A Paradigm Shift in Nursing Practice

You know, readers decide in the first few sentences whether or not they will continue to read a post. This is what I was trying to say - I did not go further due to the errors in the beginning. The "hook" was not there for me. Professionals need to keep this in mind when publishing something for all to read. I have no intention of offering to edit a post for someone who is trying to convince me of an idea or concept. I'm sure the discussion is a valid one - that was not the point of my post.

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

As a nurse in a non- socialized medicine socieity/country I can only speak to how that system is run. One of the primary components facing nursing here (USA) is lack of recognition so to speak for nursing care and nurses. Nursing care is "built in" to other charges on the facility bill. That is part of the reason that Tylenol is $40 a pill, or other medications/services are greatly inflated. Most systems now do not take acuity into account period when making decisions regarding staffing/ productivity. It is all about the numbers. And yes census should be a part of the algorithm, but not the entire algorithm. As an ED nurse we are instructed to "down-staff" periodically throughout a 24 hr period according to census or number of patients seen. The C-suite has determined that productivity should remain above 90% at all times and preferably more than 95%. The problem with this rationale is it doesn't take into account the acuity or severity of the patients being cared for. If a minimal number of patients are seen but are critical care in nature ( i.e. STEMI, trauma, sepsis, post- cardiac arrest, multiple critical care drips, etc, etc.) we are still expected to meet the same productivity guidelines. In addition, experience levels of staff are not factored into the algorithm either. It is much easier to care for those patients with less staff if most nurses are experienced. This is rarely the case. Many times you may find yourself as the only experienced nurse on shift.

So, it is a multi-faceted problem and a worthwhile discussion. While I am not sure how I think/stand regarding a strictly pay for services program for nursing there does need to be a change somewhere. The patients should see a charge for nursing care reflected in their bill. Nursing provides 90% or more of all care given to patients and yet is the only profession not represented in the billing. Every year our profession is voted "the most trusted profession" by the public, shouldn't they then know exactly how much of their care is attributed to that profession? Hospitals and other facilities have to acknowledge what nurses do, as well as consider that not all patients are created equal. Physicians do bill extra for critical care and that should be considered for nursing as well, in billing and other determinants.

We have many discussions and decisions that HAVE to be made for our profession but it is time WE THE NURSES started making them instead of others and then trying to change the decisions or undo them.. Be proactive not reactive.

ya, we need less documentation, not more...that's where I stopped reading and had to disagree with the post.

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.

Exactly what I have been saying all along. We should be friends. :)

Simply love this idea !! Will never happen but your point is well stated. I would add one more radical idea. Since false allegations against nurses for drug diversion is pandemic ,Hospitals should be required to have only designated Nurses pass out Narcotics on each floor each shift. Those Nurses should be randomly drug tested per a prescribed schedule. This would give less opportunity for retaliation against nurses the Manager simply does not like and deframation of character.

Yea... I'd be much happier with a simple change like nurses in certain specialities making more than others. Some CCRN nurse working in a high acuity critical care unit managing things like CRRT, ballon pumps, EVDs, titrating 10+ drips etc should be componsated much higher than the average med surg or tele nurse. The knowledge needed to be a strong nurse in certain units varies so greatly, yet in most hospitals every nurse makes about the same. If there needs to be some extra education requirements to have a "degree" in these specialties for nursing so be it. The gross lack of compensation between knowledge/training in certain types of nursing is the main reason I left for advanced practice. Had I stayed bedside, I was leaving critical care for something much easier and less stressful where I could have made the same money.

And the main problem with nursing as a profession is the education. Nursing doesn't get the respect it deserves because nursing school is fairly easy to get through. School needs to be harder and the weak students need to be weeded out. There are way too many licensed nurses who literally just follow orders regardless and don't have the knowledge to think critically or have any real foundation with pharm/patho. The strongest nurses didn't get that way in nursing school, they got there on the job. To be completely honest undergraduate programs are a joke for the most part.

Edited Sep 10, 2018 by Spolar

A major problem with proposals like this is that they fail to recognize that fee-for-service is one of the single greatest contributors to increased healthcare cost and decreased quality of care. I do realize that having a dollar amount attached to the specific care one provides (and thereby qualifying and legitimizing its values) is inherently attractive. But, as the modern history of healthcare can tell us, this approach leads to perverse incentives that, among other things, has caused a dramatic shortage in primary care and mental health, led to overuse of expensive and invasive medical care, and resulted in one of the poorest quality of care in the developed world. Hardly a model we want to want to perpetuate much less expand. Another major flaw with this approach is that nursing care in fundamentally nonquantifiable. What constitutes something like monitoring for adverse effects of a medication and how much is that worth? As all nurses with any experience know, the value of quality nursing care is less what we do and much more know we know.

Just as we have seen with physicians, nurses are going to flock to the specialties that are intervention/procedure heavy and away from those that require expert monitoring and unglamorous but vitally important nursing care including things like educating patients/family and psychosocial care. Long-term care nurses would not only have to cover massive amounts of patients to make a comparable income but are also going to be seen as less valuable because the work they do would literally be less valuable (in a strictly financial sense). Physicians, thanks to fee-for-service, now see a massive range in earning potential based on specialty conservatively estimated at 250% (from $199,000 for public health and preventative medicine to $501,000 for plastic surgery) which directly oppose where our priorities in healthcare should be.

Rather than imply that all healthcare professionals are susceptible to corruption when their income is at stake, consider, as Dr. Steffie Woolhandler has pointed out, that unconscious influences are likely to take a toll. She gives the example of a cardiologist doing a cath. She or he notices a partially occluded artery. All the research suggests that the best course of action is to pull the catheter and start the patient on lifestyle interventions especially diet and exercise. However, the cardiologists can put in a stent in about 90 seconds and make an extra $5000. Human nature, she suggests, says that most people would place the stent.

While this example isn't directly applicable to nursing, consider something like medications. If a nurse can take home more money for every drug she or he pushes, are we likely to see an increase in the use of PRN medications, requesting orders for medications rather than nonpharmacological options, or questioning orders that verge on polypharmacy? Again, I'm not suggesting nurses, by and large, are going to start drugging patients into oblivion just to make an extra buck but I am suggesting that a system like this further creates incentives in opposition to the best interests of the patient (and the system as a whole).

Let me suggest a far simpler and, I would contend, far more likely successful approach. As you pointed out, basic nursing care is now included in the daily rate for hospitalization and, therefore, is lumped in with everything from building maintenance to office supplies. When facilities want to reduce costs, nursing care is just a line item like the toner and water bill. In the same way a hospital might reduce cost by buying cheaper or fewer linens, they look at increasing nursing ratios and/or decreasing staffing the same way. By simply splitting the reimbursement for nursing care from the miscellanea, there would be a clear and specific value attached to nursing care. This value could be on a tiered scale where ICU and active laboring nursing care might be at a higher rate, subacute might be lower. Facilities would be required to spend reimbursement for nursing care on nursing expenses (salary and benefits) so the money isn't going to the new water feature in the lobby or valet parking. Also, instead of legally mandating nurse: patient ratios, hospitals would now have a financial incentive to staff appropriately. Is it perfect? Not at all. Are there still ways to avoid doing the right thing? Sure. But they are far fewer and it would require much more effort to justify screwing over the floor nurse.