurses right to anonymity and confidentiality. The nurse will not

have to address their identity which includes name or employee number. They will only have to

identify the hospital they work at. Complete anonymity exists when the subject’s identity cannot

be linked, even by the researcher, with his or her individual responses (Grove et al., 2013). This

will be addressed prior to conducting the research, informing the nurses that their answers cannot

be used against them, putting their career at risk.

In this study, the patients of the nurses are at risk of having no privacy. In this, the ethical

consideration of the right of privacy is used to protect the patients from their information being

leaked. This means that no patient names will be exploited based on poor outcomes and poor

relationship with the nurse. The patients will be labeled as a number based on their room

placement with number 1 being closet to the nurse’s station. This is so that no one can track their

room number to which patient was in each room. The health issue with the patient will also not

be listed due to confidentiality reasons.

Nurses are also able to choose whether or not they want to participate in the study or not.

The ethical consideration used in the case is respect for persons. Ethical principle indicating that

people should be treated as autonomous agents with the right to self-determination and the
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 10

freedom to participate or not participate in research (Grove et al., 2013). Participates also have

to right to remove from the study at any point during it if they feel. It will be made sure that the

participants know of these considerations before they participate in the study.

Annotated Bibliography

Bae, S. (2011). Assessing the relationships between nurse working conditions and patient

outcomes: Systematic literature review. Journal Of Nursing Management, 19(6), 700-

713.

This author, Sung-Heui Bae, is in the School of Nursing University at Buffalo, Sate

University of New York. A correlational study was used in this research. The research

study was conducted to evaluate the relationship between working conditions and the

patient outcomes. The working conditions was broken down into many classifications

which helped with the different aspects of the nursing roles with each patient. The

number of outcomes looked at was very small for the study which cause the validity to

decrease. The quality of this article was useful for the fact that it was easy to understand

the study being done and understand the results of this study. There were many tables that

indicated the working condition, patient outcomes and the relationship they had whether

it was a positive, negative or no correlation at all. This study shows the different aspects

of the nursing career and their relationship and effect of the patient’s outcome. The

intended for this study is for nurses and any other medical profession to be able to see the

results of the working conditions of nurses related to the patient outcomes. The link

between this and the research problem in that the working condition of the nurse relates

to having an increased number of patients which then leads to a poorer patient outcome.
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 11

The working condition of the nurses contributes to many aspects within the patient’s

outcome.

Kunaviktikul, W., Wichaikhum, O., Nantsupawat, A., Nantsupawat, R., Chontawan, R.,

Klunklin, A., & ... Sirakamon, S. (2015). Nurses' extended work hours: Patient, nurse and

organizational outcomes. International Nursing Review, 62(3), 386-393.

These authors are all professors for the Faculty of Nursing, Chiang Mai University

Thailand. They are all registered nurses as well as they all have their PhD. A descriptive

predictive study of nurses was used. The population included nurses working in different

health care facilities in Thailand. The nurses’ outcomes affected from extended work

hours was broken down into a chart showing the different aspects that could affect the

patient’s outcome. It was very detailed and showed the percentage from the population

they used from the study in each different category breakdown. They also used 1524

registered nurses from 90 different hospitals across Thailand which shows a good portion

of the nursing population. A weakness is that they were given questionnaires and they

had to be mailed back so not all the responses were mailed back. The quality of this study

was very well put together due to the breakdown of the different subcategories. It

included all the things needed to get result that are representative of the population. This

is useful for nursing practice to show that extended hours in nursing can lead to more

implications with patient outcomes and safety for the nurse and patient. The intended

audience is for all nurses to show the effects of working long hours of nursing. The link

between this and the research problem is that with a high number of patients per nurse,

nurses are getting burnt out which causes nurses to make to work an extend number of

hours. This is related to decreases patient outcomes.

PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 12

McGahan, M., Kucharski, G., & Coyer, F. (2012). Nurse staffing levels and the incidence of

mortality and morbidity in the adult intensive care unit: A literature review. Australian

Critical Care, 25(2), 64-77.

McGahan and Kucharski are in the Department of Intensive Care Medicine, Royal

Brisbane and Women’s Hospital in Butterfield St, Herston. Coyer is in the School of

Nursing and Midwifery, Queensland University of Technology. The study being done is

correlational because the relationship between nurse staffing levels and patient outcome.

