Healthcare Practices in Nursing Today

Over the last 50 years, health care systems all over the world have experienced rapid and significant changes. Some of these changes have been the result of innovative developments in medical science and technology that have greatly benefited patients, prolonging and saving the lives of millions. Some of these changes, however, have had the unfortunate result of limiting patient access to prescribed treatment and diminishing the overall quality of care.

Significant challenges are being faced in health care as systems restructure and reinvent themselves in a difficult and often painful effort to make more efficient use of their available resources (ICN, 2001). Since health care is such a labor-intensive industry, the stresses on these systems inexorably trickle down to affect those employed by the system. Nurses, who are the most highly trained caregivers who have ongoing, regular patient contact, stand at the very heart of any health care system, regardless of where it is located (Clark & Clark, 2003).

Widespread anecdotal evidence points out that the issues in health care have negatively affected the workplace experience of nurses. The media regularly reports on the challenges that nurses face daily in the workplace, ranging from low pay in Ireland, to safety and health problems in South Africa, emigration in the Philippines and mandatory overtime in the United States. It is clear that nursing is a profession in crisis, a situation that extends around the world. (Clark & Clark, 2003).

The health care reforms that have been introduced around the world, including privatization and the introduction of market-based approaches to health care, have succeeded in bringing numerous new pressures to bear on health care systems and health care workers (Clark, Clark, Day & Shea, 2001). While the crisis in health care is multifaceted, encompassing shortages of trained medical personnel, epidemics (including AIDS, tuberculosis and malaria), environmental problems (air pollution, water contamination), natural disasters, the consequences of war (civilian casualties, refugees), and changing demographics, the root of the problem is ultimately economics. In today’s world, developing nations cannot provide the most basic of health care to their citizens. The public and the private sectors in developed countries have difficulty keeping pace with the rapidly escalating cost of health care (Clark & Clark, 2003).

The purpose of this paper is to identify the successful cost-effectiveness practices that are in place in various healthcare settings in the United States, as well as to take a look at how nurses and nursing fit into these practices and which cost-control factors can make a contribution to a successful nursing budget. A summary of the research on nursing administration and the efficiency, cost-effectiveness, cost-containment and quality control issues facing the nursing profession will be provided in the conclusion.

Review and Discussion

Background and Overview

The health care systems of all capitalist democracies were subjected to radical transformation during the 1990s, rooted in the need to control the cost of health care for the government, business, insurers and individuals. Some of the factors driving this need include the increasing number of effective services, the growing population of elderly and changes in what patients expect. A central issue has been the attempt to allow market forces to control costs (Griffith, 1999).

The provision of care in the U.S. has been predominantly in the private sector, with large-scale hospital chains playing a significant part. Doctors and hospitals have traditionally been paid on a fee-for-service basis, funded primarily through insurance, which has given health care providers powerful incentives to increase costs. A result, millions of Americans today have no insurance coverage for health care, despite publicly funded systems like Medicare (for the elderly) and Medicaid (for the impoverished).

This traditional model of health care has made way for managed care plans called Health Maintenance Organizations (HMOs).

In 1980, nine million Americans were covered by HMOs, with that number rising to over 23 million in 1986 and to greater than 41 million by 1992 (which translates to over 15 per cent of the total U.S. population — in 1992 (Griffith, 1999). The transaction costs within the United States health care system are huge. A five-year study conducted in Boston, Los Angeles and Philadelphia discovered that overhead costs of 20-34 per cent were routinely claimed by managed care plans.

There is little evidence that quality of health care is poorer under managed care in the United States. Over 70 per cent of observations indicated that there is no significant difference in quality between managed care and alternative plans. However, it emerges that managed care organizations consistently achieve lower ratings for patient satisfaction (e.g. In relation to the professional competence of the clinicians and the time devoted to consultations. In one study, 27 per cent of former members of HMOs reported that they left the managed care system due to dissatisfaction with the quality of care (Griffith, 1999).

It has been reported that managed care techniques, together with market forces, have caused insurance premium growth rates to retreat from 10.6 per cent in 1992 to 1.2% in 1996. Managed care mechanisms have resulted in lowered use of expensive discretionary procedures, also leading to fewer hospital admissions. Utilization review has decreased hospital costs by 10-15 per cent.

