Committee Membership and Study Approach
The Committee on the Work Environment for Nurses and Patient Safety included the following members.
Donald M. Steinwachs, Ph.D. (Chair), is Professor and Chair of the Department of Health Policy and Management in The Johns Hopkins University Bloomberg School of Public Health. He is Director of The Johns Hopkins University Health Services Research and Development Center and Director of the Johns Hopkins and University of Maryland Center for Research on Services for Severe Mental Illness. Dr. Steinwach’s current research includes studies of (1) medical effectiveness and patient outcomes for individuals with specific medical, surgical, and psychiatric conditions; (2) the impact of managed care and other organizational and financial arrangements on access to care, quality, utilization, and cost; and (3) the development of better methods for measuring the effectiveness of systems of care, including case mix (e.g., Ambulatory Care Groups), quality profiling, and indicators of outcome. He has a particular interest in the role of routine management information systems as a source of data for evaluating the effectiveness and cost of health care. Dr. Steinwachs is past President of the Association for Health Services Research (now AcademyHealth) and is Chair of the Board of Directors, Coalition for Health Services Research. He serves as a consultant to federal agencies and private foundations, and is on the Board of Directors of Mathematica, Inc. and the Foundation for Accountability.
Ada Sue Hinshaw, Ph.D, R.N., F.A.A.N. (Vice Chair), is Professor and Dean of the School of Nursing at the University of Michigan. She was the first Director of the National Institute of Nursing Research at the National Institutes of Health. Her research interests include (1) professionals who function in bureaucracies, job satisfaction, job stress, anticipated turnover, and patient outcomes; (2) quality of patient caregiving; and (3) instrument development and testing, including measures of patient satisfaction, job satisfaction of nurses, and anticipated turnover of nursing staff. In addition, she has studied the use of ratio measurement techniques in building and testing the nurse and patient measures. Dr. Hinshaw is involved in a number of health policy activities. In addition to the Committee on the Work Environment for Nurses and Patient Safety, she has served on the Institute of Medicine’s (IOM) Nursing Research Panel Parent Committee on Monitoring the Changing Needs for Biomedical and Behavioral Research Personnel. She has also served on a number of national review committees and policy commissions, including the Advisory Council for the Agency for Healthcare Research and Quality. She is past President of the American Academy of Nursing, and a member of the IOM and its Governing Council. Dr. Hinshaw coauthored the first Handbook for Clinical Nursing Research and a text on Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. She has received numerous honors, awards, and honorary degrees.
Joy Durfee Calkin, R.N., Ph.D., is Professor Emeritus of Nursing, University of Calgary, Canada, and a health care consultant. She practiced pediatric and adult nursing in Canada, the United States, and the United Kingdom and held faculty positions in the former two countries. Dr. Calkin served as President and Chief Executive Officer (CEO) of Extendicare Inc. in Canada and the United States. Her areas of consulting have included workplace design, staffing patterns, development of clinical administrator programs in medicine and nursing, health systems design, operational and productivity analysis, workforce shortages, and performance improvement. Her research interests include the effect of work and structures for work on worker performance and satisfaction. Dr. Calkin served as a member of the Premier’s Commission on Future Health Care for Albertans, the Ontario Minister of Health Task Force on the Nursing Shortage, and the Governor of Florida’s Task Force on Accessibility and Affordability of Long-Term Care. She serves on the Board of the Canadian Stroke Network and a Canadian charitable foundation.
Marilyn P. Chow, D.N.S., R.N., F.A.A.N., is Vice President, Patient Care Services, for the Program Office of Kaiser Permanente. She is also Program Director for The Robert Wood Johnson Executive Nurse Fellows Program. A graduate of the University of California, San Francisco School of Nursing, she has held positions in acute care settings, academia, and
state and national nursing organizations and has served on numerous local, state, and national committees and boards. She is the At-Large Nursing Commissioner on the Joint Commission on Accreditation of Healthcare Organization Board, a member of the Joint Commission Resources Board, and a member of the Editorial Advisory Board of Nurse Week, and is currently serving a 2-year appointment as Senior Fellow of the Center for the Health Professions at the University of California, San Francisco. She also serves as a member of the Hartford Institute for Geriatric Nursing and is a fellow of the American Academy of Nursing. Dr. Chow has coauthored four books, including the award-winning Handbook of Pediatric Primary Care. Her awards include the American Nurses Association (ANA) Ethnic Minority Women’s Honors in Public Health and the University of California at San Francisco School of Nursing Distinguished Alumni Award.
