Unlicensed assistive personnel: A solution to dwindling health care resources or the precursor to the apocalypse of registered nursing?

Unlicensed Assistive Personnel: A Solution to Dwindling Health Care Resources or the Precursor to the Apocalypse of Registered Nursing? Carol L. Huston,

MSN, CNAA

Does increased use o f unlicensed assistive personnel in direct patient care delivery represent an effective solution to dwindling health care resources, or is it an economicdriven, short-term response that could lead to an apocalypse of registered nursing ?

care is labor intensive. Given .rising costs and shrinking reimbursement, more and more hospitals are downsizing in an effort to shrink personnel costs. In a recent survey of hospital administrators, the majority stated that they would cut staff to reduce costs before limiting capital improvements or restricting research and development.1 Registered nurses (RNs) as a group have been hit hard by downsizing and many experienced, qualified nurses have found themselves unemployed for the first time in their lives. Other health care administrators, in an effort to contain costs, have restructured health care delivery systems by altering the staffing mix and replacing licensed professional nurses with unlicensed assistive personnel (UAP). In doing so, many patient care functions and tasks normally performed by RNs have been transferred to UAP. The American Nurses Association (ANA) z defines UAP as unlicensed individuals who are trained to function in an Health

Nurs Outlook 1996;44:67-73. Copyright © 1996 by Mosby-Year Book, Inc. 0029-6554/96•55.00 + 0 3511171478

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assistive role to the licensed RN in the provision of patient/client activities as delegated by the nurse. This term includes but is not limited to nurses aides, orderlies, assistants, attendants, technicians, and nurse extenders. In fact, the North Dakota Nurses Association determined that there are more than 250 titles of assistive personnel. 3 Barter et al. 4 completed a cross-sectional descriptive survey of 102 hospitals representing members of the California Organization of Nurse Executives to determine the scope of UAP use. Their findings suggest that, while the number of full time equivalent RN positions peaked in 1991 and have declined since that time, use of UAP has consistently increased during the same time period. A study of 49 hospitals by the same authors 5 revealed a gradual decrease (7% to 8%) in the use of RNs from 1992 to 1994 and an increase in the use of UAP (4% to 7%). Total full time equivalent positions acquired by nursing departments between June 1992 and June 1993 reflected an 18% decrease in the total number of RNs and a 5% increase in the total number of UAE The National Association for Health

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Care Recruitment 6 reports that recruiters are filling fewer full-time RN positions, with hospital staff composition of RNs decreasing rapidly from 90% just a few years ago to 69% in 1994. It is UAP who are filling positions formerly held by RNs. Blegen et al., 7in their study of 1455 staff nurses, found that 80% of the RNs in acute-care institutions and 98% of RNs working in long-term care facilities are currently involved in some capacity with the assignment, delegation, and supervision of UAP in the delivery of nursing care. Ninety percent of the hospitals in the study by McLaughlin et al. 5 (n = 49) utilized UAP in their institutions. Ninety-seven

The National Association for Health Care Recruitment reports that recruiters are filling fewer full-time RN positions, with hospital staff composition of RNs decreasing rapidly from 90% just a few years ago to 69% in 1994. percent of the hospitals surveyed by the American Hospital Association 8 and 85 % of 1000 hospitals surveyed by the A N A and the American Organization of Nurse Executives indicated that they had begun nurse extender programs.9 What are the primary driving forces toward increased UAP utilization? What has motivated this paradigmatic shift in work redesign? Why has increased UAP Huston

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utilization become such a heated debate in nursing, and why do nurses feel so threatened by their use? What is the impact of U A P utilization upon "quality" of health care? Is U A P utilization costeffective? THE M O T I V A T I O N TO USE UAP The primary argument for using U A P in acute-care settings is efficiency; U A P can free professional nurses from tasks and assignments that can be completed by less

