1
Introduction

Rapid and unpredictable change throughout society is the hallmark of the twentieth century. Change has become a constant in today's environment in every employment sector, from small businesses to large corporations, from government agencies to non-governmental organizations. The health care sector is no exception, and notable advances are occurring in molecular biology, biomedical technology, data and information systems, and health care delivery.

The U.S. health care system has undergone major restructuring since the early 1980s as a result of scientific and technological breakthroughs, market forces, cost containment efforts, and radically different payment policies for Medicare patients. These forces, combined with the growth of managed care in more recent years, have had a major impact on the organization, financing, and delivery of health care and on the clinicians, technicians, and facilities (both acute care and long-term care) that deliver care.

Steady pressures for cost containment combined with competition, and the rapid escalation of restructuring and mergers, consolidations, and closures of hospitals, have led to work redesign, reconfiguration of staffing patterns, and downsizing. Market competition in an environment of economic constraints has led to a rapid growth of outpatient services and departments, home- and community-based services, and subacute care units. At the same time, inpatient use of hospitals, lengths of hospital stay, numbers of inpatient admissions, and the number of beds staffed have all declined. As a consequence, patients in hospitals have a higher level of acuity (i.e., are on average far sicker) and are in need of more professional, highly skilled nursing care than in earlier years. Professional nurses not only have sicker patients but the boundaries between medicine and



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--> 1 Introduction Rapid and unpredictable change throughout society is the hallmark of the twentieth century. Change has become a constant in today's environment in every employment sector, from small businesses to large corporations, from government agencies to non-governmental organizations. The health care sector is no exception, and notable advances are occurring in molecular biology, biomedical technology, data and information systems, and health care delivery. The U.S. health care system has undergone major restructuring since the early 1980s as a result of scientific and technological breakthroughs, market forces, cost containment efforts, and radically different payment policies for Medicare patients. These forces, combined with the growth of managed care in more recent years, have had a major impact on the organization, financing, and delivery of health care and on the clinicians, technicians, and facilities (both acute care and long-term care) that deliver care. Steady pressures for cost containment combined with competition, and the rapid escalation of restructuring and mergers, consolidations, and closures of hospitals, have led to work redesign, reconfiguration of staffing patterns, and downsizing. Market competition in an environment of economic constraints has led to a rapid growth of outpatient services and departments, home- and community-based services, and subacute care units. At the same time, inpatient use of hospitals, lengths of hospital stay, numbers of inpatient admissions, and the number of beds staffed have all declined. As a consequence, patients in hospitals have a higher level of acuity (i.e., are on average far sicker) and are in need of more professional, highly skilled nursing care than in earlier years. Professional nurses not only have sicker patients but the boundaries between medicine and

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--> nursing have shifted with the advance of science and technology, leaving them with an ever increasing work jurisdiction. The changes in the hospital sector combined with economic and other forces are changing the characteristics of persons entering nursing homes and are placing new demands for beds and for provision of nursing care on these facilities. The U.S. population is aging. The growing population of the elderly, especially the older elderly, will increase admissions to inpatient hospitals and nursing homes. This situation, combined with the rising acuity of patients in both hospitals and nursing homes, will exacerbate the long-standing problems of staffing, including the paucity of appropriately educated and trained professional nursing personnel. The emphasis on economic efficiency encourages a balance of costs and benefits. In securing these benefits, however, analysts and decisionmakers should not lose sight of the ultimate goal—the sensitive and compassionate care of patients. Hospitals are responding to the changing health care system by taking several measures, including modifying their staffing levels and their mix of nursing personnel. Individual care givers, professional and trade associations involved with nursing, and unions have expressed concerns that these changes are endangering the quality of patient care and causing nursing staff to suffer increased rates of injury, illness, and stress. Immediate Origins Of The Institute Of Medicine Study In February 1993 the Subcommittee on Health and the Environment of the House Energy and Commerce Committee held a hearing on the conditions of nursing and nursing care in the United States. A member of the Service Employees International Union (SEIU) described the adverse effects of poor or inadequate staffing on patients and nursing staff.1 The subcommittee felt that it needed independent assessment of the stated problems. Thus, as part of the National Institutes of Health Revitalization Act of 1993 (P.L. 103-43, Subtitle B, section 1512), Congress directed the Secretary of the Department of Health and Human Services (DHHS) to sponsor 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 to promote the quality of patient care and to reduce the incidence among nurses of work-related injuries and stress. For purposes of this study Congress defined ''nurse" to include registered nurse (RN), licensed 1   In response to concerns among its members, in early 1992 SEIU mailed questionnaires to 47,000 registered nurse and licensed practical nurse members inquiring about their perception of the quality of patient care and the quality of work life for the nursing staff. The report on this inquiry received much publicity (SEIU, 1993).

