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Letter to the Editor

Nursing in the Next Decade: Implications for Health Care and for Patient Safety

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Katherine A. Kany, BS, RN

Abstract

Nursing faces yet another divergence between demand and supply that is evidenced in insufficient nurse staffing with significant implications for patient safety. Many believe this shortage of registered nurses is entrenched in long-standing problems related to the value and image of nursing and the limited role nursing has had in identifying priorities within health care delivery systems. Nursing's Agenda for the Future is a plan resulting from the experience and wisdom of a broad representation of general nursing and nursing specialty organizations. Efforts to realize the priorities and objectives have evolved over the past two years in order to make larger strides, or quantum leaps, toward reaching the objectives contained within the plan. This article reviews the activities leading up to the development of this plan, presents the key areas of concern addressed in this plan, describes what has been accomplished since the publication of this plan in 2002, and outlines the work that lies ahead to bring to fruition the objectives the plan established.

Citation: Kany, K. (May 31, 2004) "Nursing in the Next Decade: Implications for Health Care and for Patient Safety" Online Journal of Issues in Nursing; Vol. 9 No. 2, Manuscript 3. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No2May04/PatientSafety.aspx

Key words: nurse staffing, nursing shortage, patient safety, nursing value, nursing image, economic value, and strategic plan

Nursing again faces a divergence between demand and supply that is evidenced in insufficient nurse staffing with significant implications for patient safety. Many believe this shortage of registered nurses is entrenched in long-standing problems related to the value and image of nursing and the limited role nursing has had in identifying priorities within health care delivery systems.

Nursing’s Agenda for the Future (NAF) (2002), is a plan based on the collective experience and wisdom of a broad representation of general nursing and nursing specialty organizations. Efforts underway to realize the priorities and objectives of this plan have evolved over the past two years in order to make larger strides, or quantum leaps, towards the priorities and objectives contained within the plan. Nurses can and must play a key role in advancing Nursing’s Agenda for the Future and participating in coalition efforts to change public policies affecting health care delivery priorities, work environments for nurses, the diversity and cultural sensitivity of the profession, and more.

This article reviews the activities leading up to the development of this plan, presents the key areas of concern addressed in this plan, describes what has been accomplished since the publication of this plan in 2002, and outlines the work that lies ahead to bring to fruition the objectives that the plan established.

Preliminary Activities

There are critical points in time when the collective expertise and resources of a community must be pulled together and drawn upon in order to swiftly and effectively defend itself against a common threat. The American Nurses Association (ANA) believed that the profession was at that point very early in 2001, when the implications of declining enrollments in schools of nursing, insufficient nurse staffing levels (particularly in acute care facilities), a burgeoning use of overtime to staff units, unsafe and dissatisfying work environments for nurses, diminishing quality of patient care, and a looming nursing shortage were becoming very clear.

Eight months earlier, the ANA had convened a National Nurse Staffing Summit Meeting. Invited by ANA to that May 2000 meeting were health services researchers and representatives of the hospital industry, regulators and policy makers, and a diverse representation of registered nurses. The goals of this meeting were to gauge concern and support among the major power brokers who could influence the staffing dilemma and to gather in one place those who needed to be accountable for the implications of a lack of responsiveness to the crisis at hand.

Following the Staffing Summit, ANA began its own internal discussion around the issue of nurse staffing. Shortly into the process, it became clear that nurse staffing issues were only symptomatic of long-standing, fundamental problems plaguing the profession. ANA identified that the skewed image of nurses and nursing, and, perhaps more fundamentally, the lack of awareness and value for what the nursing profession contributes in terms of both cost and quality of health care, were the issues that really needed to be addressed. ANA also believed that the cyclical nature of nursing "shortages" was more often related to industry economics than consumer needs since, in the past, nursing supply had not been adjusted based on demand models predicting the need for health care services.

ANA recognized the need to deal with the fundamental problems plaguing the profession, and to determine ways that nurses could take control of their profession and their practice today and in the future. To address this need, the ANA brought its concerns to a meeting of the Tri Council of Nursing (the American Association of Colleges of Nursing, the American Nurses Association, the American Organization of Nurse Executives, and the National League for Nursing). This council represents recognized nursing leadership and meets on a routine basis to discuss matters of importance to the profession and to determine strategies for action. With those concerns, ANA also brought to the Tri Council the following proposal: convene a national summit meeting of the nursing community to develop a strategic plan that would address the symptoms and the causative factors making nursing an unattractive profession and, for an increasing number of RNs, intolerable as a professional career.

