The rate of errors due to intravenous medication incompatibility can be reduced through implementing an 8-week nurse training program. The training program will educate nurses on assessing and managing drug compatibility, utilizing compatible drugs in appropriate conditions/proportions via a single IV line when possible. This addresses the issue of limited infusion lines for elderly ICU patients requiring multiple drug therapies. The objective is reducing nurse-caused errors from incompatible intravenous drugs to improve patient outcomes like mortality, morbidity, and quality of life. While the benefits include improved safety and reduced costs, a limitation is nurses' busy schedules hindering training attendance.

1. 2
Incompatibility of Intravenous Medications
Review of Literature
Errors associated with incompatible intravenous (IV) drugs
among patients aged 65 years or more patients in ICU. Srisram
et al. (2020) established that intravenous drug incompatibilities
in ICU can be reduced by establishing pharmaceutical
guidelines for administering IV drugs. The article provides
high-quality evidence supported by results from 104 medication
charts and analyzed through the Micromedex healthcare series.
The evidence provided by this article applies to the PICOT
question because supports pharmaceutical guidelines when
administering IV drugs or reducing the rate of incompatibilities
in the ICU. The finding is similar to those of other studies
(Ertuna et al., 2019). The differences between the two studies
were in data collection with Srisram et al. obtaining data from
medical charts while Ertuna et al. (2019) obtained data from
pharmacist medication review reports. There is no controversy
in this article.
Machotka et al. (2015) identify real incidences of IV drug
incompatibilities in the ICU and suggest that adhering to a few
simple rules of IV drug administration can reduce these
incidences. The article provided good-quality evidence as the
conclusions revealed the prevalence of real-life incompatibility
incidences in the ICU and were supported by the results
obtained from the study conducted. The evidence is compatible
with the PICOT question because it reveals that the rate of
errors caused by the incompatibility of IV drugs is high. The
findings are consistent with those of Fedaku et al. (2017). The
major difference between the two studies is the type of data
collected with Machotka et al. 2017 focusing on intravenous
drug incompatibility errors while Fedaku et al. 2017 focusing

2. on intravenous drug errors caused by wrong or missed doses.
There is no controversy in this article.
Fekadu et al. (2017) associate intravenous drug errors with
clinical complications that lead to undesirable results that can
be prevented. The article provides good-quality evidence that
leads to the conclusion that wrong or missed dose medication
errors are prevalent in the emergency and intensive care units.
The evidence applies to the PICOT question as it suggests that
intravenous drug errors caused by wrong or missed doses should
be addressed to reduce the rate of these errors. The evidence
provided by the authors is consistent with the findings of
Machotka et al. (2017). The difference between the two studies
is that Fedaku et al. (2017) provide wrong and missed doses
errors as the focus of the study while Machotka et al. (2017)
focus on the physiochemical incompatibility of intravenous
drugs as the cause of these errors. The controversy in this
article is that when other studies discuss intravenous drug
incompatibility, it discusses dose errors in ICU.
Ertuna et al. (2019) discuss drug-related problems (DRP) in
older adults and associate these DRPs with complex medication
regimes and the role pharmacist interventions play in reducing
the rate of DRPs. (b) The article provides low-quality evidence
that contrast with the other studies as it provides inadequate
evidence to support DRPs in elderly patients caused by
increased drug use. Evidence produced by this article is relevant
to the PICOT question because it addresses the rate of errors
caused by drugs used by older adults. The similarity between
these articles with Srisram et al. (2020) is that both articles
consider pharmacist guidance as an effective intervention for
intravenous drug errors. While Srisram et al. (2020) consider
pharmaceutical guidelines as an effective solution to
intravenous drug errors, Ertuna et al. (2019) consider
pharmacists' intervention as the ultimate solution. The
controversy observed in this article is that it proposes 329

3. interventions to reduce the rate of drug errors while other
studies propose one or two interventions.
Hanifa et al. (2018) explore the increase in the rate of
intravenous incompatibility due to the use of a single
intravenous line in the pediatric unit. The article provides high-
quality evidence to show that the use of a single intravenous
line to administer multiple drugs increases the rate of
incompatibility medication errors. The evidence applies to the
PICOT question since it shows the impact of incompatible drug
administration using a single intravenous line on the rate of
medication errors. The similarity between this article and
Mosopefoluwa et al. (2019) is that both consider the co-
administration of intravenous drugs as a major cause of
incompatibility. The main difference between the two studies is
that Hanifa et al. (2018) focus on the pediatric intensive care
unit (PICU) while Mosopefoluwa focuses on the general
intensive care unit (ICU). The controversy in this article is that
it states that there is limited evidence to show patterns of
concurrent medication use utilizing a single intravenous line but
concludes that this type of drug administration is common
practice.
Vijayakumar et al (2019), relates intravenous drug
administration of two or more incompatible drugs with the rate
of drug-related problems (DRPs) in hospitalized patients. The
article’s evidence is of good quality because the study is
conducted using a sizeable sample of 110 patients and the
results led to a conclusion that simultaneously administering
two or more incompatible drugs intravenous increases the rate
of errors in ICU. The findings in this article apply to the PICOT
question because they discuss the rate of errors impacted by
intravenous drug incompatibilities. The evidence in this article
is similar to Hanifa et al. (2019) study findings. The main
difference is that Vijayakumar et al. (2019) do not focus on a
single hospital or country where the study was conducted while

4. Hanifa et al. (2019) include a single location where the study
was conducted (Indonesian hospital). There was no controversy
identified in the article.
The study conducted by Assefa et al. (2020) discusses the
polypharmacy and drug-drug interactions (DDIs) experienced by
older cardiovascular patients due to multiple drug therapy
required to manage cardiovascular diseases. The article
provided high-quality evidence supported by the identification
of 850 potential DDIs which reduces the risk of bias in the
article. The findings in this article apply to the PICOT question
because they show the risk posed by DDIs due to drug
incompatibility in older patients. The similarity between the
articles is that they conducted cross-sectional studies. The
difference between Assefa et al. (2020) article and Ertuna et al.
(2019) is that while the former does not suggest an intervention
strategy the latter proposes pharmacist intervention as a
solution to drug-related problems such as drug-drug
interactions. There was no controversy identified in this article.
Sabzi et al. (2019) establish a connection between medication
errors and healthcare complexities such as hospital management
and work environment among other nurse work dynamics. The
article provides low-quality evidence that associates the nurse
work environment with the rate of medication errors therefore a
high risk of bias. The findings of this article are slightly
applicable to the PICOT question because they focus on work
dynamics and the role they play in the rate of medication errors.
This study is similar to other studies because it conducts a
cross-sectional study. The major difference between this article
and other articles is that this article focuses on work dynamics
as a source of medication errors while others focus on drug
incompatibility as the cause of medication errors in hospitals.
The controversy in this article is that it generalizes the results
conducted from a single hospital to suggest that work conditions
irrefutable increase or reduce the rate of medication errors.

