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Legal and Ethical Conduct
As emphasized in this week’s media presentation, all nurses need to be familiar with the laws and regulations that govern their practice: their state’s Nurse Practice Act, ANA’s Nursing: Scope and Standards of Practice, specialty group standards of practice, etc. In addition, basic ethical principles guide nurses’ decision-making process every day.
ANA’s Code of Ethics and ANA’s Social Policy Statement are two important documents that outline nurses’ ethical responsibilities to their patients, themselves, and their profession. This said, there is a dilemma: The laws are not always compatible with the ethical positions nurses sometimes take. This week’s Discussion focuses on such a dilemma.
To prepare:
Review this week’s Learning Resources, focusing on the information in the media presentation about the relationship between the law and ethics.
Consider the ethical responsibility of nurses in ensuring patient autonomy, beneficence, non-malfeasance, and justice.
Read the following scenario:
Lena is a community health care nurse who works exclusively with HIV-positive and AIDS patients. As a part of her job, she evaluates new cases and reviews confidential information about these patients. In the course of one of these reviews, Lena learns that her sister’s boyfriend has tested HIV positive. Lena would like to protect her sister from harm and begins to consider how her sister can find out about her boyfriend’s health status.
Consult at least two resources to help you establish Lena’s legal and ethical position. These resources might include your state’s Nurse Practice Act, the ANA’s Code of Ethics, ANA’s Nursing: Scope and Standards of Practice, and internal or external standards of care.
Consider what action you would take if you were Lena and why.
Determine whether the law and the ANA’s standards support or conflict with that action.
Post a description of the actions you would take in this situation, and why. Justify these actions by referencing appropriate laws, ethical standards, and professional guidelines.
Required Readings
Milstead, J. A. (2019). Health policy and politics: A nurse’s guide (6th ed.). Burlington, MA: Jones and Bartlett Publishers.
Chapter 4, “Government Response: Regulation” (pp. 56-81)
This chapter explains the major concepts of the regulation of health professionals, with emphasis on advanced practice nurses (APN) and the process of licensure and credentialing.
ANA’s Foundation of Nursing Package – (Access this resource from the Walden Library databases through your NURS 6050 Course Readings List)
Guide to the Code of Ethics: Interpretation and Application
This guide details the history, purpose and theory, application, and case studies of this must-have Code of Ethics.
Nursing Social Policy Statement
The Nursing Social Policy Statement provides an understanding of the social framework and obligations of the nursing profession.
Nursing: Scope & Standards of Practice
This book contains several national standards of practice that can be used to inform the decision-making process, development, implementation, and evaluation of several functions and aspects of advanced practice nursing.
Scope of Nursing Practice
Definition of Nursing
Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010, p. 3) builds on previous work and provides the following contemporary definition of nursing:
Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
This definition serves as the foundation for the following expanded description of the Scope of Nursing Practice and the Standards of Professional Nursing Practice.
Professional Nursing’s Scope and Standards of Practice
A professional nursing organization has a responsibility to its members and to the public it serves to develop the scope and standards of its profession’s practice. As the professional organization for all registered nurses, the American Nurses Association (ANA) has assumed the responsibility for developing the scope and standards that apply to the practice of all professional nurses and serve as a template for nursing specialty practice. Standards do, however, belong
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to the profession and, thus, require broad input into their development and revision. Nursing: Scope and Standards of Practice, Second Edition, describes a competent level of nursing practice and professional performance common to all registered nurses.
Description of the Scope of Nursing Practice
The scope of practice statement describes the “who,” “what,” “where,” “when,” “why,” and “how” of nursing practice. Each of these questions must be answered to provide a complete picture of the dynamic and complex practice of nursing and its evolving boundaries and membership.
The profession of nursing has one scope of practice that encompasses the full range of nursing practice, pertinent to general and specialty practice. The depth and breadth in which individual registered nurses engage in the total scope of nursing practice are dependent on their education, experience, role, and the population served.
Development and Function of Nursing Standards
The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The standards published herein may serve as evidence of the standard of care, with the understanding that application of the standards depends on context.