The primary argument for using UAP in acute-care settings is efficiency; UAP can free professional nurses from tasks and assignments that can be completed by less well-trained personnel at a lower cost, specifically, nonnursing functions. well-trained personnel at a lower cost, specifically, nonnursing functions. Hayes 1° defines "nonnursing functions" as the nonclinical activities often performed by RNs that should or could be performed by support service staff or nurses' aides. In a study by Hendrickson et al. ~1 of a large metropolitan hospital with six specialty units practicing modified primary care nursing, nurses spent an average of only 31% of their time with patients. The researchers concluded that most nonclinical functions and many patient-related activities done by nurses could have been accomplished by secretaries, housekeepers, transporters, or other support personnel. In Hayes '*° study of 118 RNs in a large medical center, 100% of respondents reported that they "usually" or "almost always" performed nonnursing functions. This occurred despite the fact that 87% of respondents "disagreed" or "strongly disagreed" that RNs should perform such tasks. The performance of nonnursing functions by RNs did not change despite expansion of the U A P job description, the assistance of head nurses in identifying and prioritizing nonnursing functions for staff nurses, and the provision of an educational program for nurses on delegation. The study did not speculate as to why nurses c o n 68

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tinued to perform such functions despite an increasing perception that this "was not a job they should be required to do." Hayes 1° found that RN job satisfaction correlated negatively with performance of nonnursing functions, which suggests that RNs should not perform them. Blegen et al. 7 concurred, suggesting that RN job satisfaction is significantly related to the pattern of nurse extender use; nurses who were able to delegate routine aspects of patient care to U A P were more satisfied with their jobs than those who provided all the care themselves. After evaluating how RNs were used, the Center for Nursing of the American Hospital Association recommended that they be relieved of nonnursing functions entirely, Iz and the Commonwealth Fund concurred, recommending that RNs perform tasks that capitalize on their unique education and skills. 13 Likewise, 10,000 nurses responded to a Service Employees International Union National Nurses Survey and expressed frustration that nurses were required to take on more nonnursing functions and thus had less time to spend with patients. 14If in fact RNs believe they should not be required to do nonnursing functions and if the utilization of U A P provides a means of getting these tasks accomplished at a lower cost, why has the issue of U A P become such a heated debate in nursing, and why do nurses feel so threatened by their increasing use?

THE PERCEIVED THREAT OF INCREASED UAP UTILIZATION TO RNs Many RNs fear that the current "chop and cut" mentality of downsizing will result in even greater replacement of RNs by less expensive U A P counterparts. RNs believe that, in an effort to contain costs, fewer RNs will be utilized as a result of replacement by U A P and the role of UAP will begin to encroach into professional nursing care. 15The end result, critics argue, will be a significant decline in the quality of patient care, an increase in the number of unlicensed personnel the RN must supervise, and a redefinition of the RN role away from that of care provider to that of administrator or director. The conclusion of a comprehensive survey of 1835 nurses suggested that "the ultimate effect on the patient from the increased use of U A P can range from mere

inconveniences to more serious consequences, such as medication errors, injuries resulting from frustrated patients trying to do too much on their own, failure to carry out procedures ordered by doctors, more numerous nosocomial infections, and even deaths that are perceived as having been preventable if more registered nurses had been available. ''le The A N A , in testimony before the Institute of Medicine's (IOM) Commission on the Adequacy of Nurse Staffing, stated that "the most distressing aspect of the reduced use of RNs and the deterioration of patient care is that consumers, by and large, are completely unaware of the changes taking place57 Consumers have the right to know who is caring for them when they are hospitalized." Others argue that the RN, although well trained in the role of direct care provider, is often inadequately prepared for the roles of delegator and supervisor of UAP. Many RNs who supervise UAP, especially those who entered practice in the 1980s, have experienced only total RN staffing or primary nursing systems of care delivery. Thus they have received little or no instruction in personnel supervision and are accustomed to functioning as solo practitioners. 18 With the restructuring of care delivery models, RNs are increasingly being expected to make assignments for and supervise the work of different levels of employees.