5. Mendez et al. (2018) established that to identify drug
incompatibility errors, it is crucial to consider the types and
frequency of errors that occur during drug preparation and
administration. The evidence provided by this article is of good
quality and shows that intravenous drug errors are of different
types and are very frequent during preparation and
administration. The applicability of the evidence in this article
to the PICOT question is that it focuses on incompatibility
medication errors that occur during drug administration. The
similarity between this article and Fekadu et al. (2017) is that
both conduct a hospital-based cross-sectional study on
intravenous drug incompatibility. The difference between the
two studies is that Mendez et al. (2018) focus on both types and
frequency of these errors while Fekadu et al. (2017) focus only
on the frequency (prevalence) of drug administration
errors.While other studies focused on the drugs administered,
this article focused on hand hygiene during drug preparation
and asepsis materials during infusion.
Oduyale et al. (2019) reveal that multiple intravenous drugs
can be administered using the same IV catheter as long as there
is drug compatibility the article provided low-quality evidence
by generalizing results obtained from twenty nurses and two
hospitals in the same location in England. The evidence applies
to the PICOT question because it explores drug compatibility as
an effective solution to medication errors caused by intravenous
drug administration using the same lumen of an IV catheter. The
similarity between this article and Hanifa et al. (2018) is that
both articles discuss the co-administration of multiple
intravenous drugs through a single infusion line. The article is
different from Hanifa et al. (2018) because it collects data
through focus group interviews while the other uses a mixed
model design. There was no controversy discovered in this
article.
Knowledge directly to PICOT question

6. The rate of errors due to incompatibility of intravenous
medication can be reduced by implementing a nurse-training
program that is based on the interventions suggested in the
articles. A nurse-training program will enable nurses to reduce
the rate of errors they cause when they administer incompatible
intravenous drugs using the same infusion line. The program
will also focus on the numerous interventions proposed by the
ten articles to reduce the rate of errors. They will also be able to
identify the types of errors caused by drug incompatibilities and
the frequency in which they occur, enabling them to form
evidence-based interventions to reduce the frequency of these
errors (Mendez et al., 2019).
Oduyale et al. (2018) propose administering multiple
intravenous drugs that are compatible using the same lumen of
an IV catheter. The article insists on assessing and managing
the compatibility of intravenous drugs since co-administration
of intravenous drugs in ICU is common practice and elderly
patients aged 65 years and above often require multiple drug
therapy and few infusion lines. Vijayakumar et al. (2019)
highlight the importance of forming effective strategies for
reducing the rate of errors due to the incompatibility of
intravenous medications because these errors cause drug-drug
interactions among other drug-related problems that affect
elderly patients. The strategies proposed in these two studies
help reduce medication errors and when implemented properly
with adequate nurse training can improve the safety of patients
aged 65 years and above in ICU (Vijayakumar et al., 2019).
Practice Change
Implementing an eight-week nurse training program using
Watson's caring theory reduced the rate of errors caused by
intravenous drug incompatibility. This is because nurses can
assess and manage drug compatibility in ICU during the
preparation and administration stages. Subsequently, a nurse-

7. training program provided nurses with evidence-based practice
knowledge on compatible drugs and their compatible conditions
or proportions. A nurse training program will also equip nurses
with drug preparation knowledge and skills to utilize a single or
few infusion lines that elderly patients (65 years and above)
have because the drugs cannot be administered orally (Mendez
et al., 2019).
Objective
The objective of implementing eight nurse training programs is
to reduce the rate of errors caused by the incompatibility of
intravenous drugs. Reducing the rate of these errors will lead to
positive or better patient outcomes since these errors lead to
patient morbidity and mortality due to drug-related problems
and clinical complications. The implementation of the proposed
problem change aims at improving patient safety and reducing
the rate of mortality and morbidity in elderly patients caused by
incompatibility that is preventable through a nurse-based
intervention. The problem change also focuses on improving
patient quality of life and increasing recovery rate by
preventing medication errors caused by incompatibility during
and after drug administration (Assefa et al., 2020).
Problem exists
The issue of medication errors due to the incompatibility of
intravenous medication is prevalent in intensive care units since
there are limited drug infusion lines, especially in elderly
patients who require multiple drug therapy to manage serious
health issues such as cardiovascular diseases. ICU patients
cannot take medication orally; hence, limited infusion lines
reduce the drug's effectiveness and can potentially cause
adverse drug reactions. The proposition for change is to reduce
nurse practice-based factors that lead to increased errors caused
by incompatibility. The proposition also targets elderly patients
since their high age is a risk factor for drug interactions due to

8. the low metabolism rate associated with aging (Assefa et al.,
2020).
Pros vs Cons
The benefits associated with a nurse training program focused
on drug compatibility are reduced rate of errors caused by
incompatibility, improved patient safety in ICU, reduced rate of
mortality and morbidity caused by these errors, reduced cost of
healthcare due to reduced hospitalization, and readmission rate,
increased patients quality of life and recovery rate among
others. The disadvantage presented by implementing a nurse-
training intervention is the lack of time to attend the program
due to heavy nurse workloads and high nurse-patient ratios that
prevent nurses from pursuing other ventures such as nurse
training programs. The current state of the rate of errors is
moderate to high since there has yet to be a successful
intervention implemented to reduce the frequency of these
errors (Mendez et al., 2019).
Strengths and weaknesses of all the sources
The strength of Srisram et al. (2020) article is that it studies a
1000-bed ICU unit to draw objective conclusions. The weakness
of this article is that it analyses the incompatibility of only two
drug combinations and fails to observe clinical complications
caused by these drug incompatibilities. The strength of
Machotka et al. (2015) article is that the study lasts 12 months,
a sufficient time to draw objective conclusions. However, the
article presents challenges of ensuring that the studies are blind
which could present a bias.
The strength of Fekadu et al. (2017) is, in addition to errors
caused by the incompatibility of intravenous drugs, it explores
errors due to wrong and missed doses of these drugs. The
limitation of this study is that it was conducted in one center
with a small sample size. The strength of Ertuna et al. (2019) is
that it proposes that pharmacists be part of the intervention. The

