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NCBIBookshelf.AserviceoftheNationalLibraryofMedicine,NationalInstitutesofHealth.

InstituteofMedicine(US)CommitteeontheAdequacyofNursingStaffinHospitalsandNursingHomes
WunderlichGS,SloanF,DavisCK,editors.NursingStaffinHospitalsandNursingHomes:IsItAdequate?
Washington(DC):NationalAcademiesPress(US)1996.

5 StaffingandQualityofCareinHospitals

Nursingisacriticalfactorindeterminingthequalityofcareinhospitalsandthenatureofpatient
outcomes.Twentyfourhournursingcareisoneofthedistinctivehallmarksofinpatientcarein
hospitals.Historically,hospitalshavebeenatthecoreoftheU.S.healthcaresystem,andnursing
servicesarecentraltotheprovisionofhospitalcare.Theyhavealsofunctionedasthetraditional
placeofworkfornursingpersonnelandespeciallyforregisterednurses(RN).Nursingpersonnel
comprisethelargestproportionofpatientcaregiversinahospital.Nursingcareinhospitalstakes
onaddedimportancetodaybecauseincreaseinacuityofpatientsrequiresintensivenursingcare.

Inrecentyears,thenursingprofessionhasbeenespeciallyconcernedaboutthenatureofthe
transformationtakingplaceinthehealthcaresector.ReportsofhiringfreezesandlayoffsofRNs
inhospitalshaveledtoincreasingapprehensionamongthemandtheirsupportingorganizations
aboutthepotentialthreattothequalityofpatientcareinhospitalsaswellastheirphysicaland
economicwellbeing.RNshaveexpressedconcernsthathospitalsareimplementingavarietyof
nursingcaredeliverysystemsinvolvingmajorstaffsubstitutions,reducingtheproportionofRNsto
othernursingpersonnelbyreplacingthemwithlessertrained(andattimesuntrained),andlower
salaried,personnelatatimewhentheincreasingcomplexityofhospitalinpatientcaseloadscallsfor
moreskillednursingcare.

Atthesametime,theaggregatequantityofRNsisatahighlevel,creatinguncertaintiesaboutjob
security.Muchhealthcareismovingtoambulatorysettings,thecommunity,andthehomethrough
homehealthservices.Thenursingprofessionalsohasconcernsaboutthetrainingneedsto
accommodatetheseshiftsinworksettings.Withrespecttothehospitalsetting,arapidlychanging
healthcareenvironment,continuingpressurestocontaincosts,andtherisinglevelsofseverityof
illnessandcomorbidityofinpatientsallmakeitimperativeforhospitalstoexploreinnovativeways
toredesigndeliveryofcarewithoutcompromisingquality.

Throughoutthedecadeofthe1980s,hospitalexpansion,scientificadvances,andtechnological
developmentledtotheuseofanincreasingnumberofnursingpersonnel,particularlytheRN.As
discussedinChapter4,employmentofRNsinhospitalshasincreasedsteadilyforthepastseveral
decades.In1993,RNemploymentinhospitalscontinuedtoincrease,buttherateofgrowthover
thepreviousyearshowedaslightdeclineforthefirsttimeinmanyyears(AHA,1995b).However,
acomparisonoffirstquarter1994datawithpreliminarydataforthefirstquarterof1995,shows
thatwhiletotalhospitalemploymentwasdownRNemploymentincreasedby3.5percent,and
licensedpracticalnurse(LPN)employmentdeclinedby1.2percent(seeTable4.3).Thesefigures
mayrepresenta1yearartifactoranindicationofanunderlyingshiftinthehealthcaredelivery
system.

InformationabouttrendsinemploymentlevelsofRNsandothernursingpersonnelneedstobe
understoodinthecontextofthechanginghealthcaresystem,aselaboratedinChapters3and4.In
particular,hospitalinpatientlengthsofstaycontinuedtodecline,alongwithinpatientdays
admissionsincreasedin1995afterremainingrelativelylevelin1994.Theincreasingacuityof
patientsrequiringintensenursingcare,thelargeincreaseinhospitaloutpatientservices,andthe
relativeincreaseinbedsdedicatedtointensivecareunitsalsomayaccountforatleastpartofthe
continuedincreaseinhospitalemploymentofRNs.

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Insum,althoughthecommitteeheardreportsofwidespreadlayoffsofRNsandothernursing
personnel,nationalstatisticssuggestthatintheaggregatetheseemploymentlossesappeartohave
beenmorethanoffsetbyhires.(Thisgeneralizationdoesnotholdforlicensedpracticalnurses
[LPN],whoseemploymentbyhospitalshasbeendecliningforsomeyears.)Thecontinuedgrowth
inRNemploymentappearstoruncountertomanyassertionsthecommitteeheardfromnurses
duringsitevisits,testimonyandnumerouswrittenandoralcommunicationsthroughoutthestudy.
Aggregatetrends,ofcourse,obscurelocalandregionalvariationsthatrespondtolocalmarket
conditionsandotherfactors,andanecdotalinformationcannotbediscountedtotallyasitoftenisa
warningindicatorofchangesthatarenotyetreflectedinnationalstatistics.

Thischapterexaminestherelationshipofstaffingpatternsofnursingpersonnelinhospitalsand
qualityofpatientcare.Thechapterbeginswithadiscussionoftherestructuringofhospitalcare
andthechangingrolesofnursingpersonnelinhospitals.Itthenprovidesabriefoverviewofthe
elementsofqualityofcare,measurementissues,andthestatusofqualityinhospitals.Next,it
proceedstoassesswhetherthereisanyreliableevidencelinkingnursestaffingtothequalityof
patientcareinhospitals.Thechapterendswithabriefoverviewoflegislativeandregulatory
requirementsforhospitalqualityassurance.

RestructuringInTheHospitals
Astheaveragelengthofstayforpatientsdecreasedandsubsequentlyasthenumberofstaffedbeds
alsodeclined,hospitalsbeganredesigningtheirsystemsofcare,schedulingpractices,and
approachestothecareofhospitalizedpatients,inordertoaccommodatethisdecreasedneed.

Increasingnumbersofhospitalsarerestructuringtheirorganization,staffing,andservices.
Redesignandreengineeringhavebecomeprincipalstrategiesofthe1990sformanyinstitutions
andsystems.Althoughredesigninitiativesareundertakenforavarietyofreasons,morethanhalf
oftheeffortsaredrivenbytheneedtoreduceoperatingcosts,andhavefocusedonthe
transformationofworkprocessesandtheredesignofrolesandjobs.Staffreductionsorchangesin
labormixareattimesimplementedwithoutattentiontotheorganizationalchangesthatmight
facilitatethepossibilityofbetteroutcomeswithfewer,moreappropriatelytrainedandusedstaff,
whileatthesametimefocusingonimprovedpatientoutcomes(VHA,1995).

Thelaborintensityofnursingservicesinhospitalscannotbedisputedwhenoneconsidersthefact
thattheaveragenursingdepartment'sfulltimeequivalent(FTE)personnelrepresentaround40
percentoftheoverallhospitalFTEpersonnelandaround30percentoftheaverageannualhospital
budget(WittAssociates,1990).Thismeansthatthenursingdepartmentrepresentsthelargest
singledepartmentwithintheinstitution.Inlightoftheeffortsbyhospitalstomeetthemultiple
demandsthatarereshapingtheirfutureandrequiringthemtoreducecosts,thenursingdepartment
canbeamajorareaforcostreductioneffortssimplybecauseofthesizeofthebudget.Brannon
(1994,p.3)notesthatin"responsetogreatermarketcompetitionandpressurestocontaincost,
communityhospitalsnotonlytransformedthemselvesintodiversifiedhealthcareorganizations,
[but]corporatemanagersreorganizedtheworkofhospitalworkerstocontainlaborcostsand
increaseproductivity.Nursingwasatthecenterofthesechanges."However,becauseitisassumed
thatthechanginghealthcaresystemneedstobalancecostswithmaintainingorimprovingquality
ofcare,assuringthatboththerightnumberandtherightkindofnursingresourcesareavailable
becomesessentialforacoordinatedandcosteffectivehealthcaresystem.

Concurrentwiththeeffortstorestructurehospitalserviceshasbeenthedevelopmentoftotal
qualitymanagementandwhatisoftenreferredtoaspatientcenteredandpatientfocusedcare.The
typicalpatientinatraditionallyorganizedhospitalmayinteractwithasmanyas60staffinone4
dayhospitalstay(Lathrop,1992).Hence,effortsforredesigninghospitalcarehavebeenfocused

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ontheintegrationofmanyhospitalservicesinanefforttoprovidemorepatientcenteredor
focusedcare.Boththeseeffortstotalorcontinuousqualitymanagementandpatientcenteredcare
haveledtomajorworkdesignandorganizationalchangeinseveralhospitals.Theseinnovative,
teamapproachesmayalsoinvolvecasemanagers,1thedevelopmentofcriticalpathwaysfor
managingpatientsmostefficientlyduringahospitalstay,andotherstepsthat,collectively,leadto
restructuringinthehospital.

Therestructuringofhospitalinpatientservicesisbutonepartofthelargerrestructuringeffortsof
thecaredeliverysystemrelatedinlargeparttomanagedcareandthedevelopmentofintegrated
deliverysystems.Whilemuchanecdotalinformationisavailableaboutthesechanges,objective
dataarenotavailabletodeterminehowwidespreadthesechangesareandwhetherornotthis
redesignaccomplishesitsdualgoalsofincreasingpatientcenteredcareandcostreductions.

Becauseoftheresourceintensityofhospitalnursingservices,restructuring,workredesign,and
costreductioneffortshaveadirectimpactonthenursingworkforce.Itisnotsurprising,therefore,
thattherestructuringofhospitalsandredesignofnursingservicesareamongthemostpressing
issuesforthenursingprofessionandultimatelyforthefutureofhealthcaredeliveryinhospitals.
Staffingtoprovidesafe,effective,andtherapeuticpatientcareisachallengefornurse
administratorsunderanycircumstances,andsubstantialchangesareoccurringintheorganization
anddeliveryofhospitalcare.

ChangingRolesandResponsibilitiesofRNs
WhiletheRNinthehospitalremainsinthepivotalpositionforcoordinatingcareinhospitals,
sometimesasacasemanager,thepositionofthenurseassistant(NA)hasbeenchanging.Insome
institutionsitisbeingupgraded,withNAsassuming,underthedirectionoftheRN,increasing
responsibilityformoredirectcareactivitiesthaninthepast.Thisresultsinanincreasinglevelof
managementandsupervisoryskillsbeingrequiredofRNs.Insomehospitalstheredesignofthe
nurseassistantrolehasoccurredinconjunctionwiththeredesignofothersupportactivitiessuchas
dietary,housekeeping,andtransportationservices.Theintegrationofthesefunctionsisviewedas
onewaytohavefewerpeopleinteractingwiththepatient,whilealsoprovidingthepotentialfor
costsavings.

Theseredesigneffortshaveledtochangesinthepatternsdevelopedoverthepasttwodecadesfor
organizingthedeliveryofnursingcareinhospitals.Thechallengetodayisforcaregiversand
patientstothinkaboutthecontinuumofcareneededratherthansimplytheeventofhospitalization.
Theemphasisisnolongerontheinpatienthospitalcareofapatient,butrathertoviewtheeventof
hospitalizationasoneeventintheillnesscontinuum.Changingtheemphasistoacontinuumof
carerequireshospitalnursingservicestodevelopnewstructuresandpractices.Foremostamong
thesechangesistohelpnursingandotherhealthcaregiverstolearnhowtoplanforpatientcare
beforethepatientisadmittedtothehospital,aswellasforcareneededafterdischargefromthe
hospital.

Thischangealsocallsformoreflexibilityinstaffingpatternsandtimeschedulesthatwillfocuson
theneedsofthepatient.Flexibilityinschedulingwasamajorissueofthelate1980swhen
hospitalshadnursingshortages.Achangeto12hourscheduleswithfewerdaysworkedby
nursingstaffbecameastandardinmanyhospitalsinanefforttoincreasenursesatisfactionand
therebydecreasingtheturnoverofnursingstaff.Today'sworkredesignappearstobechanging
someofthoseschedulesbacktothemoretraditional8hourdayand40hourweek,reducingsome
costsindoingsoandprovidingthepotentialformorestabilityinstaffingsystemsthatprovide
opportunityforsomenursingstafftopracticeacrosstheboundariesofinpatientandambulatoryor
communitynursingcare.

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Itisthislatterchallenge,alongwiththedemandsforincreasedefficiencywithinastandardofgood
qualityofcarethat,inpart,hasledmanyhospitalstoimplementtheconceptofcareteams.These
careteamsaregenerallyinterdisciplinaryinnature,bringingmembersoftheappropriatedisciplines
togetherfromallareas,ambulatory,inpatient,andcommunityforexample,tocollectivelydevelop
aplanofcarethatwilloptimallybenefitthepatient,meetapreestablishedsetofstandards,anduse
asfewresourcesaspossibleincarryingouttheplanofcare.Suchcareteamsoftenusepractice
guidelines,sometimesreferredtoascaremapsorcriticalpathways,todeterminetheplanofcare
andprogressofthepatientalongatimelineestablishedforthecontinuumofcare.Theseguidelines
aresimilartodecisiontreesandrequireateamofcaregiverswhoengageinhighlevelsofeffective
communicationandhavetheknowledgeandskillsrequiredtoenterintocollaborativeplanningand
evaluation.Asmanagedcarebecomesmorethenorm,expedientdecisionmakingandgood
judgmentwillbeincreasinglymoreimportantforallhealthcareprovidersandtheuseof
interdisciplinaryapproachessuchascareteamsalsowillbecomeincreasinglythenorminthe
hospitalsector(Sovie,1995).

