Summary

The nation's health care system is in a transition of potentially historic proportions driven by the need for cost-effectiveness under pressures of cost containment and competition, but also made possible by scientific and technological breakthroughs. These forces have led to major changes in the structure, organization, financing, and delivery of health care since the early 1980s.

Managed care organizations have developed rapidly, changing the nature of private health insurance and increasing price competition. These evolving care delivery and payment systems have in turn affected the structure of the health care system by limiting service and directing when and where patients receive care.

Historically the hospital has been at the core of the U.S. health care system, and nursing services are central to the provision of hospital care. However, the changes in payment systems, combined with scientific and technological advances, have permitted shifts from the traditional inpatient care settings to ambulatory, community, home, and nursing home care.1 Inpatient use of hospitals, length of hospital stay, inpatient days, and the number of beds staffed have all declined. As a consequence, hospitals are changing in ways not considered possible a few years ago. To maintain economic viability, they are rapidly restructuring, merging, and consolidating. They are also redesigning and reconfiguring staffing patterns and, increasingly, moving toward interdiscipli-

1  

Throughout the report, the terms ''nursing home" and "nursing facility" are used interchangeably.



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--> Summary The nation's health care system is in a transition of potentially historic proportions driven by the need for cost-effectiveness under pressures of cost containment and competition, but also made possible by scientific and technological breakthroughs. These forces have led to major changes in the structure, organization, financing, and delivery of health care since the early 1980s. Managed care organizations have developed rapidly, changing the nature of private health insurance and increasing price competition. These evolving care delivery and payment systems have in turn affected the structure of the health care system by limiting service and directing when and where patients receive care. Historically the hospital has been at the core of the U.S. health care system, and nursing services are central to the provision of hospital care. However, the changes in payment systems, combined with scientific and technological advances, have permitted shifts from the traditional inpatient care settings to ambulatory, community, home, and nursing home care.1 Inpatient use of hospitals, length of hospital stay, inpatient days, and the number of beds staffed have all declined. As a consequence, hospitals are changing in ways not considered possible a few years ago. To maintain economic viability, they are rapidly restructuring, merging, and consolidating. They are also redesigning and reconfiguring staffing patterns and, increasingly, moving toward interdiscipli- 1   Throughout the report, the terms ''nursing home" and "nursing facility" are used interchangeably.

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--> nary teams of care givers including registered nurses (RN), licensed practical nurses (LPN),2 and nurse assistants (NA) and other ancillary nursing personnel.3 They are also downsizing staff to accommodate the reduced volume of inpatient care and to remain economically viable. The lines between the hospital and the nursing home are beginning to blur. New developments in hospital organization combined with economic and other forces are changing the characteristics of the persons entering nursing homes and are creating new demands for beds and for provision of nursing care in these facilities. The aging and increasing diversity of the U.S. population and the projected growth of the oldest-old age group will have a major effect on the demand and supply of health services and on the level and type of resources needed to provide those services. These trends are likely to increase inpatient hospital admissions as well as admissions to nursing homes. When combined with the rising severity of illness of patients in both hospitals and nursing homes, these patterns can be expected to exacerbate the long-standing problems in these institutions involving staffing issues, including the paucity of appropriately educated and trained professional nursing personnel. The implications of these changes in the health care environment for the nursing workforce are profound in terms of numbers, adequate distribution of skills, and educational preparation. Nursing personnel are an integral component of the health care delivery system; therefore, they are affected directly by these changes. It is not surprising that concerns about the fate of patients and health care givers have grown as reported in the media. Within the nursing profession and its supporting organizations there is a high level of uncertainty and concern about what is happening to nursing staff in terms of their physical, psychological, and economic well-being. Individual care givers, professional and trade associations involved in nursing, and unions have expressed concerns that these changes 2   In two states, California and Texas, these nurses are called licensed vocational nurses. In all other jurisdictions they are known as licensed practical nurses. In this report, licensed practical and vocational nurses are referred to as licensed practical nurses. 3   Ancillary nursing personnel, nursing support personnel, assistive personnel, nurse extenders, unlicensed nursing personnel, multicompetent workers, nurse assistants, or aides are all generic terms used to refer to the various clinical and nonclinical jobs that augment nursing care. This group of employees includes an array of support nursing personnel including certified nurse assistants, order-lies, operating room technicians, home health aides, and others. They assist the licensed nurse by performing routine duties in caring for patients under the supervision of an RN or an LPN. Although Congress defined "nurse" for the purposes of this study to include RN, LPN, and NA, it has not been possible at all times to disaggregate information on NAs from the remaining support personnel because national statistics are often collected and/or tabulated for the group as a whole. For example, the American Hospital Association does not separate information on nurse assistants from that on other "ancillary nursing personnel." Throughout this report, the term ancillary nursing personnel will be used for this group of staff when nurse assistants cannot be disaggregated.

