The delivery of care for hospitalized patients is complex and

Nurse Shortage Impact Of The Nurse Shortage On Hospital Patient Care: Comparative Perspectives Physicians and hospital executives often do not associate nurses with patient safety and early detection of complications. by Peter I. Buerhaus, Karen Donelan, Beth T. Ulrich, Linda Norman, Catherine DesRoches, and Robert Dittus ABSTRACT: National surveys of registered nurses, physicians, and hospital executives document considerable concern about the U.S. nurse shortage. Substantial proportions of respondents perceived negative impacts on care processes, hospital capacity, nursing practice, and the Institute of Medicine s six aims for improving health care systems. There were also many areas of divergent opinion within and among these groups, including the impact of the shortage on safety and early detection of patient complications. These divergences in perceptions could be important barriers to resolving the current nurse shortage and improving the quality and safety of patient care. [Health Affairs 26, no. 3 (2007): 853 862; 10.1377/hlthaff.26.3.853] The delivery of care for hospitalized patients is complex and requires coordinated efforts by many health professionals. Physicians, advanced-practice nurses, registered nurses (RNs), and other allied health professionals each provide individualized health care services. Hospital administrators namely, chief executive officers (CEOs) and chief nursing officers (CNOs) develop strategic plans; build, manage, and continually improve facilities and systems of care; and oversee resource allocations. Patterns of problem recognition, communication, teamwork, and problem solving within and among these groups contribute to a hospital s capacity to operate efficiently and manage difficult and changing stressors. Peter Buerhaus (Peter.Buerhaus@vanderbilt.edu) is the Valere Potter Distinguished Professor of Nursing and director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University Medical Center in Nashville, Tennessee. Karen Donelan is a senior scientist in health policy at Massachusetts General Hospital in Boston. Beth Ulrich is senior vice president, Professional Services, at Gannett Healthcare Group in Dallas, Texas. Linda Norman is senior associate dean for academics at Vanderbilt University School of Nursing. Catherine DesRoches is an instructor in the Institute for Health Policy at Massachusetts General Hospital. Robert Dittus is the Albert and Bernard Werthan Professor of Medicine in the Department of Medicine at Vanderbilt University, and director, Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, in Nashville. HEALTH AFFAIRS ~ Volume 26, Number 3 853 DOI 10.1377/hlthaff.26.3.853 2007 Project HOPE The People-to-People Health Foundation, Inc.

DataWatch An insufficient supply of essential personnel, such as RNs, is a critical stressor for hospitals. Many hospitals are struggling with a nurse shortage that began in 1998. The shortage resulted from a combination of factors, including rising demand, little growth in RN wages, demographic changes in the RN workforce that decreased the supply of working RNs, and a stressful hospital workplace environment. 1 A growing body of research, based primarily on state and hospital administrative data, has established a relationship between inadequate hospital nurse staffing and increased risk of adverse patient outcomes, including mortality. 2 Prolonged shortages also might reduce the quantity of patient care, increase operating and labor costs, and decrease the efficiency and effectiveness of care provided. Looking ahead, recently published projections indicate large, demographically driven shortages developing in the next decade. 3 Highly visible Institute of Medicine (IOM) reports have emphasized the importance of teamwork in improving efficiency and quality in hospitals. 4 Given differences in education and the nature of work done by different providers and hospital executives, the development of strong and consistent teamwork is often not realized,evenintheabsenceofanurseshortage.thepresenceofsuchashortage makesteamworkallthemoredifficulttoachieveandmaintain. The effective communication, teamwork, and problem solving needed to address the nurse shortage and minimize its impact require providers and hospital executives to first share in the recognition of the problem and its impact on the hospital and on patient care. National surveys have revealed nurses perceptions that the shortage has caused deterioration in professional relationships and the work environment. 