9. limitation of this study is that it has limited resources and time
to evaluate the interventions.
The strength of Hanifa et al. (2018) is it explores a different
patient population to show that drug incompatibility can occur
in other units. However, the study is limited in that fails to
consider and observe the clinical implications caused by these
errors. The strength of Vijayakumar et al. (2019) is that the
article considers findings in hospitals in Germany, France, and
the UK among other countries to provide evidence with little to
no bias. The weakness of this study is that it was conducted
inwards instead of in ICUs where these types of medication
errors are prevalent.
Assefa et al. (2020) strongly point out how drug-drug
interactions caused by the incompatibility of two or more drugs
affect elderly patients with cardiovascular. However, the article
does not discuss drug incompatibility as a cause of DDIs in
detail. Sarbi et al. (2019) focus on other causes of medication
errors that affect the elderly such as nurse work conditions.
However, the study fails to show significant differences in the
rate of medication errors under diverse work dynamics.
Mendez et al. (2018) not only consider the type of errors in drug
preparation and administration, but also the frequency in which
they occur in the ICU. The study, however, was conducted in a
single center with a small sample size. the strength of Oduyale
et al. (2019) is that it proposes interventions that utilize the
available resources. the weakness of this study is that it was
conducted in two hospitals within the same critical care region
therefore the results may not reflect the perspectives of ICU
nurses in other areas.
References
Assefa, Y. A., Kedir, A., & Kahaliw, W. (2020). Survey on
polypharmacy and drug-drug interactions among elderly people
with cardiovascular diseases at yekatit 12 hospital, Addis
Ababa, Ethiopia.

10. Integrated Pharmacy Research & Practice,
9, 1. https://doi.org/
10.2147/IPRP.S231286
Ertuna, E., Arun, M. Z., Ay, S., Koçak, F. Ö. K., Gökdemir, B.,
& İspirli, G. (2019). Evaluation of pharmacist interventions and
commonly used medications in the geriatric ward of a teaching
hospital in Turkey: a retrospective study.
Clinical Interventions in Aging,
14, 587. https://doi.org/10.2147/CIA.S201039
Fekadu, T., Teweldemedhin, M., Esrael, E., & Asgedom, S. W.
(2017). Prevalence of intravenous medication administration
errors: a cross-sectional study.
Integrated pharmacy research & practice,
6, 47. https://doi.org/
10.2147/IPRP.S125085
Hanifah, S., Ball, P., & Kennedy, R. (2018). Medication
incompatibility in intravenous lines in a Paediatric Intensive
Care Unit (PICU) of Indonesian hospital.
Critical Care & Shock,
21(3).
Machotka, O., Manak, J., Kubena, A., & Vlcek, J. (2015).
Incidence of intravenous drug incompatibilities in intensive care
units.
Biomed Pap Med Fac Univ Palacky Olomouc Czech
Repub,
159(4), 652-6.
Mendes, J. R., Lopes, M. C. B. T., Vancini-Campanharo, C. R.,
Okuno, M. F. P., & Batista, R. E. A. (2018). Types and
frequency of errors in the preparation and administration of
drugs.
Einstein (São Paulo),
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https://doi.org/10.1590/S1679-45082018AO4146

11. Oduyale, M. S., Patel, N., Borthwick, M., & Claus, S. (2020).
Co‐administration of multiple intravenous medicines: Intensive
care nurses' views and perspectives.
Nursing in Critical Care,
25(3), 156-164.
Sabzi, Z., Mohammadi, R., Talebi, R., & Roshandel, G. R.
(2019). Medication Errors and Their Relationship with Care
Complexity and Work Dynamics.
Open Access Macedonian Journal of Medical Sciences,
7(21), 3579.
Sriram, S., Aishwarya, S., Moithu, A., Sebastian, A., & Kumar,
A. (2020). Intravenous drug incompatibilities in the intensive
care unit of a tertiary care hospital in India: Are they
preventable?.
Journal of Research in Pharmacy Practice,
9(2), 106.
Vijayakumar, A., Sharon, E. V., Teena, J., Nobil, S., & Nazeer,
I. (2019). A clinical study on drug-related problems associated
with intravenous drug administration.
Journal of basic and clinical pharmacy,
5(2), 49.
7
Sexually transmitted diseases are infections that are spread from
one individual to another through sexual activities (Rhodes et
al., 2021). Examples include syphilis, human papillomavirus,
gonorrhea, and genital herpes. Due to poor testing knowledge,
speaking openly about sexual things, and young girls'
susceptibility to STDs, adolescents and teenagers are more
likely to develop STDs.Even though STDs can affect any

12. population, adolescents and young adults are at increased risk
of having STDs. STDs have undeniable effects on individuals,
communities, and healthcare sectors. Adolescents and teenagers
need to be educated on STDs, especially on how to prevent the
spread and the importance of treatment. Teenage STD infection
rates are rising globally, and gonorrhea and chlamydia are the
most frequent STDs among teens in the United States. In the
2016 STD study, teenagers aged 15 to 19 had a male prevalence
of 15.3% and a female prevalence of 4.1% for chlamydia
(Shannon & Klausner, 2018). STDs among adolescents are a
problem because increased rates of infections increase the
health burden of a state. This paper focuses on the impact a 2-
month program can have on the knowledge and understanding of
adolescents aged 14-17 years about STDs.
Sexually Transmitted Diseases in Adolescents
PICOT question
Can the implementation of a 2-month program on sexually
transmitted diseases in adolescents aged 14 to 17 years improve
their knowledge about the prevention of sexually transmitted
diseases compared to their knowledge before the program's
implementation?
The population of focus is adolescents aged 14-17 who are vied
to be at increased risk of having STDs because of insufficient
knowledge (Shannon & Klausner, 2018). A 2-month program on
STDs is seen as the fit intervention for this population. The
comparison intervention is the knowledge of this population
before having the intervention. After the assessment, the
outcome is expected that this population will show increased
knowledge in understanding the topic of STDs. The program
timing is two months, which is considered reliable and enough
time for the education program.
Vulnerable populations