The goal of this proposal was to bring together the nursing community to forge a comprehensive strategy for change that could be championed by nursing leadership, implemented by nursing organizations, and embraced by both nurses and the "external stakeholder" community. The "external stakeholder" community included health care consumers, the health care industry, other health professions, policy makers, educators, insurers, and corporate America. The priority of the ANA proposal was to ensure safe, high quality care for all health care consumers and a sufficient supply of registered nurses to deliver that care!

To structure the proposal, a steering committee of nursing organization representatives was established to oversee the planning process, to set an overarching vision for the future of the profession, and to monitor and support the implementation of the plan once developed. The steering committee organizations were asked to provide leadership and planning for the overall initiative, and also specific oversight and support for ten discrete areas, called "domains" which had been identified as priorities by nursing. These domains, listed in Table 1, would become the foci for nursing’s plan. This plan was titled Nursing’s Agenda for the Future (2002).

Table 1. Nursing’s Agenda for the Future Domains and Primary Strategies

  • Leadership and Planning
    • Nursing works collaboratively to develop a plan for its own future, and then assumes accountability for monitoring and supporting the implementation of the plan.
  • Economic Value
    • Nursing quantifies its contribution to the quality of patient care and the saving of health care dollars.
  • Delivery Systems/Nursing Models
    • Nursing designs and leads, or co-leads, integrated/interdisciplinary models of care for all delivery settings.
  • Work Environment
    • Nursing determines and controls the professional practice environment.
  • Legislation/Regulation/Policy
    • Nursing affects policy changes at the local, state and federal level that assures their ability to practice in a safe and effective manner.
  • Public Relations/Communications
      • Nursing communicates its role, its value, its contribution to quality care.
    • Nursing/Professional Culture
        • Nursing achieves the infrastructure necessary to support its professional standards, image, and satisfaction.
      • Education
          • Nursing redesigns professional education to assure its relevance to societal needs.
        • Recruitment/Retention
            • Nursing accomplishes significant changes in the work environment and in career opportunities to better attract and retain a sufficient supply of registered nurses.
          • Diversity
            • Nursing evolves to reflect the cultural, ethnic, and gender diversity of the population it serves.

            Nineteen organizations agreed to assume leadership roles as part of the NAF Steering Committee. These organizations are listed in Table 2.

             

            Table 2. Nursing’s Agenda for the Future Steering Committee Organizations

            • The American Academy of Nursing
            • The American Association of Colleges of Nursing
            • The American Association of Critical-Care Nurses
            • The American Association of Nurse Anesthetists
            • The American Nurses Association
            • The American Nurses Credentialing Center
            • The American Organization of Nurse Executives
            • The American Psychiatric Nurses Association
            • The Association of Peri-Operative Registered Nurses
            • The Association of Women’s Health, Obstetric, and Neonatal Nurses
            • The Emergency Nurses Association
            • The Infusion Nurses Society
            • The National Black Nurses Association
            • The National Council of State Boards of Nursing
            • The National League for Nursing
            • The National Student Nurses Association, Inc.
            • The Nursing Organization Liaison Forum
            • The Oncology Nursing Society
            • Sigma Theta Tau International, Honor Society of Nursing

            Development of the Plan: Nursing’s Agenda for the Future


            ...the plan drives work that quantifies and defines nursing.

            For four days in September 2001, the Steering Committee of participating nursing organization representatives, and over 100 representatives of 60 specialty and nursing organizations, immersed themselves in the review of staffing and shortage problems and the various reports and initiatives regarding these staffing challenges. They also learned about techniques in strategic planning that helped them draw on their comprehensive experiences and insights to address these nursing challenges. Together, they drafted the plan, Nursing’s Agenda for the Future (2002), which addressed the previously mentioned ten domains (priority areas). Each domain discussion included: (a) a desired future (vision) statement, (b) objectives related to the primary strategies, and (c) a framework for how work and communications would move forward.


            ...the plan drives work that reinvents nursing's image to attract more candidates to the profession.