On the other hand, Health Maintenance Organizations under Medicare appear to cost almost six per cent more than non-HMO arrangements, resulting in the government losing money on the people who use them. There is also strong evidence that HMOs that operate in markets with twelve or more other HMOs charge notably lower premiums that those who operate in areas that have less competition (Griffith, 1999).

Medicine and Cost-Efficiency

Primary Care Nurses vs. Team Nursing

Primary care nursing was a reorganization that began in the late 1960s, gradually replacing other forms of nursing organization. Before that time, team nursing was the accepted form of nursing organization. Under team nursing, RNs, LPNs, and aides all worked together in providing patient care, with RNs overseeing the work. Team nursing effectively moved RNs out of direct patient care and into a managerial role. In contrast, primary care nursing has each RN assigned to the overall care of five to eight patients (Krall & Prus, 1995). Although LPNs and aides are still utilized in this type of nursing organization, their roles were diminished and subordinated to the authority of the primary RN (Marram, 1977).

Use of RNs vs. LPNs and Aides

Pope and Menke provided an analysis of the hospital labor market in the 1980s by saying, “Because of the low wages of some more highly skilled occupations relative to their productivity, hospitals could provide care at lower cost by substituting the occupational categories with higher skills (e.g. RNs) with those with lower skills (e.g. licensed practical nurses and aides)” (Pope & Menke, 1990, p. 130).

However, the history of cost containment pressure on hospitals over the past few decades shows that these pressures have changed the intensity and complexity of hospital care. In 1983, the U.S. government implemented prospective reimbursement for hospital costs, effectively categorizing admissions according to diagnosis-related groups (DRGs). As stated by Pope and Menke, “The results of these efforts and other trends has been fewer, but more severely ill, inpatients, shorter length-of-stay, and increased outpatient activity” (Pope & Menke, 1992, p. 127).

It appears that cost containment policies have essentially limited the amount of time patients may remain in the hospitals for any given health issue, and have restricted inpatient hospital care to more serious procedures. As length of hospital stay and severity of patient illness increase, more acute care is required from nursing personnel. Many of the tasks that would be performed by lesser skilled nursing personnel have simply been eliminated. Ordinarily, the need to contain labor costs might result in an increasing utilization of lower-paid workers and a minimization of the use of more highly skilled and highly paid workers. However, the change in complexity and intensity of hospital care caused hospital administrations to attempt to eliminate from the mix any workers who were not capable of being flexibly deployed (Krall & Prus, 1995).

Licensed practical nurses rapidly disappeared from acute-care hospitals as the changeover to all-RN staffs picked up momentum across the country in the 1990s. The reasons were relatively clear. As patient acuity increased and cost-containment pressures grew, nursing directors believed that they could employ only nurses who were qualified to deliver a broader range of care. At the same time, cost containment pressures created an environment in which hospitals had to more closely account for and justify their nursing costs. As Prescott pointed out in her 1986 article, “Especially now that hospitals face serious fiscal constraints associated with changing reimbursement and cost control mechanisms, administrators must look closely at both the number an d type of nursing staff they employ” (Prescott, 1986b, p. 81).

Use of Patient Classification Systems to Track Nursing Costs

Nursing costs are notoriously difficult to track due to the fact that it is difficult to predict exactly how many and which type of workers will be required at any particular point in time. This is because hospital needs fluctuate, depending on the numbers, types, and individual responses of patients on a given day.

Management developed ways to attempt to predict nursing needs that were based on patient population. This type of patient classification system is a process where RNs document patient needs. Management then uses this documentation to standardize patient care and to predict the right mix of nursing personnel that is required for any particular patient population (White, 1988).

This particular management strategy requires a high level of utilization of RNs, because RNs are more highly educated and better at the documentation process required for patient classification systems to work. In addition, RNs are trained to participate in the process. This system is being widely utilized to measure productivity in the staffing of units on both a daily and monthly basis. It is also used to make budgetary projections within various cost-containment restrictions, as well as to ensure the delivery of high quality patient and family care (Grant, Bellinger & Sweda, 1982).

Decreasing Inefficiencies

Both cost-effectiveness and cost-benefit analysis have been used in preventive, diagnostic, and treatment contexts. Over the past couple of decades, methods have certainly improved for collecting better data and for incorporating intangible quality-of-life valuations into the calculation weighing benefits against costs. One element under the control of nursing departments is to trim the inefficiency associated with the seven top tasks performed (illustrated in Table 1 below), especially focusing on methods for trimming unneeded bureaucratic tasks.