The standards are subject to change with the dynamics of the nursing profession, as new patterns of professional practice are developed and accepted by the nursing profession and the public. In addition, specific conditions and clinical circumstances may also affect the application of the standards at a given time, e.g., during a natural disaster. The standards are subject to formal, periodic review and revision.
The Function of Competencies in Standards
The competencies that accompany each standard may be evidence of compliance with the corresponding standard. The list of competencies is not exhaustive. Whether a particular standard or competency applies depends upon the circumstances.
For example, a nurse providing treatment to an unconscious, critical patient who presented to the hospital by ambulance without family has a duty to collect comprehensive data pertinent to the patient’s health (Standard 1. Assessment).
However, under the attendant circumstances, that nurse may not be expected to assess family dynamics and impact on the patient’s health and wellness (Assessment Competency). In the same circumstance, Standard 5B. Health Teaching and Health Promotion may not apply at all.
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The Nursing Process
The nursing process is often conceptualized as the integration of singular actions of assessment, diagnosis, and identification of outcomes, planning, implementation, and finally, evaluation. The nursing process in practice is not linear as often conceptualized, with a feedback loop from evaluation to assessment. Rather, it relies heavily on the bi-directional feedback loops from each component, as illustrated in Figure 1.
The Standards of Practice coincide with the steps of the nursing process to represent the directive nature of the standards as the professional nurse completes each component of the nursing process. Similarly, the Standards of Professional Performance relate to how the professional nurse adheres to the Standards of Practice, completes the nursing process, and addresses other nursing practice issues and concerns (ANA, 2010). Five tenets characterize contemporary nursing practice (see next two pages).
View Figure
FIGURE 1. The Nursing Process and Standards of Professional Nursing Practice
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Tenets Characteristic of Nursing Practice.
1. Nursing practice is individualized.
Nursing practice respects diversity and is individualized to meet the unique needs of the healthcare consumer or situation. Healthcare consumer is defined to be the patient, person, client, family, group, community, or population who is the focus of attention and to whom the registered nurse is providing services as sanctioned by the state regulatory bodies.
2. Nurses coordinate care by establishing partnerships.
The registered nurse establishes partnerships with persons, families, support systems, and other providers, utilizing in-person and electronic communications, to reach a shared goal of delivering health care. Health care is defined as the attempt “to address the health needs of the patient and the public” (ANA, 2001, p. 10). Collaborative interprofessional team planning is based on recognition of each discipline’s value and contributions, mutual trust, respect, open discussion, and shared decision-making.
3. Caring is central to the practice of the registered nurse.
Professional nursing promotes healing and health in a way that builds a relationship between nurse and patient (Watson, 1999, 2008). “Caring is a conscious judgment that manifests itself in concrete acts, interpersonally, verbally, and nonverbally” (Gallagher-Lepak & Kubsch, 2009, p. 171).
While caring for individuals, families, and populations is the key focus of nursing, the nurse additionally promotes self-care as well as care of the environment and society (Hagerty, Lynch-Sauer, Patusky, & Bouwseman, 1993).
4. Registered nurses use the nursing process to plan and provide individualized care to their healthcare consumers.
Nurses use theoretical and evidence-based knowledge of human experiences and responses to collaborate with healthcare consumers to assess, diagnose, identify outcomes, plan, implement, and evaluate care. Nursing interventions are intended to produce beneficial effects, contribute to quality outcomes, and above all, do no harm. Nurses evaluate the effectiveness of their care in relation to identified outcomes and use evidence-based practice to improve care (ANA, 2010).
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Critical thinking underlies each step of the nursing process, problem-solving, and decision-making. The nursing process is cyclical and dynamic, interpersonal and collaborative, and universally applicable.
5. A strong link exists between the professional work environment and the registered nurse’s ability to provide quality health care and achieve optimal outcomes.