            A commitment to the actualization of priorities and strategies identified by those who participated in the September 2001 meeting made this initiative unique. Beyond issuing a final report with a set of recommendations, the steering committee organizations leading the initiative made a pledge to provide: (a) ongoing coordination of work among and between various nursing associations, (b) the development of communication strategies and processes to gather and disseminate important information, (c) fund-raising activities to support the work of the plan, and (d) movement of the plan beyond the nursing community to engage all stakeholders in the support and work of the plan.

            The foundational work accomplished by the Steering Committee in September of 2001 was subjected to expert review and refinement by all meeting participants before moving forward. Particularly crucial, before determining a more final plan and a course of action, was envisioning a mutually agreeable, overarching desired outcome. That outcome, identified as "The Future Vision for Nursing," describes not only where the nursing profession wanted to envision itself at a point in time (specifically in 2020 after the current crisis would have been resolved), but also alludes to the domains where work would take place in order to achieve this future vision. "The Future Vision for Nursing" reads as follows:

            Nursing is the pivotal health care profession, highly valued for its specialized knowledge, skill and caring in improving the health status of the public and ensuring safe, effective, quality care. The profession mirrors the diverse population it serves and provides leadership to create positive changes in health policy and delivery systems. Individuals choose nursing as a career, and remain in the profession, because of the opportunities for personal and professional growth, supportive work environments and compensation commensurate with roles and responsibilities. (Nursing’s Agenda for the Future: A Call to the Nation, 2002, p. 3)

            In November 2001, the final plan was distributed to the nursing community with a request that each nursing organization review the strategies related to the ten domains (Table 1).


            ...the plan drives work that increases the authority, autonomy, and satisfaction of registered nurses...
            They were asked to identify specific work that would maximize their organizational strengths and address their members’ needs, as well as advance the plan itself. For example, if an organization was accomplished in lobbying, and a priority of their membership was to increase diversity among the nursing workforce, lobbying for increased federal funding for nursing students from diverse backgrounds would meet member needs and help to accomplish a strategy identified within the "diversity" domain. It was anticipated that centrally organizing and coordinating the work among nursing organizations would minimize redundancies and maximize resource utilization within the nursing community.


            ...the plan drives work that revamps nursing education...

            The real work that has resulted from the final plan, Nursing’s Agenda for the Future (NAF) (2002), and will continue to result from this plan, was established in the objectives in the plan that were developed to achieve each domain’s primary strategy. It is in these objectives that nursing organizations have found points to match their work to the NAF initiative, or to craft new work using NAF as their compass.

            At a conceptual level, the plan drives work that:

            • quantifies and defines nursing
            • reinvents nursing’s image to attract more candidates to the profession
            • rethinks, restructures, and reorders health care delivery
            • increases the authority, autonomy, and satisfaction of registered nurses and elevates their position within health care
            • improves the environment of care to benefit nurses, nursing practice, and patient outcomes, and to retain its workforce
            • revamps nursing education and increases opportunities for learning and leadership development over the career span
            • transforms the makeup of the profession and its ability to meet the diverse needs of our diverse population

            At the implementation level, that work may be as simple as marketing the value of nursing across all practice areas by using a standardized marketing slogan in all communications, by all nursing organizations. Or, the effort may be as complex as undertaking a major research initiative using ANA’s nursing-sensitive quality indicators to quantify the cost of adverse outcomes, such as pressure ulcers, and compare the cost of those adverse outcomes to the cost of nursing staff sufficient to prevent or minimize their occurrence.

            Accomplishments to Date

            In spite of the immensity of this undertaking, more than 200 work plans, developed by 56 nursing organizations, were submitted early in 2002. Other organizations worked to seek funding, or partners with whom to share the load, before their work could be initiated.

            To undertake future work, nursing stakeholders were surveyed in 2002 about their interest and responded unanimously that they preferred to do future work in collaboration with other nursing organizations, and/or external stakeholders. The survey results also showed that the participating organizations had identified a great need for funding to support future work, and for some, to complete projects underway.

            Given the limited window of opportunity to conquer these large problems, at the close of 2002 three very clear observations were made by the Steering Committee members:

            1. Funding would be critical to the completion of original work plans, and to enable the large scope of additional work needed.
            2. The initiative would take larger strides, or quantum leaps, forward if work would be planned and accomplished by coalitions rather than single organizations.
            3. Stakeholders outside the nursing community could bring abundant expertise to the initiative. They need to be engaged to better understand the scope and impact of the problem, and to support the work ahead.

