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to provide a high standard of safe, therapeutic, and effective patient care. Research has shown these risks can be mitigated by increasing the proportion of RNs available to care for patients. As consumers, we expect specific standards for clean air and water, limits on classroom sizes, and staffing ratios for airlines, day care centers, and nursing home staff. Hospital patients and the registered nurses who care for them should also be entitled to minimum safety standards and public protection. High-acuity patients, a high number of patients per nurse, changes in skill mix, models of care delivery, technology, organizational restructuring, fatigue, frequent interruptions, and workflow redesign continue to occur. Each of these changes in the RN practice environment potentiates the risk of patient harm, nurse burnout, and low nurse and patient satisfaction, according to the Institute of Medicine (2004). The 1996 Congressionally mandated Institute of Medicine study concluded that evidence-based standards were insufficient to guide hospitals, nurses, and policymakers in prescribing hospital nurse staffing. Pronovost (1995) and his associates helped fill this void by creating an evidence base for establishing nurse staffing standards. Their study examined the relationship between nurse-to-patient ratios in the intensive care units (ICUs) of Maryland hospitals and the risk for complications after abdominal aortic surgery. They found that patients in hospitals where ICU nurses care for three or more patients have significantly increased risk for medical complications compared with patients in hospitals where ICU nurses care for one to two patients. Of interest, California adopted an ICU nurse-to-patient maximum staffing ratio of one RN to two patients in 1976. It was signed into law by then-governor Jerry Brown. Pronovost et al. had provided evidence to validate that standard. On the other hand, the researchers noted that employing fewer nurses to care for patients would end up costing hospitals more. Inadequate nurse staffing levels lead to increased resource use, particularly in the form of longer lengths of stay, thus negating expected labor savings. Having an ICU nurse-to-patient ratio of less than 1:2 during the day increased mean ICU days by 49 percent. The findings of a 20-hospital study conducted by Aiken, et al. of inpatient AIDS care are similar to those of Pronovost and colleagues. She found substantial variation across hospitals in riskadjusted 30-days-from-admission mortality among patients with AIDS, as well as substantial differences in nurse-to-patient ratios. After accounting for other important factors, Aiken and her colleagues estimated that staffing up with an additional nurse per patient day cut the odds of dying by more than half. The researchers also found that the hospitals that had the most favorable nurse-to-patient ratios had significantly shorter overall lengths of stay as well as fewer ICU days. Thus, the overall cost of care was no greater in hospitals with more favorable nurse-to-patient ratios. These findings add to the evidence presented by health economist Dr. Uwe Reinhardt in his compelling essay, ���Spending More through ���Cost Control���: Our Obsessive Quest to Gut the Hospital.��� Reinhardt showed that flawed accounting practices in healthcare often result in managerial and policy decisions that adversely affect patients without reducing costs. More than a decade of research suggests that the organizational climate in which care takes place is as important as staffing in determining patient outcomes. The effects of excellent nurse staffing can be undermined in organizations that restrict nurses��� autonomy to act within their scope of expertise, that provide inadequate administrative support, or that fail to give nurses authority commensurate with their high level of 26 N AT I O N A L N U R S E responsibility for patient well-being. Recent restructuring and reengineering of hospitals have adversely affected nurses��� practice environments and contributed to the current perception of an acute shortage of hospital nurses. Numerous studies in the United States continue to document publicly that patient deaths are tied to a lack of sufficient numbers of nurses to meet their complex needs. In addressing the nursing shortage, the industry focus has been on incentives such as signing bonuses, tuition reimbursement and relocation fees, without addressing the underlying dissatisfaction created by the barriers to practicing the work nurses love: the hands-on work of providing care for another that Nightingale described as a physical, spiritual, moral, and artistic profession informed by science. When nurses leave organizations as fast as they are hired, money is wasted, experience is lost, and patient care deteriorates. What good is it to have an industrial model of treatment and cure or physical care when nurses and practitioners alike are disenchanted, leading to moral distress, burnout, and poor patient outcomes? Nurses strive to find the time to help the patient and the patient���s family make sense of the illness and the pain that has fallen upon them against a system whose dictates require that caring is a luxury the bottom line will not tolerate. One nurse after another today leaves her shift with a crisis of conscience knowing that all that should have been done to heal the patient is no longer possible. The consequences for the public are enormous. Poor staffing levels mean a patient may go hours without seeing a registered nurse. Is it any wonder under such circumstances that the Institute of Medicine (2003) reported that preventable medical errors claim the lives of as many as 98,000 patients every year ��� more than from highway accidents, breast cancer, or AIDS? Many nurses have chosen not to continue to work in hospitals or to leave the profession entirely, creating a growing alarm about a new nursing shortage that the healthcare industry itself largely created by reckless cost cutting and restructuring measures. The brave souls who remain as nurses are attempting to use every resource available to fight back for their patients and the dignity of their profession, which is so dramatically needed in a society with an aging population, new resistant diseases, and 50 million people without health insurance. Nurses across the country are insisting on changes in hospital conditions that will ensure safer standards, protect patients, and encourage nurses to return to the hospital setting. RNs have been forced to picket and even strike to promote the well-being and the safety of their patients. Gone are the days when nurses will quietly accept the destruction of the healthcare system and their profession. The Road to Achieving Ratios and Staffing-Up Based on Patient Needs as early as 1992, the California Department of Health Services (DHS) considered proposing regulations requiring staffing ratios for registered nurses in acute-care hospitals. However, at that time, DHS determined not to impose minimum ratios and instead opted for regulations requiring that hospitals implement a Patient Classification System (���PCS���). The PCS was intended to ensure that the number of nursing staff was aligned to the healthcare needs of the patients, while still allowing the provider flexibility for the efficient use of staff. The PCS regulations provide a framework to establish nursing staff allocations based on nursing care requirements for each shift and each unit. The PCS system requires the establishment of a method to predict nursing care requirements of individual patients. This method 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