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environment of care is paramount to achieving the optimal patient outcomes for which the nurse is held accountable. During the 1973-74 legislative session, the CNA proposed major revisions of the Nursing Practice Act, demanding the California Legislature recognize that the practice of nursing was dynamic and constantly evolving and to explicitly recognize the existence of overlapping functions between physicians and registered nurses and permits additional sharing of functions within organized healthcare systems that provide for collaboration between physicians and registered nurses. In exchange for such broad authority, the profession agreed to represent the patient���s interest and to consistently demonstrate competency. The statute defines the practice of nursing to mean those functions, including basic healthcare, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including ���[d]irect and indirect patient care services.��� Subsequent to adoption of the Nursing Practice Act, the Board of Registered Nursing (BRN) adopted a regulation establishing ���Standards of Competent Performance��� for registered nurses. Standards of Competent Performance primary nursing came into great use as the modality for the delivery of nursing care in the 1980s. The primary nurse follows all the steps of the nursing process and uses this position of authority and autonomy to assess, plan, administer and evaluate nursing interventions on behalf of the patient and families. Because primary nurses collaborate with other RNs and health practitioners about the needs of their primary patients, primary nurses become patient advocates within the healthcare delivery system. In 1986 the BRN further clarified the Nursing Practice Act by incorporating the nursing process as the model for delivery of nursing care and by explicitly defining the duty and the right of the registered nurse as patient advocate. The Standards of Competent Performance provide that a registered nurse shall be considered competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological, and physical sciences in applying the nursing process, as demonstrated in a number of circumstances. The nursing process is the process used to organize and deliver appropriate nursing care; it is based on the model of the scientific method of inquiry. Under the statute and regulations, registered nurses (���RNs���) are required to (1) formulate a nursing diagnosis through observation of the client���s physical condition and behavior and interpretation of information obtained from the client and others; (2) formulate a care plan, in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client���s safety, comfort, hygiene, and protection, and for disease prevention and restorative measures; (3) evaluate the effectiveness of the care plan through observation of the client���s physical condition and behavior, signs and symptoms of illness, and reactions to treatment and through communication with the client and health team members; and (4) act as the client���s advocate, as circumstances require, by initiating action to improve healthcare or to change decisions or activities which are against the interests or wishes of the client, and by giving the client the opportunity to make informed decisions about healthcare before it is provided. From coast to coast, registered nurses have begun to raise their voices to protest rapidly eroding care standards and unsafe staffing levels that put both nurses and patients at risk. In today���s environment of 24 N AT I O N A L N U R S E managed care and corporate medicine, registered nurses have become accustomed to fighting at the bedside, every hour of every day for their patients��� survival as well as their own, desperately trying to provide the care that patients need against all odds. Passing the Baton: The History of Safe RN Staffing Ratios in California Background and Significance: Registered nurses are a critical component in guaranteeing patient safety and the highest quality healthcare. Yet, beginning with a 1996 study entitled ���Nursing Staff in Hospitals and Nursing Homes: Is it Adequate?,��� a series of Institute of Medicine (IOM) reports initiated massive shifts in attention and effort to study hospital staffing and patient outcomes. During the following decade, there was an undercurrent of tension between hospital administrators and staff nurses regarding how many nurses are enough, what their roles should be, and how to recruit and retain them. Hospitals, with an eye on the bottom line, spent most of the 1990s reducing their RN workforce through layoffs and attrition. Reengineering and restructuring undertaken by hospital management has been designed to emulate industrial models of productivity improvement rather than address nurses��� concerns about fundamental flaws in the redesign of clinical care services and fragmentation of the hospital workforce. Many nurses began speaking out and reporting that staffing in hospitals was deteriorating and unsafe. In September of 1994, CNA presented written and oral testimony for consideration by the Institute���s Committee on Adequacy of Nursing Staffing. The association presented several key points: ��� The adequacy of nursing staffing is an important factor in protecting patient safety and maintaining positive patient outcomes. ��� Inadequate levels of nurse staffing and/or inappropriate skill mix of nurse providers have been long-standing and complex problems with a cyclically recurring pattern over a period of many years. ��� Research has shown that higher levels of staffing and higher ratios of RNs to total nursing personnel are significantly related to better outcomes of care. ��� RNs caring for patients with too few or the wrong mix of personnel deal with ���near misses��� often on a daily basis. ��� ���Near misses��� are not just occasional events or expected human mistakes. Instead, they are largely preventable or correctable events that result from too few or inappropriately assigned personnel to assess and handle patient care needs appropriately. ��� The concept of ���near misses��� encompasses a wide range of potentially dangerous situations which nurses, if present, detect, prevent, correct, or attenuate. CNA���s testimony, drawn from survey reports and letters submitted by thousands of RNs and members of the public, documented the real risks that Californian RNs and their patients face every day due to unsafe hospital staffing as a result of hospital restructuring. The survey reports and letters were submitted by CNA to the California Department of Health Services detailing specific incidents of unsafe staffing and extensive narratives on ���near misses��� and adverse outcomes. A summary of the survey results identified the following: ��� Staffing has worsened. ��� Current staffing does not allow time for unexpected events��� which occur regularly. ��� Overall patient acuity has increased. ��� Changes in skill mix and/or layoffs of hospital personnel have had a negative effect on patient care. 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 SEPTEMBER 2012