well as reconfiguration of units, departments, and care teams. The redesign of nursing services also is leading to changes in the roles and responsibilities of RNs and to increased emphasis on interdisciplinary teams. These developments have prompted uncertainty in employment and great concern among RNs about the potential for erosion of quality of hospital care, and about their own well-being.

In this chapter the committee has examined these concerns, specifically whether quality has deteriorated and whether empirical evidence exists of a link between the number and skill mix of nursing personnel and the quality of patient care. The committee has 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 the committee notes a lack of systematic and ongoing monitoring and evaluating of the effects of changes resulting from organizational redesign and reconfiguration of staffing on patient outcomes.

Researchers have concluded that although RN-rich staffing ratios are sometimes associated with improved outcomes, the results of their research indicate that they are essentially proxy measures for organizational measures. For quality of care changes, the committee was unable to isolate a number-of-RNs effect from the organizational and related factors attending different levels of staffing. The committee concludes 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.

The committee, however, is concerned about the paucity of objective research on the relationship between staffing and quality, and the effects of restructuring. The committee concludes that a clear need exists for a system for 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 and analyze current and relevant data and develop a research and evaluation agenda so that informed policy development, implementation and evaluation are undertaken in a timely manner.

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 relationship 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.

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