The upside of the nursing shortage clearly has been the focused attention on the nursing profession and its critical role in health care delivery. Earlier this month, President Bush signed the Nurse Reinvestment Act, which will provide considerable federal support for nursing education and practice, and will help ensure the adequacy of faculty as well as tuition money for students-all of which is intended to increase enrollments. The legislation garnered strong support from the Senate and House and moved through the legislative process with uncommon speed. It is expected that federal funding will begin in 2003.

So, solutions are increasing to help manage the shortage. The focus of the recent New England Journal of Medicine article on the nursing shortage reinforces the research that shows a clear relationship between the adequacy of RN staffing and better patient outcomes. While studies have indicated these positive relationships before, the timing of the release of this particular study only intensifies the support for making sure that the patient care team has an adequate number of RNs to deliver or manage care. It is important not to interpret the support for RN care as a mandate for all RN staffing. The biggest challenge we still face in nursing is determining what care the RN must deliver and to further determine the work that can be performed by other well-trained personnel.

One place we should not return to is the care process where RNs run errands, clean rooms and perform tasks that easily can be performed by others.

As easy as this sounds, it has been my experience that it is difficult to decide what activities the RN specifically should be doing. It requires careful examination of the knowledge worker aspect of nursing and a careful sorting of critical decision-making functions and patient management required by the educated nurse.

Likewise, the next steps must be to determine who will do the other work and how it will all integrate into a team effort for the patient. The past 20 years have seen multiple attempts at redesigning RN jobs to include the critical functions of a professional, and somehow in most places the efforts have fallen short-either because of poor role design that does not carefully limit the RN tasks, or because the implementation of the plan met strong resistance and failed to solve the intended problems.

As we get help for our profession from so many places, we still must do the hard work to clean up our own roles. It is estimated that as much as 50 percent of the work now being done by RNs could be done well by others, thus freeing the RN to concentrate on the critical aspects of professional care. If we were to free up 50 percent of nurses' time, there would be adequate time to provide an extraordinary level of patient care and probably would not require a tremendous increase in RNs for our health care organizations. So, the NEJM article is important for us to share with others who are committed to improving care outcomes.

In addition, we must be wise about the role of the RN as a professional provider. We must aggressively tackle the issues of role design and make it work for us as we try to find ways to best utilize the scarce RN resource. The responsibility of balancing the outcomes and costs will continue to pressure our health care systems and the process of role design should be managed by us. All the help we get will not replace the need to get our house in order and to implement every idea we can think of to improve the life of a nurse-and just as important, improve the outcomes for our patients.

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