13. Some of the social determinants for STD among adolescents
include age, ethnicity, and family background. School
characteristics and neighborhood factors are also considered
important in the acquisition of STDs by adolescents. The risk
factors of STDs among adolescents include practicing sexual
relations at an early age or practicing unprotected sex, being
shy to take about one's sex life, having a history of STDs or
HIV, and lack of regular STD tests for those who engage in
sexual relations (Ayerdi Aguirrebengoa et al., 2020). Also,
misuse of drugs can lead someone to engage in improper sexual
behaviors that increase the risks of having STDs.
Ayerdi Aguirrebengoa et al. (2020) assessed the risk factors
associated with STDs/HIV among adolescents in Madrid. The
authors found that the prevalence of STD/HIV was high among
adolescents, and the leading risk factors in their study were to
having sexual relations at an early age and having a history of
STD. Rusley et al. (2022) assessed the trends in risk behaviors
and STDs among youths who showed up in STD clinics in the
U.S from 2013 to 2017. In conclusion, the high numbers of
STDs among these youths were mostly associated with engaging
in unprotected sex and having multiple partners.
Research intervention
Kam et al. (2019) conducted a project that aimed at increasing
the knowledge of adolescents on sexual health and sexual
practices through an educational intervention in Cambodia. The
program effectively promoted sexual knowledge among
adolescents of both sexes at risks of STDs and informed the
general public in Cambodia. The education was aimed at
improving the sexual behavior of adolescents and young adults,
especially in areas with low literacy rates and poorly
accessibility. Knowledge improvement can be effective in
helping adolescents make better sexual health decisions and
reduce their chances of being infected with STDs (Kam et al.,

14. 2019).
Wilkins et al. (2022) discussed the importance of a school-
based program model devised by the Centers for Disease
Control and Prevention's Division of Adolescent and School
Health used to inform adolescents about STDs, risk behaviors,
and unwanted pregnancies. The authors established that the
model is good for adolescents and adolescent health
professionals working in schools. Sexual health education can
be effective in creating a safe and supportive environment for
children to stay healthy. The authors concluded that increasing
access to education programs on adolescents can promote the
sexual health and well-being of adolescents (Wilkins et al.,
2022).
Proposal
An educational intervention among adolescents can help reduce
the risk factors of STDs, thus reducing the unwanted effects of
STDs (Rusley et al., 2022). A 2-month training program on STD
is the proposed intervention for this paper. The population at
risk of STDs is identified as adolescents aged 14 to 17 years.
The educational program will be infused together with the
school curriculum and taught life skills by healthcare
professionals and the relevant teachers. At the end of the
program, individuals who wish to be tested for STDs will
receive free testing as part of the educational intervention. This
will encourage the trainees to engage freely with their care
providers on sexual matters.
The interdisciplinary team that will be included in the
implementation of this intervention include physician
specialists in reproductive health and sex education, advanced
nurse practitioners, certified nurses (Wilkins et al., 2022), and
life skill and biology teachers in the respective setting (school).
Physician specialists on reproductive health and sex specialists
will cover the topics of STDs broadly. Nurse practitioners and

15. certified nurses will help answer any questions the trainees have
and help do the STD testing. Teachers will oversee the activities
of their students during the program and gather knowledge for
the next classes they will teach on matters of reproductive and
sexual health.
A nurse in an advanced role has the required knowledge to see
the intervention program through successfully. Nurses are
supposed to be the key educators on matters of health and health
promotion (Santa Maria, 2018). In this intervention, the nurse in
an advanced role is regarded as important to help the specialists
provide knowledge to the students effectively. The proposed
intervention will be executed in 2 months. This time is enough
to engage the trainee in both theoretical and practical
knowledge concerning STDs and the importance of protecting
their health.
Health Belief Model (HBM)
Health belief model (HBM) as a theoretical perspective was
devised to help improve public health by providing guidance
through ways of promoting health and preventing diseases
(Ghorbani-Dehbalaei et al., 2021). The theory is mostly used to
predict and explain changes in health behaviors by individuals.
It is also utilized to evaluate and understand health behaviors
among populations as well as individuals (Ghorbani-Dehbalaei
et al., 2021). In this project, HBM will guide the training
program as an intervention to promote sexual health and prevent
the spread of STDs among adolescents. Considering that HBM
can enhance the implementation of the intervention by
influencing the health behaviors of adolescents. Implementation
of the project using HBM will result in positive impacts on
healthcare systems. The adolescent population will be
knowledgeable, which will decrease the disease burden in
communities and improve health outcomes for individuals.

16. Those infected with STDs will seek the appropriate care to
promote their health, while those not infected will be cautious
of their behaviors and create awareness (Gogineni et al., 2021).
The cost of care will be reduced as individuals will implement
ways of preventing STDs. Quality of life will be improved with
better health outcomes as individuals will maintain healthy
sexual lives and reduce STD infections among adolescents.
References
Ayerdi Aguirrebengoa, O., Vera Garcia, M., Rueda Sanchez, M.,
D Elia, G., Chavero Méndez, B., Alvargonzalez Arrancudiaga,
M., Bello León, S., Puerta López, T., Clavo Escribano, P.,
Ballesteros Martín, J., Menendez Prieto, B., Fuentes, M. E.,
García Lotero, M., Raposo Utrilla, M., Rodríguez Martín, C., &
Del Romero Guerrero, J. (2020). Risk factors associated with
sexually transmitted infections and HIV among adolescents in a
reference clinic in Madrid.
PloS one,
15(3), e0228998.
https://doi.org/10.1371/journal.pone.0228998
Ghorbani-Dehbalaei, M., Loripoor, M., & Nasirzadeh, M.
(2021). The role of health beliefs and health literacy in women's
health promoting behaviours based on the health belief model: a
descriptive study.
BMC women's health,
21(1), 421.
https://doi.org/10.1186/s12905-021-01564-2
Gogineni, V., Waselewski, M. E., Jamison, C. D., Bell, J. A.,
Hadler, N., Chaudhry, K. A., Chang, T., & Mmeje, O. O.
(2021). The future of STI screening and treatment for youth: a
National Survey of youth perspectives and intentions.
BMC public health,
21(1), 2006. https://doi.org/10.1186/s12889-021-12091-
y
Kam, J., Wong, L. K., & Fu, K. (2019). Creation of sexually