Professional nurses have an ethical obligation to maintain and improve healthcare practice environments conducive to the provision of quality health care (ANA, 2001). Extensive studies have demonstrated the relationship between effective nursing practice and the presence of a healthy work environment. Mounting evidence demonstrates that negative, demoralizing, and unsafe conditions in the workplace (unhealthy work environments) contribute to medical errors, ineffective delivery of care, and conflict and stress among health professionals.
Healthy Work Environments for Nursing Practice
ANA supports the following models of healthy work environment design:
AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES
The American Association of Critical-Care Nurses has identified six standards for establishing and maintaining healthy work environments (AACN, 2005):
Skilled Communication
Nurses must be as proficient in communication skills as they are in clinical skills.
True Collaboration
Nurses must be relentless in pursuing and fostering a sense of team and partnership across all disciplines.
Effective Decision-making
Nurses are seen as valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.
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Appropriate Staffing
Staffing must ensure the effective match between healthcare consumer needs and nurse competencies.
Meaningful Recognition
Nurses must be recognized and must recognize others for the value each brings to the work of the organization.
Authentic Leadership
Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in achieving it.
MAGNET RECOGNITION PROGRAM
The Magnet Recognition Program® addresses the professional work environment, requiring that Magnet®-designated facilities adhere to the following model components (ANCC, 2008):
Transformational Leadership
The transformational leader leads people where they need to be in order to meet the demands of the future.
Structural Empowerment
Structures and processes developed by influential leadership provide an innovative practice environment in which strong professional practice flourishes and the mission, vision, and values come to life to achieve the outcomes believed to be important for the organization.
Exemplary Professional Practice
This demonstrates what professional nursing practice can achieve.
New Knowledge, Innovation, and Improvements Organizations have an ethical and professional responsibility to contribute to healthcare delivery, the organization, and the profession.
Empirical Quality Results
Organizations are in a unique position to become pioneers of the future and to demonstrate solutions to numerous problems inherent in today’s healthcare systems. Beyond the “What” and “How,” organizations must ask themselves what difference these efforts have made
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INSTITUTE OF MEDICINE
The Institute of Medicine has also reported that safety and quality problems occur when dedicated health professionals work in systems that neither support them nor prepare them to achieve optimal patient care outcomes (IOM, 2004).
Such rapid changes as reimbursement modification and cost containment efforts, new healthcare technologies, and changes in the healthcare workforce have influenced the work and work environment of nurses. Accordingly, concentration on key aspects of the work environment—people, physical surroundings, and tools—can enhance healthcare working conditions and improve patient safety. These include:
Transformational leadership and evidence-based management
Maximizing workforce capability
Creating and sustaining a culture of safety and research
Work space design and redesign to prevent and mitigate errors
Effective use of telecommunications and biomedical device interoperability
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Model of Professional Nursing Practice Regulation
In 2006 the Model of Professional Nursing Practice Regulation (see Figure 2) emerged from ANA work and informed the discussions of specialty nursing and advanced practice registered nurse practice.
The lowest level in the model represents the responsibility of the professional and specialty nursing organizations to their members and the public to define the scope and standards of practice for nursing.
The next level up the pyramid represents the regulation provided by the nurse practice acts and the rules and regulations in the pertinent licensing jurisdictions. Institutional policies and procedures provide further considerations in the regulation of nursing practice for the registered nurse and advanced practice registered nurse.
View Figure
FIGURE 2. Model of Professional Nursing Practice Regulation (Styles et al., 2008).
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Note that the highest level is that of self determination by the nurse after consideration of all the other levels of input about professional nursing practice regulation. The outcome is safe, quality, and evidence-based practice.
Standards of Professional Nursing Practice
The Standards of Professional Nursing Practice content consists of the Standards of Practice and the Standards of Professional Performance.
Standards of Practice
The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making.
STANDARD 1. ASSESSMENT
The registered nurse collects comprehensive data pertinent to the healthcare consumer’s health and/or the situation.
STANDARD 2. DIAGNOSIS
The registered nurse analyzes the assessment data to determine the diagnoses or the issues.
STANDARD 3. OUTCOMES IDENTIFICATION
The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
STANDARD 4. PLANNING
The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
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STANDARD 5. IMPLEMENTATION
The registered nurse implements the identified plan.
