Many years ago, Joanne took a position as clinical director of medical nursing at a major medical center in the northeast. Actually, there were two positions available: one in medical nursing and another in critical care nursing. It would have been predictable had she chosen the critical care position, as she’d started her career in a cardiovascular surgical ICU and had served a term as the president of the American Association of Critical-Care Nurses. However, she asked to be interviewed for the medical nursing role as she had seen over the years the tremendous contributions that nurses in this specialty make, often unheralded by others and unrecognized by the nurses themselves. The nursing staff (including nurses, some licensed practical nurses, aides, and ward clerks) were excellent but seemed somewhat dispirited.
Here’s her story:
We set off on a journey to change that. I learned a great deal from them as to the intricacies and challenges of medical nursing, and together we forged a strong, collaborative bond between the head nurses and the staff across units to create a strong culture within medical nursing. We held staff sessions, leadership retreats, grand rounds, and team conferences. Helping staff articulate what they do and its importance was a common thread. Eventually, we devised our tagline: Medical Nursing: Making a difference in people’s lives. Some of it was lifesaving; much of it was life-enhancing since so many of the patients had chronic diseases. Medical nursing units eventually became a desired place to work.
We also helped staff articulate to patients, families, colleagues, and physicians the impact they had on patient care and to take pride in that. One of the simplest, yet most powerful examples I have seen of a confident, competent nurse occurred when a consulting physician came to her neurological unit. She approached him, extended her hand to him for a handshake, and said, “Hello, Dr. Smith. I’m Nancy Jackson, Mr. Jones’ primary nurse. I have some relevant clinical information that I think would be helpful to you as you make your assessment of him.”
Capturing nursing’s full value
Today this pride and ability to articulate the importance of the care that nurses provide have never been more important. With COVID-19, the public has a better appreciation for all that nurses do and the impact that they make. Yet there are still vast gaps in the public’s understanding—particularly of the impact that nurses have on preventing problems, eliminating barriers, and circumventing the avoidable costs of healthcare. And today’s healthcare organizations largely offer little help in conveying nursing’s full value to patient care and organizational effectiveness. For the most part, nurses continue to be quantified in healthcare organizations as labor costs with no consideration of the many ways in which they affect outcomes, revenue, costs, and value. Jack Needleman, PhD, FAAN, a national thought leader in healthcare, summed it up: “Today, nursing is considered a cost center, not a service line. Services are optimized for performance and productivity. Costs are cut, with the question how low can we get away with?”
Nurses themselves often undervalue the full value that they bring to healthcare. Nurses do indeed reduce the costs of care when they prevent complications and avoidable readmissions; ensure appropriate and timely discharges; and decrease lengths of stay. But their full value is far greater. Regina Cunningham, PhD, RN, FAAN, CEO at the Hospital of the University of Pennsylvania in Philadelphia, urges decision-makers to consider “the full value proposition.” She described a situation in her organization where a high number of complications were occurring from device usage, such as with endotracheal tubes. The team that was pulled together to address the situation reviewed the data and devised an approach to lower device usage per day. This practice change resulted in decreased infections, lengths of stay, and costs of care. Correspondingly, bed turnover increased, allowing for increased admissions and enhanced revenue opportunities. Cunningham’s insight was that the latter calculations had not been factored into the full calculation of nursing impact—but would be in the future.
Accurately valuing nursing care requires consideration of both the costs of care and the outcomes achieved by that care. Outcomes can reflect both the impact on individual patients and the impact on the organization. Costs of care include the cost of the nursing care (e.g., hours worked, salaries paid, supplies utilized). Outcomes of care reflect the quality of care, defined by the Institute of Medicine as care that is safe, timely, effective, efficient, equitable, and patient-centered. Indicators for quality include the absence of falls and complications; prevention of medication errors; judicious use of resources; and patient satisfaction. What is less commonly considered is the downstream impact on the organization of quality nursing care, such as through cost avoidance and revenue generation as in Cunningham’s example above.
