A Paradigm Shift in Nursing Practice

mamain

CONGRATULATIONS, YOU'RE JUST A NURSE

JUST a nurse. I am JUST a nurse. No big deal, had I been more adventurous maybe I would have gone to medical school. These thoughts are the thoughts of many, including myself, which I have over heard for years, even prior to nursing school. It's actually sad when you think about it.

Nursing recognized as a profession has gained it awareness in our current culture somewhat piggybacking off the Women's Right movement. Even though many nurses are now male, the stigma associated with nursing has its roots attached to a time when women, whom comprised nursing, were thought of as hysterical, at worst, and not equal to a man, at best. Doctors by contrast, predominantly male, has commanded respect and paid well for that respect for years.

THE WORLD AS WE NOW KNOW IT

The world of nursing as we currently know it is complicated by supposed "Staff shortages", high nursing to patient ratios, lack of documentation for nursing interventions, problems with compliance to "Core Measures" or other Joint Commission regulations, deficits in inventory charging, poor attitude, and lack of ambition in many situations. This in turn creates extremely high turnover, million dollars in lawsuits, millions of dollars on Core Measure fall outs, and loss of thousands of dollars in inventory, difficulty for managers to make safe staffing assignments.

To combat many of these problems the nursing world has sought legislation to control nursing ratios at the detriment of no longer having nurses aids which help feed, bath, change bedding, toilet, and other similar tasks that take much time and attention. Their supposed rectification of the situation leads to more work for the nurses and a cut in positions for other healthcare members.

A POSSIBLE ANSWER

In a perfect world, which valued nursing similar to other types of therapists or physicians we would be able to bill patients for our services. This thought is nothing new and there are several reasons many have decided that right now this is not the answer.

So what is the answer? To me it's exquisitely simple.

It is common knowledge that a floor nurse is paid out of the room expense for the patient. But when considering the average room is at least $3000 and many times much higher and then multiplied by the five to eight patients the typical nurse must take care of its easy to see that $20- $30 dollars an hour is not much in the scheme of things.

However, taking from a rare specialty in nursing which pays a base hourly rate plus one hundred dollars per patient a day I ask myself why isn't this extended to the rest of profession? If a nurse was paid based on acuity and that acuity was calculated by the end of the shift per patient based on documentation into a computer system with an algorithm (which already exists) then the nurse would be motivated to properly document, become more efficient, give the nurse the ability to control how many patients they wanted with the incentive to accept more patients per shift. In theory, this would increase positive outcomes for the patient, diminish lawsuits and fall outs over Core Measures, and increase compliance with Joint Commission standards.

AN EXAMPLE

Based on acuity a typical day might consist of a patient that is waiting for discharge at some point that day, has nothing really wrong with them and only needs some basic nursing care. For this patient the nurse might get paid $80 per shift, but since the patient leaves a little past the middle of the shift the nurse would likely be paid $50. The nurse then admits a patient whom is more acute. The patient is a direct admit patient and requires and IV to be started, a urinary catheter to be placed. The nurse is spending two hours getting this patient admitted, stabilized, calling doctors, making sure the patient is ready to go to various departments for diagnostic testing and based on all the nursing interventions this patient is fairly acute. For a whole shift with this acuity the pay to the nurse would be possibly $120, but since this patient came toward the end of the shift maybe the nurse is paid $60 considering the amount of time and interventions that this patient required. The rest of this nurse's patients consist of a patient with several wounds that need to be addressed, another patient with tracheostomy requiring hourly suctioning and tracheostomy cleaning. Another patient has a feeding tube and is trying to get out of bed frequently, but has dementia and is unable to walk. Another couple of patients are requiring blood transfusion and yet another patient is relatively stable, but not ready for discharge. Each of these patients would be a different acuity based on the algorithm the nurse would be reimbursed differently for each patient, depending on her documentation. Let's say this nurse on average makes around$100-$150 per patient for 12 hours, but this determination is based on 24 hour equivalents.

For those nurses working in a procedural type arena, the pay reimbursement would be even simpler. The nurse would be paid based on a percentage of the cost for the procedure. I am not well versed in this type of nursing, so I wouldn't be able to extrapolate the price for different procedures, though that could also be taken into consideration.

ADVOCATING FOR THE PROFESSION

This type of pay reimbursement would give the power to the nurse to direct their own practice. A new nurse may only want to take 3- 5 patients that particular day, while a 20 year veteran might be able to handle 8 or 10 safely and efficiently. However, it would be the nurse's call based on where they felt comfortable and their pay would reflect this desire. The theory advocating for nursing control of practice would also not negatively penalize the nurse for taking more patients as the currently system does. If I get paid 'X' dollars an hour for the shift and it doesn't matter if I have three patients or ten, of course, I will opt for the latter. However, if I was going to get paid significantly more to take either a sicker patient or more stable patients I would be more enthusiastic about this assignment.

IT'S NOT ABOUT THE MONEY

The first critique to this work will be that this type of philosophy is money oriented. I bet the first person to even say this will be a nurse. As nurses we can sometime perpetuate the cycle of professional disregard. And while thinking I would love to live in a land where the most important thing was taking care of my patients and making sure they had the best hospital experience possible and my direct contribution mean they got better faster.

Unfortunately, this current system does not cultivate this type of thinking and simply irradiates this type of idealism, disregarding it as a naive view point of a not-so-seasoned nurse. As much as each nurse may have come into this profession thinking they would make a world of change, reality is they are not given the tools needed for success.

Nurses are currently given all the responsibility and none of the resources to give "nursing book" quality of care. Think of it this way, a physician get to say how many patients they will take and how much they will charge. Society accepts this, may grumble a little, but still puts up with this situation. This theory would put the power back on the nurse to decide how much he/she is able to safely take on for one shift.

This theory is in no doubt a paradigm shift and it acknowledges that resistance will be met by hospital that does not want to lose profits. It is not asking that the patient pays more inherently. And to this end, when people will say it cannot be done because of the price to be paid, I would say, then why isn't this an obstacle for other professions that may only see the patient for a few minutes each day.

~ Written by Melissa Main, RN 2012

Feel free to share and comment. My ideas are fluid not set in stone.