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CE 2_Nov REV 12/10/10 8:16 AM Page 25 healthcare system with a single standard of excellent care for all based on medical need. Evidence-Based Nursing Practice Points with the prospect of increased reimbursements to healthcare providers and organizations being linked with higher patient satisfaction scores, administrators and managers might well consider the findings of a study of nurse staffing models, nursing hours, and patient safety outcomes conducted by McGillis, Hall, Doran, and Pink (2004). The authors demonstrated that increased RN-topatient ratios were positively correlated with increased patient satisfaction with the care they'd received. Decisions about nurse staffing levels should be based on sound evidence and health policy science to reduce the risk of preventable complications and ensure optimum patient outcomes. The strength of the empirical, peer-reviewed research findings of Dr. Linda Aiken and her colleagues' 2010 study supports the immediate implementation of California's landmark RN-to-patient ratio law as a benchmark on a national scale in order to protect the public and reverse the nursing shortage. The evidence is clear and convincing that minimum RN-to-patient ratios, with staffing up based on the patient's acuity and severity of illness, is the most important and cost-effective safety measure for ensuring therapeutic and effective patient outcomes. Conclusions because direct-care rns take a dim view of expensive and insulting scripting and rounding schemes, frequently reporting that they are strong work-life dissatisfiers, hospitals should reconsider the imposition of them on staff RNs because such schemes may have the unintended consequence of increasing the turnover rates of experienced RNs. Hospital nursing turnover has been correlated with a higher adjusted mortality index and severity-adjusted average length of stay, as well as a higher cost per discharge. A stable nursing workforce with experience at the facility as well as with specific patient populations, combined with collegiality with physicians, leads to higher quality. Several respectable studies published in peer-reviewed journals have concluded that nurse satisfaction leads to staff stability, which leads to improved clinical and financial outcomes. Rather than decreasing the number of RNs, hospitals should increase the ratios of RNs to patients, because RNs' higher level of knowledge and experience has been shown to reduce patient mortality and reduce the overall costs of care (Aiken, et al., 2002; Eastabrooks, Midodzi, and Cummings, et al., 2005; Needleman, 2006; Dall, Chen, and Seifert, et al., 2009). From a hospital and business perspective, improved RN-topatient ratios have a synergistic and demonstrated economic value for hospitals in terms of lower liability and improved reputation by reducing adverse outcomes such as decreased blood-borne infection rates, patient falls, decubitus ulcers, ventilator-acquired pneumonia, and medication errors. In instances where there is not a clear business case for increased nurse-to-patient ratios, there is a compelling social case that can be made due to reduced adverse outcomes and avoided additional hospital days. From a patient and social advocacy perspective, improved RNto-patient ratios have economic and non-economic benefits for patients and their families in terms of decreased pain and suffering NOVEMBER 2010 from preventable complications, decreased length of stay, lost days from work, and increased patient satisfaction. Increasing nurse staffing is associated with fewer in-hospital deaths under all options. Needleman (2006) and his colleagues concluded that 70,000 deaths could be avoided by raising the hospital nurse staffing threshold to the 75th percentile overall. Rather than weakening or lowering safe staffing standards, a more appropriate strategy would be for government and other payers to increase reimbursement rates to hospitals that comply with the standards, instead of tying reimbursement to unproven customer satisfaction surveys. Under current reimbursement systems, the incentive and financial reality for hospitals is for them to staff at levels below where the benefit to society equals the cost to employ the additional nurses (Dall, 2009). A strong reason for employers to change nursing care delivery models and practices is to encourage the development of behaviors and skills that reflect business strategy and organizational design. Salary and pay-for-performance schemes are designed to communicate these messages of strategy and control to generate compliance with organizational policies. Rounding and patient satisfaction schemes are methods by which healthcare organizations can substitute industry-aligned, performance-based competencies as a substitute for professional clinical nurses' skill, expertise, and practice-based competencies. Nurse administrators are responsible for allocating nursing staff to meet professional quality-of-care standards and unfortunately, many have aligned themselves with the business interests of their employers. The CNA/NNOC/NNU definition of quality is safe, therapeutic, and effective care, competently delivered, that allows the patient to reach his or her optimum level of health and well-being. Direct-care registered nurses are responsible for ensuring that the care they provide is in the exclusive interests of the patient they care for, even when the provision of patient care is in conflict with the financial interests, policies, or orders of the employer. Recommendations and Social Advocacy Action Plan for RNs the evidence evaluated here suggests that patient satisfaction, nurse satisfaction, and optimal patient outcomes are influenced by ensuring that there are an effective number of direct-care registered nurses to meet the needs of patients who require nursing care. Ef fective RN-to-patient ratios, not creative and illusory rounding and scripting schemes, are required for prevention, care planning, initial and ongoing assessment and evaluation of the treatment plan, patient education, and restoration to the optimal level of health and well-being attainable in the exclusive interests of the patient. The social good and public benefit of increasing RN-to-patient ratios compels nurses and other social advocates to demand healthy social policy and financial accountability when it comes to solving our current crisis in healthcare. This is congruent with our vision of advocacy for a single-payer national health program, with a single standard of excellent care for all. Standards for Evaluating Whether Scripting and Rounding Schemes Are in the Interests of Direct-Care RNs and Their Patients state nursing practice acts and registered nursing board implementing regulations, practice standards, and professional license guidelines generally impose a "fiduciary responsibility" on registered 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