            Also clear to the leadership at that time was the need to fine tune the focus of the plan so as to facilitate future work, and to invigorate and help sustain the momentum needed to reach the desired outcomes defined by nursing. Many "priorities" had been identified in the initial plan. To give focus to ongoing activities, the Steering Committee undertook the work of prioritizing the ten domains. The top priorities are listed in Table 3.

            Table 3. Prioritization of NAF Outcome Domains

            First (tied for first)

            Economic Value and Delivery Systems

            Second

            Education

            Third

            Work Environment

            Fourth

            Nursing Culture

            Fifth

            Diversity

            Sixth

            Retention

            Why is "economic value" a priority? With the exception of advance practice registered nurses, health care billing and reimbursement have not reflected the value of nursing practice. Absent that recognition and value, nursing is excluded from decision making on a range of issues, at all levels within health care facilities.


            In reality, nursing should have been able to veto these untested, cost-driven decisions...

            For example, during the early 1990s, when cost-containment strategies played out in restructuring and redesigning care delivery, decisions were made to replace registered nurses with less skilled, unlicensed personnel because nurses were seen as too costly. Also implemented were new models of patient-centered care delivered by cross-trained, unlicensed personnel. As a result, the remaining nurses spent a great deal of time supervising these unskilled staff and had less time for planning, giving, and evaluating care. These changes were made over the objections of registered nurses and despite their predictions that these changes would decrease quality of care. The predictions were alarmingly correct. The changes resulted in injury among patients and health care workers, demoralized a generation of nurses, and tarnished the profession’s image and attractiveness to potential candidates. These findings have been supported by a series of recent reports within the health care industry by the American Hospital Association (2002), the Joint Commission on Accreditation of Healthcare Organizations (2002), The Robert Wood Johnson Foundation (Kimball & O’Neill, 2002), and the Institute of Medicine (Page, 2003).


            However, the fact that little or no evidence of nursing services is found on hospital bills renders nursing invisible in all the important financial arenas.

            In reality, nursing should have been able to veto those untested, cost-driven decisions since professional nursing care is the primary service for which patients are admitted to health care facilities and for which the facilities are reimbursed. However, the fact that little or no evidence of nursing services is found on hospital bills renders nursing invisible in all the important financial arenas. As a result, major authority in decision making, such as arguing to direct cost-cutting to more appropriate targets than direct-care nursing staff, has been nearly impossible over the long history of the profession. Another contributing factor to the problem of seeing nurses as an expense, rather than a revenue-generator, has been the historical paucity of research establishing and quantifying the relationship between nurse staffing and patient outcomes. This has become a research priority identified in the Institute of Medicine’s (IOM) 1996 report: Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? (Wunderlich, Sloan, & Davis).

            Since that IOM report (Wunderlich, Sloan, & Davis, 1996), the empirical foundation to support the nursing staff to patient outcome relationship has been built, and now provides a solid springboard from which further research can be undertaken. One example of how nursing’s economic value might be measured can be seen in research (2002, unpublished) by Susan D. Horn, Ph.D., at the Institute for Clinical Outcomes Research in Salt Lake City, Utah.


            Findings...quantify nursing's value in providing safe, quality care and saving limited health care dollars, while supporting the case for improved RN staffing as a cost savings strategy, rather than an expense.

            In a 2002 presentation done for Primedia Network Learning, Dr. Horn outlined her study that identified the incidence rate of pressure ulcers in long term care, explored the relationship between pressure ulcer incidence and RN hours per patient day (hppd), and established the cost of treating ulcers. The data showed that if staffing was increased to provide an additional 30 minutes of RN care per resident day in long term care, pressure ulcer incidence would have decreased from 38.1 to 9.4 percent. In the United States, in year 2000 dollars, the cost of 30 minutes of increased RN staffing per long term care resident per day was between $415,000 and $526,500 annually. Despite the cost, facilities would still net an expected annual savings of $843,300 to $954,800 per 100 residents through savings in avoided pressure ulcer treatment ($823,400) and savings in avoided hospitalizations ($546,400). Above and beyond the savings in health care dollars is the improvement in quality of life for residents due to the reduction or elimination of pressure ulcers. Findings like these do quantify nursing’s value in providing safe, quality care and saving limited health care dollars, while supporting the case for improved RN staffing as a cost savings strategy, rather than an expense.