Paul D. Clayton, Ph.D., is Chief Medical Informatics Officer at Intermountain Health Care, Professor of Medical Informatics at the University of Utah, and Professor Emeritus at Columbia University. Dr. Clayton developed and implemented information systems in cardiology, radiology, and surgery at LDS Hospital and the University of Utah. He joined Columbia University and Presbyterian Hospital in 1987 as director of the Center for Medical Informatics and Professor of Medical Informatics. He became Chair of the newly created Department of Medical Informatics in 1994. When Dr. Clayton joined Columbia Presbyterian, he led efforts to build an integrated information system for the medical center, an effort supported by an Integrated Advanced Information Management System grant from the National Library of Medicine. He was also active in creating an advanced clinical information system with decision-making capability now widely used at Columbia Presbyterian. In 1998, he returned to Salt Lake City to work with Intermountain Health Care in establishing the information underpinnings for an integrated health delivery system. As Chief Medical Informatics Officer, he is interested in creating and implementing systems that use a clinical information system and external sources of knowledge to prompt providers and patients in ways that will improve the quality and cost of health care. Dr. Clayton is an elected fellow of the American College of Medical Informatics and the IOM. He chaired a National Research Council committee addressing issues of confidentiality of health records on the national information infrastructure, and served on the Board of Directors of the American Medical Informatics Association and as President of that organization during 1998 and 1999.
Mary Lou de Leon Siantz, R.N., Ph.D., F.A.A.N., is Professor and Associate Dean for Research at the Georgetown University School of Nursing and Health Studies and Director of the Milagros Center of Excellence in Migrant Health in Washington, D.C. She also serves as a faculty affiliate in the School of Nursing, Department of Family and Child Nursing, Univer-
sity of Washington, Seattle, Washington. She is past President of the National Association of Hispanic Nurses and of the Advocates for Child and Adolescent Psychiatric Nursing. Dr. de Leon Siantz received her bachelor of science degree in nursing from Mount Saint Mary’s College, Los Angeles, California; her master’s degree from the University of California, Los Angeles; and her doctorate in human development from the University of Maryland, College Park. She is known internationally for her seminal research in child development and mental health with Mexican migrant farm worker children and families in the migrant stream of the United States. She is the author or coauthor of numerous publications on the mental health and development of Hispanic children and their families. She has published many scholarly papers and research abstracts and contributed to numerous books. She consults with the Strategic Planning Committees for the Pacific Northwest Hispanic Health Agenda and the East Coast Migrant Council, developing research initiatives. Her research has focused on the effects of stress on the mental health and parenting behaviors of Mexican migrant mothers, and on factors that influence the successful outcomes of migrant preschool children (funded by the U.S. Department of Health and Human Services). She was a member of the IOM Committee on the Health and Adjustment of Immigrant Children and Families and the Social Policy Committee for the Society for Research in Child Development, cochairing the Subcommittee on Poverty. She has been on the Advisory Council of the National Institutes for Nursing Research. She has been honored by the Texas Migrant Council, San Diego State University, and the National Association of Hispanic Nurses. She serves on numerous review panels, editorial boards, and advisory committees, including the Secretary’s Committee on Infant Mortality. Internationally, she has served on the Pan American Health Organization’s psychiatric nursing initiative in the Southern Cone of South America.
Charlene A. Harrington, Ph.D., R.N., F.A.A.N., is Professor of Sociology and Nursing in the Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco. Her primary work has been in the area of long-term care; she has directed a number of research projects on state long-term care policies, funded by the U.S. Centers for Medicare and Medicaid services (CMS), the Agency for Healthcare Research and Quality (AHRQ), and others. She recently conducted a study of Medicare beneficiary consumer quality complaints with California Medical Review Inc. and a large study of the Medicaid home and community-based service programs in all the states in 1999 for the Health Care Financing Administration. She continues to study state long-term care programs and policies. Dr. Harrington developed a model Nursing Home Consumer Information System (funded by the AHRQ) that was used in developing the
CMS Medicare Nursing Home Compare website. She led a team of researchers in designing a state-of-the-art California Internet-based consumer information system for nursing homes, initiated in 2002. As part of this project, she conducted studies on the relationship between nurse staffing and quality measures, nursing home bankruptcies and closures, nurse staffing and turnover rates, and other quality indicators. She has also been studying the extent of paid and unpaid long-term care services in the home and estimating the costs of expanding these programs across the country. She has published a number of papers on nurse staffing levels and annual state data books on all 16,000 U.S. nursing homes since l991. She is Director of a new National Center for Personal Assistance Services, funded by the National Institute on Disability and Rehabilitation Research. She has written more than 125 articles and chapters and coedited five books. She has lectured widely in the United States, as well as in other countries.