Inordertoaccomplishtheworkofcareteamseffectivelyandefficiently,casemanagersareoften
used.Thissystemoforganizingcarereliesonthismanagertointegrateindepthclinical
knowledge,communityresources,andfinancialandorganizationalrequirementswithpatientneeds
andtheinstitutionalgoalsofprovidinghighquality,costeffectivecare.Whiletheneedsofthe
patientshoulddeterminewhowillbethecasemanager,inacutecaresettingsthisroleismostoften
performedbyanRN,frequentlyonewhohasbeenpreparedwitheducationbeyondthebasic
programofnursing.Inmosthospitalsthenursingcasemanageristhepersonwhospansthe
boundariesofinpatient,ambulatory,andcommunitynursing(Girard,1994).

Insummary,thedynamicsofstaffingandschedulinginhospitals,alwaysmorecomplexthanone
wouldexpect,havetakenonevengreatercomplexitiesascaregivingbecomesmuchmore
interdisciplinaryinnatureandcaregiversarerequiredtoconsidermorethantheeventofillness
presented,thatis,thecurrenthospitalizationorthecurrentoutpatientvisit.Thecontinuumofcare,
sharingofinformationacrossthesystem,andtheincreasinginvolvementofpatientsandfamiliesin
theirowncaregivingrequiresthatstaffingbeconsideredinitsbroadestdefinition.

EvolvingRolesinAdvancedPracticeNursing
Thecommitteetakesnoteofthegrowingtrendtowardcomplexityofillnessandsophisticatedcare
managementofpatientsinanillnessepisodethatincludestheeventofhospitalizationbutisnot
limitedtoit.Thecareplanningandmanagingbeginsbeforethepatientisadmittedtothehospital
andcontinuesbeyondthehospitalizationtodischargeplanningandmanagementofcareneeded
afterdischargefromthehospital.Leadingandmanagingtheorganizationaltransformations
describedaboverequiretalentsortrainingthatnotallRNsnowhave.Fortheevolvinghospital,the
committeebelievesthatitwillbeimperativeforthesemanagementandleadershipskillstobe
fosteredthroughvariouseducationalprograms.Thecommitteebelievesthatmoreadvanced,or
morebroadlytrained,RNswillbeneededinthefuture.Suchtrainingisessentiallylikethatnow
providedforRNswhoreceivecertificationas,forexample,advancedpracticenurses(i.e.,clinical
nursespecialists,nursepractitioners,nursemidwives,andnurseanesthetists).

Clinicalnursespecialistscanbefoundineveryspecialtyareaofnursing.Ineachoftheseareas
clinicalnursespecialistsfunctionaspractitioners,educators,casemanagers,consultants,
researchers,andadministratorsinthementalhealtharena,theymayalsoserveaspsychotherapists.
Theyplayacriticalroleintheongoingclinicalmanagementofcaseloadsofpatients.Nurse
practitionersmanagepatientswithacuteandchronicconditions.Theyfrequentlyhave
responsibilityformanagingpatientswithillnesssuchasdiabetesorhypertension.Theyalsoare
responsiblefortheongoingprimarycareofagroupofhealthyindividuals.
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Thevalueofsuchclinicalnursespecialists,intermsofbothpatientcareandeconomicfactorshave
beenstudiedoverthepast20to25years.Inparticular,anumberofrandomizedclinicaltrialshave
beenconducted.

Onesetofstudieswasdirectedattestingtheeffectivenessofprogramsconductedbyclinicalnurse
specialistsincaringforhospitalizedelderlypatients,especiallyincomprehensivedischarge
planning.Outcomessuchaslengthofstay,numberof,orlengthoftimebeforerehospitalization,
andcosts,aswellasfunctionalstatus,wereallbetteramongthosepatientswhosecarewas
coordinatedandimplementedbyclinicalnursespecialists.Neidlingerandcolleagues(1987)found
theuseofacomprehensivedischargeplanningprotocolimplementedbyaclinicalnursespecialist
savedanaverageof$60perpatientdaymorethantheircontrolgroup.Inafollowuptothisstudy
Kennedyandcolleagues(1987)foundthatforthesamecontrolandexperimentalgroupsthe
experimentaltreatmentgroup'saveragelengthofstaywasreducedby2days,andthelengthof
timebeforehospitalreadmissionincreasedby11days.

ApilotstudybyNaylor(1990)hadsimilarresults.Shefoundthattherewasasignificantdifference
betweenthetwogroupsinfrequencyofhospitalreadmissions.Later,inarandomizedclinicaltrial,
Naylorandcolleagues(1994)foundthatfrominitialdischargeto6weeksafterdischarge,patients
intheinterventiongroupmanagedbyclinicalnursespecialistshadfewernumberofhospital
readmissions,fewertotaldaysofrehospitalization,lowerreadmissioncharges,andlowercharges
forhealthcareafterdischarge.FunctionalstatuswasthefocusofastudybyWanichand
colleagues(1992).Theseresearchersfoundthatintheirclinicaltrialpatientsintheintervention
group(thosewhosecarewascoordinatedbytheclinicalnursespecialist)weremorelikelyto
improveinfunctionalstatusthanthosewhodidnotwhodidnotreceivesuchcare.Thesesame
patientswerelesslikelytodeteriorateonmeasuresoffunctionalstatusduringtheirhospitalstay.
Theseoutcomesmayalsohelptoreducelengthofhospitalstayanddecreasecosts,althoughcost
wasnotmeasuredasanoutcomeinthisstudy.

Oncologyclinicalnursespecialistshavealsobeenshowntoimprovepatientoutcomes.McCorkle
andcolleagues(1989),forexample,conductedarandomizedclinicaltrialoflungcancerpatients.
Thestudydemonstratedthatlungcancerpatientsreceivingcarefromspecializedoncologyclinical
nursespecialistsexperiencedlessdistress,lessdependence,fewerrehospitalizations,andshorter
lengthsofstaythandidpatientscaredforwithoutinterventionfromtheseadvancedtrained
personnel.AccordingtoRussell(1989)thecostofcareforpatientsundergoingamodifiedradical
mastectomywhowerefollowedbyanoncologyclinicalnursespecialistwassignificantlylower
thanforthosenotsofollowed.Theiraveragelengthofstaywas3.4days,whilethatofthecontrol
groupwas6.7days.Thecostsofhospitalizationaveragedadifferenceof$1,668.43perpatient.

Anothersetofstudiesinvolvedlowbirthweightinfantsandfamilieswhoreceivedcareand
consultationfromclinicalnursespecialists.Outcomessuchaslengthofstaywerebetterandcosts
wereloweramongstudyparticipantswhowereinthegroupusingsuchspecialistnurses(Brooten
etal.,19861988Damatoetal.,1993).

Theabilityofclinicalnursespecialiststofunctioninanumberofdifferentrolesandtheirabilityto
workindependentlytosolveproblemsandbepatientadvocatesaswellasintegralmembersofa
healthcareteamhavebeencitedasareasonforimprovedoutcomesandcostsavingsthattheyhelp
tobringabout.Nursesinthisroleareanimportantpartofthetotalpatientcarepictureacross
settingsandassuchareessentialtoimprovedpatientoutcomes.

Althoughthediscussiontothispointhasdrawnontheuseofadvancedpracticenursesin
dischargeplanningandworkingwithpatientsinthehomeafterhospitalization,theplaceofsuch
personnelintheentirecontinuumofcareforwhichhospitalsareresponsibleneedstobe
understood.Foronething,allbutthesmallesthospitalsoperateoutpatientclinicsofvarioussorts
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(includingthosethatdealwithnonurgentproblemsofpatientswhopresenttoemergency
departments).Moreover,astheU.S.healthcaresystemrestructuresitself,manylargerhospitals
andacademichealthcentersarebecomingthecenterofintegratedhealthdeliverysystemsthat
verticallyintegrateprovidersfromsmallphysicianofficepracticesthroughmultispecialtygroups
throughavarietyofotheraspectsofhealthcare.Withthistrend,plusthegrowingphenomenonof
delegationandsubstitutionofresponsibilitiesfromphysicianstonurses(i.e.,nursepractitionersor
othertypesofadvancedpracticenurses),itisclearthattheroleofadvancedpracticenursesisnow
andwillcontinuetoexpand.

Basedonthistypeofinformation,combinedwithwhatwaslearnedfromtestimony,sitevisits,and
theprofessionalexpertiseandexperienceofitsmembers,thecommitteeconcludesthathigh
quality,costeffectivecareforcertaintypesofpatients,particularlythosewithcomplicatedor
seriousclinicalconditions,willbefosteredbytheuseofsuchadvancednursespecialists.The
committeebelievesthatincreaseduseofadvancedpracticenurseswouldimprovethecost
effectivenessofourhealthcaresystemsandfacilities.Thatistosay,changingthemixofnursing
personnelinvolvedincaringforpatientswithincreasinglycomplexmanagementproblemsmay
yieldbothimprovedoutcomesandlowercosts.

RECOMMENDATION51:Thecommitteerecommendsthathospitalsexpandtheuseof
registerednurseswithadvancedpracticepreparationandskillstoprovideclinical
leadershipandcosteffectivepatientcare,particularlyforpatientswithcomplex
managementproblems.

Advancedpracticenursesaretypicallyclassifiedinatleastoneoffourways,andtheireducational
traininganddutiesdifferaccordingly.Clinicalnursespecialiststypicallyaremaster'sdegree
trainedRNssomemayalsohavePhDs.Theirclinicalspecialtiescanincludeoncology,
neonatologyand,or,pediatrics,mentalhealth,adulthealth,women'shealth,geriatrics,andAIDS.
Theycommonlyworkinclinicalsettingsandprovideprimarycarecasemanagementservices
psychotherapyandavarietyoforganizational,administrative,andleadershipservicesaswell.
Nursepractitionersareusuallypreparedatthemaster'sdegreelevelandalsocertifiedinaspecialty
areaofpractice,suchaspediatrics,familypractice,orprimarycare.Theirusualresponsibilities
includemanagingclinicalcaretheyconductphysicalexaminations,trackmedicalhistories,make
diagnoses,treatminorillnessesandinjuries,andperformanarrayofcounselingandeducational
tasks.Nursepractitionersmayalso,insomecircumstances,orderandinterpretdiagnosistestsand
prescribemedications.CertifiednursemidwivesareRNswhohavegraduatedfromanurse
midwiferyprogramaccreditedbytheAmericanCollegeofNurseMidwives(ACNM)andare
certifiedasanursemidwifebytheACNMsomemayhavetakenamaster'sprogramofferedbya
schoolofnursingoraschoolofpublichealth.Theyprovideprenatalandgynecologicalcare,
deliverbabiesinavarietyofsettings(hospitals,birthingcenters,orhomes),andrenderpostpartum
care.Finally,certifiedRNanesthetistshaveabachelorofscienceinnursingand2to3yearsof
additionaleducationandtraininginanesthesiology,oftenatthemaster'slevel.They,too,havea
rigorouscertificationprocess,managedthroughprogramsapprovedbytheAmericanAssociation
ofNurseAnesthetists.Particularlyinruralareas,thesenursespecialistsmayadministerthemajority
ofanesthesiaoranestheticsinhealthcaresettingstoday.

Clearly,welltrainedadvancedpracticenursescanfunctioninanumberofdifferentroles.They
canworkindependentlytosolvepatientcareproblems,serveaspatientadvocates,andbeintegral
membersofahealthcareteam.Advancedpracticenursescanimprovethecosteffectivenessof
healthcaresystemsandfacilitiesbecausechangingthemixofpersonnelinvolvedincaringfor
patientswithcomplexmanagementproblemsmayyieldbetteroutcomes,lowercosts,orboth.The
committeeconcludesthatthewayshouldbeclearerforsuchpersonneltobeusedinbothinpatient

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andoutpatientsettingsandforthemtobeabletotakeupleadershippositionsandact
independently.

Oneobstacle,however,toaccomplishingthechangesadvocatedinthissectionliesinthediffering
waysinwhichstatesrecognizeadvancedpracticenurses,chieflyintermsofthebreadthof
independentauthority(e.g.,diagnosing,prescribing,anddispensingofmedicaltherapeuticagents
orcontrolledsubstances)(Pearson,1995RayandHardin,1995).Somestateboardsofnursing
havenotyetrecognizedtheexpandedresponsibilitiesthatsuchpersonnelcanandshould
discharge.Toaddressthisproblem,thecommitteebelievesthatallstatesshouldrecognizenurses
inadvancedpracticeintheirnursepracticeactsanddelineatethequalificationsandscopeof
practiceofthesenurses.