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--> are endangering the quality of patient care and causing nursing personnel to suffer increased rates of injury, illness, and stress. In response to these expressed concerns, Congress directed the Secretary of the Department of Health and Human Services (DHHS) to ask the Institute of Medicine (IOM) to undertake a study to determine whether and to what extent there is need for an increase in the number of nurses in hospitals and nursing homes in order to promote the quality of patient care and reduce the incidence among nurses of work-related injuries and stress. For the purposes of this study, Congress defined "nurse" to include RNs, LPNs, and NAs. To carry out this legislative mandate, in March 1994 the Division of Nursing of the Health Resources and Services Administration requested that the IOM appoint a committee of experts to undertake an independent objective study as stipulated by Congress. In response the study committee explored: levels of quality of care in hospitals and nursing homes today; the relationship of quality of care (or quality of nursing care, to be more precise) and patient outcomes to nurse staffing levels and mix of different types of nursing personnel; the current supply and demand for nurses, including both American-and foreign-trained nurses, and the current and expected levels of workforce participation in that professional group; existing ratios of nursing personnel to other measures of demand for health care, such as numbers of patients (in hospitals) or residents (in nursing homes) or numbers of beds, and how those ratios might vary by type of facility, geographic location, or other factors; the incidence and prevalence of work-related stress and injuries among nurses in these settings; whether the epidemiology of these problems had been changing in recent years; and whether they differ by type of nursing personnel; undergraduate, graduate, and in-service education and training of different types of nurses; and the current and projected patient population of the nation, taking into account the aging of the U.S. population (and the aging of the elderly population itself) and the changing racial and ethnic composition of the population, and the implications of these demographic shifts for the types of health care providers—especially nurses of various kinds—that will be needed in future years. This report responds to that request. To address its charge in a systematic manner, the committee conducted a complex set of activities. It reviewed and analyzed an extensive body of research and relevant literature, both published and currently under way, and other relevant reports; analyzed published and unpublished data from various sources; heard from a large number of experts; held public hearings and obtained a great deal of written testimony; appointed and convened a liaison panel; conducted several site visits; met with representa-

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--> tives of professional groups, consumer advocacy groups, and trade organizations and others; and commissioned several background papers from experts. In responding to its charge, the committee decided that although interest in and concern among constituent groups about staffing conditions in hospitals and nursing homes today are intense, the future outlook for the nursing services in the health care system is equally critical for planning and policy formulation. Hence it has attempted to take a long-term view, looking ahead at nurse staffing in the context of a rapidly evolving health care system and an increasingly aging population that will dominate the practice of health care givers at all levels and disciplines as the nation moves into the twenty-first century. The committee's major findings and conclusions based on this review and its deliberations are summarized below, followed by the text of the recommendations. Findings And Conclusions Nursing Personnel in a Time of Change To determine the adequacy of nursing personnel in hospitals and nursing homes, the committee first assessed the overall supply of nursing personnel in the context of the shifting demand for their services and the factors affecting that demand. More than 3 million health care personnel work in nursing services. Hospitals are the major employers of nursing personnel. RNs are the largest group of health care givers in this country. Their supply in terms of numbers is at an all-time high. In 1992, more than 2.2 million persons held licenses to practice as RNs, and 1.8 million of them were employed in nursing positions. The hospital is the first place of employment for most RNs, where historically two-thirds of them work, and the number of RNs employed by hospitals has continued to grow. This is not the case for LPNs, whose numbers in hospitals have been declining for some time. Many LPNs and NAs also work in nursing homes. Although the focus of health care is shifting away from nursing at the hospital bedside to nursing at the patient's side in a continuum of care, in absolute terms the largest numbers of nursing personnel are still working in hospital inpatient settings. At the same time, with the emergence of rehabilitative services in nursing homes and the increasingly complex case-mix in these facilities, the need for professional nursing in nursing homes is much greater now than in previous years; and in the years ahead, it will be even greater. Recent data suggest that there might be a small increase of these personnel in nursing homes. Nursing homes accounted for about 7 percent of the RN workforce in 1992, up from 6.6 percent in 1988. The committee concludes that as long as long-term care is almost totally dependent on public and out-of-pocket financing, the current paucity of professional nurses employed in nursing homes will likely con-

