Commentary Three metaphors and a (mis)quote: thinking about staffing-outcomes research, health policy and the future of nursing SEAN P. CLARKE RN, PhD, FAAN 1,2 1 RBC Chair in Cardiovascular Nursing Research, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto and University Health Network, Toronto, Canada and 2 Adjunct Associate Professor, University of Pennsylvania School of Nursing, Philadelphia, PA, USA Metaphor one: `Because that's where the money is' The parallel IÕm about to make between bank robbers and nurse researchers is certainly not trying to equate the morality of their pursuits, but a story (apparently false) about Willie Sutton, the American bank robber, had him explaining why he robbed banks with the phrase, ÔBecause thatÕs where the money is.Õ (http:// en.wikipedia.org/wiki/Willie_Sutton). Researchers con- ducting studies of nurse staffing and outcomes in hos- pitals started with the most readily available sources of data about the independent variable, staffing – from administrative data about hospital operations, and about patient outcomes – from the stripped down coded versions of patientsÕ experiences during admissions found in hospital discharge abstracts. Why, despite everything that we knew or felt about nursing and nursingÕs contributions to patient outcomes, did we choose these measures of nursing services that are more the ÔresidueÕ of what nurses do than the substance (Clarke 2006)? Why did we choose to study patient outcomes that are so heavily influenced by patient characteristics out of the control of providers and af- fected by the actions of so many other workers and professionals? Because, to be blunt, thatÕs where the money was. Data sources for variables more closely related to what we were really interested in examining – staffing as it affects the delivery of direct care – are profoundly limited. Opportunities to study large numbers of hospitals with measures accessible relatively cheaply are similarly very slim (Clarke 2006, Clarke & Donaldson 2008). The potential funders of our work wanted Correspondence Sean P. Clarke RBC Chair in Cardiovascular Nursing Research Lawrence S. Bloomberg Faculty of Nursing, University of Toronto and University Health Network 155 College St., Rm. 256 Toronto Ontario, M5T 1P8 Canada E-mail: sean.clarke@utoronto.ca CLARKE S.P. (2009) Journal of Nursing Management 17, 151–154 Three metaphors and a (mis)quote: thinking about staffing-outcomes research, health policy and the future of nursing Conducting research on nurse staffing and outcomes is very challenging, and the application of staffing-outcomes research in practice is both fraught with contro- versy and vitally important for the safety of our patients and the future of the profession. As I stand back and think about being involved in staffing-outcomes research for nearly a decade and sharing many of my thoughts about this rapidly growing literature in reviews and commentaries in print, certain metaphors for trends in this field come to mind. I wonÕt claim originality for the insights that follow or attempt to thoroughly trace the genealogy of the stories and metaphors here, but offer them to provide what I hope is a fresh perspective to material that I and many of my colleagues have visited and revisited on numerous occasions. Keywords: health care quality, health policy, hospitals, nurse staffing, patient outcomes Accepted for publication: 17 December 2008 Journal of Nursing Management, 2009, 17, 151–154 DOI: 10.1111/j.1365-2834.2009.00991.x ª 2009 The Author. Journal compilation ª 2009 Blackwell Publishing Ltd 151