With the restructuring of care delivery models, RNs are increasingly being expected to make assignments for and supervise the work of different levels of employees. RNs who are asked to assume the role of supervisor and delegator need preparation to assume these leadership tasks. RNs who are asked to assume the role of supervisor and delegator need preparation to assume these leadership tasks. Lengacher et al. 19and Crawley et al. z° suggest that repeated education programs on delegation principles and role clarity are

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necessary to enable RNs to demonstrate consistency in delegating appropriate role activities to U A P and to begin to feel confident in delegating. However, Abts et al. z1 found that RNs' lack of skill in empowering others persisted even after a delegation class was held. Findings by Jung et al. 2z were similar, which suggests that a large percentage of RNs continue to feel uncomfortable supervising U A P even after in-service programs designed to help them in these new roles are held. Assuming the role of delegator and supervisor to UAP also increases the scope of liability for the RN. Experienced nurses have traditionally been expected to work with minimal supervision. The RN who delegates care to another competent RN does not have the same legal obligation to closely supervise that person's work as when the care is delegated to UAP. z3 In assigning tasks to UAP, the RN must be aware of the UAP job description, knowledge base, and demonstrated skills of each individual, and the RN shares their liability if the delegated task is not completed or is done inappropriately. Although there is limited case law involving nursing delegation and supervision, it is generally accepted that the RN is responsible for adequate supervision of the person to whom an assignment has been delegated, z3 This supervisory role for RNs also has implications regarding their collective bargaining classification. A 1994 Supreme Court decision held that RNs who supervise UAP can be considered "supervisors," thus making them ineligible for protection under the National Labor Relations Act. In contrast, many of the personnel that RNs supervise are eligible for unionization, and a 1991 survey of 1455 nurses suggests that these personnel use their union protection to resist delegation efforts by the RN.24 Another concern expressed about the increased utilization of U A P is that they are inadequately trained for the scope of practice they have been expected to assume. In a survey by the ANA, U A P were often described as "poorly trained, inexperienced in patient care, and either unaware of or willing to disregard the limitations of their capabilities and authority. ''16 Although the Omnibus Budget Reconciliation Act of 1987 established regulations for the education and certification of "nurse aides" (minimum of 75 hours of NURSING OUTLOOK

theory and practice and successful completion of an examination in both areas), no federal or community standards have been established for training the more broadly defined UAP. In a study of 102 hospitals by Barter et al., 4 only 20% required a high school diploma for UAP, 26% preferred previous clinical bedside experience, 29% preferred

A 1994 Supreme Court decision held that RNs who supervise UAP can be considered "supervisors, " thus making them ineligible for protection under the National Labor Relations Act.

certification as a nursing assistant, and 18% preferred that the UAP be a student nurse (licensed or vocational). A number of the hospitals did not have a standardized hiring requirement and provided only a minimal amount of training and orientation; 80% provided newly hired UAP with less than 40 hours of classroom instruction, and 99% provided less than 120 hours of onthe-job training. In addition, 59% of respondents provided less than 20 hours of classroom orientation for UAP and 59% of the hospitals in another study 5 had no distinguishing employment requirements for UAP hired into specialty areas. Perhaps, however, the greatest perceived threat of increased UAP utilization to RNs is the divisiveness of the issue itself. There simply is no agreement among nurse leaders about whether increased utilization of U A P is both necessary and desirable. Some well-respected nursing leaders have argued that to help hospitals survive, retooling is not only inevitable but is in the best interest of both patients and nurses. Dietzl~ argues that UAP will as a matter of necessity be a part of health care delivery in the future and that professional nurses must attempt to regulate and control their use instead of fighting it. Jung 25 concurs, arguing that the health care system cannot afford to have scarce, highly paid, highly educated professionals providing routine patient care that could be provided by more abundant, less skilled, lower paid workers. "Nursing must change its philosophy and acknowledge that U A P