AncillaryNursingPersonnel
Today,almostallhospitalsintheUnitedStatesusesomekindofancillarynursingpersonnel.As
statedinChapter4,thisgroupofpersonnelincludesnursesaidesorassistants(NA),someof
whommaybecertified,aswellasavarietyofotherancillarypersonnel.Bydefinition,theyhave
lessformaleducationandtrainingthanRNsorLPNsonaverage,whenhiredtheymayalsohave
lessexposureto,andtimeorexperiencein,theinpatientsetting.Theireducation,however,does
notstopafterthebasictraining.Manyserveforseveralyearsandlearnfromphysicians,RNs,and
LPNstoperformtasksthatoncewerenotdonebyNAsandtoberesponsibleforspecificaspects
ofclinicalcare.2

Asalreadynoted,farlessinformationaboutemploymenttrendsisavailableonthisgroupofthe
nursingworkforcethanonthemoretraditionalnursingcategories.However,thetransformationof
thehospitalcaredeliverysystemisclearlygoingtoinvolvethesetypesofpersonnelatleastinthe
nearfuture.TheuseofNAsandotherancillarynursingpersonneltoassistRNswithpatientcareis
reportedtohaveincreasedinrecentyears.Inmostinstances,NAsandotherancillarynursing
personnelareusedinsimplebedsidecareorasunitassistants(e.g.,changingdressings,takingvital
signssuchasbloodpressureandtemperature)insomeinstances,theyarebeingusedtoassistRNs
intotalbedsidecareorinotherdutiessuchastelemonitoring,liftingteams,electrocardiography,or
physicaltherapy(Barteretal.,1994).Inothercases,tasksperformedbythesetypesofpersonnel
mayoverlapwiththoseofothersupportunits,suchasdietary,housekeeping,ortransportation
services.

KrapohlandLarson(1995)describetheevolutionofnursingdeliverysystemsinhospitals,from
teamnursing(withallthevariationssuchasclinical,nonclinical,andintegratednursingmodels)to
primarynursingmodels.Thevarious"patientfocused"teammodelsthatsomehospitalsare
implementingincorporatelessskillednursingpersonneltovaryingextentthemodelsthemselves
varyaccordingtothespecificneedsofdifferenthospitals(orhospitalsystems).Theauthorsalso
reviewedtheliteratureregardingtheuseandevaluationofancillarynursingpersonnelinhospitals
andfoundnostrongevidencetoconfirmthatthesenursingpersonnelimprove(orreduce)quality
orincrease(ordecrease)nurseorpatientsatisfaction.Areviewofstudiesofprimarynursingalso
donotconclusivelyshowthesuperiorityofprimarynursingmodelsovervariousteamnursing
models.Theyconclude,basically,thatalthoughnursingcarehasbeenprovidedinhospitalssince
thehospital'sbeginning,nosingledeliverysystemhasemergedasideal.Theauthorsalsonotethe
methodologicalanddesignweaknessesofthestudiesreviewed.

Nevertheless,someinformalinformationaboutthesenewteamapproachesisencouraging.The
committeelearned,forinstance,aboutvariationsofthe"partnersinpractice"programpioneeredin
the1980s,whichlinkedNAsandotherancillarynursingpersonnelwithanRN(Manthey,1988,
1992).AtthesitevisitinOregon,committeemembersandstaffwereabletoobserveandinteract

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withcareteamsinwhichRNsassumedaverycloseworkingrelationshipwiththeothercare
partners.Nursingpersonnelatalllevelsworkedtogetheratalltimesthus,RNswereabletoassess
theknowledgeandclinicalcapabilitiesofeachmemberoftheteamand,wherenecessary,stepin
tosupervise,andthenteach,thelesswellpreparednursingpersonnel.Otherhospitalshave
implementedsimilarsystems,accordingtoinformationmadeavailabletothecommittee.

Theunderlyingmessageoftheliteraturereviewandtheobservationalinformationgatheredbythe
committeeisthat,inthehospitalsector,issuesoftrainingandcompetencyofnonRNstaffremain
critical.Nonationalstandardsexistforminimumtrainingorcertificationofancillarynursing
personnelemployedbyhospitals(unlike,asdiscussedinChapter6,forNAsinthenursinghome
sector)thus,theyvarywidelyineducationalattainmentsandintheirtrainingforsimplenursingor
quasinursingtasks.Furthermore,noacceptedmechanismexistseithertomeasurecompetencyor
tocertifyinsomefashionthatancillarynursingpersonnelhaveattainedatleastabasicor
rudimentarymasteryofneededskills.Hospitalsvarywidelyinthelevelsoftrainingtheyprovideto
thesepersonnel.Barterandcolleagues(1994)foundthat99percentofthehospitalsinCalifornia
reportedlessthan120hoursofonthejobtrainingfornewlyhiredancillarynursingpersonnel.
Only20percentofthehospitalsrequiredahighschooldiploma.Themajorityofhospitals(59
percent)providedlessthan20hoursofclassroominstructionand88percentprovided40hoursor
lessofinstructiontime.RNsandtheirsupportingorganizationshaveexpressedmuchconcernthat
NAsandotherancillarynursingpersonnelarebeinggivenvariousnursingrelatedtasksin
hospitalsintheabsenceofcompetencyrequirements.Thecommitteeisgreatlyconcernedabout
thislackandthepotentialforadverseimpactonpatientcare.

RECOMMENDATION52:Thecommitteerecommendsthathospitalshavedocumented
evidencethatancillarynursingpersonnelarecompetentandthatsuchpersonnelaretested
andcertifiedbyanappropriateentityforthiscompetence.Thecommitteefurther
recommendsthatthetrainingforancillarynursingpersonnelworkinginhospitalsbe
structuredandenrichedbyincludingtrainingofthefollowingtypes:appropriateclinical
careoftheagedanddisabledoccupationalhealthandsafetymeasuresculturallysensitive
careandappropriatemanagementofconflict.

Thecommitteebelievesthathospitalsshouldtaketheleadinensuringthecompetenceof,and
provisionofappropriatetrainingto,alldirectcarepersonnelemployedbythem,includingancillary
nursingpersonnel.Thecommitteedoesnotbelievethatthefirstcourseofactionshouldbe
enforcementbylaworregulationatthefederal,state,ormunicipallevel.Itdoescautionhowever,
thatifrealqualityofcareproblemsweretoemergeinhospitalsthatcouldberelatedtonegligence
byhospitalsinensuringcompetence,thenthepublicmightbeexpectedtoclamorfortheenactment
andenforcementofmorestringent,external,regulation.Suchruleswouldthenprotectthepublic
fromproblemsthathospitalsthemselvesshouldhaveguardedagainst.

HospitalsareinabetterpositionthannursinghomestoassurethecompetenceofNAsbecause
NAsarenotthepredominantcaregiversinhospitalsthattheyareinnursinghomes.HospitalNAs
aremorelikelytoworkinteamswithothercaregiversandtohavemoredirectsupervisionfrom
theRN,whoismoreimmediatelyavailablethanisusuallythecaseinnursinghomes.

Finally,culturallysensitivecarewillbecomeincreasinglyimportantintheyearsahead.Asnotedin
Chapter2,thepopulation,andthereforethepatientpopulation,isnotonlyagingbutalsois
becomingmoreraciallyandethnicallydiverse.Thus,increasingly,caregiversandcarereceivers
maycomefromdifferentculturalbackgrounds.Theimperativeforculturalsensitivityisobvious.

InvolvingPersonnelinPlanningforChange

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Thechangesbrieflydescribedaboveareappealingconceptually,andtimewilltelliftheyare
effectiveandpracticalasthehospitalsectorreinventsitself.Intheshortterm,however,theseshifts
inthewayhospitalsdobusiness,andthewaytheyorganizetoconducttheirbusiness,arecausing
notabledisruptionsandmisgivingsamongthenursingstaff.Fromthefrequencyandintensityof
thecommentariesthatthecommitteeheardduringthisstudy,RNsareconcernedaboutboththe
employmentramificationsandmoreimportantlytheprofessionalimplicationsoftheorganizational
changesthatareoccurringtheybelievethatthesechangesmayleadtoundesirableand
unanticipatedeffectsonqualityofcare.

Inresponsetopressurestocontaincostsandimprovequalityofcare,whichmayormaynotbe
relatedtothedownwardtrendininpatienthospitaluse,hospitalsarerestructuringservices,units,
andactivities.Theseeffortsaregenerallyorientedtowardincreasingproductivityorefficiency
and/orreducingoperatingcosts.Asstatedabove,redesigneffortsofteninvolvetheintegrationand
coordinationofworkacrossdepartmentallines,whichmayalsoleadtoeliminationofpositions,
layoffs,redefinitionofpositions,andrealignmentofsupervisorylines.

Restructuringofinpatientservicesinhospitals,accompaniedbyachangingmixofnursing
personnel,isaninevitableconsequenceofthedemandsbysociety,throughthepayersofcare,to
controlthecostsofhealthservices.Downsizingofthepatientcareworkforceininpatienthospital
settingswillcontinue,atleastinthenearfuture.Nursingpersonnelwillnotbeimmunefromsuch
downsizing."Reengineering"ofpatientcareprocesses,includingchangesinskillmix,willalso
continue,atleastfortheshortterm.

Overall,thesenseofdisquietaboutthefuture,especiallyamongRNs,waspalpable,inpart
becauseoftheunpredictabilityoftheeffectsofthesechangesandinpartbecauseoftheseeming
lackofinputandcontrolthatmanynursesfeltaboutthechangesbeingmade.Thecommitteeheard
fromnurseswhohadlosttheirpositionsinhospitalsaboutmanagementdecisionsfordownsizing
thathadbeenmadewithoutanystaffinvolvementaphenomenonthataddstothefeelingsof
threatanduncertaintyformanyhospitalbasedRNs.Atthesametime,thecommitteehadthe
benefitoflearningaboutotherhospitalswheremanagementinvolvedstaffinsubstantialwaysin
reachingsolutionsabouthowthenecessarystaffrestructuringoughttotakeplace.Atoneofits
publichearings,forinstance,thecommitteeheardfromwitnessesaboutthebeneficialresultsof
usingfreefederalmediatingservices.Onsitevisits,committeemembersvisitedsomehospitals
wherechangehadbeensuccessfullyimplementedthroughwellconceivedplanningand
implementationprocessesthatinvolvedbothnursingadministratorsandstaffnurses.

Inthecommittee'sview,theharmfulanddemoralizingeffectsofthesechangesonthenursingstaff
canbemitigated,ifnotforestalledaltogether,withmorerecognitiononthepartofthehospital
industrythatinvolvementofnursingpersonnelfromtheoutsetintheredesigneffortsiscritical.

RECOMMENDATION53:Thecommitteerecommendsthathospitalleadersinvolve
nursingpersonnel(RNs,LPNs,andNAs)whoaredirectlyaffectedbyorganizational
redesignandstaffingreconfigurationintheprocessofplanningandimplementingsuch
changes.

Thecommitteefoundimpressivethetestimoniesanddescriptionsofthesecollaborative"redesign"
effortsthatinvolvedalllevelsofnursingpersonnelintherestructuringprocessasillustratedabove.
Therationaleforinclusionofnursingpersonnelinhospitalrestructuringeffortsrelatestoseveral
factors:suchinvolvementbringstothetabletheprofessionalknowledgeandexperienceneededin
developingsuchchanges,staffcommitmenttothedecisionsmade,andmayaffectthelikelihoodof
successandofimprovementinthequalityofcare.Itisnotsimplytomaketheaffectednursing
stafffeelbetter.Changeislikelytofailifatopdownapproachisimposedonhospitalnursingstaff.

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Furthermore,thehealthcaresectorismovingrapidlytoadoptprinciplesofcontinuousquality
improvementandtotalqualitymanagementasmeansforaddressingissuesinqualityofcare,for
advancingthestateoftheartofqualitymeasurementandmanagement,andforpromoting
continuousprogressinhealthcareprocessesandpatientoutcomes.Thesenewerqualityassurance
andimprovementtechniquesrelyheavilyoninputfrommultiplesegmentsofahealth
organization'spersonnelanddepartmentsthatis,theydonotdealwithqualityissuesthatrelateto
onlyasingledepartment,inpartbecausemostproblemsinhealthinstitutionsandfacilitiesare
systemicratherthantraceabletosingleevents,people,orunits.Logicalonewoulddictate,
therefore,thatasanorganizationwishestoreinventitsstructureandsystems,itoughttoadopt
thesesameprinciplesofinvolvingindividualsfromacrossthedepartmentalandpersonnel
spectrum.

TrackingtheEffectsofChange
Althoughavailablenationalstatisticsonhospitalemploymentdonotshowreductionsinlevelsof
nursingstaffatthenationallevel,themediafrequentlyreportonstafflayoffsinhospitals.
Anecdotalinformationabounds,andadhocinquiriesareconductedbyunions,nurseassociations,
magazines(oftheirmembershipandsubscribers),andotherorganizations.Unfortunately,thevery
lowresponseratesofmanyoftheseinquiriesandthedeficienciesinthedesignofsurveysandof
questionsdonotpermitconsumersorpolicymakerstoderiveobjectivemeasuresofthelinks
betweenstaffingpatternsandprocessesandoutcomesofcare,andtodrawvalidconclusions.