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--> practical nurse or licensed vocational nurse2 (LPN), and nurse assistant (NA). It further directed the Secretary to ask the Institute of Medicine (IOM) to conduct the study. Committee Charge To carry out this legislative mandate, in March 1994 the Division of Nursing, 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. The IOM appointed a committee consisting of 16 members representing a range of expertise related to the scope of the study. 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 will be referred to as licensed practical nurses.

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--> Definitions Before responding to Congress' charge to assess the needs for nursing personnel, the committee had to resolve issues of definition, approach, and scope of its inquiry. How is the committee to determine the need to increase staffing? What constitutes an adequate number or type of staff, how does one measure adequacy, and relative to which goals? In mandating this study, Congress specified two goals: (1) to promote the quality of patient care and (2) to reduce the incidence of work-related injuries and stress among nursing staff. Congress defined nurse broadly. The committee's charge, therefore, is not limited to examining the adequacy of the number of RNs in this country's hospitals and nursing homes; rather, it includes all nursing personnel (RNs, LPNs, NAs). To provide an operational context for the language of congressional charge, the committee had to develop working definitions of need and adequacy. These concepts are discussed briefly below. Need Hospitals The committee, in defining need in hospitals, adopted the approach taken in a previous IOM study that assessed the needs, availability, and requirements for allied health personnel (IOM, 1989). The committee distinguished between the two different approaches implied by the term need. Need, as used in the context of health resource planning, refers to a normative idea of the number and type of personnel required to provide therapeutic and preventive services to a defined population, independently of ability and willingness to pay. Demand, by contrast, refers to the number and type of personnel that employers are willing to hire and that consumers are willing and able to pay. The demand concept recognizes that nursing services are not free and that, if all else remains the same, the quantity of nursing services demanded will increase (decrease) as the price for the service decreases (increases). The committee has construed "need" in the congressional mandate to mean "effective demand" for nursing personnel in hospitals. This decision was based on the committee's judgment that this approach is the most useful and responsible guide for hospital-based resource planning. Nursing Homes In defining need for nursing home settings, again following the principles laid out in previous IOM reports on the subject (IOM, 1986b, 1989), the committee took a patient-oriented approach in examining nursing care staffing needs; it

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--> focused on characteristics of the residents' needs and the corresponding staffing required to provide adequate nursing care. The approach places greater emphasis on the nature of the nursing services required by nursing home populations. In other words, the issue is more about "what" and less about just "how much." Nursing homes3 differ from hospitals in several respects. First, the resident in a nursing home typically lacks the power usually ascribed to consumers (even more so than patients in hospitals who are there generally for a very short time), to some extent because of the relatively long-term nature of functional and cognitive impairments. Second, as distinct from hospitals, many residents live in nursing homes for many years. Third, because any private insurance coverage for long-term nursing home care is rare, Medicaid is the principal public payer. Thus, given Medicaid's major role as payer, the government's involvement to ensure that public monies are well spent has been considerable. While identifying accurately the needed changes in the quality of staffing in a long-term care environment, one must recognize the cost in money, time, and resources required to achieve desired outcomes. These quality improvements mean providing the number, quality, and skills of the health care providers, and the organizing and delivering of services to enhance the quality of life for residents in nursing homes. Adequacy One written testimony submitted to IOM aptly described adequate staffing: "Adequacy is not just a number, it is a capability. It is critical that there be not only enough staff, but that they are properly trained and appropriately supervised in their assigned tasks, and they are motivated to care for the elderly and disabled people." That is to say, adequacy of nurse staffing means enough nursing services to provide high quality of care in hospital and nursing home settings and to ensure a safe environment for patients and staff. Further, adequacy to achieve the nursing tasks implies an understanding of the nature and scope of those tasks and a view of how those tasks can be accomplished. In the case of nursing staff, the nature and scope of the tasks reflect the contribution of nursing to a patient's overall level of quality care. In this regard, the product is an outcome—quality of patient care—that results from a number of inputs. Nursing care is one, but only one, of the important inputs in the achievement of quality patient care. Quality of care relates to a successful outcome to the illness episode, where success is defined in patient-oriented terms related to functioning, perceived health, and satisfaction. In the case of chronic disease and frailty, however, the episode of illness needs to be decomposed into subphases related to progression, 3   Throughout the report, the terms "nursing home" and "nursing facility" are used interchangeably.