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--> tinue because of fiscal reasons and because of the pay differential between RNs in hospitals and those in nursing homes. Continuation of current trends toward reduced inpatient hospitalization rates combined with increased acuity of hospitalized patients and the corresponding shift of employment to ambulatory and community care settings could have important implications for the employment of RNs in inpatient hospital settings and for their education and training. In the future, they may be called upon increasingly to fill roles that require increased professional judgment, management of complex systems that span the traditional boundaries of service settings, and greater clinical autonomy. Likewise, not all nursing homes today are single-focus settings taking care of chronically ill patients who require mostly custodial care. They increasingly are becoming the "hospital" substitute for much of the subacute care that previously was part of a hospital stay. Because of the reduced length of inpatient hospital stays nursing homes are attempting to provide transitional institutional services that in the past would have been provided in the acute care inpatient setting. All these factors raise important questions about the adequacy of the RN supply in terms of the educational preparation of future RNs. In addressing this issue, several researchers conclude that the aggregate numbers are adequate to meet national needs, at least for the near future, but that the education mix may not be adequate to meet either current or future demands of a rapidly changing health care system. The need to evaluate workforce adequacy for the future in terms both of numbers and of knowledge and skills is clear. Staffing and Quality of Care in Hospitals Nursing services are central to the provision of hospital care. Nursing care in hospitals takes on added importance today because the increase in acuity of patients requires intensive nursing care. At the same time, a rapidly changing health care environment, continuing pressures to contain costs, and the rising levels of severity of illness and comorbidity of inpatients all make it imperative for hospitals to explore innovative ways to redesign delivery of care without compromising quality. Restructuring in the Hospitals Redesign and reengineering have become principal strategies of the 1990s for many institutions and systems, and increasing numbers of hospitals are restructuring their organization, staffing, and services. Although redesign initiatives are undertaken for a variety of reasons, more than half of the hospital-based efforts are driven by the need to reduce operating costs and have focused on transforming work processes and rethinking roles and jobs. Staff reductions or changes in labor mix are at times implemented without attention to the organiza-

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--> tional changes that might facilitate the possibility of better patient outcomes with fewer, more appropriately trained and used staff. Concurrent with the efforts to restructure hospital services has been the development of total quality management and what is referred to as patient-centered care. These innovative approaches to patient care may also involve case management, the development of critical pathways for managing patients most efficiently during a hospital stay, and other steps that, collectively, lead to restructuring in the hospital. Because of the resource intensity of hospital nursing services, restructuring, work redesign, and cost reduction efforts have a direct impact on the nursing workforce. Changing Roles and Responsibilities of Nursing Personnel The challenge today is for care givers and patients to think about the continuum of care needed rather than simply the event of hospitalization. Foremost among these changes is to help RNs and other health care givers to learn how to plan for patient care before the patient is admitted to the hospital, as well as for care needed after discharge from the hospital. It is this challenge, along with the demands for increased efficiency within a standard of good quality of care that, in part, has led many hospitals to implement the concept of patient-centered care teams. As managed care expands, expedient decision making and good judgment will be increasingly more important for all health care providers, and the use of interdisciplinary approaches also will become increasingly the norm in the hospital sector. This system of organizing care relies on the case manager4 to integrate in-depth clinical knowledge, community resources, and financial and organizational requirements with patient needs and with institutional goals of providing high quality, cost-effective care. In acute care settings this role is most often performed by a RN, frequently one who has been prepared with education beyond the basic program of nursing education. Leading and managing the organizational transformations described above require talents or training that not all RNs now have. For the evolving hospital, the committee believes that it will be imperative for these management, leadership, and supervisory skills to be fostered through various educational programs. The committee believes that more advanced, or more broadly trained, RNs will 4   "Case management" includes comprehensive oversight of a patient's entire episode of illness incorporating interdisciplinary resource utilization in order to provide high quality, cost-effective care. The clinical and financial management of care is coordinated by "case managers" who often span the boundaries of inpatient, ambulatory and community settings (Satinsky, 1995). Some people prefer to use the term "care manager" in lieu of case manager. Care management suggests the provision of direct care and, in some instances a case manager may also be a care manager. For example, registered nurses who coordinate care for groups of hospitalized patients with the same diagnosis may also assume responsibility for giving some of these patients direct care.