David H. Hickam, M.D., M.P.H., is Professor in the Department of Medicine of the Oregon Health and Science University and a staff physician at the Portland Veterans Affairs Medical Center. He is board certified in internal medicine and completed a fellowship in health services research. He has maintained both a primary care clinical practice and inpatient attending responsibilities for more than 20 years. He has an active health services research program that has focused on clinical care outcomes, primary care practice variation, and patient safety. He is principal investigator on a contract to prepare an evidence report for the Agency for Healthcare Research and Quality on the effect of health care working conditions on patient safety.
Gwendylon E. Johnson, M.A., R.N.C., is a Staff Nurse in women’s health at Howard University Hospital. A diploma hospital graduate, she received a bachelor of science degree from St. Joseph’s College in Maine and a master’s with a health care administration concentration from the University of Maryland. With nearly 30 years of experience in obstetrical and gynecological nursing, her nursing career has always involved a direct-care commitment. She also has served as an adjunct professor in the graduate programs at Trinity College in Washington, D.C., and as an independent consultant on various projects, including a U.S. Department of Health and Human Services study that examined comprehensive care delivery services for HIV-infected women and their children. She is currently active in the Sigma Theta Tau International Honor Society for Nursing, Chi Eta Phi Sorority, Inc., and the Nurses Ministry and Board of Trustees of New Dawn Baptist Church. She has served on a number of committees and in many representative capacities for the ANA, including serving on the Advisory Board to the ANA Center for Ethics and Human Rights, the ANA Board of Directors, and the editorial board of the American Journal of Nursing. She
also serves as health and safety officer in her workplace for the District of Columbia Nurses Association.
David A. Kobus, Ph.D., is a Certified Professional Ergonomist with Pacific Science and Engineering Group in San Diego, California, and has been involved in human performance research and project management for over 19 years. His work on the analysis of medical errors currently places him in the forefront of the field of identifying, categorizing, and quantifying errors in health care delivery. Recently, he was one of four psychologists asked by the American Psychological Association to brief congressional committees regarding human factors efforts to reduce error in medicine. In addition, he was asked by the Food and Drug Administration to serve on an expert panel at a public hearing on medical device labeling and as a member of a panel for the safe design of home care medical devices. He is also the Cochair of the Human Factors Task Force on Medical Error for the Human Factors and Ergonomic Society (HFES), past Chair of the Medical Systems and Rehabilitation Technical Group of the HFES, and past President of the San Diego Chapter of the Human Factors and Ergonomic Society. Dr. Kobus has published more than 75 peer-reviewed papers and technical reports and has presented over 50 papers at national and international conferences on human factors, errors in medicine, and medical system design. He has extensive teaching experience at both the graduate and the undergraduate levels in the areas of experimental design, advanced statistics, cognition, biological psychology, and sensory systems. He has also served as principal investigator or as program manager on over 25 research projects related to human factors performance, many of which concerned human–computer interaction of medical systems.
Andrew M. Kramer, M.D., is Professor of Medicine and Head of the Division of Health Care Policy and Research in the Department of Medicine at The University of Colorado. The first recipient of an endowed chair in Health Policy, Dr. Kramer is also Director of the Hartford/Jahnigen Center of Excellence in Geriatric Medicine. Previously, he was Research Director for the Center on Aging and Geriatric Medicine Research Training Program Director. He has over 20 years of experience in health services research, with particular emphasis on quality of care in nursing homes, subacute settings, and home health care. Among his many research studies, he directed analyses of the association between staffing levels and quality of care in the Report to Congress on the Appropriateness of Minimum Nursing Staffing Ratios in Nursing Homes. Recently, he was principal investigator for a study to develop quality measures for use across postacute settings. His current projects include a national study of stroke outcomes across settings and a study to use quality indicators in the nursing home survey process. Dr. Kramer received his medical degree from Harvard Medical School.
