providing safe and adequate care. Under the nursing practice acts of each state, nurses are responsible for all care delivered under their supervision; furthermore, they are liable for patient abandonment if they do not accept reasonable assignments, but they must not accept unreasonable work assignments. Many state nursing organizations and unions have responded by encouraging their members to use "assignment despite protest" forms to document their concerns; this is not, however, considered a solution to the concerns about patient safety and quality of patient care. Furthermore, according to one union, some hospitals are pushing for "reinterpretation or revisions in state nurse practice acts so as to allow unlicensed personnel to perform significant nursing duties, while leaving ultimate responsibility and legal liability in nurse hands."

Most of the testimony noted the current challenges of delivering nursing care: higher levels of patient acuity; an aging population; shorter lengths of stay in which to deliver care and teach patients self-care; the use of ANP in place of RNs; and sometimes the loss of support services. Many RNs expressed concern that ANP are replacing RNs rather than supporting them, and a few mentioned that at their institution new and less knowledgeable ancillary personnel were replacing those with greater skills and better training. Others spoke of a general "de-skilling" of nursing practice.

Specific concerns about the quality of patient care included less preventive care; more "near misses," considered by many RN organizations to be a critical "invisible" indicator; inappropriate transfers to other units or to the home; and more unsafe patient loads. Another perception was reduced continuity of care, especially with the growth of cross-training, and increased reliance on floating and per diem nurses. Cross-training and floating,2 it should be noted, are regarded as appropriate solutions for both hospitals and nurses if implemented properly, but many testifiers believe that these tactics are often poorly implemented and, as a consequence, the risks to quality of care are high.

Specific problems involving injuries, illness, and stress were also mentioned. Violence, back injuries, and the risk of infectious diseases are all serious occupational hazards. One example raised was that equipment that could prevent or minimize injuries is not being used because of cost considerations. In addition, strains on family life and personal time, job security worries and layoffs, and either mandatory overtime or days without work are significant sources of stress. Some complaints about increased stress and risks to their health came from experienced nurses who have been providing care for decades.

By and large, most representatives of the state associations expressed con-


Cross-training is on-the-job training of nursing personnel to deliver specialized clinical care in an area outside their primary expertise and experience. Floating is the temporary assignment of nursing personnel to a clinical unit other than the one to which they are usually assigned.

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