Nursing Staff in Hospitals and Nursing Homes -- Copyright -- Acknowledgments -- Contents -- Part I Review And Recommendations -- Summary -- FINDINGS AND CONCLUSIONS -- Nursing Personnel in a Time of Change -- Staffing and Quality of Care in Hospitals -- Restructuring in the Hospitals -- Changing Roles and Responsibilities of Nursing Personnel -- Measuring Quality of Care in Hospitals -- Relationship of Nursing Staff to Quality of Care -- Staffing and Quality of Care in Nursing Homes -- Status of Quality of Care in Nursing Homes -- Relationships Among Nursing Staff, Management, and Quality of Care -- Staffing and Work-Related Injuries and Stress -- RECOMMENDATIONS -- 1 Introduction -- IMMEDIATE ORIGINS OF THE INSTITUTE OF MEDICINE STUDY -- COMMITTEE CHARGE -- DEFINITIONS -- Need -- Hospitals -- Nursing Homes -- Adequacy -- STUDY APPROACH -- Liaison Panel -- Testimony -- Site Visits -- UNDERLYING ASSUMPTIONS AND VALUES -- ORGANIZATION OF THE REPORT -- 2 Implications of Population Change -- INTRODUCTION -- GROWTH OF THE POPULATION -- DIVERSITY OF THE POPULATION -- Racial and Ethnic Composition -- Sociodemographic Characteristics -- Gender Distribution -- Living Arrangements -- Income and Poverty -- HEALTH STATUS AND DISABLING CONDITIONS -- Use of Health Services -- CONCLUSION -- 3 Evolving Health Care Scene -- OVERVIEW -- Impetus for Cost Containment -- Focus of the Chapter -- PRIVATE INSURANCE AND PUBLIC PAYERS FOR HEALTH CARE -- MANAGED CARE -- OWNERSHIP STRUCTURE -- HOSPITALS -- Restructuring of Hospital Services -- Integrated Systems -- Closures and Mergers -- Inpatient Activities -- Continuum of Care -- Outpatient Care -- Hospital-sponsored Home Health Services -- Hospital-Based Skilled Nursing Units -- NURSING HOMES -- Forces Affecting Demand for Nursing Home Services -- Expenditures and Payments Policies -- Cost Containment Policies.

Alternative Sites of LTC Care -- Restructuring of the Nursing Home Industry -- Special Care Units -- Subacute Care Units -- IMPLICATIONS FOR NURSING SERVICES -- 4 Nursing Personnel in a Time of Change -- SUPPLY OF NURSING PERSONNEL -- Registered Nurses -- Characteristics of RNs -- Educational Preparation of RNs -- Licensed Practical Nurses -- Nurse Assistants -- CHANGING DEMAND FOR NURSING PERSONNEL -- Employment Settings -- Hospitals -- Shift in Service Settings -- Nursing Homes -- Implications of Current Trends -- Salaries -- IS THE SUPPLY ADEQUATE FOR THE DEMANDS OF THE NEXT CENTURY? -- Nursing Education and Training for the Future -- Interdisciplinary Team Care -- Management of Care -- New Modes of Care Delivery -- Advanced Practice Nurses -- Differentiated Practice -- SUMMARY -- 5 Staffing and Quality of Care in Hospitals -- RESTRUCTURING IN THE HOSPITALS -- Changing Roles and Responsibilities of RNs -- Evolving Roles in Advanced Practice Nursing -- Ancillary Nursing Personnel -- Involving Personnel in Planning for Change -- Tracking the Effects of Change -- MEASURING QUALITY OF CARE IN HOSPITALS -- Elements of Quality of Care -- Structural Variables -- Process of Care -- Outcomes of Care -- Measurement of Quality -- Status of Hospital Quality of Care -- RELATIONSHIP OF NURSING STAFF TO QUALITY OF PATIENT CARE -- Nursing Staff and Quality of Care -- Report Cards -- LEGISLATIVE AND REGULATORY REQUIREMENTS -- SUMMARY -- 6 Staffing and Quality of Care in Nursing Homes -- MEASUREMENT OF QUALITY -- Elements of Quality of Care -- Patient Characteristics -- STATUS OF QUALITY OF CARE IN NURSING FACILITIES -- Legislative and Regulatory Efforts to Improve Quality -- OBRA 87 -- HCFA Regulations -- Nursing Home Resident Assessment Tools -- Survey and Certification -- HAS QUALITY OF CARE IMPROVED SINCE OBRA 87? -- Status of Staffing -- Federal Standards.