5 Unfortunately, there is little documentation of hospital executives and physicians perceptions of the nurse shortage s impact on patient care, professional relationships, and the work environment. In this paper we report the results of national random-sample surveys of RNs, physicians, and hospital CEOs and CNOs on their perceptions of the current nurse shortage. These surveys were designed to provide comparative data from multiple perspectives of providers and hospital executives, using common measuresinsurveysfieldedonlymonthsapart.thesurveysprobeperceptionsofthe impact of the shortage on patient care delivery processes, team communication, hospital capacity, RNs ability to provide patient care, and the six aims for highquality health care systems (patient-centered, effective, safe, timely, efficient, and equitable) advocated by the IOM. 6 Establishing common understandings among health care providers and executives of the problems associated with the nurse shortage is a critical first step toward developing solutions to mitigate its impact. Study Data And Methods This study was conducted as part of a collaboration of researchers at Vanderbilt University Medical Center and Massachusetts General Hospital to evaluate the Johnson and Johnson Campaign for Nursing s Future. The campaign, a national 854 May/June 2007

Nurse Shortage initiative that began in February 2002, is aimed at increasing nurse recruitment in the United States, retaining nurses in clinical practice, and increasing the capacity of the nation s nursing education programs. 7 We report data from national surveys of physicians, RNs, and hospital CEOs and CNOs. All surveys were designed, pretested, and analyzed by our research team and administered by Harris Interactive during 2004 and 2005. Necessary Institutional Review Board (IRB) approvals were obtained for all surveys. Although each survey contained items tailored to the population studied, several questions in the three surveys were identical. Items assessed included perceptions of the extent and severity of the current nurse shortage; causes, effects, and hospitals responses to the shortage; characteristics of nurses work environment; quality of professional practice and relationships among nurses, physicians, and managers; perceptions of nursing careers; awareness and impact of the Johnson and Johnson campaign; and demographic characteristics. National survey of physicians. The National Survey of Physicians about Nursing was conducted 6 January 5 March 2004. Using the American Medical Association (AMA) Physician Masterfile, a random sample of physicians was drawn to be representative of primary care and specialist physicians who spend more than twenty hours per week engaged in patient care activities, excluding resident physicians and federal employees. The four-page survey instrument contained approximately sixty items intended to be completed in less than fifteen minutes. The survey instrument was initially mailed with a check for $25 as an honorarium for completing the survey, and up to five follow-up contacts were made to nonresponders. Of 840 physicians initially mailed questionnaires, 20 returned blank questionnaires or cashed the incentive check without completing the survey and were categorized as eligible respondents refusing participation. Additionally, eighty-four cases were proved ineligible because of a physician s death, retirement, or change in specialty or practice. Four hundred completed surveys were returned; using guidelines established by the American Association for Public Opinion Research (AAPOR, RR1), we calculated a response rate of 53 percent. 8 National survey of registered nurses. We conducted the 2004 National Survey of Registered Nurses 11 May 12 July. Harris Interactive mailed the six-page questionnaire to a random sample of 3,500 RNs drawn from a national database compiled from lists at all state boards of licensure and developed and maintained by Nursing Spectrum, a national weekly news publication for nurses. Respondents were given the option of responding at a secure Web site or by mail, and up to five mailings were sent to nonresponders to encourage participation. Response enhancement incentives included two hours of continuing education courses valued at $35 and the opportunity to be entered into a lottery drawing for vouchers redeemable for travel to professional conferences. Following exclusion of retired nurses or those not working at the time of the survey, 1,697 re- HEALTH AFFAIRS ~ Volume 26, Number 3 855

DataWatch sponses were usable for analysis. Using AAPOR guidelines (RR1), we calculated a 53 percent response rate among eligible respondents. For the analysis reported here, we used a subset of the data that represents all RNs who deliver direct patient care in acute care hospitals (n = 657). National survey of hospital CNOs and CEOs. The national survey of hospital CNOs and CEOs was conducted during 28 January 11 March 2005. Harris Interactive drew the sample from lists of hospital executives compiled from all U.S. hospitals and maintained by SK&A Information Services. After an advance letter was mailed to all potentially eligible respondents, the respondent s hospital office was contacted by telephone to establish eligibility, with up to ten attempts made to speak to eligible respondents. If a direct interview was not accomplished, follow-up attempts by priority mail and facsimile were employed. Respondents were offered a $100 honorarium for their participation, which they could either accept or donate to the American Red Cross. Completed telephone interviews averaged twenty minutes in length. Response-rate