Table 1. A Data-Envelopment Analysis of Average Inefficiency (39 Hospitals, 1991)

Factor (Workload/Input)

Current Value

Workload per Case-Mix-Adjusted Admission

1. General nursing administration

18.6% inefficient

2. Assessing and monitoring physical condition

17.4% inefficient

3. Planning for patient discharge

14.9% inefficient

4. Completing evaluation/outcome documentation

14.8% inefficient

5. Administering tube of IV feedings

9.5% inefficient

6. Placing special tubes (NGs, Foley, O2)

8.2% inefficient

7. Monitoring tech equipment (Swan-Ganz catheter)

7.9% inefficient

Labor Input

1. Nursing administration

21.3% oversupply

2. Nurse extender (technicians)

24.7% undersupply

Source: Grosskopf & Valdmanis, 1987.

Judging by the results for labor inputs, the 22 inefficient nursing departments could cut administrative activities by 21.3% and expand the supply of technician employees by 24.7%. Task delegation to technicians, a leaner nursing administration bureaucracy, and nurse-scheduling systems that utilize Optimizer Linear Programming Software (Shorr, 1991) appear to be three keys to the improvement of nursing productivity. Nurse productivity is critical, since nurses represent over 60% of total hospital employees (Eastaugh, 1992).

Other departments also can benefit from productivity improvement. Better scheduling systems for both staff and patients can certainly enhance productivity in radiology, respiratory therapy, and numerous other departments.

Staffing standards for efficient/good (70th percentile) hospital departments and very good (90th percentile) departments are shown below in Table 2.

Table 2. Productivity Standards for Performance in Select Departments, 1991

Performance

Target Standards per Unit of Service (UOS)

Department

70th Percentile

90th Percentile

Radiation oncology

Respiratory therapy (RT

Pulmonary (in dept. RT)

EEG (in dept. RT)

EKG (in heart center, HC)

Echocardiology (in dept. HC)

Emergency department (ED)

Behavioral services (M.H. – S.W.)

Laundry (linen per diem)*

16 lbs/patients day

14 lbs/patients day

Source: Eastaugh, 1992.

Productivity enhancement can also involve decreasing unnecessary units of activity or unneeded output, for example, minimizing linen consumption per patient per day.

Total Quality Management Approach total quality-management program focuses on both external (e.g. patients, employers) and internal customers. Often, one department does not understand how its work product is used by another department (e.g. quality and productivity may be increased if a hospital laboratory does not skimp on hiring a $7.50 per hour technician who can preclude the problem of a $75 per hour emergency-room doctor wasting time waiting for lab results). The concept of internal customers (Deming, 1986) fosters respect and efficient teamwork between departments and increases morale in the total organization.

In this environment, doctors become “customers” of the nursing department, the medical floor is a “customer” of the recovery room, and the recovery room is a “customer” of the operating room. Some departments may be inappropriate or excessive customers of another department (Eastaugh, 1992).

In one example of doctors as customers of the nursing department, attending physicians at one hospital frequently complained of seldom seeing the same faces twice. A team studied the problem and came up with solutions. The problem was caused primarily by the belief of nurses in 100% RN primary-care nursing. The solution was to maximize the use of the existing RNs’ clinical skills by employing technicians to perform the 43% of nursing work that the law allowed a non-nurse to do, rather than to continue the expensive habit of hiring outside agency nurses who were new to the department and unknown to the doctors. Morale among the nurses was significantly improved since their time was no longer wasted doing menial work. Morale among the attending physicians also improved, since now they could identify specific RNs with their individual patients.

Creating a Leaner Organization

Hospitals need to annually reevaluate workload-driven staffing ratio, to ensure that they are in line with fiscal goals and shifts in payment rates. Managers should use “best-cost” standards from appropriate engineering studies. Down-staffing usually correlates with better-quality care (Walton, 1990), while staff-to-patient ratios can be reduced by over 15% in many cases (e.g., Emanuel Hospital in Portland in 1990 and Beloit Hospital in Wisconsin in 1987).

