Critically evaluate the role of the registered nurse in ensuring the delivery of safe effective quality care that reflects recognised benchmarks.

For several decades, health services researchers have reported associations between nurse staffing and the outcomes of hospital care.^2–4 However, in many of these studies, nursing care and nurse staffing were primarily background variables and not the primary focus of study.⁵ In the 1990s, the National Center for Nursing Research, the precursor to the National Institute of Nursing Research, convened an invitational conference on patient outcomes research from the perspective of the effectiveness of nursing practice.⁶ It was hoped that as methods for capturing the quality of patient care quantitatively became more sophisticated, evidence linking the structure of nurse staffing (i.e., hours of care, skill mix) to patient care quality and safety would grow. However, 5 years later, the 1996 IOM report articulating the importance of nurses and nurse staffing on outcomes concluded that, at that time, there was essentially no evidence that staffing exerted an effect on acute care hospital patients’ outcomes and limited evidence of its impact on long-term care outcomes.¹

There has been remarkable growth in this body of literature since the 1996 IOM report. Over the course of the last decade, hospital restructuring, spurred in part by a move to managed care payment structures and development of market competition among health care delivery organizations, led to aggressive cost cutting. Human resources, historically a major cost center for hospitals, and nurse staffing in particular, were often the focus of work redesign and workforce reduction efforts. Cuts in nursing staff led to heavier workloads, which heightened concern about the adequacy of staffing levels in hospitals.