Asaconsequenceofdecliningtrendsininpatienthospitaluse,somehospitalshavebeenreducing
thenumberofoperatingbedsandreducingnursingpositionsbyattritionorlayoffs.Otherhospitals
areclosing,andsomeareconvertingbedstolongtermcareandotherservices.SomeRNs,LPNs,
andNAshavebeenlaidofforredeployedfromacutecareunitstootherservices,programs,or
settings.Thesetypesofdownsizingandconsequentrestructuringeffortsnecessarilyaffect
employmentofnursingpersonnelandwillcontinueaslongashospitalsfacelowusepatterns.This
turbulenceinthehealthcaredeliverysystemandtheresultantunstablesituationfueltheconcern
thatlargedecreasesinRNstaffinginhospitalsarebothoccurringandleadingtodecrementsin
patientcareandtothreatstothehealthandwellbeingofnursingpersonnel.

Asstatedearlier,throughouttheperiodofthecommittee'sstudychangeswereoccurringin
hospitalsintheuseofRNsandintheratioofRNstoothernursingpersonnelintheorganizationof
thedeliveryofpatientcare.Manyofthemintimatedthatsuchchangespotentiallywilldiminishthe
qualityofcareprovidedbutthecommitteewasunabletofindevidenceofadeclineinthequality
ofhospitalcarebecauseofanychangesinstaffing.Lackingreliablemeasuresanddata,nooneis
inapositiontodrawvalidconclusions.Theamountoftestimonyprovided,however,andthedepth
ofconcerncited,wassufficienttoleadthecommitteetobelievethatthisisanareathatrequireson
goingmonitoringandresearchinordertoensurethattheresponsibilityforprovidingsafe,
effective,quality,andcosteffectivecareisfulfilledwithinthehealthcaresystem.

Thecommitteefindsthatlackofreliableandvaliddataonthemagnitudeanddistributionof
temporaryorpermanentunemployment,reassignmentsofexistingnursingstaff,andsimilar
changesinthestructureofnursingemploymentopportunitiesgreatlyhamperseffortsat
understandingtheproblemandplanningforthefuture.Answersareneededtonumerous
questions,suchas:Whathappenstonursingstaffaftertheyarelaidoff?Aretheyemployedin
anotherhospitalorreemployedatthesamehospital?Dotheymovetooutpatient,community,or
longtermcaresettings?Dotheyreturntoschoolforretrainingorformoreadvancednurse
training?Dotheyleavenursingaltogetherforanotheroccupation?

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InformationonRNemploymentpatternsisnecessary.Researchisneededonwhethercareerpaths
ofRNswillchangemarkedlyoverthenext5to10years.Thesechangescanhaveimplicationsfor
careerchoices,curriculumdesign,structureofoccupationalladders,andperhaps,qualityofcare.
Amongthemanyquestionsthatwarrantattentionaretheimplicationsofrestructuringforcareer
choices,thestructureofoccupationalladders,andbothentryandmidcareercurriculumdesign.

RECOMMENDATION54:Thecommitteerecommendsthathospitalmanagement
monitorandevaluatetheeffectsofchangesinorganizationalredesignandreconfiguration
ofnursingpersonnelonpatientoutcomes,onpatientsatisfaction,andonnursingpersonnel
themselves.

MoredetaileddataalsoareneededontheemploymentpatternsofNAsandLPNsovertime.
ThroughoutitsdeliberationsthecommitteefocusedlargelyonRNsnotonlybecausetheyformthe
largestproportionofnursingpersonnelinthiscountryandbecausetheirprofessionalassociations
arethemostwellorganized,butalsobecauseofthepaucityofcomparablydetaileddataonNAs
andLPNs.Forthatreason,hospitalsshouldnotconcentratetheirmonitoringandevaluationsolely
ontherelationshipsbetweenRNstaffingandqualityofcareoronworkrelatedillnessandinjury.
Rather,hospitalsshouldfocustheirmonitoringandevaluationeffortsoftherestructuringand
redesignofstaffingontheentirespectrumoftheirnursingpersonnel.

Thefederalagenciesconcernedwithhealthworkforcedataandresearchhaveamajorroletoplay.
Thus,inthisregardthecommitteesupportsthemissionsofagenciessuchastheDivisionof
NursingoftheBureauofHealthProfessions(intheHealthResourcesandServices
Administration),theNationalInstituteofNursingResearch(intheNationalInstitutesofHealth),
andtheNationalCenterforHealthStatistics(intheCentersforDiseaseControlandPrevention)all
intheDepartmentofHealthandHumanServices.Theneedfortimelyandrelevantdatathatis
amenabletointegrationacrosssystemsisurgent.Inthecommittee'sview,theseagenciesshould
workproductivelytogetherandincollaborationwithprivateorganizationstodevelopdatabases
containinginformationthatwillshedlightonworkforceissuesandontherelationshipsofstaffing
ofnursingpersonnelandcareprocessesandpatientoutcomes.

MeasuringQualityOfCareInHospitals
ThelegislativemandatetothisInstituteofMedicine(IOM)committeeasksittoexaminestructural
issuesthenumberofnursesandthemixoftypesofnursesbutitalsoasksthecommitteeto
focusonoutcomeissuesintermsofnursesthemselvesaswellasthequalityofpatientcarethat
couldinvolveeitherprocesses,orpatientoutcomes,orboth.

Thecommitteelookedatqualitybroadlybeyondnursinginputsintermsoftheoverallqualityof
carereceivedbythepatientinthehospital,andexaminedtherelationshipbetweenstructural
variablesandbothprocessesandoutcomesofcare.Inthiseffort,itwasguidedbytheIOM's
definitionofqualityofcare:''thedegreetowhichhealthservicesforindividualsandpopulations
increasethelikelihoodofdesiredhealthoutcomesandareconsistentwithcurrentprofessional
knowledge"(IOM,1990,vol.I,p.21).

TheIOMdefinitiondoesnotcontendthatqualitycanorshouldbedefinedintermsofavailable
resources.ExcludingresourceconstraintsinthedefinitionprovidestheopportunityforQuality
assurance(QA)andQualityImprovement(QI)systemstodistinguishqualityofcareproblems
fromproblemsarisingfromresourceavailability.QualitymeasurementmethodsandQA/QI
approachesshouldbeableto(1)identifyhowandtowhatdegreeresourceconstraintsaffect
structure,process,andoutcomeelementsofhealthcare(2)identifytheagent(s)thatare
responsiblefortheconstraintsandhavetheauthoritytoaddresstheproblemstheymaybecausing
and(3)perhapsconductcorrectiveactionsandmonitorprogressinimprovingcare.
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Howonemeasuresorimprovesthequalityofhealthcareislinkedcloselytotheassumptionsmade
aboutwhatconstitutesqualityofcareinthefirstplace.Thismultidimensionaldefinitionofquality
ofcareiscompatiblewiththeperspectivethatpatients,consumers,providers,payers,andpublic
entitiesallhaveinterestsinthequalityofcarerenderedbyhealthcareinstitutionsandpersonnel.
Havinganunderstandingoftheimportantdimensionsofqualityofcareisakeyinitialsteptoward
developingmeasurementandinterventionapproachesandimplementingQA/QIstrategies.
Standardsandindicatorsofperformancemustbecloselylinkedtotheoperationalconceptsusedin
definingquality.Careisthenassessedormeasuredagainstcriteriaorbenchmarkstodetermine
whetherstandardsaremetandwherelieopportunitiesforimprovement,regardlessofwhether
specificstandardshavebeenmetorexceeded.

ElementsofQualityofCare
Themostfundamentalconceptualframeworkintheareaofqualityofcarewasarticulatedthree
decadesagobyAvedisDonabedian(1966)hisformulationisbasedonatriadofstructuralfactors,
processofcarevariables,andoutcomesorendresultsofthatcare.Theseelementsarebriefly
discussedbelowtoprovidesomecontextfordiscussionsinthisandthenextchapter.

StructuralVariables

Structuralcriteriaare,ineffect,proxymeasuresofqualityofcareforanentireorganizationsuch
asahealthplan,hospital,ornursinghome,orforanindividualhealthcarecliniciansuchasanurse
orphysician.Structuralcriteriamayinvolvevariablessuchasthenumbersofvariouskindsofstaff
(suchasRNsorLPNsorNAs),stafftopatientorstafftobedratios,thetrainingandsupervision
expectedoforgiventostaff,thepatientrecordsystem,theproceduresforinfectioncontrol,
buildingcoderequirements,andthequalityofthephysicalplantandequipment.Theseelements
mayallreasonablybethoughttoaffecttheprocessesofcareand,hence,thesubsequenthealthand
functionaloutcomesofpatientsinhospitalsorresidentsinnursinghomes.

Structuralmeasuresfocusonthepresumedcapacityofpeopleandentitiestodeliveradequateor
highqualitycare,buttheydonotmeasurethecareitself.Accordingly,deficienciesinstructural
measurescannotbeconfidentlyusedasdirectevidenceeitherofpoorcareorpooroutcomes,but
failingsinthisarea,whetherperceivedorreal,certainlycanbeconsideredindicativeofproblems
untilprovenotherwise.

Theprincipalproblemwithstructuralvariablesisthatlittleempiricalevidencehasbeengenerated
linkingstructuralvariablesdirectlywithgood(orbad)processesor(especially)outcomesofcare.
Thus,thequestionofwhetherproblemswiththelevelsofnursestaffingorthemixof
competencieswithinanursingstaffmaybeassociatedwithpoorcareandriskofpatientharmsisa
reasonableone,buttheprobablelackofexplicitinformationonanyassociationbetweensuch
structuralvariablesandthelargerissuesofinterestmustbeclearlyunderstoodfromtheoutset.

ProcessofCare

Theprocessofcareencompasseswhatisdoneto,with,andforthepatientorhealthcareconsumer.
Processcriteriapertaintotheappropriateandcorrectperformanceofspecific"technical"
proceduresandservicestheyalsoinvolveinterpersonalskillsandattitudes,suchasthoseof
compassionatecommunication.Processindicatorsareverybroad,andovertheyearstheyhave
constitutedthemostwidelyusedsetofmeasuresofqualityofcare.Theycanincludesuch
elementsofgoodqualitycareaspromotingtheparticipationofthepatientorresidentinthe
selectionofcaremanagementstrategiesandhonoringprivacyofinformationandpersonalspace.

OutcomesofCare
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Outcomemeasuresaretypicallyconsideredtobetheendresultsofhealthcareintermsofbiologic,
psychologic,andfunctioningvariables.Theymayincludevarioushealthindicatorssuchasdeath
rates,ratesofillness,orratesofspecificcomplicationsofillness,aswellasphysiologicmeasures
suchasbloodpressure,serumglucose,orcholesterollevelsthatis,thekindsofclinicalmeasures
thatappeartomattermoretophysiciansandotherclinicians.Morebroadly,however,health
outcomesencompassfunctionalabilities(bothphysicalandcognitive),painordiscomfort,energy
andvitality,andmentalandemotionalwellbeinginshort,aspectsofhealthstatusthatmatter
mosttopatientsandtheirfamilies.Thiscommitteeembracesthebroadviewofoutcomemeasures
takenbypriorIOMcommittees(IOM,1990),thatis,healthrelatedqualityoflifevariables
regardingphysical,social,andemotionalheath,cognitiveandphysiologicfunctioning,andoverall
wellbeing.

Table5.1showsanillustrativelistofmeasurespertinenttonursingqualityintheinpatienthospital
setting.Althoughtheitemsinthetableareselectiveandillustrativeonlyofmajorareasofinterest,
thecommitteeiscognizantofthefactthatdatawouldnotbeeasytoacquireformanyofthese
measures.

TABLE5.1

IllustrativeMeasuresofQualityofCareinInpatientHospital
Settings,withSpecificAttentiontoNursingCare.

MeasurementofQuality
Inthecurrenthealthcareenvironment,theattentionto,andimportanceplacedon,qualityofcare
areincreasingatanotablerate.Thisispredicatedonseveralfactors:thebeliefthatinstitutionsand
plansinacompetitionormarketorientedhealthcaresectorwillhavetocompeteonmorethan
pricethevastlygreaterabilitythanbeforeofthoseinthehealthsectortomeasurebothprocesses
andpatientoutcomesreliablyandthemarkedlyimprovedunderstandingofhowtoimplement
effectiveprogramsforimprovingquality.Moreeffortisalsobeingdirectedatunderstandingthe
effectivenessofservicesandoutcomesforbothindividualsandpopulations.

Recentyearshaveseenimportantadvancesinmeasuringqualityofpatientcareattheindividual
patientandpopulationlevels,3involvingbothprocessandoutcomemeasures.Fromthevantage
pointofthisstudy,however,existingworkhasnottypicallyfocusedonisolatingthecontribution
ofnursingcareinmeasuringthequalityofpatientcareinhospitals.Hegyvary(1991),forinstance,
notesthattheliteratureaboutproductivityinnursingservicesdoesnotaddressresultsinpatient
careandalmostwithoutexceptiondoesnotraisethequestionofqualityofcare.