calculations were made using the response-rate calculator version 2.1 developed for telephone surveys by the AAPOR. The rates we used considered as eligible all respondents for whom contact with an office was established and the respondent s identity was confirmed. Overall, we completed interviews with 222 of 443 eligible CNOs contacted, for a response rate of 50 percent. We encountered much more difficulty establishing contact with and interviewing hospital CEOs. We obtained 142 complete responses of 404 eligible CEOs, for a response rate of 31 percent (AAPOR, RR3). An additional 405 CEOs were sampled and initial contact was made, but eligibility was never established despitemultipleattempts.ifweaccountforthesecasesinthedenominator,according to AAPOR guidelines (RR1), the response rate is 17.5 percent. This survey demonstrates the complexity of calculating response rates in surveys involving settings where the primary contact is with an intermediary, the intended respondent is difficult to reach, and data collection is accomplished in multiple modes. Statistical analysis. The physician survey data were weighted using the original AMA Masterfile demographic data to reflect the original random sample of physicians by specialty, region, and year of medical school graduation. Nurse survey data were weighted to reflect the age and geographic distribution of nurses, using the 2000 National Sample Survey of Nurses conducted by the Bureau of Health Professions. CEO and CNO survey data were not weighted for analysis. The information available from the sample source included hospital bed capacity and geography, as well as job title and contact information. The distributions of respondents and nonrespondents within all known demographics were not significantly different. We used SPSS version 11.5 for all analysis. SPSS has procedures that allow for the analysis of weighted data so that standard errors are adjusted properly. All surveys are subject to sampling and nonsampling error. For surveys reported here, in theory, one can say with 95 percent certainty that the results have a statistical precision of plus or minus three percentage points for the RN survey, 856 May/June 2007

Nurse Shortage six percentage points for the physician survey, and nine percentage points for the CEO and CNO survey, of what they would be if the entire relevant populations had been surveyed with complete accuracy. Efforts to minimize nonsampling error attributable to nonresponse bias, question wording, and ordering effects included pretesting all instruments, checking internal consistency and reliability, reviewing each instrument by multiple experts, and using questions tested previously for other studies. Study Findings Prevalence and severity of shortage. In each of the three surveys, we asked: In the past year, in the hospital where you admitted patients or worked most, has there been a shortage of registered nurses? All clinicians and hospital executives who reported observing a shortage were then asked about its severity. A majority of physicians (81 percent), RNs (82 percent), CNOs (74 percent), and CEOs (68 percent) perceived a very or somewhat serious shortage. However, more hospital CEOs (32 percent) and CNOs (25 percent) than physicians (19 percent) and RNs (13 percent) perceived that there was no shortage of nurses. Impact on care delivery and hospital capacity. All respondents were asked whether they had observed any of a list of situations as a result of nurse shortages in hospitals (Exhibit 1). Overall, many respondents reported an impact on the four process indicators and the four capacity indicators. Respondents perceived that the nurse shortage had affected processes more often than capacity. Additionally, RNs were significantly more likely than other respondents to report that the shortage had affected six of the eight process and capacity indicators. Impact on registered nurses. All respondents were asked how much of a EXHIBIT 1 Impact Of Nurse Shortage On Processes Of Care And Hospital Capacity, 2004 05 In the past year, have you observed any of the following as a result of nursing shortages in the hospital? RNs (2004) (N = 657) MDs (2004) (N = 445) Hospital executives (2005) CNOs (N = 222) CEOs (N = 142) Impact on care delivery processes Delayed nurse responses to pages or calls Increased patients complaints about nursing care Increased staff communication problems Increased physician workload Impact on hospital capacity Reduced number of available beds Delayed discharges Increased patient wait time for surgery or tests Discontinued/closed patient care programs 82% 84 85 50 67%** 74** 71** 55 84% 58** 72** 29** 76%** 55** 69** 30** 78 69 68 44 64** 50** 45** 49 60** 60** 47** 20** 56** 61 48** 20** SOURCE: Data derived from authors study and analysis. NOTES: Statistical significance denotes difference from registered nurses (RNs). MD is medical doctor (physician). CNO is chief nursing officer. CEO is chief executive officer. **p 0.05 HEALTH AFFAIRS ~ Volume 26, Number 3 857