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--> arrest, and palliation of disease. Outcome, therefore, for any particular patient is multidimensional, an array of attributes, and not just whether one recovers or not. Thus, an assessment of the adequacy of nursing staff must be contextual. Increased nursing staff levels (or a richer skill mix in the nursing staff) may or may not result in an overall increase in quality of patient care, depending on what other inputs would produce in terms quality of patient care. Briefly, adequacy of nursing staff cannot be viewed independently of the availability of other resources with which nurses combine their skills and knowledge to produce quality patient care. The committee believes that no single model, in all contexts and all circumstances, necessarily leads to an optimal outcome. Many different quantitative and qualitative staffing patterns for nursing care could lead to quality patient care. Thus, adequacy of nurse staffing should be considered not in terms of numbers or ratios alone. Needs for nursing services are affected by other variables such as severity of illness and organization of nursing care. Management and leadership, a culture of caring and compassion, a sense of staff teamwork, availability of facilities conducive to human care, experience, education, and support systems—all are necessary considerations in assessing whether a staffing pattern for nursing care is adequate to contribute to quality patient care. Focusing on nurse staffing inputs without consideration of the totality of circumstances and inputs can lead to a distorted view and appraisal of the conditions affecting patient care. The committee had to consider another fundamental question: What level of quality is desired by those paying for the services? In health care particularly, quality is a multifaceted concept. The structure of the health care system is not necessarily monolithic; levels of resources committed to the purchase of health care by different private-employer purchasers and by public purchasers (Medicare and Medicaid) differ across states. One cannot determine the adequacy of nurse staffing without making some assumptions regarding the level of demand or willingness to pay on the part of payers. Ultimately, the appropriate level of adequacy is an economic and political decision. The committee viewed as its first responsibility to provide Congress information on the nature and status of knowledge about the relationship of staffing and quality of patient care and work-related injuries and stress. The committee believes that it has made a substantial contribution in this report by providing insights into the following questions: (1) Is quality of care adequate or deficient? (2) Is staffing related to quality of care? If so, how is it related? (3) Has the incidence of work-related injuries and stress increased? If yes, is this related to staffing levels? and (4) What should be done? Furthermore, in responding to its charge, the committee decided that although current interest and concern among constituent groups about the staffing conditions in hospitals and nursing homes are intense, the future of nursing services in a health care system is equally critical for planning and policy. Hence,

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--> the committee addressed today's needs, and also attempted to take a somewhat long-term view, looking ahead at nursing staff in the context of the health care delivery system evolving into the next century. By the beginning of the next century, the types of care delivered at various sites will undoubtedly differ from the care boundaries that existed only two decades ago. Study Approach The committee addressed its charge with several activities. Mainly, it relied on the use of existing information from a variety of sources to focus on important issues. It reviewed and analyzed an extensive body of research literature, published and currently under way. It also consulted a wide selection of other relevant materials, including various reports, published and unpublished, prepared by unions, nurse and hospital associations and others, based on responses from their members. It assessed comments from their members, reports and other material from nursing home industry groups and nursing home resident advocate groups, analyses of published and unpublished data from the federal statistical systems, trade and professional associations and special detailed tabulations on trends at national and subnational levels obtained from the American Hospital Association; special small surveys conducted by various groups; and research workshops held on behalf of the study committee. The committee did not collect primary survey data or undertake independent inferential analyses of data. The committee met five times between March 1994 and July 1995 to deliberate on the issues outlined above. Experts were invited to speak to the committee on the various issues at four of these meetings. A listing of these presentations can be found in Appendix A. To avail itself of expert and detailed analysis of some of the key issues beyond the time and resources of its members, the committee commissioned background papers from experts in areas of relationship of staffing to quality of care, work-related injuries and stress, and education and training issues. The specific papers are included in Part II, Section 3 of this report. The committee also expanded and augmented its perspective and views with deliberations of a liaison panel, testimony, and site visits. Liaison Panel Because of the considerable number and array of professional groups and trade organizations concerned with the issues studied, a liaison panel comprising representatives of 20 organizations was appointed. A roster of the liaison panel members and their affiliations can be found in Appendix B. The panel met formally early in the study. It served in a consultative and information exchange capacity. Several members of the panel provided the committee with results of