Afairlywidearrayofqualityindicatorshasbeendevelopedincludingmortality,unanticipated
hospitalreadmission,hospitalacquiredcomplications,andnosocomialinfections.Hospitalspecific
mortalityrateshavereceivedparticularattentioninthepastfewyears,beginningwiththereleaseof
suchinformationbytheHealthCareFinancingAdministration(HCFA)inthelate1980sand
subsequenteffortsbyvariousstatestodothesame(atleastforselectedtypesofadmissionsor
operatingproceduressuchascoronaryarterybypassgraftsurgery).Manyoftheseeffortshave
beencarriedoutusinglargeadministrativedatabases.Ingeneral,majorquestionsremainaboutthe
reliability,validity,andgeneralizabilityoftheinformationfromthesetypesofmortalityratestudies.

Forexample,Thomasandcolleagues(1993)reviewedtheseminalworkonriskadjustedmortality
ratesandconducteddetailedvaliditystudiesforthreeconditions(cardiacdisease,acutemyocardial
infarction[AIM],andsepticemia)todeterminewhetherdeathratesappeartorelatetoqualityof
careasevaluatedbyanexperiencedphysicianpeerreviewer.Theyreportthatof9,721cases
involvinganginaandcardiacsurgery,1,103(11percent)wereconsideredpoorqualitythefigures
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forAMIwere776of6,004cases(13percent),andforsepticemia,285of1,709cases(17percent)
(Thomasetal.,1993,Tables3,4,and5).Withrespecttothequestionofusingriskadjusted
mortalityratesderivedfromlargeadministrativedatabases,however,theinvestigatorsconcluded
thatthisstrategymaybeinappropriateunlessthequalityoutcomerelationshipisexplicitly
validated.

Especiallycomplexarequestionsof(a)whetherinformationonhospitalperformanceasmeasured
bydeathratesorcomplicationrateswillbecorrelatedfordifferentclinicalservicesand(b)whether
deathratesarecorrelatedwithcomplicationrates.Recentwork(e.g.,Iezzonietal.,1994Silberet
al.,1995)suggests,inparticular,thatcomplicationrateswillnotberelatedsignificantlytomortality
rates.Thoseproblemsnotwithstanding,itshouldbeclearthatforthepurposesofthisstudy,such
informationtellslittle,ifanything,aboutthepreciseroleofnursestaffinglevelsormixin
promotinghigherqualitypatientcare.Infact,onestudypresentsdatathatlinkmortalitywith
lengthofstay(andwithotherresourceusevariables)butthatdonotdemonstrateanyrelationship
betweenmortalityandstaffing,suchaspersonnelmeasuredinFTEs,totalstaffperadmission,or
RNtoLPNratio(Bradburyetal.,1994).

Inaddition,formanyyears,"genericscreens"havebeencorequalitymeasuresforhospital
inpatientcare.4Usuallybasedonactualreviewofpatientrecordsordischargeabstracts,these
involveditemssuchasadequacyofdischargeplanning,medicalstabilityofthepatientat
discharge,unscheduledreturntosurgery,ortraumasufferedinhospitalinadditiontothebroader
measuresnoted.Dependingonthelevelofdetailinsuchqualityscreens,moreinformationonthe
roleofnursingstaffinproducinghigh(orlow)qualityofcarecouldbeobtainedoratleast
inferred.However,thistypeofdatacollectioncanbeverytimeconsumingandcostlyforthe
amountofusefulinformationgainedthatmightpointtoqualityofcareproblemsthefederalPeer
ReviewOrganization(PRO)programforMedicare,atleast,hasinrecentyearsturnedawayfrom
useofrecordreviewforgenericscreensasabasictacticforqualityassessment.

Theuseofcomputerizedalgorithmstoscreenforpossiblequalityproblems,byapplyingthemto
hospitaldischargeabstractdata(e.g.,largescalehospitaldatabases),hasbeenamorerecent
development.Somemethodologicalresearch(Iezzonietal.,1992)suggeststhatcomputerized
indicatorsshowsomepromiseintermsofidentifyinghospitalsthatwarrantmoreintensivereview
forqualityofcarereasons(e.g.,untowardcomplicationsofcare),becausetheydoareasonably
goodjobofidentifyingqualityproblems,althoughtheymayalsoincorrectlypointtoproblemsina
ratherlargenumberofcases.5Thus,moreworkisrequiredtodemonstratethereliabilityand
validityofcomputerizedscreensfortargetinghospitalsformoreindepthqualityreview.Moreover,
aswiththeearliergenericscreenapproach,thesetypesofmeasurestelllittleaboutnursingcareper
se.

StatusofHospitalQualityofCare
Qualityofpatientcareiscentraltothedeliveryofhealthcareservicesinhospitals.Amajorfactor
precipitatingthisstudywerereports,emanatingchieflyfromnursinggroups,thatthequalityof
hospitalcareisdeclining,broughtaboutbyrestructuringandreengineering,andconsequent
reductionsintheproportionofnursingpersonneltrainedasRNs.Duringthestudy,thecommittee
heardconsiderableconcernexpressedbyRNsthathospitalsarerestructuringandreengineeringin
increasingnumbersthatareresultinginsmallerproportionsofRNstototalnursingpersonnel,and
abouttheprobablenegativeimpactonqualityofpatientcareinthosehospitals.Unfortunately,very
littlerecentobjective,nationaldataareavailablethatdescribethestatusofqualityofcarein
hospitalsandassessifithasbeenaffectedinanywaybychangesinthesystemofdeliveryofcare.
ThereisvirtuallynoresearchontheeffectsofratiosofRNsperbedonpatientoutcomes.Unlike
staffingbasedonpatientacuity,acrosstheboardstaffingratiosassumethatallpatientscanbe
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caredforwiththesamelevelandtypeofresources.Thedifficultyinestablishingstaffingratios
appropriateforallsettingsandsituationsacrossthecountryisobvious.Giventhevariationthat
existsinpatientacuityandthetotalpatientcareenvironment,thecommitteebelievesthatitis
neitherpracticalnordesirabletoestablishspecificratiosofnursingpersonnelenforceableby
regulationorlaw.Thecommitteeisnotdiscountingwhatitheardatthepublictestimonyandsite
visitsthatunequivocallyexpressedconcernsabouttrendsinquality,bothpresentandfuture.
However,basedonstudiesconductedinthe1980s,thereareindirectindicatorsthatingeneral
qualityofhospitalcarehasnotdeclined.

SimilarconcernswereexpressedatthetimetheMedicareProspectivePaymentSystem(PPS)was
implementedintheearly1980s.Manyobserverspredictedmajorqualityproblemsinthehospital
sector.Themainreasonwassimplythatthediagnosisrelatedgroups(DRG)basedPPSsystem
turnedfinancialincentivesforhospitalscompletelyaround(comparedtotheincentivesunder
traditionalcostreimbursementschemes),leadingmanytobelievethathospitalswouldbeforcedto
scrimponpatientservices.AnindepthbeforeandafterevaluationoftheeffectsofDRGbased
PPSwasconductedbyateamofinvestigatorsfromtheRANDCorporation(Draperetal.,1990
Kahnetal.,1990a,b,cKeeleretal.,1990,1992Kosecoffetal.,1990Rogersetal.,1990
Rubensteinetal.,1990).Theresearchersfoundthatingeneralqualityofhospitalcaredidnot
sufferasaresultofPPSimplementation,andindeedmayhaveevenimprovedinsomeareas.6The
researchersfoundthatwheretheprocessofcareandthedocumentationwereimproved,the
outcomeswereimproved.Thestudyrevealedconsistentresultsbetweenoutcomeasmeasuredby
mortalityandtheprocessofcarevariables(Keeleretal.,1992).Severityadjustedmortality
decreasedafterPPS.

TheRANDresearchersalsofoundwidevariationsinqualityamonghospitals.Differences
betweentypesofhospitalswerelarge,withthelowestgroupestimatedtohavefourpercentage
pointshighermortalitythanmajorteachinghospitalsinacohortofpatientswithanaverage
mortalityrateof16percent(Keeleretal.,1990).

Moreover,althoughqualityofcaredidnotsufferafterPPS,theRANDstudyconfirmedthatmore
patientsweredischargedtoosoonandinunstablecondition.Thosewhoweredischargedin
unstableconditionshadsignificantlyhighermortalityrates.Kosecoffandcolleagues(1990)
analyzedthedataonthelevelofpatient'smedicalinstabilityatthetimeofhospitaldischarge.
Usingdataaboutfivemedicalconditionscongestiveheartfailure,acutemyocardialinfarction,
pneumonia,cerebrovascularaccident,andhipfracturetheauthorsestablishedthefollowing
measuresofmedicalinstability:fever,newincontinence,newchestpain,newshortnessofbreath,
newconfusion,newelevatedheartrate,newelevatedrespiratoryrate,highdiastolicblood
pressure,newlyloweredsystolicbloodpressure,newlyloweredheartrate,andnewpremature
ventricularcontractions.Theyfoundthat17percentofthepatientsinthestudyweredischarged
withatleastonedisability39percentweredischargedwithatleastonemeasureofsickness24
percenthadanabnormallastlaboratoryvalue.Theriskofdeathat90daysfollowingdischarge
was16percentforpatientsdischargedunstableand10percentforpatientsdischargedinstable
conditions.InstabilityatdischargehadincreasedsincetheintroductionofPPS.PrePPS,15
percentofdischargedpatientswereunstable,ascomparedwith18percentpostPPS,a22percent
increase.Mostoftheincreaseininstabilitywasconcentratedinthosepatientswhoweredischarged
totheirhomesafterPPS,43percentofthemweremorelikelytobeunstablethanpriortoPPS.
Theycommentthatgivencontinuedreductionsinhospitalcompensationrates,theproblemof
instabilityatdischargewarrantsadditionalresearchtoanswerquestionssuchas,"Areincreasesin
instabilitycausedbyinappropriatelyearlydischarges,toomanytestsinashortenedhospitalstay,
incorrectuseofnewmedications,orbychangesinnursingpractices(e.g.,fewernursesperpatient
andlesstimetotalkwiththepatientormonitorincontinenceordisorientation)?"(p.1982).The

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studyalsorevealedthatonequarterofnursinghomepatientswereadmittedfromthehospitalwith
aninstability.Answerstothesequestionsrequirenewdata.

Someoftheissuesraisedbytheauthorsmayberesponsivetonursingcare.Althoughthequalityof
nursingcarewasmeasured,detailsaboutperformanceofRNshavenotbeenprovidedinthe
reportspublishedtodate.7Inferentially,however,thelevelsofqualityofnursingcaremusthave
beenwellwithinacceptablelimits,giventheoverallfindingsofacceptablequalityofcareandthe
factthatdecisionstodischargepatients(unliketheplanningfordischargeandforcare
postdischarge)arenotmadebynurses.

Thislandmarkresearchillustratesthevalueofawellexecutedandcomprehensivestudyofthe
effectsofaninterventiononthequalityofhospitalcare.Unfortunately,suchstudiesarevery
expensiveandcanbesomewhatdatedbythetimethedataarecollectedandanalyzed,andthe
resultsarepublished.DatafromtheRANDstudiesarebasedontheexperienceinthelate1980s.
Similarstudieshavenotbeenundertakensincehence,nocomparablerecentdataareavailableto
examineifqualityofhospitalcareisimproving,deteriorating,orremainingunchanged.

Similarly,withsomeexceptions,studiessuggestthatqualityofcarehasremainedthesameor
possiblyimprovedundermanagedcare(seeChapter3).Itshouldbeacknowledgedthatthestudies
reviewedwereconductedinthe1980s,anerawhentherewerecomparativelyfewmanagedcare
organizations.Caredeliveredbysomeofthemorerecententrantsintomanagedcaremaybemore
problematic.

Thecommitteeisshockedbythelackofcurrentdatarelatingtothestatusofhospitalqualityof
careonanationalbasis,apartfrominformationonindicatorssuchashospitalspecificmortality
rates(whichHCFAnolongermakeseasilyaccessible).Thecommittee,therefore,isunableto
drawanydefinitiveconclusionsorinferencesaboutthelevelsofqualityofcareacrossthenation's
hospitalstoday.Briefly,qualityofhospitalcareingeneraldidnotsufferandmayhaveeven
improvedafterimplementationofPPS,asshownbythefewstudiesavailable.Atthesametime,
theremaybeproblemareaswithqualityofhospitalcareassuggestedbythesestudies,butthe
extentoftheproblemtodayisnotknownbecauseofthelackofobjectivecurrentdata.The
committeeisconvincedthatinvestigationofhospitalqualityofcarewarrantsincreasingand
immediateattention.Researchalsoneedstomovebeyondhospitalmortalityandfocusalsoonthe
processofcareproblemsandconditionsthatoccurduringshorthospitalstaysandinvestigate
outcomesoveranepisodeofcare.

