nary teams of care givers including registered nurses (RN), licensed practical nurses (LPN),2 and nurse assistants (NA) and other ancillary nursing personnel.3 They are also downsizing staff to accommodate the reduced volume of inpatient care and to remain economically viable.

The lines between the hospital and the nursing home are beginning to blur. New developments in hospital organization combined with economic and other forces are changing the characteristics of the persons entering nursing homes and are creating new demands for beds and for provision of nursing care in these facilities.

The aging and increasing diversity of the U.S. population and the projected growth of the oldest-old age group will have a major effect on the demand and supply of health services and on the level and type of resources needed to provide those services. These trends are likely to increase inpatient hospital admissions as well as admissions to nursing homes. When combined with the rising severity of illness of patients in both hospitals and nursing homes, these patterns can be expected to exacerbate the long-standing problems in these institutions involving staffing issues, including the paucity of appropriately educated and trained professional nursing personnel.

The implications of these changes in the health care environment for the nursing workforce are profound in terms of numbers, adequate distribution of skills, and educational preparation. Nursing personnel are an integral component of the health care delivery system; therefore, they are affected directly by these changes. It is not surprising that concerns about the fate of patients and health care givers have grown as reported in the media. Within the nursing profession and its supporting organizations there is a high level of uncertainty and concern about what is happening to nursing staff in terms of their physical, psychological, and economic well-being. Individual care givers, professional and trade associations involved in nursing, and unions have expressed concerns that these changes


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 are referred to as licensed practical nurses.


Ancillary nursing personnel, nursing support personnel, assistive personnel, nurse extenders, unlicensed nursing personnel, multicompetent workers, nurse assistants, or aides are all generic terms used to refer to the various clinical and nonclinical jobs that augment nursing care. This group of employees includes an array of support nursing personnel including certified nurse assistants, order-lies, operating room technicians, home health aides, and others. They assist the licensed nurse by performing routine duties in caring for patients under the supervision of an RN or an LPN. Although Congress defined "nurse" for the purposes of this study to include RN, LPN, and NA, it has not been possible at all times to disaggregate information on NAs from the remaining support personnel because national statistics are often collected and/or tabulated for the group as a whole. For example, the American Hospital Association does not separate information on nurse assistants from that on other "ancillary nursing personnel." Throughout this report, the term ancillary nursing personnel will be used for this group of staff when nurse assistants cannot be disaggregated.

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