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--> be needed in the future. Such training is essentially like that now provided for RNs who receive certification as, for example, advanced practice nurses. Over the past 20 to 25 years, a number of studies have attempted to capture adequately the benefits of the clinical nurse specialist for the patients as well as for economic reasons. In particular, the evidence from several randomized clinical trials indicates that: clinical nurse specialists can foster high quality, cost-effective care especially for patients with complicated or serious clinical conditions care, and improve the cost-effectiveness of health care systems and facilities because changing the mix of personnel involved in caring for patients with complex management problems may yield better outcomes, lower costs, or both. The committee concluded that the way should be clearer for such advanced practice nurses to be used in both inpatient and outpatient settings and for them to be able to take leadership positions and act independently. One obstacle to this, however, is found in the differing ways in which states recognize advanced practice nurses. Some state boards of nursing have not yet recognized the expanded responsibilities that such personnel can and should discharge. To address this problem, the committee believes that all states should recognize nurses in advanced practice in their nurse practice acts and delineate the qualifications and scope of practice of these nurses. Today, almost all hospitals in the United States use some kind of ancillary nursing personnel. In recent years the position of the nurse assistant (NA) has been changing. In some institutions they are assuming, under an RN's direction, increasing responsibility for more direct care activities than in the past. This results in rising levels of management and supervisory skills being required of RNs. By definition, NAs have less formal education and training than RNs or LPNs. Far less information about employment trends is available on this group of the nursing workforce than on the more traditional nursing categories. No national standards exist for minimum training or certification of ancillary nursing personnel employed by hospitals. Furthermore, no accepted mechanism exists either to measure competency or to certify in some fashion that ancillary nursing personnel have attained at least a basic or rudimentary mastery of needed skills. The committee is greatly concerned about these lacks and the potential for adverse impact on patient care. It believes that hospitals should take the lead in ensuring that all ancillary nursing personnel employed by them have documented evidence of competency and appropriate training. Culturally sensitive care will also become increasingly important in the years ahead. The population is not only aging but also is becoming more racially and ethnically diverse. Thus, increasingly, care givers and care receivers may come from different cultural backgrounds. The imperative for cultural sensitivity in training and practice is obvious. The changes briefly described above are appealing conceptually, and time will tell if they are effective and practical as the hospital sector reinvents itself. In

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--> the short term, however, these shifts in the way hospitals do business and the way they organize themselves to conduct that business, are causing notable disruptions and misgivings among the nursing staff. From the frequency and intensity of the commentaries that the committee heard during this study, RNs are concerned about the employment ramifications and, more importantly, the professional implications of the organizational changes that are occurring; they believe that these changes may lead to undesirable and unanticipated effects on quality of care. In the committee's view, the harmful and demoralizing effects of these changes on the nursing staff can be mitigated, if not forestalled altogether, with more recognition on the part of the hospital industry that involvement of nursing personnel from the outset in the redesign efforts is critical. Rapid changes in the health care delivery system and the resultant unstable situation fuel the concern among the nursing community that large decreases in RN staffing in hospitals are both occurring and leading to decrements in patient care and to threats to the health and well-being of nursing personnel. The committee finds that lack of reliable and valid data on the magnitude and distribution of temporary or permanent unemployment, reassignments of existing nursing staff, and similar changes in the structure of nursing employment opportunities greatly hampers efforts at understanding the problem and planning for the future. Furthermore, answers to such questions are needed for all levels of nursing personnel. Therefore, hospitals should not concentrate their monitoring and evaluation solely on the relationships between RN staffing and quality of care or on work-related illness and injury. Rather, hospitals should focus their efforts in monitoring and evaluating the redesign of staffing on the entire spectrum of their nursing personnel. The committee also supports productive collaboration between federal agencies and private organizations to develop databases containing information that will shed light on workforce issues and on the relationships of staffing, care processes, and patient outcomes. Measuring Quality of Care in Hospitals The committee first looked at quality in terms of the overall quality of care received by the patient in the hospital and examined the relationship between structural variables and both processes and outcomes of care. Recent years have seen important advances in measuring quality of patient care at the individual patient and population levels, involving both process and outcome measures. Existing work, however, has not typically focused on isolating the contribution of nursing care to overall hospital quality. Ensuring the quality of patient care is central to the mission of health care services in hospitals. During the study, the committee heard considerable concern expressed by RNs that increasing numbers of hospitals are restructuring and re-engineering, resulting in smaller proportions of RNs to total nursing personnel and in a probable negative impact on quality of patient care in those hospitals.

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--> This committee investigated the question of whether the quality of care in hospitals has deteriorated and whether empirical evidence exists of a link between the number and skill mix of nursing personnel and the quality of care. The committee found that little empirical evidence is available to support the anecdotal and other informal information that hospital quality of care is being adversely affected by hospital restructuring and changes in the staffing patterns of nursing personnel. At the same time, it noted a lack of systematic and ongoing monitoring and evaluating of the effects of organizational redesign and reconfiguration of staffing on patient outcomes. Unfortunately, few recent and objective national data are available that either describe the quality of care in hospitals or that show whether quality has been affected in any way by changes in the system of delivery of care. Indeed, the committee was shocked by the lack of current data relating to the status of hospital quality of care on a national basis, apart from information on indicators such as hospital-specific mortality rates. Because of this lack, the committee is unable to draw any definitive conclusions or inferences about the levels of quality of care across the nation's hospitals today. The committee does conclude, however, on the basis of the few available studies, that the quality of hospital care in general has not suffered, and may even have improved in some areas, after implementation of the Medicare prospective payment system (PPS). Although quality of hospital care did not suffer after PPS implementation, more patients were discharged too soon and in unstable condition and patients discharged in unstable condition had significantly higher mortality rates. This research suggests that there may be problem areas with the quality of hospital care, but that the extent of these problems today is not known because of the lack of objective current data. The committee is convinced that investigation of hospital quality of care warrants increasing and immediate attention. Research needs to move beyond hospital mortality as an outcome measure and to focus as well on process-of-care problems that occur during short hospital stays and on outcomes over an episode of care. Relationship of Nursing Staff to Quality of Care One of the research challenges in determining the relationship between staffing and quality of care has been the difficulty of isolating the factors (and the relative importance of these factors) that are involved in producing improved patient outcomes. Literature about the effect of RNs on mortality and about variables that affect the retention of RNs is available; differences in mortality rates across hospitals are well documented by several researchers and the literature on RNs' impact on hospital mortality rates is considerable. There is, however, a serious paucity of recent research on the definitive effects of structural measures, such as specific staffing ratios, on the quality of patient care in terms of