STANDARD 5A. COORDINATION OF CARE
The registered nurse coordinates care delivery.
STANDARD 5B. HEALTH TEACHING AND HEALTH PROMOTION
The registered nurse employs strategies to promote health and a safe environment.
STANDARD 5C. CONSULTATION
The graduate-level prepared specialty nurse or advanced practice registered nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change.
STANDARD 5D. PRESCRIPTIVE AUTHORITY AND TREATMENT
The advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.
STANDARD 6. EVALUATION
The registered nurse evaluates progress toward attainment of outcomes.
Standards of Professional Performance
The Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health. All registered nurses are expected to engage in professional role activities, including leadership, appropriate to their education and position. Registered nurses are accountable for their professional actions to themselves, their healthcare consumers, their peers, and ultimately to society.
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STANDARD 7. ETHICS
The registered nurse practices ethically.
STANDARD 8. EDUCATION
The registered nurse attains knowledge and competence that reflects current nursing practice.
STANDARD 9. EVIDENCE-BASED PRACTICE AND RESEARCH
The registered nurse integrates evidence and research findings into practice.
STANDARD 10. QUALITY OF PRACTICE
The registered nurse contributes to quality nursing practice.
STANDARD 11. COMMUNICATION
The registered nurse communicates effectively in all areas of practice.
STANDARD 12. LEADERSHIP
The registered nurse demonstrates leadership in the professional practice setting and the profession.
STANDARD 13. COLLABORATION
The registered nurse collaborates with healthcare consumer, family, and others in the conduct of nursing practice.
STANDARD 14. PROFESSIONAL PRACTICE EVALUATION
The registered nurse evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
STANDARD 15. RESOURCE UTILIZATION
The registered nurse utilizes appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible.
STANDARD 16. ENVIRONMENTAL HEALTH
The registered nurse practices in an environmentally safe and healthy manner.
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Professional Competence in Nursing Practice
The public has a right to expect registered nurses to demonstrate professional competence throughout their careers. The registered nurse is individually responsible and accountable for maintaining professional competence. It is the nursing profession’s responsibility to shape and guide any process for assuring nurse competence. Regulatory agencies define minimal standards of competency to protect the public.
The employer is responsible and accountable to provide a practice environment conducive to competent practice. Assurance of competence is the shared responsibility of the profession, individual nurses, professional organizations, credentialing and certification entities, regulatory agencies, employers, and other key stakeholders (ANA, 2008).
ANA believes that in the practice of nursing competence can be defined, measured, and evaluated. No single evaluation method or tool can guarantee competence. Competence is situational and dynamic; it is both an outcome and an ongoing process. Context determines what competencies are necessary.
Definitions and Concepts Related to Competence
A number of terms are central to the discussion of competence:
An individual who demonstrates “competence” is performing at an expected level.
A competency is an expected level of performance that integrates knowledge, skills, abilities, and judgment.
The integration of knowledge, skills, abilities, and judgment occurs in formal, informal, and reflective learning experiences.
Knowledge encompasses thinking, understanding of science and humanities, professional standards of practice, and insights gained from context, practical experiences, personal capabilities, and leadership performance.
Skills include psychomotor, communication, interpersonal, and diagnostic skills.
Ability is the capacity to act effectively. It requires listening, integrity, knowledge of one’s strengths and weaknesses, positive self-regard, emotional intelligence, and openness to feedback.
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Judgment includes critical thinking, problem solving, ethical reasoning, and decision-making.
Formal learning most often occurs in structured, academic, and professional development practice environments, while informal learning can be described as experiential insights gained in work, community, home, and other settings.
Reflective learning represents the recurrent thoughtful personal self-assessment, analysis, and synthesis of strengths and opportunities for improvement. Such insights should lead to the creation of a specific plan for professional development and may become part of one’s professional portfolio (ANA, 2008).