RelationshipOfNursingStaffToQualityOfPatientCare
Theissuessurroundingtherelationshipofstaffinglevelsandstaffingpatternsofnursingpersonnel
andoutcomeshavetakenonaddedimportancesincethecommitteewasestablished.Hospitalsare
restructuringandredesigningtheorganizationanddeliveryofpatientcare,andthecommittee
heardmanyreportsofreductionofnursingstaffanditsadverseeffectsonqualityofcare.Very
littlecurrentdataareavailabledescribingthequalityofcareinhospitals,andassessingifithas
beenaffectedinanywaybychangesinthesystemofdeliveryofcareinthehospitals.

Theprecisequestionsabouttherelationshipofnursingstafftoqualityofpatientcareinhospitals
mustbeclear.Oneinquiryasks:Dosimplythetotalnumbers(orFTEs)ofRNs,ortheratioof
differenttypesofnurses(usuallyRNstoLPNs,orRNstoNAsandotherancillarystaff),makea
difference?Forexample,arehigherratiosofRNstoLPNscorrelatedinsomefashionwithbetter
outcomemeasures(suchaslowerdiagnosisspecificorhospitalspecificdeathorcomplication
rates)?Theotherquestionasks:Whatparticularnursingtasks,skills,orwaysoforganizingteams
ofnurses(andpossiblyotherhealthcarepersonnel)arerelatedtobetterprocessesofcareand
superiorpatientoutcomes?Theseissuesareexaminedintheremainderofthissection.
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NursingStaffandQualityofCare
Differencesinmortalityratesacrosshospitalsarewelldocumentedbyseveralresearchers.
LiteratureonRNs'impactonhospitalmortalityratesisconsiderable.Prescott(1993)providesa
comprehensivereviewofempiricalevidenceoftheimpactofnursingstafflevelsandmixon
qualityofpatientcareinhospitals.Muchoftheevidencecamefromregressionanalysesthatused
RNsasashareoftotalhospitalnursingemploymentasanexplanatoryvariableessentially,a
basic''numbers"variable.Overall,shefound"substantialevidencelinkingRNstaffinglevelsand
mixtoimportantmortality,lengthofstay,costandmorbidityoutcomes"(p.197).Whilenurse
staffingisnottheonlyfactorpredictiveofmortalityoutcome,itisanimportantoneaffectingthe
qualityofhospitalcare.

ManyfactorspotentiallycontributetohighqualityofcareinanysettingPrescott'sreview
appropriatelyemphasizedstudiesthatconsideredtheroleofmultipledeterminants.Because
hospitalsareverycomplexorganizations,isolatingtheroleofasingleinputisdifficult,andone
cannoteliminatethepossibilitythat,eveninawellcontrolledanalysis,variablessuchasRNshare
issurrogatesforother,unmeasuredqualitydeterminants(Hegyvary,1991).Forexample,hospitals
withahighproportionsofRNstootherstaff,mayalsohavetheattributesofgreaterstatus,
autonomy,andcontrolbyRNs(Aiken,1994)theseattributes,inturn,maybethedetermining
variableforbetterqualitynursingcareandthusbetterpatientoutcomes.Ontheotherhand,the
ratioofRNstototalnursingemploymentmaybehighinhospitalswithcomparativelyfewtotal
nursingpersonnelifthetotalnumberofnursingstaffislowenough,thehighproportionofRNs
maynotbecorrelatedwithparticularlygoodqualitylevels.

Theperformanceofasystemisdeterminedasmuchbythearrangementandinteractionofitsparts
asbytheperformanceoftheindividualcomponents(ScottandShortell,1983).Isolatingthe
specificcontributionofnursingpersonneltothequalityofpatientcaremaynotbefeasiblebecause
ofthewaycareisdeliveredinahospital,involvingcontributionsofawidearrayofstaffnurses,
therapists,physicians,andotheralliedhealthpersonnel.

Knausandcolleagues(1986)comparedpredictedandactualmortalityratesfortreatmentin13
ICUs.PredicteddeathratesforeachICUwerederivedfromtheacutephysiologyandchronic
healthevaluation(APACHE)scoresofindividualpatients.TheauthorsfoundthatalthoughRN
staffinglevelsandpositivephysiciannursecommunicationwereimportantfactorsinachieving
lowerthanexpectedmortality,thedifferencebetweenpredictedandactualmortalityrateswere
morerelatedtotheprocessofcare(e.g.,thelevelofcoordinationandcommunicationamongcare
givers)thantothestructuralattributesoftheICUs(e.g.,therapiesoffered,teachingversus
nonteachingstatus).Mitchellandcolleagues(1989)inademonstrationprojecttodocumentfiscal
costsandpatientcareeffectivenessofcriticalcarenursinginaunitcharacterizedbyvalued
organizationalattributes,reportedfindingssimilartothoseofKnausandcolleagues.Units
characterizedbyahighperceivedlevelofnursephysiciancollaboration,highlyratedobjective
nursingperformance,andsignificantlymorepositiveorganizationalclimatewereassociatedwith
desirableclinicaloutcomessuchaslowmortalityratio,nonewcomplications,andhighpatient
satisfaction.

InalateranalysisbasedontheAPACHEIIIstudy,Zimmermanandcolleagues(1993)reporton
thedifficultyofmeasuringICUperformancewithcurrentlyavailablemeasures.Theauthors
attemptedtoidentifyandevaluatethoseorganizationalandmanagementfactorsthatmightbe
associatedwithICUeffectivenessandriskadjustedmortalityrates.NineICUsparticipatinginthe
APACHEIIIstudywereidentified.Theseunitsvariedsignificantlyintheirriskadjustedmortality
rates.Structuralandorganizationaldatawerecollected,andonsiteobservationsofthenineunits
wereconducted.Theauthorsreportthattheonsiteanalysisfailedtoidentifytheunitswith

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significantlyhighorlowperformancelevelsandthatorganizationalandmanagementpracticesare
notsufficienttoidentifylevelsofICUperformanceasmeasuredbyriskadjustedpatientsurvival
rates.HighlevelsofteamorientationamongcaregiverswasassociatedwithICUefficiency,but
notwithICUriskadjustedmortalityrates.Furthermore,unitswithlowerlevelsofperformance
exhibitedsomeexcellentorganizationalpracticesandhighperformingunitsexhibitedsomepoor
organizationalpractices.

Hartzandcolleagues(1989)analyzedMedicaredischargesin1986andfoundthatthepercentage
ofnursingpersonnelwhowereRNswasoneofthefivesignificantpredictorsofhospitalmortality
rates.Specifically,hospitalswithahigherpercentageofRNsandhospitalswithahigherstaffing
levelshadloweradjustedmortalityrates.

Verran(PartIIofthisreport)8preparedforthecommitteeadetailedreviewoftheliteratureon
qualityofhospitalcare,organizationalvariables,andnursestaffing.Onthebasisofbothpublished
researchandresearchrecentlyreportedataninvitationalconference,sheconcludedthat(1)the
proportionofRNsonanursingstaffhasapositiveinfluenceonseverityadjustedMedicare
mortalityrates(2)aprofessionalpracticeenvironment(definedasaunitlevelselfmanagement
modelincludingparticipantdecisionmaking,useofprimarynursing,peerreview,andasalaried
statusforRNstaff)hasabeneficialinfluenceonseverityadjustedMedicaremortalityrates,over
andabovetheinfluenceofstaffingmixand(3)implementationofaprofessionalpracticemodelis
costneutral.

Verrandiscussedseveralmethodologicalproblemswithexistingstudies:lowsamplesize,inpart
reflectingthehighcostofdatacollection,attheunitofthehospitalinwhichnursespracticethe
lackofnursesensitivepatientoutcomemeasuresthefactthatmanypertinentoutcomesoccurafter
thepatientleavesthehospitaland,relatedly,thelackoflongitudinaldataonpatientspostdischarge
andtheinconsistencyofoutcomemeasuresamongstudies,whichmakesbroadgeneralizations
difficult(Verran,PartIIofthisreport).

Shenotesthatmuchoftheresearchtodatehasnotaddressedtheassociationbetweennurse
staffingskillmixesandnumbersandqualityofcare.Thestudiesreportedattheconference,for
instance,wereconceptualizedandfundedinresponsetothenursingshortageofthelate1980s.
Consequently,thevariablesusedinthosestudiesaremorefocusedonnurseretentionthanonthe
effectsofnursestaffingonpatientoutcomes.Moritz(1995)alsogivesanexhaustivereviewof
outcomesandeffectivenessresearchthatbearsonquestionsofqualityofcareandthelinkbetween
nursingprocessesoroutcomesandbroaderpatientoutcomes.Forexample,inreviewingthe
availableinformationontheimportanceoforganizationalmodels,shedrawsattentiontothe
growingbodyofworkonclinicaloutcomesandhealthstatusasitappliestonursingresearch.Her
paperdoesnotmitigatetheview,however,thatatpresenttheevidenceoftheimpactofnurse
staffingandmixonqualityofhospitalcareshouldbeviewedas,atbest,suggestiveofa
relationship,butnotconclusive.

Ininvestigatingtherelationshipofnursingstaffandpatientoutcomes,hospitalorganizationhas
receivedcomparativelylittleattentioneventhoughasubstantialbodyofresearchdocumentsa
relationshipbetweenorganizationalattributesofhospitalsandnursesatisfactionandturnover.Far
lessattentionhasbeengiventotherelationshipbetweennursingorganizationandpatientoutcomes
(KramerandSchmalenberg,1988a,bAikenetal.,1994).Wheninstitutionalattributesor
characteristicsarethefocusofhospitalmortalitystudies,manyorganizationalcorrelatesare
examined,ofwhichnursingoftenisone(ShortellandHughes,1988Hartzetal.,1989).Nurseto
patientratiosornursesasapercentageoftotalnursingpersonnelaresometimesfoundtobe
significantcorrelatesofpatientmortalityrates,butusuallythesestudiesgivelittleconsiderationto
themechanismsbywhichstaffingratiosmightaffectpatientoutcomes.

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Severalrecentstudiespointtotheorganizationofnursingwithinhospitalsastheoperant
mechanismbywhichnursestaffingaffectspatientoutcomes.Shortellandcolleagues(1994)
studiedtheroleofnursestaffingandmanagerialfactorsasdeterminantsofperformanceofhospital
intensivecareunits(ICU).Althoughtheirsamplesizewassmall(42ICUs),thisresearchis
importantinitsattempttoisolatetheroleofvariousorganizationalvariablesandstaffingon
hospitalperformance.Inparticular,controllingforpatientcasemix,theauthorsfoundthatthe
availabilityofstateofthearttechnologywasastatisticallysignificantdeterminantofriskadjusted
mortality.ThequalityofthecaregiverinteractionaffectedriskadjustedICUlengthofstay.When
theseandotherfactorsareheldconstant,theICUnursetopatientratiohadnoeffectonanyofthe
outcomesanalyzed,givingweighttothesuspicionthatvariablesotherthannursestaffingperse
affectpatientoutcomesinthehospitalcontext.

InastudyexaminingMedicaremortalityrates,Aikenandcolleagues(1994)foundthatmagnet
hospitals(thatis,hospitalswithlowRNturnoverandvacancyratesandhighlevelsofRN
satisfaction)havelowerpatientmortalitythancontrolhospitals.InapresentationtotheIOM
committee(October,1994),Aikensummarizedthestudyfindings.Thesefindingsindicatethat
lowerMedicaremortalityrates,aswellasimprovedworkrelatedwellbeingforRNs,arelinkedto
hospitalorganizationcharacteristicsthatresultinRNshaving:(1)moreautonomytoprovidecare
intheirprofessionalrolesandwithintheirareasofexpertise(2)greatercontroloverwhatother
caregiversdointhepatientcareenvironmentandoverresourcesand(3)welldocumentedand
welldevelopedprofessionalrelationshipswithphysicians.

AikenandcolleaguesalsoconductedastudyofspecializedAIDScareunits.Thecombinedresults
ofthesetwostudiesprovideinterestinginformationconcerningtheorganizationofnursingcare.
Themagnethospitalstudyindicatesthatthepreferredorganizationalstructureisoneinwhichthe
hospitalmanagementseesitsprimaryresponsibilityasdeliveringpatientcare,andthereforeboth
placesahighvalueonthequalityofnursingservicesandactivelysupportstheprofessionalroleof
nursingservices.TheresearchonspecializedAIDScareunitsdemonstratedhow,intheabsenceof
thepreferredhospitalwideorganizationofnursingservices,unitlevelorganizationofcarecan
helpcreateenvironmentswheretheRNautonomyandcontrolthatpromotelowermortalityrates
candevelop.Specifically,AikenandcolleaguesfoundthatAIDScareunitsfosterRNautonomy
andcontrolthroughRNspecialization(whichpromotesautonomyandinteractionwithphysicians
basedonmutualexpertise)andthecorrelationbetweenpatients'highcareneedsandRNs'areasof
specialization.Furthermore,thesetwostudiesconfirmthatthesamefactorsthatleadhospitalstobe
identifiedaseffectivefromthestandpointoftheorganizationofnursingcareareassociatedwith
lowermortalityamongMedicarepatients.

