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��� Nurses have witnessed inappropriate transfers of patients who were too sick to be sent home or to a less acute-care area of the hospital. The IOM Committee, at the time, refused to recognize the importance of RN staffing levels and skill mix on quality of patient care in hospitals regardless of existing empirical evidence. Dr. Patricia Prescott published the evidence in 1993 after conducting a comprehensive review. Overall she found substantial evidence linking RN staffing levels and mix to important mortality, length of stay, cost, and morbidity outcomes. Increased RN core clinical staffing was shown to reduce mortality, length of stay, cost, complication rates, and improve both RN and patient satisfaction. However, the IOM reports were not the first set of clear statements of concern regarding hospital safety and quality. Nor were these reports the first efforts at calling attention to the need for data, public reporting, and the consideration of healthcare quality in light of payment for care. More than 140 years earlier, Florence Nightingale, the founder of modern nursing, raised these same issues. In spite of the passage of well over a century between Nightingale and the release of the IOM reports, seemingly little attention was paid in the interim to creating safer healthcare environments. Three comparisons of Nightingale���s concerns and recommendations with those expressed in the IOM reports illustrate similar problem identification as well as a shared view regarding the building blocks essential to creating solutions. First, in her publication, Notes on Hospitals, Nightingale identified the paradox of the problem at hand: ���In practice a hospital may be found only to benefit a majority and to inflict suffering on the remainder.��� Well over a century later, To Err Is Human reports, ������ a person should not have to worry about being harmed by the health system itself.��� Nightingale goes on to say, ���Even admitting to the full extent the great value of hospital improvements of recent years, a vast deal of suffering, and some at least of the mortality, in these establishments is avoidable.��� Similarly, To Err Is Human notes, ���A substantial body of evidence points to medical errors as a leading cause of death and injury.��� Finally, in a search for solutions and with an eye toward measurement, developing evidence, public reporting, and linking payment with quantifiable performance, Nightingale theorized, ���It is impossible to resist the conviction that the sick are suffering from something quite other than the disease inscribed on their bed ticket���and the inquiry ��� arises in the mind, what can be the cause?��� Related to this, To Err Is Human notes, ���Sufficient attention must be devoted to analyzing and understanding the causes of errors in order to make improvements.��� By 2001, two-thirds of U.S. nurses were reporting that their hospitals did not have enough nurses to provide high-quality care, and 45 percent said the quality of care had deteriorated significantly in the previous year. A Commonwealth Fund survey of doctors published that year found that doctors ranked nurse staffing levels of hospitals as one of their most serious concerns in being able to provide top-quality healthcare. A subsequent survey of physicians revealed 64 percent rated hospital nursing staff levels as fair to poor. Patients and their families were also expressing dissatisfaction with their care and an increasing number began bringing private-duty nurses with them to the hospital. Hospital-based errors leading to the deaths of up to 98,000 patients per year were viewed as scandalous by many. The Institute of Medicine, which produced the report, studied all conceivable variables related to deterioration of patient care conditions except RN staffing ratios according to the Institute for Health and Socio-economic Policy. SEPTEMBER 2012 Hospitals began implementing a variety of nursing care delivery systems, involving so-called ���transformational care��� and ���clinical work redesign��� schemes to reconfigure staffing patterns. This clinical restructuring reduced the proportion of RNs to other nursing and/or unlicensed ���assistive��� personnel and led to increased concerns among direct-care RNs about the threats to their ability to provide safe, therapeutic, and effective patient care. As hospitals signaled to nursing schools that fewer nurses were needed, school budgets were slashed and training programs for RNs were cut. This was occurring when the increasing complexity and acuity of hospital caseloads called for even more skilled nursing care provided by registered nurses. Hospitals hired consulting firms, paying them hundreds of millions of dollars to implement work/role redesign models with an emphasis on shifting registered nurses away from hands-on care to serve as ���team leaders��� of the lowerpaid, lower-skilled licensed and unlicensed assistive personnel. Guided by market-driven goals of cost-cutting and profit-making rather than assurance of quality care, health firms began to implement restructuring programs in the corporate, clinical, and technological arena. Although based on a manufacturing model that devalues the intellectual work of nursing by breaking up the nursing process into a series of ���tasks,��� these schemes are often referred to as ���patient-centered��� or ���patient-focused��� care. Patient care staffing standards sharply deteriorated in hospitals across the country as hospitals cut vital services. Administrators failed to staff available beds in order to maximize their profitability. Patients and nurses experience the effect every day with unsafe staffing levels. Many nurses fled the profession due to unsafe staffing, mandatory forced overtime, and double shifts. They feared the conditions would cause them to harm patients and they feared losing their license when required to delegate complex care to lowerskilled workers. Today, it is still legal for RNs in 49 states to be assigned 10 to 16 patients, or more, at a time! Workplace Hazards and Risk of Patient and Nurse Harm although there are five categories of potential workplace hazards found in hospitals, the U.S. Department of Labor���s Occupational Safety and Health website lists ���stress, workplace violence, shift work, inadequate staffing levels, heavy workload, financial constraints and increased productivity demands/speed up, increased intensity of work, exposure to occupational violence and increased patient acuity��� in the ���psychological hazard��� category. This category is defined as: ���Factors and situations encountered or associated with one���s job or work environment that create or potentiate stress, emotional strain, and/or other interpersonal problems.��� Implications for the quality and efficacy of the healthcare an organization provides have been a particular focus on investigations of stress and burnout. Both generally and specifically are related to psychological aggression, hostile work environments, horizontal violence, and bullying. Stress and burnout in nurses negatively affects patients��� perception of the quality of their care and also contributes to a higher likelihood of medical errors. Stress-related attrition exacerbates already inadequate RN-to-patient ratios and can generate considerable labor costs for healthcare organizations. A survey of turnover in acute-care facilities found that replacement costs for nurse positions were equal to or greater than two times their annual salaries. All of these factors are cited in the literature as being associated with or potentiated by too few staff and/or an insufficient number of appropriately licensed, clinically competent RN staff present and available W W W. N A T I O N A L N U R S E S U N I T E D . O R G N AT I O N A L N U R S E 25