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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