17. transmitted diseases education program for young adults in rural
Cambodia.
Frontiers in public health,
7, 50.
https://doi.org/10.3389/fpubh.2019.00050
Rhodes, S. D., Daniel-Ulloa, J., Wright, S. S., Mann-Jackson,
L., Johnson, D. B., Hayes, N. A., & Valentine, J. A. (2021).
Critical elements of community engagement to address
disparities and related social determinants of health: the centers
of disease control and prevention community approaches to
reducing sexually transmitted disease initiative.
Sexually transmitted diseases,
48(1), 49.
https://doi.org/10.1097/OLQ.0000000000001267
Rusley, J. C., Tao, J., Koinis-Mitchell, D., Rosenthal, A. E.,
Montgomery, M. C., Nunez, H., & Chan, P. A. (2022). Trends in
risk behaviors and sexually transmitted infections among youth
presenting to a sexually transmitted infection clinic in the
United States, 2013–2017.
International journal of STD & AIDS,
33(7), 634.
https://doi.org/10.1177/09564624221077785
Santa Maria, D. (2018). Feasibility and efficacy of a student
nurse-delivered, parent-based sexual health curriculum in
underserved communities: A pilot randomized-controlled trial.
Pediatric Nursing,
44(1).
Shannon, C., & Klausner, J. (2018). The growing epidemic of
sexually transmitted infections in adolescents: A neglected
population.
Current opinion in pediatrics,
30(1), 137.

18. https://doi.org/10.1097/MOP.0000000000000578
Wilkins, N. J., Rasberry, C., Liddon, N., Szucs, L. E., Johns,
M., Leonard, S., Goss, S. J., & Oglesby, H. (2022). Addressing
HIV/Sexually transmitted diseases and pregnancy prevention
through schools: An approach for strengthening education,
health services, and school environments that promote
adolescent sexual health and well-being.
Journal of Adolescent Health,
70(4), 540-549.
https://doi.org/10.1016/j.jadohealth.2021.05.017
PAGE
1
High nurse turnover is one of the major issues that nurse leaders
and hospital management face. High nurse turnover has a
significant negative impact on nurse leaders, hospital managers,
nurses, patients, doctors, and the entire healthcare system (Bae,
2022). (i) There are several reasons for high nurse turnover
rates among which is burnout which causes physical and mental
strain on nurses forcing them to leave their jobs. Nurse turnover
forces hospitals to spend more resources hiring and training new
nurses and affects the overall morale of nurses and increases the
burden of heavy workload as the remaining nurses have to cover
the gap left by others (Bae, 2022). The purpose of this paper is
to examine the impact of high nurse turnover on nurses’ mental
health and how a ten-week mental health program implemented
based on Orem’s self-care theory can reduce the rate of this
turnover.
The rate of turnover for registered nurses is approximately 26.8
% in the U.S. and the rate of turnover for new graduate nurses is
18.1% with 17.1% of new nurses leaving their jobs within the
first year of employment (Zhao et al., 2018). High turnover rate

19. caused by burnout is a major nursing issue that negatively
affects nurse motivation and mental health and therefore should
be properly addressed (Bae, 2022). The purpose of the ten-week
mental program is to reduce the impact of turnover rates caused
by burnout on nurses' mental health, therefore, reducing the rate
of turnover. (f) The program will address nurses’ mental health
wellness and help them cope with work-related stress which
causes burnout.
Turnover Rates due to Burnout in Healthcare
PICOT question
The PICOT question evaluates whether a mental health program
can help reduce the nurse turnover rate in comparison to the rate
of turnover before the program. The intervention aims to
address high nurse turnover caused by burnout. The population
in this intervention is the critical care nursing staff, the
intervention is implementing a mental health program, the
comparison is the rate of turnover before the program, the
outcome is a reduced nurse turnover rate and the time is ten
weeks.
Population
The vulnerable populations to high nurse turnover rate due to
burnout are critical care nurses as they are exposed to high
stress work. The heavy workloads of critical care nurses as a
result of the high nurse-patient ratio affects nurses mentally and
physically. Due to the high turnover rate, nurses' performance
level reduces increasing the risk of medical errors because they
are overworked and their commitment and motivation are
adversely affected forcing them to consider leaving their jobs
(Kaddourah et al., 2018). Various risk factors increase turnover
rates such as unfavorable work environment, job dissatisfaction,
salaries and compensations, communication barriers, and high
nurse-patient ratio.
According to Kim and Kim (2021), a high nurse-to-patient ratio

20. is one of the major causes of burnout that directly leads to a
high turnover. When there is a high turnover rate, nurses have
to take additional shifts and take up heavy workloads to cover
the gap left by other nurses. A high nurse-patient ratio impacts
patient safety adversely and leads to low-quality services as
nurses are often exhausted mentally affecting their well-being.
According to Dewanto and Wardhani (2021), an unfavorable
work environment causes approximately 10% of the turnover
rate. When nurses work in a stressful environment with limited
resources to perform their duties, they are more inclined to
leave their jobs to pursue better options leading to a high
turnover rate.
Nursing research
According to Lockhart (2020), improving the nurse-to-patient
ratio is an effective intervention that reduces turnover rates
caused by burnout. The research conducted by American
Medical Association shows that hospitals with a low nurse-to-
patient ratio (4:1) have a high nurse retention rate compared to
those with a high nurse-to-patient ratio (8:1) (Lockhart, 2020).
Reducing the 8:1 nurse-to-patient ratio by half reduces the rate
of turnover due burnouts by approximately 25% (Lockhart,
2020). According to Lockhart (2020), over four patients per
nurse increases nurse burnout by 23% affecting the mental
health of nurses with heavy workloads. This intervention
requires a hospital to incur additional expenses to hire more
nursing staff.
According to Luo et al. (2019), one effective strategy for
reducing the high turnover rate caused by burnout is
implementing support groups where nurses can voice their
concerns and gain emotional and mental support. These support
groups help nurses cope with the pressure that comes with their
demanding nursing practice. Nursing support groups are
important as they teach better scheduling, discuss well-being
and overall nurses' health and provide safe respite areas for