State Standards -- Empirical Evidence on Staffing -- Public Hearings and Site Visits -- RELATIONSHIPS AMONG NURSING STAFF, MANAGEMENT, AND QUALITY OF CARE -- Nursing Staff Levels and Skill Mix -- Staffing and Resident Characteristics -- Staffing and Quality of Care -- Geriatric Specialists -- Nurse Assistants -- Management and Leadership -- Job Satisfaction, Turnover, and Compensation -- Staff Turnover -- Compensation -- Ownership -- EFFECTS OF REIMBURSEMENT AND OTHER FACTORS ON NURSING STAFF -- Reimbursement and Staffing -- Method and Level of Reimbursement -- Case-Mix Reimbursement -- Incentives to Enhance Quality of Care -- RESIDENTS, FAMILIES, VOLUNTEERS, AND OMBUDSMEN -- CONCLUSION -- 7 Staffing and Work-Related Injuries and Stress -- OVERVIEW -- INCIDENCE OF WORK-RELATED INJURIES AND ILLNESS -- Relationship of Staffing and Injuries and Stress -- Back Injuries -- Needlestick Injuries -- VIOLENCE, ABUSE, AND CONFLICT -- Violence and Abuse of Health Care Workers and Nursing Staff -- Hospitals -- Nursing Homes -- Violence and Abuse Against Patients and Residents -- Nursing Homes -- Conflict Resolution -- WORK-RELATED STRESS -- Sources and Consequences of Stress -- SUMMARY -- 8 Epilogue -- Appendixes -- Appendix A Presentations Made to the Committee -- Appendix B Liaison Panel -- Appendix C Separate Statement and Responses -- Part 1: Separate Statement From The Report Of The Committee -- Part 2: Committee Members' Responses To The Separate Statement Of James F. Blumstein -- Personal Response to the Separate Statement of James F. Blumstein -- Appendix D Acronyms -- REFERENCES -- Biographical Sketches of Committee Members -- Part II Resources For The Study -- 1 Study Activities -- WRITTEN AND ORAL TESTIMONY SUBMITTED TO THE COMMITTEE -- Hospital-Related Testimony -- Nursing Personnel -- Institutional Providers of Acute Care.

Nursing Homes-Related Testimony -- Resident Advocacy Groups and Long-term-Care Ombudsmen -- Nursing Personnel -- Providers of Care in Nursing Facilities -- Education-related Testimony -- Testimony from Observers -- Concluding Remarks on Testimony -- SITE VISITS CONDUCTED BY THE COMMITTEE -- Approach -- General Issues in Health Care Delivery -- Staffing Issues -- Staffing Issues in Hospitals -- Staffing Issues in Nursing Facilities -- Quality of Patient Care and Quality of Life -- Quality of Patient Care and Patient Life in Hospitals -- Quality of Patient Care and Patient Life in Nursing Facilities -- Injuries and Stress -- Reimbursement Issues -- Education -- Concluding Remarks About Site Visits -- REQUEST FOR TESTIMONY -- Background -- Providing Testimony -- Guide to Preparing Testimony -- 2 Statistical Resources -- Contents -- 3 Commissioned Papers -- QUALITY OF CARE, ORGANIZATIONAL VARIABLES, AND NURSE STAFFING -- Introduction: The State Of The Science -- American Academy Of Nursing Invitational Conference -- Current and Recently Completed Research Projects -- Demonstration Research -- Descriptive Research -- Variables Addressed in Current Research -- Independent Variables -- Staff Outcomes -- Organizational Outcomes -- Client Outcomes -- Findings Related to the Independent Variable -- Findings Related to Staff and Organizational Outcomes -- Findings Related to Client Outcomes -- Discussion of Findings -- Published Research -- Mortality -- Complications -- Adverse Incidents -- Service Utilization -- Methodological Note -- Patient Satisfaction -- Methodological Note -- Relationship of Staff Satisfaction to Client Outcomes -- Summary: Linkages And Gaps -- Methodological Issues -- Sampling -- Measurement Sensitivity -- Consistency of Measures -- Summary -- References -- Appendix -- PROFESSIONAL NURSING EDUCATION-TODAY AND TOMORROW.

A Brief History Of Nursing Education -- Uncontrolled Diversity Versus Innovative Career Ladder -- Program Definitions For Figure 1 -- Forces Shaping Health Care Delivery -- A Time Of Redirection On Campus -- Health Care And Academia: Nursing's Advantages And Disadvantages -- Major Challenges Ahead -- Differentiating Practice -- Creating a More Educated RN Work Force -- Reconfiguring RN Work Force Demographics -- Supporting Creative Pedagogy and Community-Centered Care -- Encouraging Interdisciplinary Collaboration -- Supporting Informatics and Health Systems Delivery Research -- Removing Practice Barriers -- Renewing Displaced Nurses -- Addressing Fundamentals -- Author's Note -- References -- NURSING STAFF AND QUALITY OF CARE IN NURSING HOMES -- Background And Historical Development Of Nursing Homes In The United States -- From Almshouses to Nursing Homes -- Development of Long-Term Care for the Mentally Ill Elderly -- Current Status Of Institutional Long-Term Care -- Numbers and Types of Homes -- Traditional Nursing Homes -- Recent Alternative Long-Term-Care Models -- Case-Mix Data -- Regulations and Reimbursement -- Staffing, Staff-Mix, and Qualifications -- Nature of the Work in Nursing Homes -- Staff Salaries and Incentives -- Selected Issues In Long-Term Care -- Cultural Diversity Among Staff and Residents -- Issues Regarding Minority Care Providers -- Institutional Care Needs of Minority Elderly -- Violence, Abuse, and Conflict -- Access -- Future Demand for Institutional Long-Term Care -- Effect of Demographic Trends -- Trends in Case-Mix and Characteristics of Nursing Homes -- Subacute Care -- Special Care Units for Dementia -- Projected Staffing Requirements -- Regulatory and Reimbursement Projections -- Review of Research Relevant to Linkage of Staffing and Quality of Care -- Definitions and Measurement of Quality -- Cost of Quality.

Factors that Influence Staff Performance.