Pamela H. Mitchell, Ph.D., R.N., F.A.A.N., is Associate Dean for Research and Professor of Biobehavioral Nursing and Health Care Systems at the University of Washington School of Nursing, where she holds the Elizabeth S. Soule Distinguished Professorship of Health Promotion. She is also adjunct professor of health services at the University of Washington School of Public Health and Medicine and has been engaged in advanced nursing practice, clinical research, and interprofessional clinical education for over 30 years. Her practice and research are in the areas of neuroscience and critical care nursing, and features of health care delivery systems that affect clinical outcomes. She is currently developing and testing a national faculty leadership program in interprofessional education to promote patient safety. She is the founding Director of the Center for Health Services Interprofessional Education and Research at the University of Washington, chairs the American Academy of Nursing Expert Panel on Quality Care, and serves on the Steering Committee for the Agency for Healthcare Research and Quality’s Patient Safety Research Coordinating Center. She also has studied organizational work environment issues in multisite studies of the critical care work environment and was a member of the technical advisory board of the recent national study of nurse staffing and patient outcomes in hospitals, funded by the U.S. Department of Health and Human Services. She also is coinvestigator on a new Veterans Administration study to investigate nursing work environments and patient outcomes.
Audrey L. Nelson, Ph.D., R.N., F.A.A.N., has over 26 years of experience as a staff nurse, nurse administrator, and nurse researcher. Dr. Nelson is nationally known for her expertise in patient safety. Currently, she is Center Director for three research centers: the Veterans Health Administration (VHA) Patient Safety Center of Inquiry, VHA Health Services Research Enhancement Program on Patient Safety Outcomes, and Suncoast Development Evaluation Research Center on Safe Patient Transitions, funded by the Agency for Healthcare Research and Quality. Dr. Nelson has joint faculty appointments at the University of South Florida in the Colleges of Public Health and Nursing, where she serves as Associate Director for Clinical Research. Her program of research focuses on safe environments for patients and nurses in the areas of falls and safe patient handling and movement. She has established four research laboratories: Patient Safety Simulation, Gait and Balance, Biomechanics Research, and Patient Safety Engineering. Dr. Nelson also is nationally known in spinal cord injury nursing. She is past President of the American Association of Spinal Cord Injury Nurses, past Chair of the Rehabilitation Research Foundation for the Association of Rehabilitation Nurses, and Steering Committee member for the Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Administratively, she participated in the VHA National Expert Panel on Nursing Staffing Methodologies, chaired a national VHA Task Force on Patient Care
Ergonomics, and chaired a national Veterans Administration task force on Patient Fall Prevention.
Edward H. O’Neil, Ph.D., M.P.A., is Professor of Family and Community Medicine and Dental Public Health at the University of California, San Francisco. He also serves as Director of the Center for the Health Professions, a research, advocacy, and training institute he created to stimulate change in health professions education. The Center for the Health Professions houses a number of initiatives designed to understand and address the issues facing health care and health professionals. Dr. O’Neil is principal investigator for the Pew Scholars Program in the Biomedical Sciences, The Robert Wood Johnson Executive Nurse Fellows Program, the California Workforce Initiative, and the Future Leaders Program, funded by the California HealthCare Foundation. From 1989 through 1999, Dr. O’Neil served as Executive Director of the Pew Health Professions Commission—a nationally recognized advocacy group focused on reform in health workforce issues. He has published numerous articles, chapters, and books on this and other work. He is or has served as a consultant to the World Health Organization, the Government of New Zealand, the Rockefeller Foundation, the Pew Charitable Trusts, the W. K. Kellogg Foundation, the Fetzer Institute, The Robert Wood Johnson Foundation, and the California HealthCare Foundation, as well as a number of federal, state, and institutional agencies. He holds undergraduate and masters degrees from the University of Alabama, a masters of public administration and doctorate in history from Syracuse University, and an honorary degree from New York Medical College.