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--> outcomes when controlling for all other likely explanatory or confounding variables. Part of the problem lies in the area of severity of illness and risk adjustment, where patient acuity is a significant factor. Across-the-board staffing ratios tend to assume that in some measure all patients are "alike" and can be cared for with the same level and type of resources. Equally difficult is the task of establishing ratios that will be appropriate for all settings and situations. Staffing levels need to be specific to different types of acute care units and facilities. RN-rich staffing ratios are sometimes associated with improved patient outcomes, such as lower mortality rates among Medicare patients. Such staffing ratios are essentially proxy measures for other organizational attributes of hospitals that grant nurses autonomy over their own practice and control of the resources necessary to deliver patient care and create good relationships with physicians. That is, when nurses have more autonomy, status, and control, their behaviors on behalf of patients result in better outcomes. Despite this type of information on organizational and related factors, the committee was unable to isolate a number-of-RNs effect. The committee concludes, therefore, that high priority should be given to obtaining empirical evidence that permits one to draw conclusions about the relationships of quality of inpatient care and staffing levels and mix. Such data should focus on nursing care and quality of care across institutions and within given institutions, and across departments and services. The committee is convinced that more rigorous research on the relationship between nursing variables, broadly defined, and quality of care would have significant payoffs for policymakers, nursing educators, hospital administrators. The committee also is concerned about the paucity of objective research on the relationships among restructuring, staffing, and quality. The committee concludes that a clear need exists for some system of monitoring and evaluating the impact of the rapidly changing delivery system on the quality of patient care and the well-being of nursing staff. For this reason, it has advanced several recommendations intended to provide better information on hospital restructuring and to help in delineating those factors that affect patient outcomes. It also calls for the development of a research agenda in this area and for the articulation of reliable, valid, and practical measures of structure, process, and outcome to be used in quality-of-care research as well as quality assurance and improvement programs. A systematic effort is needed at the national level to collect data and develop a research and evaluation agenda so that informed policy development, implementation, and evaluation are undertaken in a timely manner. A major part of any such research agenda might call for elaboration of the actual variables—in terms of structure, process, and outcome—that warrant high priority attention in studies of the relationship of nursing care, staffing patterns for nursing, to patient outcomes. The American Nurses Association (ANA), for example, has been developing quality indicators that warrant further investiga-

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--> tion. The committee commends the ANA for its exploratory efforts to develop a set of nursing care quality indicators. This research can set an important precedent and standard for the development of meaningful quality standards relating to nursing. This research offers promise for further evolution of external regulatory quality assurance mechanisms (e.g., those of the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) and for improved public information efforts. Nevertheless, the committee judged that in the future, a broader set of inputs from the nursing community and other affected parties would be desirable. It also believed that efforts based solely in the private sector, with little or no public sector involvement, might be less useful than if federal and state perspectives were taken into account. The committee supports the current federal requirements and accreditation standards for nursing services in hospitals and emphasizes the need for hospitals to maintain the highest possible standards for nursing care. Moreover, the committee agrees that hospitals should develop improved methods for matching patient needs (severity-of-illness or acuity measures) with the level and type of nurse staffing. The committee endorses efforts to improve systems for planning appropriate nursing care as well as monitoring the outcomes of that care. Regulation of hospitals is a long-standing part of government responsibility and can take many forms, including certification, licensure, and accreditation. Under the Social Security Act, one pathway to hospital certification is through accreditation by the JCAHO; this is the route to certification used by most hospitals. Hospitals found to have met the JCAHO accreditation standards are deemed automatically to have met the federal Conditions of Participation for the Medicare program and are in effect considered certified to receive Medicare (and Medicaid) reimbursement. Among the key requirements of JCAHO certification are that: nursing care be provided on a 24-hour-a-day, 7-day-a-week basis; nursing services show evidence that each patient's status is monitored and that nursing care is coordinated with the care provided by other professionals; and specific patient care plans be in place and in use for each patient. Given the continued reliance of the federal government on JCAHO accreditation for hospital reimbursement by federal health programs, the committee was encouraged by the evolution of JCAHO's methods and standards in the past few years and by the more sophisticated attention being paid to the role of nursing care within those standards. The committee endorses the current federal requirements for hospitals to participate in Medicare, which incorporate the use of voluntary accreditation, to assure the quality of hospital care, and it is particularly supportive of requirements that call for matching nursing resources with patient needs. The committee believes that Congress ought to continue to support this element of assuring the quality of care in hospitals. Some broader issues of changes in nursing services, such as the enhanced responsibilities of advanced practice nurses and the use of ancillary nursing personnel and their competency, cut across the straightforward issue of the rela-