DataWatch problem they thought the shortage of nurses has been for the six items shown in Exhibit 2: a major, minor, or no problem. Overall, more than half of RNs and CNOs perceived that the shortage had exerted a major problem for all items. The majority of physicians agreed with respect to quality of patient care, nurses time for patients, and quality of work life for nurses; however, compared with RNs, significantly fewer physicians and CEOs saw a major impact on patient safety, early detection of patient complications, or time for team collaboration. Once again, RNs were significantly more likely than others to report that the shortage had been a major problem for each item. Also, in general, the responses of CNOs and RNs tended to align on most items as did the responses of physicians and CEOs. Impact on IOM health system indicators. We used the six aims of highquality health care systems advocated by the IOM and the National Quality Forum to assess the impact of the nurse shortage on the quality of patient care. Respondents were asked how often (frequently, often, sometimes, or never) they would say the shortage of nurses had affected various aspects of patient care. The vast majority of RNs reported that all six aims had been adversely affected, but there was much variation in perceptions among physicians, CEOs, and CNOs (Exhibit 3). RNs were significantly more likely than others to report that each of the six aims had been affected. Although the gaps in perceptions between RNs and physicians were not as great as those between RNs and executives, twice as many RNs as physicians perceived that the shortage frequently or often had adversely affected two aims: safety and equity of patient care. Expectations for the future. We asked all respondents whether the nurse shortage would lead to higher pay for nurses, the need to substitute other staff for nurses, nurses leaving for jobs outside nursing, more respect for nurses, lower-quality care for patients, and improvements in the work environment (Exhibit 4). On nearly every item, RN responses were significantly different from those of physicians, CEOs, and CNOs. All respondents were in substantial agreement on three EXHIBIT 2 Impact Of Nurse Shortage On Nurses And Their Ability To Provide Care, 2004 05 From what you know, how much of a problem do you think the shortage of nurses has been for...? Percent reporting major problem RNs (2004) MDs (2004) CNOs (2005) CEOs (2005) Quality of patient care Time for collaboration with teams Ability of nurses to maintain patient safety Early detection of complications Nurses time for patients Quality of nurses work life 78 55 69 61** 33** 21** 64** 56 62 54** 50 38** 65 91 82 44** 78** 59** 60 66** 76 47** 59** 62** SOURCE: Data derived from authors study and analysis. NOTES: Statistical significance denotes difference from registered nurses (RNs). MD is medical doctor (physician). CNO is chief nursing officer. CEO is chief executive officer. Sample sizes are provided in Exhibit 1. **p 0.05 858 May/June 2007

Nurse Shortage EXHIBIT 3 Impact Of Nurse Shortage On Institute Of Medicine s (IOM s) Six Aims For High- Quality Health Care Systems, 2004 05 Thinking about the criteria for quality of care established by the IOM (six aims), how often would you say the shortage of nurses has had an adverse impact on the following aspects of patient care? Percent responding frequent or often adverse impact RNs (2004) MDs (2004) CNOs (2005) CEOs (2005) Patient-centered Effective Safe Timely Efficient Equitable 74 74 65 61** 58** 36** 44** 34** 26** 44** 28** 17** 84 72 63 72** 55** 38** 50** 55** 23** 41** 46** 18** SOURCE: Data derived from authors study and analysis. NOTES: Statistical significance denotes difference from registered nurses (RNs). MD is medical doctor (physician). CNO is chief nursing officer. CEO is chief executive officer. Sample sizes are provided in Exhibit 1. Definitions of each aim for improving the quality of the U.S. health care system provided by IOM, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001). **p 0.05 items: the need for other staff to provide some nursing care, the likelihood that nurses will leave their jobs, and the likelihood that the nurse shortage will lower the quality of patient care. There was much disagreement on expectations for more respect for nursing and improvement in the workplace environment. And only 48 percent of RNs believed that the shortage will lead to higher wages, whereas more than 75 percent of respondents in the other groups agreed with this perception. Discussion Our findings from three surveys conducted within one year (2004 05) provide a kind of quantitative roundtable that elicits the voices of doctors, nurses, and hospital executives on the impact of the nurse shortage on a variety of health care EXHIBIT 4 Perceptions Of Where The Current Nurse Shortage Will Lead, 2004 05 Regardless of whether a shortage of nurses has affected your workplace, the problem has been highlighted in the nation in recent years. Do you think the current shortage will lead to? Percent responding yes RNs (2004) MDs (2004) CNOs (2005) CEOs (2005) Higher pay for nurses Need to have other staff perform some nursing patient care activities Nurses leaving for nonnursing jobs More respect for nurses Lower-quality care for patients Improvements in workplace environment 48 83 91 78** 92** 84** 86** 81 83** 94** 87 79** 21 90 25 44** 83** 34** 36** 71** 74** 59** 69** 75** SOURCE: Data derived from authors study and analysis. NOTES: Statistical significance denotes difference from registered nurses (RNs). MD is medical doctor (physician). CNO is chief nursing officer. CEO is chief executive officer. Sample sizes are provided in Exhibit 1. **p 0.05 HEALTH AFFAIRS ~ Volume 26, Number 3 859