AikenandcolleaguesconcludedthatalthoughRNrichstaffingratiosaresometimesassociated
withimprovedoutcomes,theresultsoftheirresearchindicatethatsuchstaffingratiosare
essentiallyaproxymeasureforotherorganizationalattributesofhospitalsthatgrantnurses
autonomyovertheirownpracticeandcontroloftheresourcesnecessarytodeliverpatientcareand
creategoodrelationshipswithphysicians.ThecommitteeconcurswiththefindingsofAikenand
colleagues(1994,p.783),"thatthemortalityeffectderivesfromthegreaterstatus,autonomyand
controlaffordednurseinthemagnethospitals,andtheirresultingimpactonnurses'[RNs']
behaviorsonbehalfofpatientsi.e.,thisisnotsimplyanissueofthenumberofnurses,ortheir
mixofcredentials."

Clearly,oneoftheresearchchallengesindeterminingtherelationshipbetweenstaffingandquality
ofcarehasbeenthedifficultyofisolatingthefactors(andtherelativeimportanceofthesefactors)
thatareinvolvedinproducingimprovedpatientoutcomes.AikenandSalmon(1994,p.324)
contendthat"[n]ursesplaceconsiderableimportanceonhavinghighnursetopatientstaffingratios
andthat,ingeneral,theyhavebeenreluctanttothinkcriticallyaboutotherstrategiesthatcouldbe
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as,ormore,importantinachievinggoodpatientoutcomes."Theissueisnotjustamatterof
staffingratios.Intheauthors'view,whatRNsdoandhowtheydoitarebothmoreimportantthan
simplyhowmanyRNsthereare.ThesestudiessuggestthatRNsmayhaveoverestimatedthe
valueofstaffingratiosandskillmixinhospitalsandunderestimatedtheimportanceofthe
organizationofnursing.Thecommitteeisoftheviewthatmoreattentiontoorganizationalfactors
canleadtomoreefficientuseofRNsandothernursingpersonnelandatthesametimeimprove
patientoutcomes.

Insummary,thecommitteeconcludesthatliteratureontheeffectofRNsonmortalityandon
factorsaffectingtheretentionofRNsisavailable.Butthereisaseriouspaucityofrecent
researchonthedefinitiveeffectsofstructuralmeasures,suchasspecificstaffingratios,onthe
qualityofpatientcareintermsofpatientoutcomeswhencontrollingforallotherlikely
explanatoryorconfoundingvariables.Partoftheproblemliesintheareaofseverityofillness
andriskadjustment,wherepatientacuityisasignificantfactor.Acrosstheboardstaffingratios
tendtoassumethatinsomemeasureallpatientsare"alike"andcanbecaredforwiththesame
levelandtypeofresources.Equallydifficultisthetaskofestablishingratiosthatwillbe
appropriateforallsettingsandsituations.

Atleastonecommitteememberstronglysupportsmandatedminimumstaffinglevelsspecificto
differenttypesofacutecareunitsandfacilitiesbutrecognizesthatspecifyinganyparticular
minimumlevelwasbeyondthescopeandcompetencyofthecommittee.Allcommitteemembers
supportthecurrentfederalrequirementsandaccreditationstandardsfornursingservicesand
supporttheneedforhospitalstomaintainthehighestpossiblestandardsfornursingcare.
Moreover,thecommitteeagreesthathospitalsshoulddevelopimprovedmethodsformatching
patientneeds(severityofillnessoracuitymeasures)withthelevelandtypeofnursestaffing.The
committeesupportseffortstoimprovesystemsforplanningappropriatenursingcareaswellas
monitoringtheoutcomesofthatcare.

Thecommitteebelievesthathighpriorityshouldbegiventoobtainingempiricalevidencethat
permitsonetodrawconclusionsabouttherelationshipsofqualityofinpatientcareandstaffing
levelsandmix.Suchdatashouldfocusonnursingcareandqualityofcareacrossinstitutionsand
withingiveninstitutions,andacrossdepartmentsandservices.Existingworkhasnottypically
focusedonisolatingthecontributionofnursingcareinmeasuringthequalityofpatientcarein
hospitals.

Thus,thecommitteeisconvincedthatmorerigorousresearchontherelationshipbetweennursing
variables,broadlydefined,andqualityofcarewouldhavesignificantpayoffsforpolicymakers,
nursingeducators,andhospitaladministrators.

RECOMMENDATION55:ThecommitteerecommendsthattheNationalInstituteof
NursingResearch(NINR)andotherappropriateagenciesfundscientificallysoundresearch
ontherelationshipsbetweenqualityofcareandnursestaffinglevelsandmix,takinginto
accountorganizationalvariables.ThecommitteefurtherrecommendsthatNINR,along
withtheAgencyforHealthCarePolicyandResearch(AHCPR)andprivateorganizations,
developaresearchagendaonstaffingandqualityofcare.

SeveralotheragenciesoftheU.S.DepartmentofHealthandHumanServicesalsohaveamajor
roleinhealthworkforcedatacollectionandresearch,includingtheDivisionofNursinginthe
BureauofHealthProfessions,theHealthResourcesandServicesAdministrationtheNational
CenterforHealthStatistics(theprincipalhealthstatisticsagencyofthefederalgovernment)inthe
CentersforDiseaseControlandPreventionandtheHealthCareFinancingAdministration.
Finally,privateorganizationscouldbepartnersintheseresearchprograms,forexample,hospital
associations(e.g.,HospitalResearchandEducationTrust,theAmericanHospitalAssociation
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[AHA]andstatehospitalassociations,someofwhich[e.g.,inMarylandandNewYorkState]
conductworkofthissortalready)andprivatephilanthropicandresearchfoundations,particularly
thosewithlongstandinginterestsinhealthpersonnel,organizationofthehealthcaresector,or
qualityofcare.

Amajorpartofanysuchresearchagendamightcallforelaborationoftheactualvariablesin
termsofstructure,process,andoutcomethatwarranthighpriorityattentioninstudiesofthe
relationshipofnursingcare,staffingpatternsfornursing,topatientoutcomes.Asdiscussedbelow,
forexample,theAmericanNursesAssociation(ANA)hasbeendevelopingqualityindicatorsthat
warrantfurtherinvestigation.

ReportCards

Duringitswork,thecommitteeheardagreatdealabouttheneedformoreinformationonhospital
qualityofcaretobemadeavailabletopolicymakersandthepublic.Thereasonsareseveral:to
improvetheworkingsofacompetitivehealthcaremarket,toenablethepublictomakebetter
choicesabouthealthcareplans,andgenerallytoreflectthenation'sexpandinginterestin
generatingandusinginformationtohelpimprovethequalityandcosteffectivenessofhealthcare.
Onenotableindicationofthismovementisthegrowingbeliefin"reportcards"thatis,summary
collectionsofindicatorsormeasuresofhealthcareproviders'performance.Suchreportcardsmay
serveasconduitsofinformationaboutthequalityofinpatientcareinindividualinstitutionsand
facilitiesorentirehealthcaresystems.9Despitethesurgeofinterestandactivityinreportcards,
however,theyarestillintheearlystagesofdesignandimplementation.Theultimatefeasibilityof
linkingreportcardusetoactualimprovementsinthequalityofcareremainstobeseen.

Oneexampleofareportcardapproachthatrelatestothecentralquestionsbeforethiscommittee
theroleofnursinginqualityofcareandpatientoutcomesisthatbeingdevelopedbyLewinVHI
fortheANA(ANA,1995bLewinVHI,1995).Becauseveryfewofthereportcardsunder
developmentdocumentthespecificeffectsofnursingonthequalityofcaredeliveredinhospitals,
ANAfelttheneedforqualityindicatorsthatwouldclarifyelementsofqualityofcarefroma
nursingpracticeperspective.TheorganizationthuscommissionedLewinVHI,in1994,todevelop
performanceindicatorsfornursingcareinhospitalsettings.

Inthefirstphaseoftheproject,thedevelopersidentified21categoriesofmeasureswithan
apparentconceptuallinktonursing.Thecandidatemeasuressufferedfromsignificantpractical
limitations,however:lackofastrongresearchbaselinkingthemtonursingoutcomes,lackof
specificitytonursing,lackofnecessarydatacollectionmechanisms,andlackofapplicablerisk
adjustmentsystems.Thus,considerableempiricalvalidationofthemeasureswasneeded.

Thecommitteeisinformedthatworkonthesecondphaseoftheprojectisunderway.Seven
indicatorshavebeenidentifiedforfurtherresearchbecausethenecessarydatacollection
mechanismexistsand/orbecauseoftheirspecificitytonursing:(1)patientsatisfaction(2)pain
management(3)skinintegrity(4)totalnursingcarehoursperpatient(5)nosocomialinfections
(urinarytractinfection,pneumonia)(6)patientinjuryrateand(7)assessmentofpatientcare
requirements(TelephonecommunicationswithJanetHeinrich,Director,AmericanAcademyof
Nursing).

ThecommitteecommendstheANAforitsexploratoryeffortstodevelopasetofnursingcare
qualityindicators.Thisresearchcansetanimportantprecedentandstandardforthe
developmentofmeaningfulqualitystandardsrelatingtonursing.Itofferspromiseforfurther
evolutionofexternalregulatoryqualityassurancemechanisms(likethoseoftheJointCommission
ontheAccreditationofHealthCareOrganizations[JCAHO])andforimprovedpublicinformation
efforts.Nevertheless,thecommitteejudgesthatinthefuture,abroadersetofinputsfromthe
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nursingcommunityandotheraffectedpartiesisdesirable.Italsobelievesthateffortsbasedsolely
intheprivatesector,withlittleornopublicsectorinvolvement,mightbelessusefulthaniffederal
andstateperspectivesweretakenintoaccount.Therefore:

RECOMMENDATION56:Thecommitteerecommendsthataninterdisciplinarypublic
privatepartnershipbeorganizedtodevelopperformanceandoutcomemeasuresthatare
sensitivetonursinginterventionsandcare,withuniformdefinitionsthataremeasurableina
uniformmanneracrossallhospitals.

Suchapartnershipshouldinvolveagroupcomprisingthefollowing:variousprofessional
associationsofnurses(clearlyincludingANAbutnotlimitedtoit)leadersinthenursing
professioninareassuchasqualityassessmentandimprovement,healthservicesresearch,and
nursingeducationhospitalsystemsandassociationsaccreditingbodiesthathavelongexperience
withsettingqualitystandardsandcriteriaresearchersandexpertsinadministrativedatabaseswho
arefamiliarwithdevelopinguniformminimumdatasetsinthehealthareaandgovernment
officialsrepresentingthehealthagenciesthatpayforcare,monitorqualityofcare,ortrack
educationandtrainingcurricula,aswellashavelongexperienceindevelopinguniformminimum
datasetsfornationaluse.

LegislativeAndRegulatoryRequirements
Regulationofhospitalsisalongstandingpartofgovernmentresponsibility.Stateshavehadtheir
ownlicensingrequirementsforhospitalsandotherfacilitiessincetheearlypartofthecentury.
Regulationhastakenmanyforms,suchascertification,licensure,andaccreditation.10

SinceMedicareandMedicaidlegislationwaspassedin1965,theSocialSecurityActhasrequired
thatprovidersbecertifiedasaconditionofparticipationintheprogram.Thisisaccomplished
throughmechanismsknownasConditionsofParticipationthatarepromulgatedthroughspecific
standardsintheCodeofFederalRegulations.Forhospitalstobesocertifiedforparticipation,the
SocialSecurityActrequiresthatfacilitiesbelicensedandingoodstandingbythestate.Inaddition,
hospitalsmustmeetallfederalcertificationstandards,andthefederalHCFAisauthorizedto
determinewhetherhospitalsmeetthesefederalrequirements.HCFAmayconductonsite
inspectionstoobservecareandreviewrecordstodeterminecompliance,oritmayaskstate
agenciestocarryoutthesesurveys.

UndertheSocialSecurityAct,certificationmayalsobebasedonaccreditation,whichisinturn
basedonaconceptofdeemedstatus.Hospitalsfoundtomeetaccreditationstandardsbythe
JCAHOaredeemedautomaticallytomeetthefederalConditionsofParticipationintheMedicare
programineffect,theyareconsideredtobecertifiedtoreceiveMedicare(andMedicaid)
reimbursement.HCFAperformsindependentvalidationsurveysofindividualhospitalsona
samplebasisasanassurancethatthefederalgovernmentcanrelyontheJCAHOapproach.In
addition,accreditationbytheJCAHOisarequirementforhospitalsapprovedtoconductgraduate
medicaleducationresidencyprogramsandisfrequentlyarequirementforpaymentbyhealth
maintenanceorganizations(HMO)andhealthinsurancecompanies.