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--> tionship between nurse staffing and quality of hospital care. In reflecting on the role of nursing personnel in the future, therefore, the committee has also proposed recommendations about these specific types of nursing personnel. Staffing and Quality of Care in Nursing Homes The nursing home market is being stressed by an increasing demand for services combined with a constrained growth rate. To gain insights on issues surrounding the relationship of staffing patterns of nursing personnel to quality of resident care, the committee examined statutory requirements and information gathered during site visits and public testimony; it also reviewed an extensive body of research literature and empirical evidence on the relationships between staffing patterns and quality. Status of Quality of Care in Nursing Homes Quality of care in nursing homes is a complex concept, and defining it has been a difficult process. Some facilities provide high quality of care even in the face of fiscal constraint, but the quality of care provided in nursing facilities has for years been a matter of great concern to consumers, health care professionals, and policymakers. Since enactment of the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), some improvement has been reported as a result of increased efforts by the federal government to regulate the quality of nursing homes. Many facilities have increasingly focused on reducing negative outcomes and improving the process of care; in many others, however, quality-of-care problems continue to be reported. Several studies have identified negative outcomes in nursing facilities. Relationships Among Nursing Staff, Management, and Quality of Care The committee sought to determine if staffing as a measure of quality of care in nursing homes has improved since the implementation of OBRA 87. A slight but noticeable increase in staffing was evident, attributable partly to the requirements of the 1987 legislation and partly to the staffing needs created by the increased complexity of care required for subacute and other special care residents. The committee strongly endorses the intent of OBRA 87 and supports efforts by facilities and states to improve professional nurse staffing in nursing homes consistent with the intent of the statute. Many factors, both internal and external, influence staff performance and the quality of care provided to residents. Internal factors include staffing and staff characteristics such as education and training levels, patient characteristics such as acuity levels, job satisfaction and turnover of staff, salaries and benefits, and management and organizational climate. External factors include regula-

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--> tions, reimbursement policies, incentives, excess demand for services, and type and ownership of facility. The committee examined all of these factors through review of the research literature, information from administrative databases, information gathered during site visits and from testimony, review of regulatory requirements, and other relevant reports and reached several conclusions. During site visits the committee heard complaints from some nursing home staff about the paperwork involved in completing the Minimum Data Set (MDS), which is a crucial part of resident assessment procedures. Although the committee is sympathetic about the time-consuming nature of the forms, it strongly endorses the concept of an individualized care plan for each resident, which requires the use of tools such as the MDS. The committee also endorses current efforts by the Health Care Financing Administration (HCFA) to improve the MDS and to require all facilities to computerize MDS data and provide them to state and federal agencies, thus providing a mechanism for a national database. The research literature generally agrees on the strong relationship among resident characteristics, nurse staffing time requirements, and nursing costs in nursing homes. It shows that facilities need to adjust their staffing levels to take into account the condition of the residents so that they can ensure sufficient staff to provide for residents' basic needs. The preponderance of evidence, from a number of studies using different types of quality measures, shows a positive relationship between nursing staff levels and quality of nursing home care, which in turn indicates a strong need to increase the overall level of nursing staff in nursing homes. The research literature does not, however, answer questions about what particular ratio of staff to residents is optimal. Varying circumstances among nursing homes, case-mix differentials, and other external factors affect the type and level of staff needed. The committee thus endorses the HCFA staffing standards but is not inclined to recommend a specific minimum staffing ratio across all types of facilities to meet the needs of all types of patients. The committee affirms that nursing facilities should ensure adequate nursing services to meet the acuity needs of their residents. The committee recognizes the differences in nurse staffing and quality of patient care in nursing homes, on the one hand, and in hospitals, on the other. Hospitals and nursing homes may operate on very different segments of a staffing–quality relationship curve. Hospitals could be operating in the segment of the curve where returns from increases in staffing are low because they already have relatively high staffing levels; by contrast, nursing homes are operating at the low end of the staffing scale where positive returns from increases in staffing are observable. Extensive research literature exists on the effect on quality of care of the presence of professional nursing (RNs) to provide hands-on training and guidance to NAs. Given the level of NAs' direct care responsibilities and the minimal training for resident care required of them, professional nurse oversight and