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have an important place in health care. ''25 Blegen et al. 7 state that the days of all-RN staffs and the supremacy of the nurse as direct care provider are gone. "Nurses must be willing to accept that they can no longer do it all and be willing to give up some of the more routine tasks without being threatened. All other professionals use assistants, and nurses shouldn't be threatened by their presence." Other nursing leaders have argued that there is no evidence that nursing is responsible for rising health care costs and thus redesign of professional nursing practice is not the answer. Research by the California Nurses Association (CNA) suggests that wage and benefit costs as a percentage of hospital budgets have actually fallen dramatically during the past three decades. 26 In 1962, labor costs accounted for 67% of hospital expenditures. In 1984 the total had dropped to 56%, and by 1992, the percentage was under 54%. In contrast, administrative costs have risen 180% since 1968, and capital expenditures rose 36% in the 1980s. Taking inflation into account, RN wages increased only a total of 13% in the 1980s, whereas hospital executive compensation increased between 123% and 142%. z6 While continuing to cry "poor," hospitals recorded record profits for 1992, posting aggregate profits of $11.9 billion. This represents an increase of 19% over 1991 profits and the highest 1-year total profit since 1983.17 Huntington z7 and Burda zs concur, arguing that health care has been the most profitable industry in the nation for the past 5 years and that even though 1993 aggregate profits earned by acute care hospitals were down $100,000 from the year before, total revenues remained high at $277.9 bill i o n - a n increase of 6.9% from 1992. Likewise, although total hospital admissions decreased from 32 million in 1992 to 30.7 million in 1993 and the average length of stay dipped from 7.1 to 7.0 days, total outpatient visits climbed more than 5% to 367 million last year. Baer and Gordon z9 argue that "by distancing RNs from their patients, financial consultants believe they're raising bedside nursing to a more sophisticated level of practice. What they're really doing is destroying it." Nursing is "a tapestry woven from countless threads into an intricate whole...at one minute, the nurse is involved in a sophisticated clinical proceHuston

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dure that demands advanced scientific and technological education and judgment. And the next moment, or concurrently, the nurse may perform what many people consider to be a trivial or menial task. What the public doesn't understand is that seemingly menial tasks give nurses the opportunity to explore the details of the patient's daily life, that often make the difference between safety and danger, illness and health, even life and death. ''29Clearly, the increased use of UAP is a "hot issue." The move to supplement nursing staff with UAP has aroused concern in the ANA, the Joint Commission for the Accreditation of Health Care Organizations, the American Association of Critical Care Nurses, and other major organizations. 3°'33Blegen et all summarized these concerns in the following two questions: "Do U A P free nurses from non-nursing tasks or do they require so much supervision that they hinder rather than help? Do their lower salaries help keep health care costs down or do they create or amplify a whole host of other problems-such as reducing the quality of care ?" In an attempt to more objectively analyze the validity of these concerns, it may be helpful to look at the following issues: the impact of U A P utilization upon the "quality" of health care, and the cost-effectiveness of U A P utilization.

approximately 15% in the areas of physical needs and care planning and almost 25% in documentation of care provided. Small improvements were noted in the areas of nonphysical needs and completion of unit procedures. In a pilot study by Neidlinger et al. 35 that used a nonrandomized, control group, time series design, the incorporation of

In 1962, labor costs accounted for 67% of hospital expenditures. In 1984 the total had dropped to 56%, and by 1992, the percentage was under 54%. In contrast, administrative costs have risen 180% since 1968, and capital expenditures rose 36% in the 1980s.

U A P into an existing professional nursing practice model resulted in a decline in compliance with quality indicators from 97% before implementation to 81% after implementation. Control groups averaged 84% compliance before implementation and 87% after implementation. Patient satisfaction in the experimental units improved slightly after the U A P were introTHE IMPACT OF UAP duced. Satisfaction with staffing levels on UTILIZATION ON " Q U A L I T Y " the experimental units held over time, but OF CARE In a modular nursing model of RNs, li- work satisfaction scores declined. In the censed vocational nurses (LVNs), and control group, satisfaction with staffing U A P described by Abts et al. 21 and imple- levels decreased and work satisfaction mented on a 50-bed surgical unit, quality scores increased. Bostrom and Zimmerman, 36 using freof care as a measure of satisfaction level improved. This finding was consistent in quency of incident reports as a rough measurveys completed by patients, physicians, sure of quality, found no significant differnurses, and ancillary departments. Simi- ence in quality on three units of a 600-bed larly, the study by Jung et al. 2z of a 547- tertiary care medical center after the addition of U A P to a primarily RN staff. bed, acute care, regional referral center, Lengacher et al. .9 argue that a review hospital-wide program to increase UAP use suggested that "some improvements in of the literature demonstrates that many quality and satisfaction may have occurred new models for nursing practice and delivery of care are not closely examined and as a result of the program." In contrast, in a 1-year pilot study of a evaluated. Barter et al. 4 concur, stating that although nursing personnel job satisfaction "co-worker model" (paired RNs with UAP) at the University of Kentucky Hos- and patient and physician satisfaction with pital of Lexington in 1988, Powers et al. 34 nursing care are indicators of "quality" found that quality m o n i t o r i n g scores health care, most hospitals have not atshowed some downward trends that did not tempted to measure the impact of U A P use occur in the national database of similar on these indicators. Huber et al. 24 agree, units across the United States. Scores fell stating "there is an absence of systematic 70