Competence and Competency in Nursing Practice
Competent registered nurses can be influenced by the nature of the situation, which includes consideration of the setting, resources, and the person. Situations can either enhance or detract from the nurse’s ability to perform. The registered nurse influences factors that facilitate and enhance competent practice. Similarly, the nurse seeks to deal with barriers that constrain competent practice. The expected level of performance reflects variability depending upon context and the selected competence framework or model.
The ability to perform at the expected level requires a process of lifelong learning. Registered nurses must continually reassess their competencies and identify needs for additional knowledge, skills, personal growth, and integrative learning experiences.
Evaluating Competence
“Competence in nursing practice must be evaluated by the individual nurse (self-assessment), nurse peers, and nurses in the roles of supervisor, coach, mentor, or preceptor. In addition, other aspects of nursing performance may be evaluated by professional colleagues and patients.
Competence can be evaluated by using tools that capture objective and subjective data about the individual’s knowledge base and actual performance and are appropriate for the specific situation and the desired outcome of the competence evaluation … However, no single evaluation tool or method can guarantee competence” (ANA, 2008, p. 6).
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Professional Registered Nurses Today
Statistical Snapshot
In 2008, there were an estimated 3 million registered nurses (RNs) in the United States, of which 2.6 million are currently employed. The majority of registered nurses initially entered nursing with an associate degree; however, the percentage of nurses entering practice with a bachelor’s degree or higher has increased steadily. Most registered nurses work in hospitals (62%) and identify themselves as “staff nurses” (66%).
In addition to hospitals, nurses report working in ambulatory care (10%), public/community health (7.8%), home health (6.4%), nursing home/extended care (5.3%), academic education (3.8%), and other areas, including insurance, benefits, and utilization review (3.9%). Public/community health includes school and occupational health settings, and ambulatory care includes medical and physician practices, health centers and clinics, and other types of non-hospital clinic settings.
About 9% of nurses identify themselves as one of the four recognized advanced practice registered nurse roles, and other identified roles include management, patient coordinator, instructor, patient educator, and researcher. (U.S. Dept. of Labor, 2010; U.S. DHHS, 2010)
Licensure and Education of Registered Nurses
The registered nurse is licensed and authorized by a state, commonwealth, or territory to practice nursing. Professional licensure of the healthcare professions is established by each jurisdiction to protect the public safety and authorize the practice of the profession. Because of this, the requirements for RN licensure and advanced practice nursing vary widely.
The registered nurse is educationally prepared for competent practice at the beginning level upon graduation from an accredited school of nursing and qualified by national examination for RN licensure. ANA has consistently affirmed the baccalaureate degree in nursing as the preferred educational preparation for entry into nursing practice.
The registered nurse is educated in the art and science of nursing, with the goal of helping individuals and groups attain, maintain, and restore health whenever possible. Experienced nurses may become proficient in one or more practice areas or roles. These nurses may concentrate on healthcare consumer care in clinical nursing practice specialties. Others influence nursing and support the direct care rendered to healthcare consumers by those professional
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nurses in clinical practice. Credentialing is one form of acknowledging such specialized knowledge and experience. Credentialing organizations may mandate specific nursing educational requirements, as well as timely demonstrations of knowledge and experience in specialty practice.
Registered nurses may pursue advanced academic studies to prepare for specialization in practice. Educational requirements vary by specialty and educational program. New models for educational preparation are evolving in response to the changing healthcare, education, and regulatory practice environments.
Roots of Professional Nursing
Nursing has evolved into a profession with a distinct body of knowledge, university-based education, specialized practice, standards of practice, a social contract (ANA, 2010), and an ethical code (ANA, 2001). With this grounding, registered nurses and their profession are concerned with the availability and accessibility of nursing care to healthcare consumers, families, communities, and populations, and seek to ensure the integrity of nursing practice in all current and future healthcare systems. This professional evolution is described in the following pages.
Nursing Research and Evidence-Based Practice
Contemporary nursing practice has its historical roots in the poorhouses, the battlefields, and the industrial revolutions in nineteenth-century Europe and America. Initially nurses trained in hospital-based nursing schools and were employed mainly providing private care to patients in their homes. Florence Nightingale provided a foundation for nursing and the basis for autonomous nursing practice as distinct from medicine.