21. nursing staff. According to Luo et al. (2019), support groups
help nurses find self-care techniques that improve their mental
health and prevent or reduce burnout therefore indirectly
reducing the turnout rate.
Proposal
Implementing a mental health program can reduce the turnover
rate caused by burnout among critical care nurses. When
implementing this program, there are numerous resources
required. The intervention would allow nurses to examine their
mental well-being and take care of their health. It also gives
nurses insight into how to deal with the pressures and
challenges of the nursing profession. When implemented
effectively, this intervention has the potential to reduce nurse
burnout because it addresses all stakeholders involved and who
work with nurses such as doctors, nurse leaders, and other
clinicians.
Resources
These resources include a printed guide to help nurses cope
with burnout, online support forums, training courses, a venue,
therapy platforms, a computer, a tablet or a projector, and a
thought record diary among others (Lockhart, 2020). (i) The
individuals that would be involved in implementing this
intervention are hospital managers, nurse leaders, nurses, and
other physicians such as doctors and psychiatrists. (ii) Nurse
can play an advanced role in ensuring that this intervention is
implemented effectively to reduce the rate of turnover that leads
to nursing staff shortages. Nurses with advanced skills are able
to provide leadership, and use their critical thinking skills to
solve problems that may arise during the program. (iii) The
program is expected to run for ten weeks upon implementation
where the rate of turnover after the mental health program will
be compared to the turnover rate before the implementation of
this intervention to determine its effectiveness.

22. Orem’s self-care theory
Orem’s self-care theory is the ideal nursing theory that one
cause use as a foundation when implementing this intervention.
According to Dorothea Orem, the founder of Orem’s self-care
theory nurses should be responsible for their care, be self-
reliant and provide quality care to patients who need their
services (Khademian et al., 2020). This theory is best-suited in
dealing with burnout which causes a high turnover rate as
nurses have to be responsible for their care including mental
well-being first before they can offer their best to their patients.
this theory requires nurses to maintain autonomy, benevolence,
nonmaleficence, and justice on themselves before they can do
the same for their patients. self-care in form of mental health
program helps nurses cope with burnout and therefore reduces
the turnover rate.
High turnover rate negatively impacts patient care, therefore,
affecting patients' quality of life. It also adversely affects the
cost of care as patients are forced to spend a long time in
hospitals. High nurse turnover also affects hospital managers
who have to spend a significant amount of time screening new
nurses who have high qualifications and skills that suit the
hospital's needs (Zhao et al., 2018). A high nurse turnover rate
is also costly to patients and hospitals as the former incur
additional medical costs due to low-quality patient care and
prolonged hospital stay while the latter spends more on training
new nurses, hiring additional nursing staff, and providing
incentives to retain experienced nurses.
References
Bae, S. H. (2022). Noneconomic and economic impacts of nurse
turnover in hospitals: A systematic review.
International Nursing Review,
69(3), 392-404.

23. https://doi.org/10.1111/inr.12769
Dewanto, A., Febrina, S. S., & Wardhani, V. (2020). The
importance of nurses’ cognitive and emotional engagement in
developing hospital quality culture.
Enfermería Clínica,
30, 97-101.
Kaddourah, B., Abu-Shaheen, A. K., & Al-Tannir, M. (2018).
Quality of nursing work life and turnover intention among
nurses of tertiary care hospitals in Riyadh: A cross-sectional
survey.
BMC Nursing,
17(1), 1-7. https://doi.org/10.1186/s12912-018-0312-0
Khademian, Z., Ara, F. K., & Gholamzadeh, S. (2020). The
effect of self-care education based on orem’s nursing theory on
quality of life and self-efficacy in patients with hypertension: a
quasi-experimental study.
International Journal of Community-Based Nursing and
Midwifery,
8(2), 140. https://doi.org/
10.30476/IJCBNM.2020.81690.0
Kim, H., & Kim, E. G. (2021). A meta‐analysis on predictors of
turnover intention of hospital nurses in South Korea (2000–
2020).
Nursing Open,
8(5), 2406-2418. https://doi.org/10.1002/nop2.872
Lockhart, L. (2020). Strategies to reduce nursing turnover.
Nursing Made Incredibly Easy,
18(2), 56.
https://doi.org/10.1097/01.NME.0000653196.16629.2e
Luo, Y. H., Li, H., Plummer, V., Cross, W. M., Lam, L., Guo,
Y. F., ... & Zhang, J. P. (2019). An evaluation of a positive
psychological intervention to reduce burnout among nurses.
Archives of Psychiatric Nursing,

24. 33(6), 186-191.
https://doi.org/10.1016/j.apnu.2019.08.004
Zhao, Y., Russell, D. J., Guthridge, S., Ramjan, M., Jones, M.
P., Humphreys, J. S., & Wakerman, J. (2018). Cost impact of
high staff turnover on primary care in remote Australia.
Australian Health Review,
43(6), 689-695.
https://doi.org/10.1071/AH17262
2
Turnover Rates due to Burnout in Healthcare
Review of Literature
High turnover rates as a result of nurse burnout are a major
issue in healthcare that needs to be resolved. Kelly et al. (2021)
established that burnout can be addressed by improving
resilience through mental health awareness and mindfulness-
based stress reduction to address nurses’ turnover. The article
provided high-quality evidence as the conclusions made were
definitive and supported by the data provided. The evidence is
applicable to the PICOT question as it supports improvement in
mental well-being could reduce burnout and turnover. The
findings are consistent with those of other studies (Kwon et al.,
2021). The major difference was the methodologies used to
collect data as Kelly et al. (2021) obtained patient data from
health databases while Kwon et al. (2021) used anonymous
online surveys. The controversy in the article is that it does
rule out the contribution of other factors in improving nurses’
resilience.
In another study, Kwon et al. (2021) associated burnout
with turnover intention and suggested that nurses’ turnover
intention could be mitigated by improving their mental health.
The article provides low-quality evidence as the sample size is