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data that can evaluate the impact of new delivery systems and staffing models on patient outcomes, work stress, and the ability to decrease nursing workload while maintaining high standards of care." A preliminary literature review by this author supports a scarcity of empirical research on the impact of U A P on "quality" of health care. A literature review by A N A 17 stated that 13 recent studies on nursing care have documented that hospitals with a higher percentage of RNs have lower mortality rates and that RNs have a positive effect on patients' length of stay, knowledge of and compliance with treatment regimens, complications, readiness and ability to function upon discharge, and quality of care, but did not specifically look at the U A P issue. In the A N A survey, more than three fourths of the nurses who worked in institutions that had cut back on staff said that the quality of patient care has been degraded as a result; however, no quantitative measurement of this decline had been attempted. 16 The literature does not provide a clear picture yet regarding outcomes of increased U A P utilization on quality of care. Gwen Johnson, a member of the A N A Board of Directors, testified before the IOM in October 1994 "that through their wholesale redesign of patient care organizations and their use of unlicensed staff, some hospitals are essentially forcing consumers to accept an untested product. Patients who receive care under these innovative models are, in essence, the subject of field experiments, without their knowledge or explicit consent. ''17 In fact, C N A filed a lawsuit against Alta Bates Medical Center in Berkeley, California, after the hospital announced a redesign plan that would eliminate 50% of the RN staff. The lawsuit charges Alta Bates with consumer fraud and business practices intended to "deceive healthcare consumers about the potentially harmful effects on patient care standards" resulting from proposed, untested work redesign programsY A major study currently underway that may contribute to our understanding of the impact of increased U A P utilization on the quality of health care is a cooperative effort between the A N A and the Congressional Office of Technology Assessment. This study wilt examine recent changes in the health care workforce and attempt to delineate the effects these changes have

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on patient care. 37 In addition, the A N A has allocated funds to commission a study on quality indicators and patient outcomes that link adequate RN staffing with quality patient care, as well as a survey to gather data regarding the effects on patient care as a result of the layoffs of RNs and substitution by lesser skilled employees. A n o t h e r study underway is the 22month IOM, National Institute of Nursing Research Study to determine whether and to what extent there is a need for an increase in the number of RNs in hospitals and nursing homes. This increase in staff is to be examined in relationship to its relevance and necessity in promoting quality patient care. The IOM undertook this study in response to what it perceived to be "the virtually undefined and potentially undervalued relationship between cost, quality, and nursing care. ''38

THE COST-EFFECTIVENESS OF UAP UTILIZATION As with quality, a preliminary literature review yielded limited empirical research regarding the cost-effectiveness of utilizing UAP. Barter et al. 4 found that 66% (67 of 102) of the hospitals in their study were not collecting data on the cost-effectiveness of U A P use. A review of the literature by Huber at al. z4 suggested that the limited evidence to date indicates that U A P may help keep health care costs down but that their use creates or amplifies a host of other problems. A redefining of the care delivery system on a surgical unit at St. Luke's Regional Medical Center in Sioux City, Iowa, from a professional nursing practice model to a modular nursing delivery system composed of RNs, LVNs, and U A P maintained or reduced the aggregate costs per patient day. A reduction in the RN staffing mix from 63% to 46% resulted in a cost savings of $58,000 to $60,000 dollars per year in salary expenses, zl Likewise, in the patient care technician model described by Smeltzer et al. 39at a 269bed hospital, a $1,856,454 cost reduction was noted as a result of decreasing RN staffing from 87% to 62% and increasing UAP skill mix from 13% to 38%. This savings represented 15% of the nursing operations budget. In the model described by Bostrom and Zimmerman, 36the introduction of UAP resulted in significant costs savings as well. Average cost per patient day declined by

