In 2013, Harlan Krumholz, a well-known professor of medicine at Yale University, wrote an article for the New England Journal of Medicine about a common phenomenon.1 “Patients come to the hospital to be treated for an illness, but they leave with another serious ailment that interferes with their recovery and can lead to long-term disability: the post-hospitalization syndrome. During hospitalization, patients are deprived of sleep, adequate nutrition, and exercise. In addition, patients often receive medications that alter their cognition. Hospitalization-associated disability impacts an estimated one-third of patients 70 years of age and older. Although readmission can occur for various reasons, this syndrome is certainly the cause of many patients returning to the hospital unnecessarily. According to the Centers for Medicare & Medicaid Services, readmissions cost $26 billion annually of which $17 billion are unnecessary.”1 In our studies of missed nursing care (i.e., required and standard nursing care that is not being completed) reported by both nursing staff and patients, we found a large amount of omitted care.2–5 Examples identified by nursing staff (registered nurses, licensed practical nurses, and nursing assistants) include ambulation (76% omitted), interdisciplinary rounds (65%), mouth care (64%), medications on time (60%), turning (59%), feeding (58%), full documentation (56%), and patient teaching (56%). Patients identified similar omitted care: mouth care (50%), ambulation (42%), getting out of bed into a chair (39%), and providing information about tests and procedures (27%). These findings are consistent across hospitals, pointing to systems failures as causative factors. This problem is not about “bad” nurses. Our studies have shown that the less the missed nursing care, the higher the job satisfaction.6 A review of research studies that have been conducted in acute care hospital settings have shown that missed nursing care, as most nurses are aware, can have very serious consequences. Not ambulating patients can result in newonset delirium, pneumonia, delayed wound healing, pressure ulcers, increased pain, muscle wasting and fatigue, physical disability, and increased length of stay.7,8 Failure to turn patients can lead to pressure ulcers, pneumonia, venous stasis, thrombosis, embolism, stone formation, urinary tract infections, atelectasis, and bone demineralization. Recent studies have shown that not conducting interdisciplinary rounds can result in adverse events, readmissions, leaving catheters in too long, and higher mortality. These are just examples. Over 150 studies have demonstrated that the amount of nurse staffing has a strong, significant relationship to patient outcomes. What has not been studied is what goes on in the process or the “black box” of nursing care. We need to know when staffing is better ,what is it that happens that makes the difference in outcomes. It is only with this knowledge that we can develop interventions to improve the quality of care. If it was possible for nurses to provide all of the standard, required nursing care, would patients go home from the hospital able to walk, be well nourished, rested, free from infections including pneumonia, mentally clear, and knowledgeable about how to care for themselves? Most nurses would say “yes”. Our challenge is to figure out how to make this happen.