Action items
What are some of the ways that nurses are adding value to their organizations which are less visible or downstream? How can nurses articulate and take pride in this impact, and how must organizations update their databases to track and trend these results? These are a few of our suggestions:
- Reducing costs – Preventing complications, efficiently using resources, shortening lengths of stay, reducing readmissions, and ensuring timely transfers or discharges.
- Improving outcomes – Preventing complications, improving patient and family satisfaction, contributing to a positive environment, working effectively as part of the team, employing evidence-based care practices, and promoting innovative care changes.
- Generating revenue – Improving pass-through of patients, identifying new opportunities for organizational products and services, and where feasible, offering services for reimbursement.
Nurses add value through their use of the nursing lens, a “viewpoint from which someone sees things holistically, considering the person, population, or community in the larger context. The nursing lens also enables us to establish effective interpersonal relationships that help people achieve their goals and do their very best work …” Nurses are holistic and pragmatic in coming up with solutions that fit individual needs. In a 1983 editorial, Claire Fagin and Donna Diers in the New England Journal of Medicine called nurses: “tough, canny, powerful, autonomous, and heroic.” Because of this viewpoint, nurses are needed in patient care, as well as in the administrative suite, the boardroom, at policy tables, and in governmental leadership positions. Not just because nurses are good people but because this viewpoint is invaluable in society today.
Several approaches are needed to amplify the value that nurses bring:
1. With each patient or family, nurses must not assume that their worth or impact is evident. Each nurse should be able to concisely state what they are doing to make a difference, using statements such as:
- “I’m going to be working with you today to practice this dressing change so that you can do it safely at home.”
- “I’m closely watching your blood pressure and pulse to make sure that they stay within normal range.”
- “I’m checking your husband’s incision frequently to make sure that it’s healing properly.”
- One nurse manager invited the chief financial officer (CFO) to make rounds on her oncology unit. The unit was seeing an increase in the care required for these patients and yet the unit was not receiving the needed adjustments in nursing staff. The CFO, who had never been on a patient care unit before, listened intently as they went to each patient’s room, with each nurse carefully describing the care requirements of her patients. Staffing levels were adjusted.
- In a phone interview with us, Syl Trepanier, DNP, RN, CENP, FAAN, FAONL, CNO at Providence, suggested that nurses “show up with a value-based mind. Use the language of investment, returns, and value.” When talking with finance or administrative colleagues, recommend that costs of care be fully captured and that the corresponding impact on patient outcomes also be captured (e.g., reduced length of stay or savings from the absence of infection or other complications).
- Nursing leaders should work with finance leaders to quantify the average cost of most complications seen in the institution. As nurses help prevent these complications—and the resultant cost—this should be included in the full value calculation. Further, these leaders should work together with information technology staff to design databases that routinely track and connect the full impact of nurses’ care (i.e., the cost and quality of the services provided).
- Yakusheva and Buerhaus urge us to think about value-informed nursing practice, or “nursing practice that aims to improve patient outcomes while minimizing the cost of care.” This will require changes in norms, attitudes, and behaviors. Specifically, nurses will need to move away from long-held beliefs that they shouldn’t consider the cost (or use of resources) in their delivery of care, but only their impact on quality. Moreover, nursing leaders will need to work closely with nursing staff to educate them about the costs of nursing care and to devise strategies for reducing that cost while maintaining, if not improving, the care.
Final thoughts
“What difference do I make?”
In today’s healthcare environment, it’s essential that nurses are able to fully appreciate (and articulate) the value that they bring to healthcare. Similarly, it’s essential that organizations that provide healthcare, whether they be small ambulatory facilities or massive healthcare systems, can capture the full impact that nurses have on quality and financial outcomes. Without this recognition, nurses will continue to be undervalued and overextended, patients and their families will continue to experience suboptimal outcomes, and organizations will continue to be in financial jeopardy.
Joanne Disch, PhD, RN, FAAN, is a Professor ad Honorem at the University of Minnesota School of Nursing and serves as chair of the Chamberlain University Board of Trustees. She is a member of Sigma’s Zeta Chapter.
Nanne Finis, MS, RN, is the Chief Nurse Executive at the UKG and a board member of The Workforce Institute.