25. insufficient for the study. The findings can be applied to the
PICOT question to address nurse turnover. The evidence
provided in the article is supported by other studies that
associate burnout and nurses’ intention to leave (Chen et al.,
2019). The similarities between the studies included the
methodology as they were both cross-sectional studies and some
of the variables in the studies. The difference identified
included the location of the studies as one was conducted in
Korea and the other in Taiwan (Chen et al., 2019; Kwon et al.,
2021). There was no controversy identified in the study.
However, Tununu and Martin (2020) established that
psychiatric nurses did not suffer from burnout because they had
low emotional exhaustion. The article provides low-quality
evidence that cannot be generalized as it was conducted in one
psychiatric hospital, and the evidence varied from that of other
studies (Scanlan & Still, 2019). The evidence applies to the
PICOT question as it provides an alternative view of the
existence of burnout among psychiatric nurses. The similarity
between the articles is that they were single-site studies The
differences noted include the geographical location and the
participants’ response rates since one had 100% and the other
25% response rate (Scanlan & Still, 2019; Tununu & Martin,
2020). The controversy identified is the sufficiency of the
sample size yet the findings were inconsistent with those of
other studies.
Research indicates that there is an inter-correlation
between turnover intention and burnout (Scanlan & Still, 2019).
The evidence provided was of high quality as the findings were
supported by data from the study. The findings are applicable to
the PICOT question to provide a solution to the issue of
turnover by developing strategies to reduce burnout. The
evidence is similar to the findings of Chen et al. (2019).
However, the major difference between the studies was that
Chen et al. (2019) investigated burnout as a mediating factor

26. influencing turnover intention among nurses with high patient-
nurse ratios. The controversy that exists in the articles is the
different measurements of turnover intention (Chen et al., 2019;
Scanlan & Still, 2019).
Wei et al. (2022) established that burnout was prevalent among
nurses in delivery and peri-operative settings. The article
provided high-quality evidence as the conclusions were
supported by the results of the study. The evidence is applicable
to the PICOT question since the researchers recommended the
need to improve burnout symptoms and nurses’ physical and
mental health. The findings are consistent with the evidence in
other studies that associated work-related stress and increased
burnout in nurses (Karimi et al., 2022). The difference noted is
the location of the study as Wei et al. (2022) was conducted at a
single site and the other in two hospitals (Karimi et al., 2022).
No controversy has been identified in the study.
Karimi et al. (2019) found that some elements of burnout
influenced turnover intention such as a personal
accomplishment. The quality of the evidence provided was
affected by the small sample size, which could have influenced
the results, but the study was conducted in multiple settings,
which improves the generalizability of the findings. However,
the evidence is related to the PICOT question as the authors
recommended monitoring nurses’ mental health to prevent the
effects of burnout such as turnover. Other researchers have also
identified burnout as a common problem among nurses during
the COVID-19 pandemic (Maunder et al., 2022). The two
studies were conducted in multiple settings. The studies were
conducted in two different geographical locations. The
controversial information in the article is that work position
was the highest predictor of the intention to leave.
In their study, Maunder et al. (2022) found that nurses
experienced high levels of burnout during the COVID-19

27. pandemic. The findings were consistent and generalizable and
can be applied to the PICOT question to address the problem of
nurse turnover due to burnout by helping nurses cope with
work-related stressors such as COVID-19. A similar study
conducted by Karimi et al. (2019) had similar findings where
data was collected through surveys. The differences identified
include the setting, and the measures of burnout used. No
controversies were identified in the study.
There are some other elements of burnout such as client-based
and personal burnout that influence the intention to leave among
nurses (Chen et al., 2019). The quality of the evidence was
supported by the statistical data and the sample was sufficient.
The findings provide important information for answering the
PICOT question by reducing burnout to address nurses’
intention to quit their jobs. Similar findings were provided by
Kwon et al. (2021). But the difference is that Chen et al. (2019)
used a large sample from multiple settings and conducted the
study in one setting. No controversial information was
identified from the study.
Kowalczuk et al. (2020) associated burnout symptoms
with working excessively, which increased nurses’ tendency to
frequently take sick leave. The evidence was consistent with
the data provided and was correctly interpreted. The sample size
was sufficient for generalization and the study was conducted in
multiple sites. The evidence can be used to answer the PICOT
question since the researchers explained that burnout and
excessive work affect employees’ mental health. Therefore,
reducing workload could reduce burnout and prevent nurses
from leaving. The similarity identified with the other articles
include the research design; But differed in the data collection
procedure as the authors applied paper-questionnaires
Kowalczuk et al. (2020), other than online surveys (Maunder et
al., 2022; Wei et al., 2022).

28. Rudman et al. (2020) associated nurse burnout with various
mental health problems such as insomnia, depressive symptoms,
and cognitive problems. The article provided high-quality
evidence as the sample size was sufficient and the results were
consistent and generalizable. The findings apply to the PICOT
question since improving nurses’ mental health would prevent
them from such problems and could be overwhelmed by the
demands of their careers. The evidence is consistent with other
studies that identified the association between burnout and
mental health issues (Maunder et al., 2022). However, the
study involved nursing students while the others mostly focused
on nurses and other healthcare professionals (Kowalczuk et al.,
2020; Maunder et al., 2022).
PICOT question support
Burnout is a major issue among nurses that should be addressed
to prevent nurse turnover. Current research indicates a
significant association between burnout and nurses’ intention to
quit their jobs to seek other opportunities. Studies have
suggested that addressing burnout could help reduce nurses’
intention to leave their careers or positions by improving their
resilience (Kelly et al., 2021). Burnout is associated with
increased psychological distress (Maunder et al., 2021), and low
satisfaction with their jobs (Scanlan & Still, 2019).
It is important to note that the relationship between
nurse turnover and burnout can be influenced by other factors
such as workload, which may not independently affect nurse
turnover. The PICOT question seeks to establish whether
improving mental health and well-being could address the
problem of nurse turnover. Available evidence indicates the
need to create strategies to reduce burnout and improve nurses’
job satisfaction to reduce their intentions to leave (Scanlan &
Still, 2019). Strategies to help nurses cope with stressors in the
workplace could reduce nurses’ burnout and turnover intentions