            What about the other first place priority, delivery systems? Although economic value and delivery systems share top priority, Steering Committee members believed that research targeted at quantifying the nursing profession’s role in contributing to cost-effective care delivery might also identify those models of care delivery that have been led or co-led by nurses and that have demonstrated lower overall costs and improved outcomes. If so, that information would provide cost-effective, high quality care delivery models for further replication.

            A range of potential benefits for the nursing profession, health care consumers, and the health care industry can result from research that quantifies the value of nursing services. In particular, there are high hopes that the data will drive new policy that could:

            • create changes to better ensure a sufficient supply of registered nurses
            • require a sufficient number (and mix) of direct-care nursing staff in order to reduce health care costs through better outcomes for patients, increased patient and nurse satisfaction, and reduced length of stay for patients
            • eliminate reduction of registered nurse staff as an appropriate cost-containment strategy
            • reorder the decision-making hierarchy across delivery settings to provide nursing with greater control over its own practice and the environment of care, in order to increase the likelihood of improved outcomes and reduced cost
            • replicate nursing led, or co-led, models of care delivery that are effective in improving cost, accessibility, and quality of care

            Approximately 50 percent of work plans have been completed as of 2004, and nursing organizations continue to work on unfinished projects they have identified as helpful to the initiative. Despite that success, the work to date has only moved NAF (2002) incrementally.

            In early 2004, a series of research proposals describing how work might be done to quantify the economic value of nursing were reviewed by the NAF Steering Committee. As this article goes to press, a contract is being finalized with the Lewin Group in Falls Church, VA. Based on projected time lines in the submitted proposals, it is reasonable to expect that the research for this project will be completed by late 2004, with a final report within the first quarter of 2005.

            In addition to the research proposed on nursing’s economic value, the Steering Committee has recognized the need to identify additional large-scale, or quantum leap, projects for the other outcome domains that will fill the gaps in Nursing’s Agenda for the Future (2002). It is anticipated that as the first project is completed and others are identified and proposed for funding, further interest, support, and large-scale activity for the initiative will increase. To that end, work is also underway to support NAF through the Invest in Nursing Campaign, a $30 million capital fund-raising campaign managed by the American Nurses Foundation. Once funding is secured, the opportunity for participation increases for all nursing organizations.

            The Work Ahead


            The opportunities for the nursing profession...to address current staffing and patient safety problems...are abundant, but the window of opportunity is rapidly closing.

            The opportunities for the nursing profession to intervene and make changes to address current staffing and patient safety problems and the growing nursing shortage are abundant, but the window of opportunity is rapidly closing. According to predictions by Geolot (2000), it is estimated that the available supply of registered nurses will actually begin to fall short of demand by 2010. At that point, if the RN supply has not improved, no incentives or workforce redistribution will resolve the problem.

            Nursing’s Agenda for the Future (2002) outlines the priorities nursing has defined for its profession, its practice, and for patient and nurse safety. Many of those same priorities have been reinforced by subsequent reports and recommendations across the industry.

            At a national level, nursing needs to be working from a standardized strategic plan to address priorities. While each association may have specific needs, the basic needs cross the specialties. Nursing’s Agenda for the Future can strategically guide organizational work by serving as a resource for use in priority and budget development.


            The nursing community needs to focus on collaborative efforts to change policy at the local, state, and national levels...

            The nursing community needs to focus on collaborative efforts to change policy at the local, state, and national levels to address their mutually identified priorities for patient safety and for the nursing shortage. Nursing’s Agenda for the Future (2002) provides a wealth of information for developing policy priorities and serves as a tool for educating members, consumers, other health professionals, purchasers, employers, insurers, and policymakers, to name a few. The more broadly the plan is utilized by nursing, the more focused and effective nursing’s efforts can be.

            At a state level, nursing needs to expand its relationship within the nursing community and with other stakeholders in order to increase understanding of the problems and engage support in their resolution. Nursing’s Agenda for the Future (2002) has been utilized in several states to serve as the focal point for meetings with legislators, health care industry representatives, nursing unions and organizations, educators, consumers, and other professionals. In these meetings, participants quantify the problems within their own state, and develop state-specific solutions using NAF as their model.