William P. Pierskalla, Ph.D., is Professor in the Department of Operation and Technology Management in the Anderson Graduate School of Management at the University of California, Los Angeles. He is former Dean of The Anderson School, 1993 to 1997. His current research interests include the management aspects of health care delivery, operations research, operations management, and issues of global competition. He is former President of the International Federation of Operational Research Societies, and serves in an editorial capacity on Production and Operations Management, International Transactions in Operational Research, Encyclopedia of Operations Research and Management Science, Health Services Management Research, and the Health Care Management Sciences Journal. Dr. Pierskalla is currently Vice President for Publications for the Institute for Operations Research and Management Sciences. He is former President of the Operations Research Society of America and past Editor of Operations Research. He previously was Deputy Dean for Academic Affairs, Director of the Huntsman Center for Global Competition and Leadership, and Chairman of the Health Care Systems Department at the Wharton School and
Executive Director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. He has given numerous lectures and seminars at universities and organizations in the United States, Europe, South America, and the Far East, and has authored over 50 refereed articles in mathematical programming, transportation, inventory and production control, maintainability, and health care delivery. Dr. Pierskalla has served as a consultant to the American Red Cross, analyzing blood supply management, including delivery, testing, and inventory.
Karlene H. Roberts, Ph.D., is Professor in the Haas School of Business at the University of California, Berkeley, where she researches and consults on organizational behavior and industrial relations as they pertain to safety issues. Her areas of expertise include high-reliability organizations and human and organizational error. She has published extensively on such topics as research and management strategies to improve patient safety, the causes and prevention of catastrophic organizational errors, systems theory and how it can be applied to maximizing patient safety, patient safety as an organizational systems issue—lessons from a variety of industries, design and management of high-reliability organizations, risk mitigation in large-scale systems, decision support, the development of technology over time, and the relationship of technology to organizational structure and other organizational processes.
Denise M. Rousseau, Ph.D., is H. J. Heinz II Professor of Organizational Behavior at Carnegie Mellon University, serving jointly in the Heinz School of Public Policy and Management and the Graduate School of Industrial Administration. She has been a faculty member at Northwestern University, the University of Michigan, and the Naval Postgraduate School (Monterey), and visiting faculty member at Chulalonghorn University (Bangkok), Renmen University (Beijing), and Nanyang Technological University (Singapore). Her research addresses the impact of work group processes on performance and the changing psychological contract at work. Dr. Rousseau has authored more than 110 articles that have appeared in academic journals, such as the Journal of Applied Psychology, Academy of Management Review, Journal of Organizational Behavior, and Administrative Science Quarterly. Her books include Relational Wealth: Advantages of Stability in a Changing Economy (Oxford), with Carrie Leana; Psychological Contracts in Employment: Cross-National Perspectives (Sage), with Rene Schalk; the Trends in Organizational Behavior series (Wiley), with Cary Cooper; Developing an Interdisciplinary Science of Organizations (Jossey-Bass), with Karlene Roberts and Charles Hulin; and The Boundaryless Career (Oxford), with Michael Arthur. Psychological Contracts in Organizations (Sage) won the Academy of Management’s best book award in 1996. Professor Rousseau has consulted in diverse organiza-
tions and written numerous articles for managers and executives, including “Teamwork: Inside and Out” (Business Week/Advance), “Managing Diversity for High Performance” (Business Week/Advance), and “Two Ways to Change (and Keep) the Psychological Contract” (Academy of Management Executive). She has taught in executive programs at Northwestern (Kellogg), Cornell, and Carnegie Mellon Universities and in industry programs for health care, journalism, and manufacturing, among others. She is a Fellow in the Academy of Management, the American Psychological Association, and the Society for Industrial/Organizational Psychology, and is Editor-in-Chief of the Journal of Organizational Behavior. Her current and past editorial board memberships include Administrative Science Quarterly, Journal of Applied Psychology, and Journal of Management Inquiry.
William C. Rupp, M.D., is President/CEO of Immanuel St. Joseph’s—Mayo Health System and Vice Chair of Mayo Health System. Previously, Dr. Rupp was President and CEO of Luther Midelfort in Eau Claire, Wisconsin. He led that institution’s integration with Mayo Health System and Luther Midelfort’s nationally recognized efforts and innovations in patient safety. He is a frequent speaker at Institute for Healthcare Improvement meetings regarding medical practice innovations. He is Vice Chair for Planning of Mayo Health System and has served in multiple community leadership roles in Eau Claire. Dr. Rupp is a practicing oncologist.
The committee began its work in June 2002. It convened four times during September 2002, November 2002, February 2003, and April 2003 to review evidence and deliberate. Additional deliberations between meetings were held through conference calls.
