A Paradigm Shift in Nursing Practice

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. Nurses Announcements Archive Article


A Paradigm Shift in Nursing Practice


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 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.


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.


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.


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.


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.

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Don't know what happened to spacing when I posted this. I tried to clean it up. Hopefully, that doesn't distract from what is actually being said, as I feel that it is a worth while conversation.

While the ideas posted are radical. I'm not one to be against radical ideas.

My curiosity and pondering is over staffing. How would these staffing patterns go and where do the nursing numbers come in. Say a med surg unit has 42 patients, and as you propose nurses charge for their nursing care- as physicians do, then if newer nurses don't feel comfortable with more than 3-5 patients and it is felt that the 20+ yr veteran nurse can take on 8-10, how does a unit determine how many nurses are needed to staff the unit. assuming all beds are filled with varing degrees of acuity patients and hopefully a mix of experience level nurses. Or what of there is only 1 veteran nurse on the unit for a 12 hr shift and say, lets be generous, 6 new nurses. Does every patient get a nurse?

Nurse practioners are charging for their care just as physicians do. They are being reimbursed by medicaid/medicare just as physicians are but of course at a lower rate, which is one of the arguments for the nurse practioners - to make up for the physician shortage especially in Family and Primary care practice. And if things keep going the way their going- NP's will soon be the life jacket to the OB- Women's Health world also.

Specializes in ED/ICU/TELEMETRY/LTC.

While I don't disagree, I see major problems here. The paper work alone would be massive.

Think of the potential for error.

And then, you have that 20 year veteran who wants those 8 patients for the money and doesn't take care of 5 in a way that is beneficial to the patient. Or the new nurse, heavily in debt from school, taking more patients than he/she can handle to improve salary.


Specializes in Hospice.

what a novel yet radical idea. i don't think its ever safe to take 8- 10 pts and personally i would rather take five easy ones and leave the one higher for one someone else based on the rates your saying ;) I think it would certainly take the teamwork out of nursing. although if someone else put an iv in for me i suppose under this system if they charted it they would get reimbursed so maybe not?. I make decent money, but i to want to see the professional and respect of our profession increased and we have a lot of hurdles to overcome. it may just take a radical ideal like this to get there. ;)

Specializes in ER, ICU.

I'm not sure I agree or disagree but its these kind of ideas that we need to move our practice forward. Thanks.


Read this post with interest and some curiosity. I work in a socialised medical environment. thus care concept, and methodology of payment differs in many ways. The factors you describe which influence how a nurse is paid, ie. per patient and amount/ time/ acuity of need and care are also influenced by the number of discharges and


This would obviously provoke, especially under present economic challenges, a good deal of stress and insecurity in all nurses , impacting patients, and as you stated, new grads with educational debt.

As I have not worked in this type of health care management/ administration my comments are limited.

One factor which stands out overall is the emphasis on payment vis a vis patient quotas and care. This strikes me as having significant influence on level of patient care, safety and most important, the level of fear and stress the system produces in nurses.

Socialised medicine has it own problems, obviously, higher taxes being one aspect. My question is how does your nursing management recognise the impact of the fee systems upon nursing staff and are there supportive approaches for the nurses employed there

Specializes in FNP, ONP.

The potential problem that I see (and forgive me if it has been mentioned, I skimmed) is that interventionist environments and procedures will likely offer higher payment structures and yield worse outcomes due to the nature of the diagnoses among those seeking the services. How would your fee for service approach, which has largely failed in medicine, reconcile these conflicts in Nursing?

Specializes in Critical Care, Education.

The OP has resurrected some arguments that have been around for as long as I have been in nursing - and that's quite a while. They are always popular because they support the "nursing is valuable and should be rewarded" proposition. I agree wholeheartedly.

However (you knew it was coming) US healthcare is rapidly evolving beyond a "piecework" mentality into one of value-based purchasing... from paying for process to paying for outcomes. The old model has resulted in a devaluation of chronic care and reward for invasive & high-tech interventions. This has created a serious imbalance since an increasing majority of care now and in the future will be devoted to chronic care. It also devalues nursing care in a very real sense because our work is not defined by CPT codes.

Oddly enough, the very fact that the public is very aware that nurse salaries are not tied to interventions is why they trust us so much... they know we don't receive any financial gain from 'up-selling'.

I disagree with one point made by the PP. Chronic care is not devalued. In fact, from my own job offers, those LTC/LTAC/SNF jobs I have had or was offered paid MORE than the hospital job!

I would rather have my care based on CPT code than patient surveys!!

Fact is that too many Americans have been taught that outcome is the goal...not equal opportunity but equal outcome....translated medically that it isn't equal opportunity for good nursing care but better outcomes for the patient. Doctors are not Gods and they cannot always predict who will or will not survive. They cannot predict one head injury outcome over another...it is 'wait and see'. How many stories have we heard where a patient wasn't expected to survive but did or vice versa.

How do we as nurses begin to get the world to realize our true value? It will never come from becoming medical waitresses. As a career transitioner, I had NO concept of all the knowledge that a nurse needs to pass the NCLEX and then to provide care. Somehow, some way we need to get the general public to know that we are not just the doctor's handmaidens.

Honestly, the silliest, but most effective way would be proper nurse based drama shows. As long as the public sees nurses behind the desk as the station gossiping about nothing....then see the doctor do all the procedures that are the nurses area of practice, they will NEVER see our value.

Specializes in psych, general, emerg, mash.

since florence practised in the battle field, of years gone by, nothing has changed. Nurses can do nothing, without a dr written order,

Funny, I just wrote about it as a way for nurses to gain power. Good to see it is out there. I began exploring this four years ago.There are revenue codes for billing and it has been tried with good results. Look up the work of Dr John Welton and Joyce Batchelor. Talk about upsetting the apple cart. Imagine at a board meeting them having to say that nursing services brought in twenty million dollars in revenue. A CNO worth half her measure in gold would say. "And we want this...."