Nightingale also is credited with identifying the importance of collecting empirical evidence, the underpinning of nursing’s current emphasis on evidence-based practice, “What you want are facts, not opinions … The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—which are of none—which are the evidence of neglect—and what kind of neglect.” (Nightingale, 1859, p. 105)
Although Nightingale recommended clinical nursing research in the mid-1800s, nurses did not follow her advice for over 100 years. Nursing research was able to flourish only as nurses received advanced educational preparation.
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In the early 1900s nurses received their advanced degrees in nursing education, and thus nursing research was limited to studies of nurses and nursing education. However, case studies on nursing interventions were conducted in the 1920s and 1930s and the results published in the American Journal of Nursing.
In the 1950s, interest in nursing care studies began to rise. In 1952, the first issue of Nursing Research was published. In the 1960s, nursing studies began to explore theoretical and conceptual frameworks as a basis for practice. By the 1970s, more doctorally prepared nurses were conducting research, especially studies related to practice and the improvement of patient care. By the 1980s, there were greater numbers of qualified nurse researchers than ever before, and more computers available for collection and analysis of data. In 1985, the National Center for Nursing Research was established within the National Institutes of Health, putting nursing research into the mainstream of health research (Grant and Massey, 1999).
In the last half of the twentieth century, nurse researchers (1950s) and nurse theorists (1960s and 1970s) greatly contributed to the expanding body of nursing knowledge with their studies of nursing practice and the development of nursing models and theories. These conceptual models and theories borrow from other disciplines such as sociology, psychology, biology, and physics.
For example, the work of Neuman and King makes extensive use of systems theory. There is also Levine’s conservation model, Roger’s science of unitary human beings, Roy’s adaptation model, Orem’s self-care model, Peplau’s interpersonal relations model, and Watson’s theory of caring. The 1980s brought revisions to these theories, as well as additional theories developed by nursing leaders, such as Johnson, Parse, and Leininger, that added to the theoretical basis of nursing (George, 2002). In the 1990s, research tested and expanded these theories, which in turn continued to define and elaborate the discipline of nursing.
Evidence-based practice (EBP) is a scholarly and systematic problem-solving paradigm that results in the delivery of high-quality health care. In order to make the best clinical decisions using EBP, external evidence from research is blended with internal evidence (i.e., practice-generated data), clinical expertise, and healthcare consumer values and preferences to achieve the best outcomes for individuals, groups, populations, and healthcare systems.
Nursing’s embrace of EBP is part of a larger call to integrate it into the entire spectrum of healthcare disciplines and professions. The Institute of Medicine (IOM) developed a vision for clinical education in the health professions that is centered on a commitment to meeting patient needs (IOM, 2003). This report
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stresses that all health disciplines must embrace evidence-based practice, quality improvement, and informatics in delivering healthcare consumer-centered care, and that their education should reflect and teach them to value those competencies. Interprofessional team collaboration is necessary to achieve quality outcomes for the improvement of health care.
Nursing research and EBP contribute to the body of knowledge and enhance outcomes. As a profession, nursing continually evaluates and applies nursing research findings. Evaluation of outcomes is a critical step in EBP. New knowledge is translated to healthcare consumer care to promote effective and efficient care and improved outcomes. It is then disseminated to decrease practice variations, improve outcomes, and create standards of excellence for care and policies. In addition, nurses ensure that changes in practice are based on current evidence; they should have expert resources in their practice environment and seek out those resources to assist them with specific steps in EBP.
The complex dynamics of health care, and demands for healthcare reform, will challenge the profession to quantify and qualify the value of nursing and nursing care. In alignment with the current edition of Nursing’s Social Policy Statement (ANA, 2010) and this publication, the nursing profession continually examines nursing practice. An example is the study of unit-based nurse staffing levels, and demonstrating through evidence that safe staffing is imperative to quality patient care. This includes ongoing systematic evaluation of the impact of staffing and staffing effectiveness on patient outcomes.