The committee invited testimony from multiple nursing, labor, health care delivery, quality oversight, advocacy, and other organizations. Those providing testimony included Barbara Blakeney, President, American Nurses Association; Linda Burnes Boltin, Dr.P.H., American Academy of Nursing; Kathleen Long, Ph.D., President, American Association of Colleges of Nursing; Phil Authier, President, American Organization of Nurse Executives; Eileen Zungolo, Ed.D., President, National League for Nursing; Jeanne Surdo, Secretary-Treasurer of United American Nurses; Martha Baker, President, Service Employees International Union, Local 1991; Katherine Cox, Policy Analyst, American Federation of State, County, and Municipal Employees; Gerry Shea, Assistant to the President for Government Affairs, AFL-CIO; Jim Bentley, Senior Vice President for Strategic Policy Planning, American Hospital Association; Steven Chies, Vice Chair, American Health Care Association; Robyn Stone, Ph.D., Executive Director, Institute for the Future of Aging Services, an affiliate of the American Association of Homes
and Services for the Aging; Tim Flaherty, M.D., of the American Medical Association and National Patient Safety Foundation; Steven Edelstein, J.D., of the Paraprofessional Institute; Donna Lenhoff, Esq., Executive Director, National Citizens Coalition for Nursing Home Reform; Dennis O’Leary, President, and Margaret van Amringe, Vice President for External Relations, Joint Commission on the Accreditation of Healthcare Organizations; Cathy Rick, Chief Nursing Officer, U.S. Department of Veterans Affairs; Sean Clarke, R.N., Ph.D., of the University of Pennsylvania Center for Health Outcomes and Policy Research; Caryl Lee, R.N., Program Manager, National Center for Patient Safety, U.S. Department of Veterans Affairs; Joyce Berger, Senior Advisor, Health Technology Center; Daved van Stralen, M.D., Medical Director, Totally Kids© Specialty Healthcare, The American Association of Critical Care Nurses; Philip Greiner, Past Chair, and Sonda Oppewal, Chair, Public Health Nursing Section, American Public Health Association; Laurence Wellikson, Executive Director, and Janet Nagamine, National Association of Inpatient Physicians; John Hoff, Deputy Assistant Secretary, and Jennie Harvel, Policy Analyst, U.S. Department of Health and Human Services; and Paul Ginsburg, Ph.D., President, Center for Studying Health System Change.
The committee also commissioned nine papers to provide background information for its deliberations and to synthesize the evidence on particular issues. The authors and their papers were as follows: Julie Sochalski, Ph.D., “The Nursing Workforce: Profile, Trends, Projections”; Barbara Mark, Ph.D., “The Work of Registered Nurses, Licensed Practical Nurses, and Nurses Aides in Acute Care Hospitals”; Barbara Bowers, Ph.D., “The Work of Nurses and Nurse Aides in Long Term Care Facilities”; Karen Martin, “The Work of Nurses and Nursing Assistants in Home Care, Public Health, and Other Community Settings”; Ann Rogers Ph.D., “Work Hour Regulation in Safety-Sensitive Industries”; Gail Ingersoll, EdD, and Madeline Schmitt, Ph.D., “Interdisciplinary Collaboration, Team Functioning, and Patient Safety”; Ann Hendrich, “Evidence-based Design of Nursing Workspace in Hospitals”; Pascale Carayon, Ph.D., Carla Alvarado, Ph.D., and Ann Hundt, Ph.D., “Reducing Workload and Increasing Patient Safety Through Work and Workspace Design”; and Murat Bayiz, “Work and Workload Measurements in Nurse Staffing Models.”
In undertaking its work, the committee focused predominantly on nursing care delivered in acute care hospitals and inpatient nursing facilities, because these are the settings in which the greatest amount of evidence exists about the nature of threats to patient safety and possible remedies in the work environment of nurses. The committee noted a number of issues related to, but not part of, its charge, including the nursing shortage, nurse safety in the work environment, and problems with nurse retention. It also noted issues with respect to the varying educational paths to licensure as a
registered nurse that may have implications for nurse performance in the workplace. As tempting, important, and deserving of study as these issues were, they were beyond the considerable charge given to the committee by the Agency for Healthcare Research and Quality. The committee calls attention to the need for further study in these areas.