White Memorial Medical Center in East Los Angeles reduced total nursing hours per patient day from 10 in 1988 to 7.1 by September 1990. Redundant staffing in a fat organization almost always leads to lower quality care (Ahmadi 1989; Caldwell, McEachem & Davis 1990). In departments with direct patient care responsibilities, it is clear that much of the bureaucracy, paperwork, and other useless units of activity should be eliminated. For example, one hospital used six separate patient charting forms until that process was replaced by a single flow sheet in 1991. Lab results should be reported by computer, and medication orders should be faxed to the pharmacy or sent by computer systems, in order to eliminate the wasted time involved in transcribing orders (Eastaugh, 1992).

Increasing Nurse Productivity

The results of a 1990 study by Eastaugh showed that employment of technicians to assist nurses in many tasks reduces wasted labor, enhances productivity, and therefore, improves cost-efficiency (Eastaugh, 1990). Judging from the deployment of technicians at prestigious hospitals (e.g., Johns Hopkins), task delegation can enhance the quality of patient care (Eastaugh & Regan-Donovan, 1990).

Beyond the traditional technician tasks of obtaining vital signs and EKG results, patient transport, procuring supplies and equipment, procedural assistance, and paperwork, some hospitals have begun to utilize specialist technicians to dress wounds and to do other basic nursing functions. Some of the other activities that may be performed by technicians are outlined in Table 3 below.

Table 3. Selective Examples of Non-nursing Menial Tasks vs. Important Nursing Tasks

Non-nursing Tasks to Delegate to Technicians*

Important Nursing Tasks

1. Obtaining vital signs

Interpreting vital signs

2. Patient transport

Physical assessment and condition monitoring

3. Housekeeping and bedmaking

Technological monitoring, Infusion pumps, Swan-Ganz catheters

4. Meal trays

Tube and IV feedings

5. Physician procedural assistance

IV Therapy: nitroglycerine, insulin, TPA drips

6. Venipuncture

Evaluation/outcome documentation

7. Getting supplies and equipment

Discharge planning

8. Secretarial (e.g., lab slips)

Special tube placements: NGs, foleys, oxygen therapy

9. Obtaining EKGs

Narcotic count

Source: Eastaugh, 1990.

Non-nursing tasks, often called “scutwork,” are activities that can be easily delegated to technicians in a high productivity unit.

Progressive nurse managers should participate in careful studies designed to set the standards, study task-delegation feasibility, and set out the job descriptions for two to three levels of specialist technicians (Powers, Dickey & Ford, 1990; Bennett & Hylton, 1990). With ongoing anticipation of future funding limitations, barebones reimbursement demands that the recent tradition of 100% RN primary-care nursing must be altered. The creation of an efficient staff mix in the field of nursing should only enhance nursing’s rising sense of professionalism (Eastaugh, 1992).

Manthey, one of the originators of the primary-care nursing concept, has recently capitulated to the idea that the 100% RN concept is not an absolutely necessary component for primary care nursing (Manthey, 1988; 1970).

Maximizing the employment levels of RNs in hospitals is neither a desirable nor an economical goal unless the United States were in a situation with a huge oversupply of nurses. No such oversupply situation exists, so an increased reliance on specialist technicians is simply good economics, good nursing, and good medicine.

Software Utilization

Software is available in the marketplace today to simplify the employee appraisal process and streamline the accreditation process. It includes medical-specific features with benefits for HR administrators, line managers and the entire organization, helping to increase efficiency and lower costs. One such software package is called Halogen eAppraisal Healthcare.

Features include:

Automatic personalized reminders to decrease the amount of time spent following up and ensuring that processes run smoothly, with appraisals completed on schedule, unique report center providing real-time progress tracking and generating detailed reports to meet JCAHO® accreditation criteria,

Centralized storage that eliminates the potential for duplicate copies of appraisals and archives data for future reference,

Intuitive user interfaces,

Encryption technology that provides safeguards against inappropriate access to the appraisals,

Electronic signature capability that eliminates the need for paper,

Advanced configurability, allowing administrators to measure important elements and ensure that appraisals reflect organizational values and strategic goals,

Human Resources Information Systems integration that incorporates employee data,

Automatic step-by-step reminders for reviews and accreditation,

Authoring aids to save time and produces meaningful reviews that challenge high achievers and improve poor performance,

An employee log / progress notes / performance journal to substantiate performance ratings with recordings of relevant accomplishments and issues throughout the year, spell checker with medical dictionary and language-sensitivity,

Centralized storage to eliminates searches for past appraisals and performance plans medical-based competency library that reduces time spent defining job profiles and competencies, centralized report center that provides valuable data to help prepare for JCAHO â„¢ and State Accreditation surveys, as well as to produce board governance and competency reports, and web-based framework to eliminate geographic barriers with anywhere anytime access.

