Dr. Gooloo S. Wunderlich, a researcher with more than 40 years' experience at the program and policy levels in health and population statistics, delivered the 1996 Hugh P. Davis Lecture at the School of Nursing.

The 1996 Hugh P. Davis Alumnae Lecture at the Nell Hodgson Woodruff School of Nursing was presented on March 29, 1996 by Dr. Gooloo S. Wunderlich, Senior Program Officer at the Institute of Medicine (IOM), National Academy of Sciences. The title, "Overview and Major Findings of the Report of the Committee on Nursing Staff in Hospitals and Nursing Homes," was based on a recent report developed from a study requested by the National Institute of Nursing Research (NINR) to the IOM. In response, an interdisciplinary committee on the Adequacy of Nursing Staffing in Hospitals and Nursing Homes was established in 1994 to conduct a national study that was directed by Dr. Wunderlich. The Emory Nursing Dean, Dr. Dyanne Affonso, was one of the nursing representatives on the committee.

According to Dr. Wunderlich, the rapid growth of managed care organizations combined with continuing demands to deliver cost-effective care under pressures of cost containment and increasing competition, has led to major changes in the structure and delivery of health care in this country. The shift to outpatient, ambulatory, and community-based care in general, and managed care in particular has resulted in a reduced volume of inpatient care. As a consequence, hospitals are restructuring, redesigning staffing patterns, moving towards interdisciplinary teams of caregivers, and downsizing staff. Nurses, their professional organizations, and their unions have expressed concerns that hospitals are implementing delivery systems involving major downward staff substitutions, thereby endangering patient care quality and causing higher incidence of work-related injuries and stress. The IOM committee, however, was unable to find evidence of decline of quality of hospital care because of changes in staffing patterns, or of reductions of registered nurse (RN) staffing levels in hospitals on a national level, suggesting that in the aggregate these losses appear to have been more than offset by hires. Dr. Wunderlich emphasized the need for valid and timely information on employment patterns of nursing staff in the health care system and several other issues the committee was charged to examine. She noted that the redesign of nursing services in hospitals is leading to changes in the role and responsibilities of nursing personnel and increasing the emphasis on interdisciplinary teams. While the RN remains in a central position for coordinating care in the hospital, sometimes as case manager, nurse assistants are being assigned, under the direction of the RN, increasing responsibility for direct care activities, without benefit of uniform national requirements for training and certification. As a result, RNs are increasingly being called upon to fill roles that require increased professional judgment, supervision and direction of work of others, requiring increasing levels of supervisory and management skills.

The study determined that nursing staffs are being cut as a result of the rapid growth of managed care organizations and the resultant pressure to deliver cost-effective care amid soaring competition for health care dollars.

General recommendations from the IOM committee that were described by Dr. Wunderlich included the need by hospitals to expand the use of RNs with advanced practice preparation, and the skills to provide the clinical leadership and cost-effective patient care, particularly for patients with complex management problems. Also, hospitals should have documented evidence that nurse assistants and other ancillary nursing personnel in patient care positions are tested and certified for this competence by an appropriate entity. The committee also cautioned that if hospitals do not take these steps now, ultimately, regulation may become necessary.

In addition, the committee was emphatic about the significant contribution of professional nursing care in nursing homes. The IOM committee found problematic the lack of any RN presence in many facilities in the evening and on night shifts. According to Dr. Wunderlich, "The knowledge and judgment of an RN is critical in a crisis or a regression of a condition; early detection and intervention often forestall the use of expensive measures such as hospitalizations and admissions to emergency rooms. In addition to the beneficial effect on patient outcomes, reduced rehospitalizations and visits to emergency rooms were also found to lead to cost savings in the long run."

Dr. Wunderlich had insightful final remarks regarding the dynamics surrounding the nursing workforce within the context of rapidly changing demands in the U.S.: "The nursing workforce issues should be studied not in isolation but as an integral part of the overall health workforce. If we do not take the initiative to collect and analyze appropriate data and undertake rigorous research, a few years from now there will be a call for another study of nurses, and we will continue to be plagued with similar issues and no adequate answers."

Reprinted from Emory Nursing, Spring 1997

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