The strengths in this study is that several different literature databases were used which

gives credibility. This shows that there are many articles from the different databases. A

weakness in this study is that in the end, only 19 articles were included after 25 did not

meet the inclusion criteria. This is a very low number of articles for this study. The

quality of the study is not very good because of the low number of articles that were used

for the study. This study is useful for nursing practice because it shows the relationships

in the different areas in the hospital and the mortality rate due to the short staffing. The

intended audience for this study is those that are short staffed nurses in a high mortality

rate area. The link between this study and the research problem is that due to short

staffing nursing are required to have more patients at one times which can lead to more

mortality’s and the relationships between the staffing and mortality of the patients.

Yang, P., Hung, C., & Chen, Y. (2015). The impact of three nursing staffing models on nursing

outcomes. Journal Of Advanced Nursing, 71(8), 1847-1856.

These authors are all professors for the School of Nursing, Kaohsiung Medical University

Taiwan. They all have their PhD as well as they are registered nurses. This study was

done using a retrospective cohort study design. In this study they compare 3 nursing staff
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 13

models. The strengths in this study is that there were different phases for this study, so

the study was conducted 3 times to give it validity. A weakness in this study is that a

convenience sample was used so not all people were able to be used for the results. The

quality of the study is very helpful for the relationship between staffing and mortality.

The study used many different phases of the study to reinforce the results. The findings in

this study are useful for nursing practice because it determines if there is a relationship

between short staffing and mortality rates. The intended audience in this study is nurses

that are required to have more patients due to short staffing. The link between this study

and the research problem is that due to short staffing the nurses are required more

patients and because of this the care for their patients is not as good as it could be if they

had less patients.

Implications

Nursing Knowledge

Knowledge is a critical aspect when it comes to nursing research. In the research,

knowledge of decreased patient to nurse ratios lead to more efficient and successful

relationships. This will progress to improved patient outcomes. With the knowledge of this,

nurses will see more progressed and lasting health progress in their patients. This will help the

nurses to become less burnt out and potentially make fewer medication errors. Nurses will know

that increasing their communication with the patients, as well as the families will aid in more

success in the health of the patient.

Nursing Theory

Relationships help establish lasting trust within the nurse and the patients. Using

Peplau’s theory, these relationships can lead to increased patient outcomes. With this study, the
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 14

relationships are more easily created when the nurse has a lower number of patients. A

decreased number of patients per nurse gives the nurse an opportunity to spend more time

communicating with the patient and family. She referred to an earlier version of her theory

as talking to patients, which would be transformed as a therapeutic interpersonal relation theory

that would not only be used in treating psychiatric patients but all patients (Senn, 2016). Nurses

in every different field are utilizing Peplau’s theory to increase the outcomes of their patients.

Currently in the nursing profession, nurses are being required to have a higher number of patients

due to a shortage in nurses and an increase in patients. The study confirms Peplau’s theory,

because it confirms that relationships can help create desired health results. And those

relationships are better established when the patient to nurse ratio is decreased.

Nursing Practice

Nursing practice in this study is carried out by making sure that all medications are

correct and correct procedures are being implicated. With a lower patient ratio to a nurse, the

nurse will have more time to make sure that all procedures are being done correctly and

efficiently. This will allow them to double check medications and apply patient teaching to

ensure that the patient is also doing all that they can to improve their health. Also, with a better

relationship established between the patient and the nurse, the patient is more likely to do what

the nurse has told them, for example, using an incentive spirometer. The patients are more likely

to listen to the nurse and do what they say if they feel like they can trust them. The nurse and

patient’s relationship will expand due to the nurse being able to spend more time in the room,

talking to the patient and explaining everything that is taking place and the reason for it. This

establishes trust between the patient and the nurse. The patients will feel comfortable expressing

their feelings with the nurse which then could facilitate better care.
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 15

Improve Patient Care

This study will improve patient care by improving outcomes for patients. Nurses will

spend more time making more rounds to visit their patients and focus on their needs and issues

rather than running around to all the different patients and spending minimal time with each

before going to the next. This gives the nurses a chance to make full assessment on their patients

every time and to look through labs and past history that they might not be able to look at if they

have many patients. This gives the nurse to better understanding of the patients need to then

facilitate a proper care plan to increase the health and outcome of the patient more effectively

and time efficient.

Patient care will also be enhanced by improving the safety for patients. With an

exceeding number of patients to one nurse, the nurse tends to hurry more so that they can get

around to all of their patients within a timely matter especially when medications are due. With a

decreased number of patients, the nurse is less likely of to mix up the medications, causing an

error of administering the wrong dose or wrong medication. When they are in a time crunch,

nurses will often grab all the patient’s medication that are due around the same time and put

them in their pockets. This could cause a mix up and the nurse could administer the wrong

medication to the wrong patient. When they have fewer patients, they will have more time to

take care of one patient at a time rather than all at once.