Halogen eAppraisal Healthcare software was designed with industry-specific capabilities for healthcare organizations, making the task of performance management easier, efficient and cost effective. It has been implemented by numerous healthcare organizations that were seeking to streamline and automate the administration that is associated with the employee appraisal and accreditation processes (Halogen, 2004).

Use of Technology to Increase Efficiency

New technology brings both benefits and problems for nurses (Sinclair, 1988). Sophisticated computerized systems can provide nurses with accurate and precise physiologic measurements, providing a timely picture of the patient’s status and allowing rapid intervention if complications should develop. Nurses can receive automatic updates on chest drainage, urine output, and hemo-dynamic measures every two minutes. Some computer systems can even be programmed to administer blood, fluids, or drugs in small increments, based upon the computer’s periodic assessment of volume loss or changes in blood pressure (Zalumas, 1995).

Some new technologies can even replace invasive and high-risk techniques with less expensive and lower-risk ones. Automation helps nurses to accomplish timely interventions, since critical changes in patient status may occur rapidly, requiring quick and accurate decision-making. However, it must be remembered that technology also cam have hazards. Patient injuries may result from some treatments (called iatrogenic injuries) as a result of invasive monitoring techniques.

Such risks have become even more likely during a time of nursing shortages and the entry into the picture of inexperienced personnel. In a five-year study, Abramson found that 25% of iatrogenic incidents happened during the months of July and August, a time of year generally associated with the presence of new interns, residents, nurses, and other health care personnel (Abramson, 1980). Sinclair notes that the continual introduction of new technology into critical care units exacerbates the problem of under-trained personnel (Sinclair, 1988). Another complicating factor that may add to the hazard of new equipment is the lack of uniformity in the equipment used with new technologies. Free market competition among companies and cost-containment programs of hospitals may add to the ongoing changes in acute care settings (Zalumas, 1995). The use of technology in the correct applications and with the appropriate caution can be a valuable source of cost-reduction for nurses.

Reducing Medication and Other Errors

Most medication errors are the result of errors in management, rather than from patient factors such as allergic reactions. Many physicians (and most lawyers) seem to believe that all errors result from negligence. However, such a judgment is terribly harsh, and this type of thinking can be a major barrier to efforts to reduce errors. Although some errors are definitely egregious and should be legitimately thought of as negligent, the vast majority of mistakes are simply that, mistakes (Bogner, 1994).

Minor slip-ups or momentary lapses are common, things like writing the wrong dosage for a drug or forgetting to obtain the results of a laboratory test. These slips and mistakes occur for everyone in everyday life. Although they are probably among the most careful people in society, doctors, nurses, and pharmacists also make mistakes. Unfortunately, even a very small error rate can have disastrous consequences in a modern hospital. The arithmetic is staggering.

For example, in a teaching hospital setting, the average patient receives over 30 different medications during the course of his or her hospitalization. Therefore, an average-sized (600-bed) teaching hospital may administer more than 4 million doses of drugs each year. Every dose of medicine provides several opportunities for error. If medication ordering, dispensing, and administration systems were 99.9% error free, more than 4,000 errors a year would still result. Even if only 1% of these errors result in a death or serious injury to a patient, this commendably low error rate would cause 40 accidental injuries from medications alone. As we know, even doctors, nurses, and pharmacists do not function at the 99.9% level, so actual accidental injury rates in practice are no doubt higher than they were in this hypothetical example (Bogner, 1994).

Most hospitals rely on self-reporting systems, such as incident reports, to track the occurrence of accidental injuries. However, even when reporting is required, such systems seem to have low yields in comparison to active investigations. One of the first principles of continuous quality improvement is to obtain data on the types and rates of errors and accidental injuries. To assist in the mitigation of this problem, nurses can establish data collection methods that accurately discover and describe the errors that do occur. The incidence of accidental injuries could then be reduced, resulting in major cost and timesavings.