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--> availability for close supervision of NAs and LPNs is critical—more so today than in previous years because of the changing characteristics of the residents. Based on the empirical evidence amassed, the committee concludes that a strong relationship between RN-to-resident staffing in nursing facilities and various dimensions of quality, especially resident outcomes, has been established. The committee, therefore, underscores the need to increase the presence of professional nurses in nursing homes on all shifts. Given the findings on the beneficial effects of continuous RN presence on various dimensions of quality, especially resident outcomes, the committee recommends an RN presence on all shifts in nursing homes as an enhancement of the currently required 8-hour RN presence. The committee of course recognizes that issues of staffing enhancement in nursing facilities cannot be viewed separately from costs. Ultimately, the committee was of the opinion that the public interest and the need for acceptable quality of care must be considered in addition to cost if we as a society are going to maintain a sense of values and responsibility for the care of the elderly, disabled, and disadvantaged. The committee, however, is reluctant to impose uncompensated costs on nursing facilities, and it concludes, therefore, that Medicaid and Medicare payment levels need to be adjusted accordingly. The committee further believes that waivers to this requirement could be granted by states only under exceptional circumstances. All but one of the committee members were in agreement with these positions. Based on its review of a number of studies, the committee concludes that there is sufficient evidence to show that the presence of geriatric nurse specialists and practitioners enhances quality of care in nursing homes. Moreover, research has shown that cost savings in the long run accrue, particularly due to reduced rehospitalizations and visits to emergency rooms. Nurse assistants constitute 70 to 90 percent of the nursing staff in nursing facilities. They provide most of the direct care and spend the most time with residents, but as stated earlier, they are the least trained. On the basis of experience and information gathered from the testimonies received, the committee came to the view that the organization, use, and education of NA staff make a substantial difference in the humane care, comfort, and health of nursing home residents and in the job satisfaction and health of the staff. The committee concludes that the training received by NAs should be enriched and that research is needed on the relationship of NA and LPN staff levels and training to quality of care. The changing focus of services and the increasingly complex nature of the care provided in nursing facilities create new demands for skill, judgment, supervision, and the management of nursing services, Most directors of nursing (DON) in nursing facilities are not academically prepared for their positions. Furthermore, turnover among DONs is high, their salaries are low in comparison with hospitals, and they have limited opportunities for advancement. None of these factors is conducive to strong leadership. In view of the number of employees,

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--> budgets, and complexity of care in nursing facilities today, strong leadership from DONs is required if high quality, cost-effective care is to be provided. The committee concludes that nursing facilities should place greater weight on educational preparation when employing new DONs. In the area of reimbursement policies, the committee notes the existence of several experiments designed to look at outcome-based incentives for improved quality of care. The committee concludes that additional research and demonstration projects on the use of financial and other incentives are needed to improve the quality of care and outcomes in nursing homes. Staffing and Work-Related Injuries and Stress Nursing is a hazardous occupation. Whereas the injury and illness rate in private industry as a whole has been stable or declining slightly since 1980, the rates for hospitals and nursing homes during the same period have increased by about 52 percent and 62 percent, respectively. Recent statistics and other information suggest that these institutions are becoming increasingly hazardous places to work, exposing workers to a wide range of risks. The committee reviewed the literature on work-related injuries, in particular back injuries and needlestick puncture wounds, that affect nursing personnel in hospitals and nursing homes. It also reviewed available research to assess the factors that contribute to work-related stress. The committee was struck by the high rate of injuries to nursing personnel in both hospitals and nursing homes, but except for back injuries the committee is unable to substantiate conclusively any linkages among staffing numbers, skill mix, and work-related problems. The committee is impressed, however, with the apparent effects of leadership from management, good employee training, and existing technologies on reducing the probabilities of injuries among nursing personnel. The committee concludes that considerable levels of injuries and risk of injury may exist at the level of NAs and other ancillary personnel, especially in long-term-care facilities, who may be subject to great stress and probability of injury (especially back injury) and who may be newly employed and comparatively thinly trained. The committee thus found an important need, especially among new employees, for more aggressive training related to the use of lifting devices, lifting teams, and ergonomic training in lifting techniques to prevent back injuries. The committee concludes that all personnel giving direct care (especially in nursing homes) should receive annual training in lifting and transferring patients. Such efforts would improve the quality of life for health care workers and could represent a significant savings to the health care industry. The committee also concludes that hospitals and nursing homes should develop effective programs to reduce work-related injuries. Violence toward health care workers appears to be on the rise. Increased violence in the general population, greater use of mind-altering drugs and alcohol