29. by enhancing personal accomplishment and reducing emotional
exhaustion (Karimi et al., 2019).
Practice Change
To address the problem of the high turnover rate of nurses
affected by burnout, implementing a mental health program to
reduce burnout can help nurses to cope with job-related stress.
Kelly et al. (2021) identified improving employee well-being as
essential in preventing nurses from leaving their positions or
units. Tununu and Martin (2020) explained that promoting open
communication and resources could help reduce burnout among
nurses and provide a safe working environment. It is important
to identify and prevent factors that lead to nurse burnout to
successfully prevent nurses from the intention to leave,
especially when faced with critical situations (Karimi et al.,
2019).
Objective
The project change aims to reduce the nurse turnover rate
caused by burnout by providing nurses with a program that will
improve their mental health. When the nurses’ mental health is
improved, it would be easy to cope with stressors that arise in
the workplace and prevent them from burnout and subsequently
intentions to quit. The intervention will protect not only nurses
from harm but also patients since burnout is associated with
psychological distress which threatens patients’ safety
(Maunder et al., 2022). Improving nurses’ mental health would
translate to improved patient outcomes.
Problem
The problem of nurse turnover resulting from burnout is
common among nurses working in busy and understaffed units.
There is a relationship between a high workload and increased
burnout, which is a predictor of high turnover (Chen et al.,

30. 2019). Nurses are more likely to be overwhelmed when they ate
overworked Therefore, there is a need to improve nurses’ ability
to cope with the stress that arises due to high workloads and
help them to be more resilient. Nursing is a challenging
profession that is faced with many challenges such as staffing
shortages and nurses are bound to find themselves in difficult
situations; thus, have to be mentally strong.
Current state of problem
Since the emergence of the COVID-19 pandemic, nurses have
been faced with relentless pressure to care for many patients.
The pro of the problem is the increasing demand for nurses as
the opportunities for front-line workers have increased as more
nurses leave the profession to seek other opportunities.
However, the negative part of the problem is that many
healthcare institutions still need to hire more nurses as they still
struggle to properly compensate the existing workforce putting
more pressure on the remaining workforce. Hospitals have been
faced with the challenge of managing their costs and providing
quality care (Chen et al., 2019).
Strengths and weaknesses of review of literature
The major strength of Kelly et al. (2021) was a sufficient
sample size and consistent results, while the limitation was the
fixed times of data collection. In Kwon et al. (2021), the main
strength was the relevance of the article to the PICOT question,
while the weakness was that it was a single-site study, which
limited its generalizability. The main strength of Tununu and
Martin (2020) was a sufficient sample size but was conducted in
a single hospital. In Scanlan and Still (2019), the main strength
was the consistency of the findings but lacked a random sample.
Wei et al. (2022) provided consistent findings from a sufficient
sample size but only focused on peri-operative units of one
hospital.

31. Karimi et al. (2019) provided consistent findings, but the
sample size was small and relied on self-reported data, which
can be biased. The main strength of Maunder et al. (2022) was
the study design that allowed for follow-up, but there was a
high drop-out, which created an opportunity for bias. Chen et al.
(2019) had a sufficient sample size for the study, but the model
may not be used with other mediators. In Kowalczuk et al.
(2020), the main strength was that the hypothesis was
confirmed, and the major weakness was the cross-sectional
study design and self-reported data, which can be biased.
Lastly, Rudman et al. (2020) had a sufficient sample size from
different settings, and the major weakness was the over-reliance
on self-reported data.
References
Chen, Y. C., Guo, Y. L. L., Chin, W. S., Cheng, N. Y., Ho, J. J.,
& Shiao, J. S. C. (2019). Patient–nurse ratio is related to
nurses’ intention to leave their job through mediating factors of
burnout and job dissatisfaction.
International journal of environmental research and
public health, 16(23), 4801.
https://doi.org/10.3390/ijerph16234801
Karimi, L., Raei, M., & Parandeh, A. (2022). Association
between dimensions of professional burnout and turnover
intention among nurses working in hospitals during coronavirus
disease (COVID-19) pandemic in Iran based on structural
model.
Frontiers in public health, 10.
https://doi.org/10.3389/fpubh.2022.86026
Kelly, L. A., Gee, P. M., & Butler, R. J. (2021). Impact of nurse
burnout on organizational and position turnover.
Nursing outlook, 69(1), 96-102.
https://doi.org/10.1016/j.outlook.2020.06.008.

32. Kowalczuk, K., Krajewska-Kułak, E., & Sobolewski, M. (2020).
Working excessively and burnout among nurses in the context
of sick leaves.
Frontiers in psychology, 11, 285.
https://doi.org/10.3389/fpsyg.2020.00285
Kwon, C. Y., Lee, B., Kwon, O. J., Kim, M. S., Sim, K. L., &
Choi, Y. H. (2021). Emotional labor, burnout, medical error,
and turnover intention among South Korean nursing staff in a
University Hospital setting.
International journal of environmental research and
public health, 18(19), 10111.
https://doi.org/10.3390/ijerph181910111
Maunder, R. G., Heeney, N. D., Hunter, J. J., Strudwick, G.,
Jeffs, L. P., Ginty, L., ... & Wiesenfeld, L. A. (2022). Trends in
burnout and psychological distress in hospital staff over 12
months of the COVID-19 pandemic: a prospective longitudinal
survey.
Journal of Occupational Medicine and Toxicology,
17(1), 1-11. https://doi.org/10.1186/s12995-022-00352-4
Scanlan, J. N., & Still, M. (2019). Relationships between
burnout, turnover intention, job satisfaction, job demands and
job resources for mental health personnel in an Australian
mental health service.
BMC health services research, 19(1), 1-11.
https://doi.org/10.1186/s12913-018-3841-z
Tununu, A. F., & Martin, P. (2020). Prevalence of burnout
among nurses working at a psychiatric hospital in the Western
Cape.
Curationis, 43(1), 1-7.
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33. Wei, H., Aucoin, J., Kuntapay, G. R., Justice, A., Jones, A.,
Zhang, C., ... & Hall, L. A. (2022). The prevalence of nurse
burnout and its association with telomere length pre and during
the COVID-19 pandemic.
Plos one, 17(3), e0263603.
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