shifts in work settings. With respect to the hospital setting, 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.

Throughout the decade of the 1980s, hospital expansion, scientific advances, and technological development led to the use of an increasing number of nursing personnel, particularly the RN. As discussed in Chapter 4, employment of RNs in hospitals has increased steadily for the past several decades. In 1993, RN employment in hospitals continued to increase, but the rate of growth over the previous year showed a slight decline for the first time in many years (AHA, 1995b). However, a comparison of first-quarter 1994 data with preliminary data for the first quarter of 1995, shows that while total hospital employment was down; RN employment increased by 3.5 percent, and licensed practical nurse (LPN) employment declined by 1.2 percent (see Table 4.3). These figures may represent a 1-year artifact or an indication of an underlying shift in the health care delivery system.

Information about trends in employment levels of RNs and other nursing personnel needs to be understood in the context of the changing health care system, as elaborated in Chapters 3 and 4. In particular, hospital inpatient lengths of stay continued to decline, along with inpatient days; admissions increased in 1995 after remaining relatively level in 1994. The increasing acuity of patients requiring intense nursing care, the large increase in hospital outpatient services, and the relative increase in beds dedicated to intensive care units also may account for at least part of the continued increase in hospital employment of RNs.

In sum, although the committee heard reports of widespread layoffs of RNs and other nursing personnel, national statistics suggest that in the aggregate these employment losses appear to have been more than offset by hires. (This generalization does not hold for licensed practical nurses [LPN], whose employment by hospitals has been declining for some years.) The continued growth in RN employment appears to run counter to many assertions the committee heard from nurses during site visits, testimony and numerous written and oral communications throughout the study. Aggregate trends, of course, obscure local and regional variations that respond to local market conditions and other factors, and anecdotal information cannot be discounted totally as it often is a warning indicator of changes that are not yet reflected in national statistics.

This chapter examines the relationship of staffing patterns of nursing personnel in hospitals and quality of patient care. The chapter begins with a discussion of the restructuring of hospital care and the changing roles of nursing personnel in hospitals. It then provides a brief overview of the elements of quality of care, measurement issues, and the status of quality in hospitals. Next, it proceeds to assess whether there is any reliable evidence linking nurse staffing to the quality

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