CertificationbyJCAHOrequiresthat(a)nursingcarebeprovidedona24houraday,7daya
weekbasis(b)nursingservicesshowevidencetothesurveyorsthateachpatient'sstatusis
monitored(c)provisionofnursingcareiscoordinatedwiththeprovisionofcarebyother
professionalsand(d)specificpatientcareplansbeinplaceandinuseforeachpatient.
Furthermore,JCAHOstandardsfornursingcareplaceanewemphasisontherole,responsibility,
qualifications,andaccountabilityofthenurseexecutive,includingtheauthorityandresponsibility
forensuringthatstandardsofnursingpracticeareinplaceandmeetJCAHO'spatientcare
standards(JCAHO,1994).
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Thehospitalorganizationmustprovide"asufficientnumberofqualifiednursingstaffmembersto
assessthepatient'snursingcareneedsplanandprovidenursingcareinterventionsprevent
complicationsandpromoteimprovementinthepatient'scomfortandwellnessandalertothercare
professionalstothepatient'sconditionasappropriate"(JCAHO,1994,p.521).The"Careof
Patients"chapterofthestandardsmanual(partofthepatientfocusedsection)directsattentiontoa
widesetofelementsofgoodcare.Theseincludethefollowing:

"Formulation,maintenance,andsupportofapatientspecificplanforcare,treatment,and
rehabilitation"

"Implementationoftheplannedcare,treatment,andrehabilitation"

"Monitoringthepatient'sresponsetothecare,treatment,andrehabilitationprovided,the
actionsorinterventionstaken,and/ortheoutcomesofthecareprovided"

"Modificationoftheplannedcare,treatment,andrehabilitationbasedonreassessment,
thepatient'sneedforfurthercare,andtheachievementofidentifiedgoals"and

Planningandcoordinationofthe"[c]are,treatmentandrehabilitationnecessaryafterthe
patient'sdischargefromtheorganization"(JCAHO,1994,p.125).

Alargemajorityofhospitalsseekandattainaccreditedstatus.11TheJCAHOrendersfivetypesof
accreditationdecisions,dependingontheextenttowhichhospitalsarejudged(onthebasisof
institutionspecificsurveydata)tocomplywithpublishedstandardsofperformancethefive
accreditationlevelsare(1)accreditationwithcommendation,(2)accreditation,(3)conditional
accreditation,(4)provisionalaccreditation,and(5)notaccredited.

Giventhecontinuedrelianceofthefederalgovernmentonthisapproachtocertificationforhospital
reimbursementthroughfederalhealthprograms,thecommitteeisencouragedbytheevolutionof
JCAHOmethodsandstandardsinthepastfewyearsandbythemoresophisticatedattentionbeing
paidtotheroleofnursingcareinthosestandards.Italsotakesnoteofanewinitiative,theCouncil
onPerformanceMeasurement,whichwillserveasanadvisorybodyforevaluationofperformance
measurementsystems,especiallywithrespecttoconsideringwhethertheyaresuitablefor
incorporatingintofutureaccreditationprocesses.

Allinall,therefore,thecommitteeendorsesthecurrentfederalrequirementsforhospitalsto
participateinMedicare,whichincorporatetheuseofvoluntaryaccreditation,toassurethe
qualityofhospitalcare,anditisparticularlysupportiveofrequirementsthatcallformatching
nursingresourceswithpatientneeds.ThecommitteebelievesthatCongressoughttocontinueto
supportthiselementofassuringthequalityofcareinhospitals.

Summary
Hospitalrestructuringandredesignofstaffingsystemsareundertakenforavarietyofreasonsthat
includecontrollingcostsandadjustingtothedramaticchangesinthedeliveryofhealthcare.
Hospitalsarerestructuringtomaintaintheireconomicviability,buttheyneedtodosowithout
adverselyaffectingtheoutcomesofthecaretheyprovide.Thechangesnowtakingplaceinthe
hospitalsectorinvolvemajorrethinkingoftheuseofdifferenttypesofclinicalstaff,aswellas
reconfigurationofunits,departments,andcareteams.Theredesignofnursingservicesalsois
leadingtochangesintherolesandresponsibilitiesofRNsandtoincreasedemphasison
interdisciplinaryteams.Thesedevelopmentshaveprompteduncertaintyinemploymentandgreat
concernamongRNsaboutthepotentialforerosionofqualityofhospitalcare,andabouttheirown
wellbeing.

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Inthischapterthecommitteehasexaminedtheseconcerns,specificallywhetherqualityhas
deterioratedandwhetherempiricalevidenceexistsofalinkbetweenthenumberandskillmixof
nursingpersonnelandthequalityofpatientcare.Thecommitteehasfoundthatlittleempirical
evidenceisavailabletosupporttheanecdotalandotherinformalinformationthathospitalquality
ofcareisbeingadverselyaffectedbyhospitalrestructuringandchangesinthestaffingpatternsof
nursingpersonnel.Atthesametimethecommitteenotesalackofsystematicandongoing
monitoringandevaluatingoftheeffectsofchangesresultingfromorganizationalredesignand
reconfigurationofstaffingonpatientoutcomes.

ResearchershaveconcludedthatalthoughRNrichstaffingratiosaresometimesassociatedwith
improvedoutcomes,theresultsoftheirresearchindicatethattheyareessentiallyproxymeasures
fororganizationalmeasures.Forqualityofcarechanges,thecommitteewasunabletoisolatea
numberofRNseffectfromtheorganizationalandrelatedfactorsattendingdifferentlevelsof
staffing.Thecommitteeconcludesthathighpriorityshouldbegiventoobtainingempirical
evidencethatpermitsonetodrawconclusionsabouttherelationshipsofqualityofinpatientcare
andstaffinglevelsandmix.

Thecommittee,however,isconcernedaboutthepaucityofobjectiveresearchontherelationship
betweenstaffingandquality,andtheeffectsofrestructuring.Thecommitteeconcludesthataclear
needexistsforasystemformonitoringandevaluatingtheimpactoftherapidlychangingdelivery
systemonthequalityofpatientcareandthewellbeingofnursingstaff.Forthisreason,ithas
advancedseveralrecommendationsintendedtoprovidebetterinformationonhospitalrestructuring
andtohelpindelineatingthosefactorsthataffectpatientoutcomes.Italsocallsforthe
developmentofaresearchagendainthisareaandforthearticulationofreliable,valid,and
practicalmeasuresofstructure,process,andoutcometobeusedinqualityofcareresearchaswell
asqualityassuranceandimprovementprograms.Asystematiceffortisneededatthenationallevel
tocollectandanalyzecurrentandrelevantdataanddeveloparesearchandevaluationagenda
sothatinformedpolicydevelopment,implementationandevaluationareundertakeninatimely
manner.

Somebroaderissuesofchangesinnursingservices,suchastheenhancedresponsibilitiesof
advancedpracticenurses,andtheuseofancillarynursingpersonnelandtheircompetency,cut
acrossthestraightforwardissueoftherelationshipbetweennursestaffingandqualityofhospital
care.Inreflectingontheroleofnursingpersonnelinthefuture,therefore,thecommitteehasalso
proposedrecommendationsaboutthesespecifictypesofnursingpersonnel.

Footnotes
1 ''Casemanagement"includescomprehensiveoversightofapatient'sentireepisodeofillnessincorporating
interdisciplinaryresourceutilizationinordertoprovidehighquality,costeffectivecare.Theclinicaland
financialmanagementofcareiscoordinatedby"casemanagers"whooftenspantheboundariesofinpatient,
ambulatoryandcommunitysettings(Satinsky,1995).Somepeopleprefertousetheterm"caremanager"in
lieuofcasemanager.Caremanagementsuggeststheprovisionofdirectcareand,insomeinstancesacase
managermayalsobeacaremanager.Forexample,registerednurseswhocoordinatecareforgroupsof
hospitalizedpatientswiththesamediagnosismayalsoassumeresponsibilityforgivingsomeofthesepatients
directcare.

2 ThisphenomenonmayhaveaparalleltotheRN'srole.RNstrainedsomeyearsbackwerenotinstructedto
performdutiessuchasutilizationreview,casemanagement,longtermdischargeplanning,orcost
containment,ortobeinvolvedinmanagedcare,capitation,orcontractualagreementsforreimbursement.
Theyhavebeenlearningthenewconceptsnecessarytofunctiontoday.

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3 ConcernsabouthospitalqualityofcaredatetothepioneeringnurseFlorenceNightingaleandBritishbattlefield
hospitalsintheCrimeanWar,andtothesurgeonE.A.Codmanandhisconcernsabouttheendresultsofcarein
Bostonhospitalsattheturnofthecentury.Withoutquestion,hospitalcareleftmuchtobedesiredthen.

4 "Genericscreens"aremeasuresofvariousaspectsofcare,typicallyinhospitalsforinpatientcare,thatare
usedbyqualityassuranceorriskmanagementstafftoidentifypotentialproblemswithqualityofcare.
Commonlyusedaretheadequacyofdischargeplanning,medicalstabilityofthepatientatdischarge,deaths,
nosocomialinfections,unscheduledreturnstosurgery,andtraumasufferedinthehospital(IOM,1990).They
aregenericinthesensethattheyarenotconditionordiagnosisspecificand,thus,theycanbeappliedtothe
careofeverytypeofpatientinthefacility.

5 Inthisstudy,ofthe100dischargeabstractsreviewedbyapanelof24physiciansforqualityproblems,30
wereconsideredtoreflectsomekindofproblemsbutthenumberofproblematicabstractsvariedfromabout
15to45amongthereviewingphysicians.

6 TheRANDresearchteamsampledhospitalrecordsofabout17,000patientsinatotalofsixDRGsfrom300
hospitalsinfivestatesbeforeandafterimplementationoftheMedicarePPS.Thegoalwastodeterminethe
effectofDRGbasedPPSonqualityofhospitalcare.Qualitywasmeasuredbybothoutcomemeasures30
and180daymortalityratesafteradmissionandanindicatorofwhetherthepatientwasdischargedfromthe
hospitalinanunstableconditionandmeasuresofimplicitandexplicitprocess.Theimplicitprocess
indicatorsweresummarymeasuresofprocessofcaregivingthephysicianreviewers'overallassessmentof
thequalityofthecareprocessforaparticularhospitalization.Theexplicitmeasuresconsistedoffive
standardizeddiseasespecificprocessscalestheseincludedphysiciancognitivediagnosticprocesses,nurse
cognitivediagnosticprocesses,technicaldiagnosticprocesses,technicaltherapeuticprocesses,andintensive
careunit/telemetrymonitoring.Nursingwasreflectedinmostoftheexplicitprocessmeasures.Detailed
severityofillnessdatawererecordedandusedtocontrolforseverityofillnessintheempiricalanalysis.

7 Asthisreportgoestopress,theRANDresearchersarefurtheranalyzingtheirdatawiththegoalofpublishing
analysesconcerningnursingprocessesofcareandthequalityofcareundertheDRGbasedPPSsystem.

8 TheIOMcommitteecommissionedthispaperfromJoyceVerran.Thecommitteeappreciatesher
contributions.ThefulltextofthepapercanbefoundinPartIIofthisreport.

9 Thecommitteechargedidnotdirectlyincludethetopicofreportcardsforhospitals.However,thisisa
growingmovement,andthecommitteejudgedthatsomeobservationswererelevantforthisdiscussion.

Foronething,mostsetsofindicatorsthatmightbeusedinhospitalspecificreportcardsfallshortofthose
impliedintheIOMdefinitionofqualityofcare(IOM,1990).Althoughtheygenerallyincludesomepatient
satisfactionindicator,rarelydotheyincludefunctionalstatusandwellbeing(i.e.,reliableandvalidmeasures
of"desiredhealthoutcomes")asthatconceptismeanttobeunderstood.Neitherdoanyoftheexistingsetsof
hospitalqualityindicatorsapparentlyincludethedetailedstructuralmeasuresthatwouldallowexamination
ofrelationshipsbetweendifferentstaffingpatternsorteamcompositionsandthe"endresults"ofcare.

LewinVHI(1995)identifiestwocategoriesofreportcards:providerbasedandplanbased.Accordingtothis
report,mostproviderbasedreportcardsaddressthequalityofhospitalcarebuttendtofocusonalimited
numberofqualityindicatorssuchasmortalityratesorlengthofstay(atbest,aproxymeasureofquality).As
discussedelsewhereinthischapter,thisapproachpresentsseriouslimitationstoanyefforttoexaminethe
effectsofnursingcareonqualityofhospitalcareforatleasttworeasons:(1)nomeasuresreflectnursingcare
asdistinctfromhospitalcare,and(2)theinformationprovidedbyonlymortalityandlengthofstaydatais
insufficienttounderstandthequalityofpatientcareprocessesoroutcomesotherthandeath.

10 Acomprehensivereviewofhospitalaccreditation,deemedstatus,andsimilarregulatoryissues,aswellasof
qualityassurancerequirementsandprograms(e.g.,HCFA'sPeerReviewOrganizations)wasbeyondthis

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committee'scharge.Suchreviewsareavailablefromothersources(e.g.,IOM,1990).Hencethecommittee
didnotundertakesuchareview.

11 SomehospitalsareaccreditedinasimilarfashionbytheAmericanOsteopathicAssociation,ratherthanthe
JCAHO,buttheunderlyingphilosophyofbeingcertifiedtoreceiveMedicarereimbursementandtoconduct
graduatetrainingprogramsisthesame.

Copyright1996bytheNationalAcademyofSciences.Allrightsreserved.
BookshelfID:NBK232662

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