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--> special surveys, specific informational material, and other background information from their organizations throughout the study. Testimony Public hearings provided an opportunity for interested and concerned parties to express their views to the committee and for the committee to obtain, firsthand, an extensive range of opinion on the matters under consideration. In the summer of 1994, the committee sent out over 500 announcements to health care givers, industry associations, unions, nurse associations, national and state boards of nursing, nursing home resident advocates, hospital and nursing home associations, and concerned and interested individuals. The committee received more than 100 written statements in response to its request. Two public hearings were held in conjunction with the committee meetings, one in Washington, D.C., and the other in Irvine, California. Of the persons and organizations who sent in written statements, 44 of them presented oral testimony at these hearings and responded at that time to questions from the committee. These witnesses represented an extensive range of health care givers and provider organizations, consumers and consumer advocates, professional organizations, unions, and others across the country. A summary of the testimony is included in Part II, Section 1 of this report. Site Visits Site visits to localities and facilities around the country collectively are intended to offer insights on the issues confronting the study committee and supplement in important ways the research, analysis of data, discussions with experts, and the committee's own experience. The purpose of these visits is to seek understanding of the issues pertinent to the study mandate and the views of concerned and interested parties, and not to evaluate or draw public judgments about local efforts. Those hosting the site visit teams for this study were assured confidentiality about any information or remarks they might provide to the committee. Consequently, no specific material that could identify facilities or individuals is made public without their explicit permission. During the fall and winter of 1994–1995, the committee conducted site visits in Mississippi, Missouri, New York, and Oregon. During each of these site visits, two or three committee members and IOM staff met with staff of various hospitals, nursing homes and other organizations, members of professional associations, and groups of concerned individuals to hear firsthand about their concerns, what they perceive as problems, how their operations function, and similar topics. Committee members attempted to observe a broad range of nurse staffing arrangements in a variety of facilities—public, for-profit, not-for-profit and aca-

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--> demic hospitals, proprietary and voluntary hospitals, and nursing facilities—in metropolitan and nonmetropolitan locations. Because individual sites are chosen for the insights they can provide, and loosely to represent a few broad categories, the site visits are not intended to result in an objective, quantitative analysis of national or even subnational nurse staffing patterns. Rather, they afford committee members an opportunity to form impressions based on their personal observations and also to benefit from the experiences of individuals involved directly in issues related to the study mandate. A summary report of the site visits is included in Part II, Section 1 of this report. Underlying Assumptions And Values The present study should be considered a first step toward addressing a major topic of concern in health care policy, namely, the role of nursing services in ensuring the delivery of quality patient care. These issues must be considered in an environment undergoing rapid changes that are themselves influenced by pressures of cost containment and competition. The issues are complex, and all involve difficult choices. The choices will reflect societal values. In the current health care environment, the traditional roles of various individual and institutional participants are undergoing substantial change. Purchasers of health care are becoming more aware of rising costs. They want cost containment without sacrificing quality of care. They are challenging traditional professional autonomy on decisions pertaining to health care. They are pushing health care providers toward more cost-effective methods. In response to the emerging dominance of payers, health care providers are considering alternative forms of organization. The open-ended financing that has characterized the health care industry in the past is no longer acceptable. Payers are challenging professionals and other providers to justify the effectiveness and efficiency of their services and to compete on price. Increasingly, providers also are confronting a fixed budget, negotiated in advance, and are expected to make do (or make a profit) within these financial constraints. Institutions are investigating ways to find more efficient means to deliver services and to cut costs. The goal is to retain quality, but the characteristic of market competition is that, at times, the quality of care that some professionals believe is appropriate is not "in sync" with the level of quality that payers are willing or able to pay for. Thus, costly incremental quality enhancements may be reconsidered in light of fiscal realities. Health care providers are actively thinking about issues of institutional structure and staffing levels and mix of personnel. At the same time, the committee strongly believes that during these times of rapid change, while weighing legitimate concerns about health care costs and acknowledging past overuse of some services, society must balance against those concerns both the rights of consumers to receive quality care in a digni-

