The ANA (1994) has expressed concern about a number of events that are occurring with ever-increasing frequency:

  • adoption of new models of care delivery without sufficient testing, including changes in workforce patterns that may cause a decline in patient safety and quality of care;

  • downsizing, layoffs, and other cost containment measures, with substitution of less highly skilled personnel for RNs; and

  • lack of education and redeployment strategies to ensure a supply of appropriately prepared RNs for the demands of the future.

Along with these trends, health services research has documented a statistically significant relationship between the level and mix of nursing staff in hospitals and patient outcomes (Prescott, 1993). Specifically, as the number of nurses and the percentage of RNs on staff increases, risk-adjusted hospital mortality rates decline, as does length of inpatient stay.

The ANA is concerned about the possibility of declining patient safety and adverse health outcomes, as well as the increasing stress (physical and psychological) on nurses that is likely to increase work-related injuries as a consequence of downsizing and lowered skill requirements of the patient care workforce. As noted by Redman (1994), current changes in workforce patterns at healthcare facilities are resulting in fragmentation of nursing care, with fewer opportunities for one-to-one contact of nurses with patients. The replacement of RNs with unlicensed assistant personnel (UAPs) further distances RNs from direct contact with patients. According to the ANA, almost half of the state nursing associations deem the new mix or proportions of RNs and UAPs as unsafe. To paraphrase Redman, it may be possible to get knowledge of environmental concepts into the nurse, but because of declining direct patient contact by RNs, it cannot be assumed that such environmental health concepts will be integrated into nursing practice (Redman, 1994).

Under such circumstances, the call for adding more environmental health content to nursing practice may ring very hollow to some. However, the committee is not recommending something new, but rather a return to earlier, broader views of the nursing profession that include environmental concerns. Enhancing environmental health content in nursing practice will involve an elaboration of existing skills and perspectives, such as including environmental factors in history taking and seeking methods of primary prevention to eliminate illness and injury.

Funding for Public Health

Recent efforts toward health care reform on both federal and state levels focus attention on improving access to care for the sick through



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