DataWatch measures. An understanding of how these points of view diverge and converge may help in creating innovative approaches to coping with nurse shortages and improving patient care. Areas of agreement and disagreement. On the agreement side, most respondents found that the major effects of the nurse shortage to date have been in the areas of communication, nurse-patient relationships, hospital capacity as measured in the management of bed availability, and quality of care, reflected by timeliness, efficiency, and patient-centered care. On the disagreement side, nurses were divided in only three domains: the impact of the shortage on physician workloads, closure of patient programs and services, and the time available for team collaboration. In these domains, physicians and hospital executives also were not convinced that the shortage has had an impact. Study findings also make clear the areas in which RNs and CNOs share common perceptions but physicians and CEOs do not. These areas are clustered around issues of patient safety and the quality of nurses work environment. Majorities of RNs and CNOs expressed considerable concern about the impact of the shortage on the early detection of patient complications and nurses ability to maintain patient safety, whereas majorities of physicians and CEOs did not share this perception. Similarly, providers perceptions clustered around certain survey items where executives perceptions were in sharp contrast. This pattern was demonstrated most vividly by perceptions of the IOM quality improvement aims: Doctors and nurses perceived that most of the six aims had been negatively affected far more frequently than did hospital CEOs and CNOs. Although not an unexpected finding given the different focus of providers and executives work, nevertheless, this divergenceinperceptionsidentifiesgapsthatcouldbeimportantbarriersnot only to resolving the current nurse shortage but also to improving the quality and safety of patient care. Study limitations. In addition to sampling and nonsampling error that affect all surveys, as noted earlier, we acknowledge the difficulty in achieving a high response rate in the CEO survey with the consequence of not obtaining the views of all of those executives who had been selected for inclusion. Most importantly, these surveys are measures of people s attitudes and experiences; therefore, we cannot validate whether some problems reported do, in fact, exist in the hospitals where respondents are employed. Implications and policy recommendations. Building teamwork. We believe that the study findings support the need to develop team communication and collaborationtoimprovepatientcareandpatientsafety.elsewherewehavereported that the 2004 surveys of physicians and nurses indicated that less than 15 percent of both groups perceived that they have an excellent relationship with each other, and less than one-quarter perceived that their relationship was very good. With respect to relationships with managers, RNs rated their relationships even less fa- 860 May/June 2007

Nurse Shortage Ensuring the safety of hospital patients belongs to no one profession; it is a shared responsibility. vorably. Additionally, nearly half of nurses reported that they were not involved in decisions affecting both how patient care is delivered and how nursing care is organized and delivered. 9 By developing and sustaining teams, it is possible to build upon the areas of agreement between providers and hospital executives found in this study, address areas of disagreement, and, in the process, identify strategies to improve professional relationships. For example, hospitals might select one or more of the IOM aims where the present study indicated large gaps among providers and executives perceptions of how the shortage affected the aim(s). An interdisciplinary team could be organized to develop (or adopt existing) indicators of the aim, implement strategies or use simulation exercises to improve outcomes associated with the aim, measure performance of both providers and executives, and feed results back to the team. Beyond improving the quality and safety of care, team building can lead to better communication and greater awareness of the contributions of each member of the team, all of which are likely to improve intraprofessional relationships, nurses work environment, and even retention of the RN workforce. Improving patient safety. A majority of all respondents indicated concern for the amount of time nurses have to spend with patients, although significantly fewer physicians and CEOs expressed concern about the impact of the shortage on the early detection of patient complications and nurses ability to maintain patient safety. Studies have linked nurses to the timely identification of complications that, if acted upon quickly, might prevent deterioration in patients condition and even avoid preventable deaths. 