            Joining state nurses' associations and/or specialty organizations offers the best opportunity for individuals concerned about the future.

            What can an individual nurse do to further the work of NAF (2002)? Keeping abreast of the initiative, spreading the word about its importance, and engaging broader support within and outside the nursing community are paramount. As mentioned previously, the scale of work outlined in the plan and the human and financial resources required call for work at an organizational level, or more frequently among organizations. Since one of the goals is to coordinate and streamline work, individual nurses can best contribute to the initiative by serving on professional committees that are striving to achieve the NAF objectives and/or supporting nurses who are actively involved in developing and implementing the plan to reach the objectives of this report.

            Joining state nurses’ associations and/or specialty nursing organizations offers the best opportunity for individuals concerned about the future. Membership provides one with the ability to set the direction of work within associations and organizations and provides the organizations with the capacity to work at a level sufficient to overcome the current problems facing the profession, the health care industry, and the consumer of health care services.


            ...the most important outcome of this work is that the profession works together and works aggressively to protect its future.

            As a final point, the most important outcome of this work is that the profession works together and works aggressively to protect its future. A sufficient supply of nurses is essential for the delivery of safe, quality patient care.

            Over the course of the next year (2005), ANA will be managing the economic value research contract with the Lewin Group on behalf of the entire Steering Committee and the nursing community. At the same time, ANA is partnering with the American Nurses Foundation in its efforts to raise the $30 million needed to fund future projects designed to enhance the profession and turn around the looming shortage of nurses. ANA work will focus not only on this and other research projects designed to ultimately shape and improve health policy, but also on increasing the tools, resources, and strategies needed by nurses on a day-to-day basis to ensure safe, high quality care for all health care consumers and a sufficient supply of registered nurses to deliver that care!

            Author

            Katherine A. Kany, BS, RN
            E-mail: kkany@ana.org

            Katherine Kany is a registered nurse with 16 years of clinical nursing experience and 16 years of experience working for organizations representing registered nurses. Katherine also has an undergraduate degree in Broadcast Journalism, and is currently completing a Master of Science in Management, with an emphasis in Project Management. Katherine works in the Department of Nursing Practice and Policy at the American Nurses Association (ANA), and has been the Project Manager for Nursing’s Agenda for the Future since its inception in March of 2001. Her primary focus at the ANA is on issues related to nurse staffing.

            Reference

            American Hospital Association (2002).In our hands: How hospital leaders can build a thriving workforce. Available: www.hospitalconnect.com/aha/key_issues/workforce/commission/InOurHands.htm1

            American Nurses Association. (2002). Nursing’s agenda for the future: A call to the nation. Available: www.nursingworld.org/FunctionalMenuCategories/AboutANA/WhatWeDo/Reports/AgendafortheFuture.aspx.

            American Nurses Association. (1995). Nursing care report card for acute care. Washington, DC: ANA.

            Geolot, D. (2000, May). Resources and funding. Paper presented at the Nurse Staffing Summit of the American Nurses Association, Washington, DC.

            Horn, S.D. (2002). Economic Value of Nurses in Long Term Care. Paper presented by the Institute for Clinical Outcomes Research on May 8, 2002 for Primedia Network Learning, Salt Lake City, UT.

            Joint Commission on Accreditation of Healthcare Organizations. (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Available: www.jcaho.org/about+us/public+policy+initiatives/health+care+at+the+crossroads.pdf

            Kimball, B., & O’Neil, E. (2002). Health care’s human crisis: The American nursing shortage, Princeton, NJ: The Robert Wood Johnson Foundation. Available: www.rwjf.org/research/researchByArea.jsp?title=Nursing%3A+Transforming+Care+at+the+Bedside&id=000010

            Page, A. (Ed.). (2003). Keeping patients safe: Transforming the work environment of nurses. Committee on the Work Environment for Nurses and Patient Safety, Washington, DC: Institute of Medicine. Available: http://books.nap.edu/catalog/10851

            Wunderlich, G., Sloan, F., & Davis, C. (Eds.). (1996). Nursing staff in hospitals and nursing Homes: Is it adequate? Committee on the Adequacy of Nursing Staff in Hospitals and Nursing Homes. Washington, DC: Institute of Medicine. Available: www.nap.edu/catalog/5151


            © 2004 Online Journal of Issues in Nursing
            Article published May 31, 2004

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