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$8 to $13 on two units and $88 on the third unit. The annual savings were anticipated to be more than $3 million dollars. Lengacher et al. ~9found no significant difference in labor cost between a unit staffed entirely by RNs and one staffed by RNs and multiskilled technicians. This occurred because the savings from the decrease in RN salaries was offset by the need for an increased total number of staff on the combination unit. However, more direct care hours were available for patients because of the change in role and responsibilities of the RN. These results are similar to those ofWong et al., 4°who compared the costs of nursing care in 16 nursing units at Johns Hopkins Hospital. Eight of the units had adopted a nursing staffing raix of RNs, LVNs, and UAP, whereas the other eight units used a professional practice model. No significant difference was found between the cost per patient day on the two types of inpatient units, a c o r n -

The widely accepted premise that UAP utilization models are less expensive or more cost-effective than models that use an all-licensed professional staff cannot be universally supported. Neither can all-professional nursing models claim to be less expensive or more costeffective than their UAP counterparts. parison of unit expenditures on supplies, repairs, and services showed that, on average, more resources were used by nonpro. fessional practice model inpatient units. Likewise, recruitment and orientation costs were higher on the nonprofessional practice model inpatient units. In the study by Neidlinger et al., 35 personnel costs per patient day increased on both experimental (UAP utilized) and control (licensed staff utilized) units (14.6% and 7.6%, respectively). Before the intervention, control unit personnel costs were higher, and although their costs continued to be higher after the intervention, their overall increase in costs was lower (0.3% compared with 7.3% for the experimental group).

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In the 1988 "co-worker model" pilot study, personnel costs for sick time, overtime, and use of on-call nurses increased when fewer registered nurses and more nonprofessional staff were employed. 34 However, the model allowed some beds to stay open that would have closed because of a lack of RN staff. In a study by Kostovich et al. 41 of a health delivery team that used "clinical technicians" to complete higher level task skills not requiring licensure by the Illinois Nurse Practice Act, two clinical nursing technicians were needed on the nursing units for every one job eliminated in a support department. To create budget neutrality, it was necessary to share clinical technicians between units and to delete FTEs from support departments. In the model of O'Brien and Stepura, 4z budget figures from the pilot study between 1990 and 1992 revealed a 12% reduction in worked RN full-time equivalent positions. However, overall expenses increased because of the addition of nonprofessional caregivers. The ANA, in testimony to the IOM, supported the findings of O'Brien and Stepura, arguing that reducing skill mix has been found in many instances to increase costs, in terms of money for training of unlicensed personnel, training RN staff to oversee their work, and significantly increased overtime monies for nurses who stayed past their shift to finish work related to their increased patient load. In summary, the findings of the literature are mixed. The widely accepted premise that U A P utilization models are less expensive or more cost-effective than models that use an all-licensed professional staff cannot be universally supported. Neither can all-professional nursing models claim to be less expensive or more costeffective than their U A P counterparts.

