The committee understands that a number of the workforce issues it was asked to address should be examined in the context of emerging forms of practice, such as patient-centered teams, networks, and independent practice. The evolution in duties and responsibilities of a wide array of health care workers might be characterized as a revolution. The nursing community, including RNs, nurses in advanced clinical practice, licensed practical nurses (LPN), and nurses assistants (NA) and other ancillary nursing personnel, lies absolutely at the center of this revolution. Clinical practice, management, education and training, and research are a few of the different roles RNs undertake. Anecdotal information suggests that increasing numbers of NAs are being employed in hospitals, and at times are assigned tasks that have not been clearly delineated and for which they may not have been trained. The rapid rate of change in these and other areas requires more research and, doubtless, changes in education and training programs for the future.

The committee found itself deliberating on many issues involving RNs, LPNs, and ancillary nursing personnel such as nurse assistants, in terms of the roles they play in the delivery of care in hospitals and nursing homes, respectively. Supply and demand information about LPNs is not as rich as the information available about RNs. Even less is known, and few data are available, about NAs; yet they are a large proportion of the total nurse workforce. To the extent that these nursing personnel remain a significant, but comparatively invisible, part of the nursing community, this paucity of information about their actual roles in health care delivery, their training, and their career paths complicates sensible policy-making about education, reimbursement, and similar matters.

The committee observed the need for: (1) greater investment in the nursing workforce; (2) improved leadership, organizational, and management skills within the ranks of the nursing community; and (3) the need for better coordination with other care givers. Nursing should not be viewed in isolation from other professions and training should reflect the relation to those other professions. At the same time, there is a need for a clear nursing identity reflecting new skills and new roles within the health care system. Recent reorganizations of hospitals sometimes result in a diminution of the old nursing identity. If adjustments are not forthcoming such changes could ultimately impact negatively on patient care.

The committee stands firmly behind the proposition that the relationship between nurse staffing and quality of patient care has been clearly established for the nation's nursing homes. In other words, the value added to resident health and well-being by an adequate number and educational mix of nurses is clear. The committee recognizes the differences in nurse staffing and quality of patient care in nursing homes on the one hand, and in hospitals on the other. Hospitals and nursing homes may operate on very different segments of a staffing–quality relationship curve. Hospitals could be operating in the segment of the curve where returns from increases in staffing are low because they already have relatively high staffing levels. By contrast, nursing homes are operating at the very



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