10 The gaps in perceptions measured and reported here may indicate that physicians and CEOs do not associate nurses with patient safety or might not understand the impact nurses have in detecting complications early before they worsen and threaten a patient s life. This disconnect is troubling and deserves further consideration by providers and hospital executives. Ensuring the safety of hospital patients belongs to no one profession; it is a shared responsibility. Study findings indicate that nurses, physicians, and executives appear to have differing perspectives on what constitutes a threat to patient safety. We believe that these differences could be addressed by changing the way professionals are educated. Specifically, schools of nursing, medicine, pharmacy, allied health, and health care management could develop a set of required interprofessional competencies and jointly offer courses on improving patient safety and the quality of care. 11 Together in the same classroom or clinical learning environment, student health care providers and future health care executives could learn about the theory and science of human factors, change strategies, teamwork HEALTH AFFAIRS ~ Volume 26, Number 3 861

DataWatch and communication, and strategies to promote and maintain safe patient environments. Developing a shared understanding, valuing each other s contributions, and working in teams should be ingrained long before the stressors of the real world of hospital care delivery and nurse shortages take hold. Future shortages of nurses might not be prevented, but making improvements in interdisciplinary teamwork, coupled with ensuring that providers and executives have greater interdisciplinary education in improving quality and building safe environments for patients, could mitigate their harmful impacts. This study was funded by an unrestricted grant from the Johnson and Johnson Campaign for Nursing s Future and by Nursing Spectrum. Johnson and Johnson played no role in the design and conduct of the study, analysis and interpretation of results, and preparation or approval of the manuscript. The authors appreciate the assistance of SandraApplebaumandDavidSandman,wholedthesurveyfieldworkteamfromHarrisInteractive. NOTES 1. P.I.Buerhaus,D.O.Staiger,and D.I.Auerbach, Why Are Shortages of Hospital RNs Concentrated in Specialty Care Units? Nursing Economic$ 18, no. 3 (2000): 111 116; and American Hospital Association, In Our Hands: How Hospital Leaders Can Build a Thriving Workforce (Washington: AHA, 2002). 2. J. Needleman et al., Nurse Staffing and the Quality of Care in Hospitals, New EnglandJournal of Medicine 346, no. 22 (2002): 1715 1722; L.H. Aiken et al., Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction, Journal of the American Medical Association 288, no. 16(2002): 1987 1993; M.A. Blegen, C.J. Goode, and L. Reed, Nurse Staffing and Patient Outcomes, Nursing Research 47, no. 1 (1998): 43 49; and C. Kovner and P.J. Gergen, Nurse Staffing Levels and Adverse Events following Surgery in U.S. Hospitals, Image: The Journal of Nursing Scholarship 30, no. 4 (1998): 315 321. 3. D.I. Auerbach, P.I. Buerhaus, and D.O. Staiger, Better Late than Never: Workforce Supply Implications of Later Entry into Nursing, Health Affairs 26, no. 1 (2007): 178 185. 4. Institute of Medicine, Keeping Patients Safe: Transforming the Work Environment of Nurses (Washington: National Academies Press, 2004); and L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington: National Academies Press, 1999). 5. B.T. Ulrich et al., How RNs View the Work Environment: Results of a National Survey of Registered Nurses, Journal of Nursing Administration 35, no. 9 (2005): 389 396; and P.I. Buerhaus et al., State of the Nursing Workforce in the United States, Nursing Economic$ 24, no. 1 (2006): 6 12. 6. IOM, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001). 7. See the Johnson and Johnson Discover Nursing home page, http://www.discovernursing.com. 8. See American Association for Public Opinion Research, StandardDefinitions: Final Dispositions of Case Codes and Outcome Rates for Surveys, 4th ed., pp. 32 36, February 2006, http://www.aapor.org/pdfs/standarddefs_4.pdf (accessed 15 February 2007). 9. Ulrich et al., How RNs View the Work Environment. 10. J. Silber et al., Hospital and Patient Characteristics Associated with Death after Surgery: A Study of Adverse Occurrence and Failure to Rescue, Medical Care 30, no. 7 (1992): 615 629; Aiken et al., Hospital Nurse Staffing and Patient Mortality ; and Needleman et al., Nurse Staffing. 11. See A. Greiner and C. Kneble, eds., Health Professional Education: A Bridge to Quality Committee on Health Professions Education (Washington: National Academies Press, 2003). 862 May/June 2007