RECOMMENDATIONS A N D CHALLENGES FOR NURSE ADMINISTRATORS The following represent some of the recommendations and challenges suggested by experts 4'23'25'32'35'43'44as control mechanisms for U A P utilization. • Well-designed studies that measure patient outcomes, cost-effectiveness, and work satisfaction are needed to understand the effect of U A P use in nursing care delivery systems. Two

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such studies are those currently underway by the A N A and the Congressional Office of Technology Assessment and the IOM National Institute of Nursing Research Study. Research is also needed to more clearly determine work intensity and acuity relationships so that need and use can be identified and attached to nursing services. Titles and job descriptions of U A P must be standardized. Standards for ongoing supervision and periodic verification of U A P competency must be established. Implementation of any new practice model must be preceded by an understanding of the present environment, a clear notion of the desired outcome, and a definition of how to move the organization from the present environment to the desired outcome. Job descriptions must be developed by health care agencies that clearly define the roles and responsibilities of all categories of caregivers. These descriptions should be consistent with community standards of care and should reflect differences between the roles of licensed and unlicensed personnel. Policies should facilitate adequate supervision of U A P by RNs and restrict U A P to simple tasks that can be performed safely. The organization structure must facilitate RN evaluation of U A P job performance and encourage U A P accountability to the RN. There must be adequate program development in leadership and delegation skills for RNs before U A P are introduced. Educational programs that produce graduate nurses must explore the nature of the RN role, with a focus on professional nurse leadership role functions, to better prepare them to meet the challenges of working in restructured health care settings. Uniform training and orientation programs for U A P must be established to ensure that preparation is adequate to provide at least minimum standards of safe patient care. Organizational education programs must be developed for all personnel to learn the roles and responsibilities of different categories of caregivers. Huston

CONCLUSION

Gollard and Soo Hoo 45 argue that an action plan for the future should have three objectives: maximal utilization of each staff member in delivering safe, effective, and appropriate patient care; increased productivity of both professional and ancillary staff; and a contemporary and stable framework for nursing practice. Recently, many nursing care delivery systems have been proposed and implemented in an effort to accomplish these three objectives. Most of these models have advocated increased use of U A P and a reduction in licensed staff.

Until the nursing profession can justify its continued existence with empirical data regarding its costeffectiveness in maintaining quality client care, nurses can expect greater use of ancillary nursing staff and the development and promotion of new patient care delivery models that rely heavily on UAP. Despite the human resources, time, cost, and organizational energy devoted to such major redesign changes, inadequate systematic study has been done regarding the effectiveness of such programs on the intended outcomes or on other aspects of the work environment. Evaluation has been limited to the effect of new models on nurse job satisfaction and turnover, with less attention given to the impact on organizational performance or work unit effectiveness. Likewise, research has not addressed the dynamics of change and factors influencing the degree to which implementation is effective within specific work units. 4~ Consequently, "restructuring of nursing care is often a shot in the dark, triggered by the rapidly accelerating pressures to reduce health care costs. ''36To provide a thorough and unbiased evaluation of work redesign, "organizations must begin to justify the implementation of resource intensive practice model innovations through carefully documented performance and cost-effectiveness results. ''46 The driving force behind work design in today's health care system is econom-

ics, and the reality is that these economic forces show no sign of reprieve for health care providers, especially nurses27 Fralic 48 argues that "all of our health care organizations are under extrerae pressure to deliver affordable quality care...and it has become increasingly more difficult to constantly drive h e a l t h care costs down within existing patient models. A n d therein lies the important caveat. Yesterday's models will not and can not be right for tomorrow." Restructuring appears to be the chosen answer for the 1990s. Throughout its divided history, nursing has struggled with controversial reporting structures, contested management strategies, conflicting educational systems, strife-ridden attempts to organize practice licensure, dissension in the ranks, and fractious relationships with other professions, z9 Nurses must now face the issue of increased utilization of UAP. Do they represent a solution to dwindling health care resources, or are they the precursor to the apocalypse of registered nursing? Until the nursing profession can justify its continued existence with empirical data regarding its cost-effectiveness in maintaining quality client care, nurses can expect greater use of ancillary nursing staff and the development and promotion of new patient care delivery models that rely heavily on U A E • REFERENCES

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CAROL L. HUSTON is a professor at the California State University-Chico School of Nursing in Chico, Calif., and a doctoral student at the University of Southern California School of Public Administration, Sacramento.

Write! Send letters concerning Nursing Outlook to the Editor: Carole A. Anderson, PhD, RN, FAAN College of Nursing The Ohio State University 1585 Neil Avenue Columbus, OH 43210 Letters may be edited for length.

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