During the nearly 2 years in which this Institute of Medicine (IOM) committee met, it learned much about health care delivery and the role of nursing personnel in the health care system that did not relate directly to its formal charge. The committee acknowledges that many issues relating to nursing and health extend beyond the scope of this report. Some of those issues should at least be mentioned. Committee members believe these observations provide a richer context in which their specific views of the future and recommended next steps should be understood. At its last meeting, the committee listed a number of points here.
Issues surrounding the adequacy of nursing staff proved inextricable from broader issues of health care access, quality, workforce, and costs. The committee believes that its findings and conclusions will inform current dialogues concerning the organization and delivery of health care, quality of patient care, safety and work experience of all nursing personnel, and suggest increased flexibility of the nation's nursing community for meeting tomorrow's health care challenges. It also believes that the changes now taking place in health care organization and financing, and in other parts of the health care workforce, will have important consequences for nursing. Because of the manner and extent to which health systems are being reconfigured, job security to registered nurses (RN) is declining in favor of new boundary spanning career opportunities.
The committee also recognizes the centrality of nursing care to the provision of health care services in an immensely broad array of health care settings, from institutional to community-based to home-based care. Large numbers of people, day in and day out, are directly touched by nursing personnel.
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
low end of the staffing scale, so positive returns from increases in staffing are observable.
The committee recognizes that the relationships between quality and costs are complex and difficult to disaggregate. Analysis of the mechanisms underlying these relationships merits a high priority. The committee thus underscores the importance of conveying to the public the need for much better mechanisms by which policymakers can analyze these factors.
The level of external interest in this project and the implied level of expectations on the part of several interested constituencies were extraordinarily high. The committee welcomed all input and appreciated the many individuals and organizations who provided information or otherwise helped the committee to meet its charge.
Several committee members were aware of the fact that many analyses of the nursing workforce, as well as several related IOM studies, have appeared in recent years. Some (such as the 1986 IOM study on improving the quality of nursing home care) have had instant impact; in other cases, however, recommendations not unlike those appearing in this report have required a longer time to exert an appreciable influence. The committee reflected on the question of what differences have arisen since the previous studies were conducted. It concluded that one major difference is the ability of researchers, policymakers, and others to use better measures of patient outcomes and nursing processes of care, and thus to determine and document how the proposed changes will bring about meaningful improvements in the health care system and in the well-being of patients and the nation's population in general.
In settings where patients and residents cannot receive all necessary services from paid staff members, volunteers can be a distinct asset. Volunteers can never fully replace staff, but they can provide companionship, contact, comforts (such as letter writing and craft materials) and assistance (such as help with eating), and can even be part of an informal quality assurance mechanism. The committee was impressed with the devotion of nursing personnel, families, volunteers, and other care givers. The committee noted that it is critical that the public—and not just investors and policymakers—have a participatory role in the major decisions ahead on health care.
This study was mandated at a time that, in retrospect, seems rather calm. In the intervening months, press and media reports on the issues studied by the committee increased, and unstructured and unpredictable changes driven by continuing cost containment pressures, private sector interests, and market forces are swiftly and unmistakably altering the health care landscape. This turbulence has made the work of the committee markedly more challenging, and also more difficult; in particular, it has complicated the task of issuing recommendations that will be timely and pertinent beyond today. In the committee's view, policymakers and the public need to understand, far more deeply than they may at this moment, how rapid change is affecting the nation's ability to make reasoned
decisions about the health of the nation into the next century. While markets will adjust to supply and demand conditions over the long-term, it is possible for policy to influence these demand and supply conditions. Incentives to invest in new technologies, for example, may result in an increased demand for new technical skills by nurses or, possibly, a substitute for those skills. Policies can range from laissez faire (do nothing) to active intervention in demand and supply conditions such as education, research, regulation, taxation, and information. Then it is important to ask the question what the effect will likely be on the quality of patient care and on the nursing staff providing the care. This then leads to the question of appropriate policy responses.
Finally, the committee's work on several of the issues it was asked to examine was impeded by the spotty availability of timely, reliable, and valid data with uniform definitions and classification. Thus, committee members expressed a common concern about the lack of sufficient data to address the questions they were charged to address. Insights gleaned from public testimony, site visits, and similar activities cumulatively added to the understanding of today's health care system, nursing services, and the quality of patient care. These issues will continue to represent major concerns in the years ahead. Adequate funding is essential for research and evaluation to help ensure that efforts to constrain the costs of nursing do not, in fact, result in serious consequences for the health of our citizens.