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--> fied manner and the rights of those providing that care to work in a safe and healthy environment. The twin goals of providing quality health care can be described as (1) meeting individual needs and (2) ensuring an equitable provision of basic care in a cost-effective manner. The challenge is to assure that all persons (poor and minority included) have equal opportunity to quality health care, i.e., nursing services should be adequate for such care and understanding of, and sensitive to, special needs. The committee further recognizes the fundamental importance of considering the quality of life of patients and residents in hospitals and nursing homes. The goal of long-term care has been defined as the maintenance or restoration of the highest possible level of physical, mental, and social functioning of individuals within the constraints of their illness, disabilities, and environmental settings (IOM, 1989). For residents in nursing facilities, who are there for a sustained period of time, quality of life means provision of a home-like atmosphere, care and caring, dignity, and sustained efforts to maintain or improve living conditions and, for some, to recognize the inevitability of death. For care delivered in hospitals, the balance between quality of care and quality of life differs somewhat from the qualities of care and life in nursing homes, but is no less important. Most people with acute care needs enter hospitals for short-term medical attention and the attendant nursing care. Quality-of-life considerations (as distinct from quality of patient care) do not affect such patients as much as they do the residents of nursing facilities, because of the comparatively brief length of stay. In hospitals, quality of care has relevance more in terms of the long-term results of medical decisions and actions taken during the current episode of illness. Organization Of The Report The committee used four criteria for judging the contents of its final report and its specific recommendations. First, the topic should be within the scope and purview of the committee's charge. Second, the topic should be important, relevant, and within the scope of the study. Third, the evidence about the subject should be sufficient to support and justify its findings and recommendations. Fourth, a recommendation should be attainable at reasonable cost. The report is organized in a manner responsive to the legislative mandate and the contract charge. Part I of the report contains the committee's findings and recommendations. Part II contains the resources obtained and used by the committee to assist in committee deliberations, including the study activities undertaken, statistical information, and background papers on key issues commissioned from experts in the field. Hospitals and nursing homes represent two separate but related markets; they have different financing sources, and they face different issues with regard

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--> to several topics within the purview of this study. For the most part, they are discussed separately in the report. The next three chapters set the framework and provide the context within which the committee addressed the key issues under study. They briefly describe the changing demographic profile of the nation, and the implication of these changes for the health care system, the changing demand for, and use of, health resources in hospitals and nursing homes, and the implications for the future supply of nursing staff and the type of education and training that will be needed to adequately prepare them to meet the demands of tomorrow's jobs. The three chapters that follow review the research literature and the analyses of the key issues studied by the committee. Chapters 5 and 6 review and analyze the relationship of staffing issues and their linkage, where it exists, with quality of care in hospitals and nursing homes. Chapter 7 reviews available information on the incidence of work-related injuries and stress to nursing staff in hospitals and nursing homes, and examines the nature and strength of the relationship between work-related injuries and stress and staffing patterns. Finally, Chapter 8 provides the committee's epilogue to the study. Although the committee has made a concerted effort to obtain data and objective evidence based on research, some of its conclusions and recommendations are ultimately derived from professional judgment based on the expertise and experience of committee members, anecdotal information, testimony, and information provided by concerned constituencies. The committee consisted of persons with diverse backgrounds and expertise. Extensive discussions of the available evidence were undertaken during committee meetings to achieve consensus. For a number of reasons the committee did not address every possible issue that might be considered relevant or related to its specific charge. For instance, the issues surrounding foreign-trained nurses is not addressed by the committee in its discussion of nursing personnel. The committee deferred to the Immigration Nursing Relief Advisory Committee (1995) established under Public Law 101-238. That committee was advisory to the Secretary of Labor and issued its report in May 1995. The committee also did not address in depth the growth of long-term care settings other than nursing homes. Although the importance of these settings is growing, their detailed discussion was beyond the scope of the contract charge. The committee did not research issues of access to hospital and nursing home care in order to keep the report focused. There is some evidence that lack of insurance and discrimination may be factors in reduced access to care by minorities. At first glance the scope of the study—nursing staff in hospitals and nursing homes— may appear to some to be narrow; in reality, however, it is very broad and complex, especially at a time when the U.S. health care system is undergoing rapid and profound changes. The magnitude of the material that needed to be collected, reviewed, and analyzed to address adequately the study topics also

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--> demanded that the committee stay within the specific mandate of the contract and not try to cover all possible related topics. Although the principal intent of the report is to address the specific concerns of Congress as defined in its mandate, the committee believes that the report will provide guidance to a wider audience responsible for organization, delivery, and financing of health care and for federal health care policy. Finally, when the study originally was requested, the national debate on health reform was under way. Since then many changes have occurred and many others are under consideration. Because the complexity of the various issues are so great and volatile, the committee made a decision not to speculate outcomes but to conduct its study based on objective and scientific evidence available to it.