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--> abuse, and easier availability of weapons may all contribute to the problem of violence in health care settings. In examining available information on violence and abuse, the committee realized the intricate problems of work situations and of violence and abuse directed at patients, especially residents in nursing homes. Clearly many NAs are not abusive. A certain proportion, however, do verbally or physically abuse, steal from, or otherwise take advantage of nursing home residents. Unfortunately, even a small proportion of abusive staff can affect the health, quality of care, and peace of mind of thousands of nursing home residents. In the committee's view, therefore, nursing facilities should be required to ensure a safe and protective environment for residents by employing personnel who protect and care for residents and do not abuse and steal from them. The committee believes that much of the incidence of violence in hospitals and nursing homes are preventable and that prevention is a shared responsibility among employers and employees. The committee concludes, therefore, that health care institutions should implement a variety of strategies to prevent assaults against workers and residents and that they should screen applicants for patient care positions for past histories of abuse. Abuse prevention measures should ultimately apply to all who work in nursing homes and, for that matter, in all health care institutions. Recommendations On the basis of its findings and conclusions the committee has provided three categories of recommendations: (1) the level and staffing patterns of nursing personnel to promote quality of care in hospitals; (2) the level and skill mix of nursing personnel in nursing homes to promote quality of care in these facilities; and (3) strategies to reduce work-related injuries and stress. The text of the panel's recommendations, grouped according to these categories, follows, keyed to the chapter in which they appear in the body of the report The sequence in which the recommendations are presented does not reflect a priority order.

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--> RECOMMENDATIONS ON STAFFING AND QUALITY IN HOSPITALS Recommendation 5-1: The committee recommends that hospitals expand the use of registered nurses with advance practice preparation and skills to provide clinical leadership and cost-effective patient care, particularly for patients with complex management problems. Recommendation 5-2: The committee recommends that hospitals have documented evidence that ancillary nursing personnel are competent and that such personnel are tested and certified by an appropriate entity for this competence. The committee further recommends that the training for ancillary nursing personnel working in hospitals be structured and enriched by including training of the following types: appropriate clinical care of the aged and disabled; occupational health and safety measures; culturally sensitive care; and appropriate management of conflict. Recommendation 5-3: The committee recommends that hospital leaders involve nursing personnel (RNs, LPNs, and NAs) who are directly affected by organizational redesign and staffing reconfiguration in the process of planning and implementing such changes. Recommendation 5-4: The committee recommends that hospital management monitor and evaluate the effects of changes in organizational redesign and reconfiguration of nursing personnel on patient outcomes, on patient satisfaction, and on nursing personnel themselves. Recommendation 5-5: The committee recommends that the National Institute of Nursing Research (NINR) and other appropriate agencies fund scientifically sound research on the relationships between quality of care and nurse staffing levels and mix, taking into account organizational variables. The committee further recommends that NINR, along with the Agency for Health Care Policy and Research (AHCPR) and private organizations, develop a research agenda on quality of care. Recommendation 5-6: The committee recommends that an interdisciplinary public–private partnership be organized to develop performance and outcome measures that are sensitive to nursing interventions and care, with uniform definitions that are measurable in a uniform manner across all hospitals.

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--> RECOMMENDATIONS ON STAFFING AND QUALITY IN NURSING HOMES Recommendation 6-1: The committee recommends that Congress require by the year 2000 a 24-hour presence of registered nurse coverage in nursing facilities as an enhancement of the current 8-hour requirement specified under OBRA 87. It further recommends that payment levels for Medicare and Medicaid be adjusted to enable such staffing to be achieved. Recommendation 6-2: The committee recommends that nursing facilities use geriatric nurse specialists and geriatric nurse practitioners in both leadership and direct care positions. Recommendation 6-3: The committee recommends that the training for nurse assistants in nursing homes be structured and enriched by including training of the following types: appropriate clinical care of the aged and disabled; occupational health and safety measures; culturally sensitive care; and appropriate management of conflict. Recommendation 6-4: The committee recommends that research efforts on staffing levels and skill mix specifically address the relationship of licensed practical nurses and nurse assistants to quality of care. Recommendation 6-5: The committee recommends that, in view of the increasing case-mix acuity of residents and the consequent complexity of the care provided, nursing facilities place greater weight on educational preparation in the employment of new directors of nursing. Recommendation 6-6: The committee recommends that the Secretary of Health and Human Services fund additional research and demonstration projects on the use of financial and other incentives to improve quality of care and outcomes in nursing homes. RECOMMENDATIONS ON WORK-RELATED INJURY AND STRESS Recommendation 7-1: The committee recommends that hospitals and nursing homes develop effective programs to reduce work-related injuries by providing strong leadership, instituting effective training programs for new and continuing workers, and ensuring appropriate use of existing and emerging technology, including lifting and moving devices and needleless medication delivery systems. Recommendation 7-2: The committee recommends that all hospitals and nursing homes screen applicants for patient care positions filled by nurse assistants for past history of abuse of patients and residents, and criminal records.