A faster response time from the nurse will increase patient care due to treating the

symptoms and patient needs to a timely manner. If the patient is in severe pain but waits until

the nurse comes in to inform them, this could lead to set back to improving their health. When

the nurse makes more frequent visits within the patient’s room, they are able to treat the patient’s

symptoms faster, facilitate new physician orders, develop new plans of care if the one prior is not
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 16

showing improvements, etc. The nurse will also be able to obtain the patients vitals more often

to determine if improvements are being shown or a decline has been made. More frequent

monitoring will also increase the patients trust in their nurse.

Recommendations

A recommendation for this study would be to evaluate to the outcomes of the population

in the intensive care unit in the hospital. The nurses in the ICU have patients that have life

threatening conditions. Most of the time the patients are unconscious but even when they are not,

the relationship with families is still essential, because they are the ones making the decisions.

This could observe a whole different part of relationships within nursing because it is different

than a regular medical/surgical floor in hospital. This would display how the outcomes of the

patient are controlled within a nurse and family relationship as well.

Another recommendation would be to adjust the type of design to an exploratory-

descriptive qualitative study. This would aid in identifying a different factor that can be

associated with the desired patient outcomes. Using this, a survey can be conducted to gather

data from nurses within the population used in the study conducted. This would collect various

ideas from the nurses, to view what would increase the relationships with patients to develop

desired outcomes. The nurses would be given an incentive so that they are drawn into taking this

survey for the study. This would give different results based upon the type of research.

In this study, a recommendation for how it could be used in practice is by assigning less

patients to a nurse and determine if that makes a difference in the outcomes of the patients they

have. The nurses may also focus on the relationships with the patients and demonstrate to them

that they care and are there to help them rather than just do their job. This study could be

implicated in all types of nursing and not just the medical/surgical floors in hospitals. Nurses
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 17

should do all that they can in providing the best care for their patients to meet their goals and

desired outcomes.
PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 18

References

Bae, S. (2011). Assessing the relationships between nurse working conditions and patient

outcomes: Systematic literature review. Journal Of Nursing Management, 19(6), 700-

713.

D'Antonio, P., Beeber, L., Sills, G., & Naegle, M. (2014). The future in the past: Hildegard

Peplau and interpersonal relations in nursing. Nursing inquiry, 21(4), 311-317.

Deane, W. H., & Fain, J. A. (2016). Incorporating Peplau's Theory of Interpersonal Relations to

Promote Holistic Communication Between Older Adults and Nursing Students. Journal

Of Holistic Nursing: Official Journal Of The American Holistic Nurses'

Association, 34(1), 35-41.

Grove, S., Gray, J., Burns, N. (2013). The practice of nursing research: Appraisal, synthesis, and

generation of evidence, 7th ed. Philadelphia: Elsevier Saunders.

Grove, S., Gray, J., Burns, N. (2015). Understanding nursing research, 6th edition. [Bookshelf

Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781455770601/

Harmon, A. (2016). Nurse-patient ratio. Salem Press Encyclopedia Of Health.

Kunaviktikul, W., Wichaikhum, O., Nantsupawat, A., Nantsupawat, R., Chontawan, R.,

Klunklin, A., & ... Sirakamon, S. (2015). Nurses' extended work hours: Patient, nurse and

organizational outcomes. International Nursing Review, 62(3), 386-393.

McGahan, M., Kucharski, G., & Coyer, F. (2012). Nurse staffing levels and the incidence of

mortality and morbidity in the adult intensive care unit: A literature review. Australian

Critical Care, 25(2), 64-77.

Oulton, J. A. (2016). The global nursing shortage: An overview of issues and actions. Policy,

Politics, & Nursing Practice, 7(3_suppl).

PATIENT TO NURSE RATIO CAUSES DECLINE IN OUTCOMES 19

Peplau, H. E. (2004). Interpersonal relations in nursing: a conceptual frame of reference for

psychodynamic nursing. Retrieved from https://ebookcentral-proquest-

com.byui.idm.oclc.org

Senn, J. F. (2013). Peplau's theory of interpersonal relations: application in emergency and rural

nursing. Nursing Science Quarterly, 26(1), 31-35.

State House News Service (2017, May 12). Nurses: Too many patients hurts quality of care.

Retrieved from

http://www.wbjournal.com/article/20170512/NEWS01/170519974/nurses-too-many-

patients-hurts-quality-of-care

Yang, P., Hung, C., & Chen, Y. (2015). The impact of three nursing staffing models on nursing

outcomes. Journal Of Advanced Nursing, 71(8), 1847-1856.