Law and Cost-Efficiency

Informed consent is a means of respecting the independent preferences of people who are seeking health care or participation in research projects. The ethical justification for informed consent rests on the philosophical principle of respect for autonomy, as well as the political principle of liberty. The need for obtaining informed consent for medical treatments arose as the direct result of a series of court cases. Initially, this related solely to acquiring consent for specific treatments (Sugarman, 2003).

Later, it evolved to include providing information about the treatments themselves. Around that time, informed consent for participation in research arose as an issue, clearly illustrated by international declarations concerning ethics in research. Although a number of conceptual models for informed consent have been developed, there seems to be a consensus today that informed consent is a process, rather than a single event consisting of completing an informed consent form.

One accepted model consists of three steps, including threshold, information and consent (Beauchamp & Childress, 1994). The threshold step requires that a person possess adequate decision-making capacity (competency) to provide informed consent, as well as being in a position to make that voluntary choice. The information step states that the individual obtaining consent must divulge understandable information about the risks, benefits and alternatives to the proposed procedure. Finally, after the individual considers this information and has any questions answered, authorization may be given to proceed, generally through completing a consent document summarizing the information provided during the disclosure. Because of legal actions articulating the need for informed consent, within the therapeutic setting, formal and written informed consent is obtained for invasive procedures and other medical activities that are either new or pose a substantial risk (e.g., cancer chemotherapy). On the other hand, informed consent is not required for most routine clinical procedures (Sugarman, 2003).

There has been a marked deterioration in the area of ethical discourse, particularly in the usage of “rights” language. The special status is traditionally given to the concept of rights has been lessened by the addition of many other “rights” that are actually only “claims” people want to make. The pertinent example here is the “right to informed consent,” which can scarcely be considered to have the same status the rights to life, liberty, and the pursuit of happiness, for example (Wear, 1998).

These rights are mandatory for a decent society and are not in any way controversial, since they place no burden of action upon others, but only the need to not deprive another of them. However, positive rights, encompassing such things as the right to informed consent or the right to health care, merit consideration within the context trade-offs and questions of cost-effectiveness. To define such things as rights is understandable based on the primary value most people tend to give them.

Informed consent is a useful tool for medical management, potentially changing outcomes at the bedside for the better. Current laws focus mainly on identifying actionable departures from minimally adequate informed consents. It is simply not adequate to the ethical and clinical goods and values that are at risk. The law fails to provide sufficient operational guidance to determine how to satisfy standards of disclosure or assessment of competence (Wear, 1998).

The costs of obtaining informed consent and of monitoring whether or not patients have been adequately informed can be mitigated by having a system in place that provides consistency and reliability. The penalties for non-compliance can be severe, with lawsuits as a result. The costs are real and controlling the possibility of non-compliance, as well as the efficiency of providing informed consent should be an element of an effective nursing departmental budget.

Theology and Cost-Efficiency

Most of the modern world of healthcare appears to have lost a sense of the sacred, in its often-hostile environments and organizations, in a feeling of “disconnectedness” and lack of relationships between colleagues and patients, and in the apparent lack of reverence for life and human need in the face of cost controls.

There is still something happening, but it is rarely spoken of. Reaching out in an act of compassion, expressing human caring, providing a kind touch – each of these acts illuminates the real spirit of healthcare (Sayer-Adams & Wright, 2000).

The work of one of the most caring of professions is increasingly built on scientific foundations, reinforced by ‘evidence-based practice’. Florence Nightingale is often remarked upon as a noble example of basing work on evidence. She mastered the skill of debate based on sound research, but she never denied that the inspiration for her work, one that defied scientific explanation, was her simple belief that God guided her.

Reverend David Stoter suggested that looking at spiritual care only as religious care limited its true nature and effectively relegate it to a footnote at the end of a ward report, something simply to be handed on to another worker (Stoter, 1995).

Despite the prominence of the humanistic paradigm in most modern healthcare literature, education and practice, certain spiritual values and practices seem to have been kept.

Nurses participate in countless acts of compassion on every shift. They may not be dropping to their knees in regular bouts of prayer, but they are bring support and understanding into every patient encounter, even though they may not always even be aware of it. While nurses may not ascribe to or acknowledge a particular religious faith, the mere service of caring for another human being with compassion is a spiritual act unto itself (Sayer-Adams & Wright, 2000).

Many healthcare systems throughout the world have seen the effect of an entirely rationalist-positivist view as more and more demands are made for cost control and hard, evidence-based practice from healthcare workers. Jones remarks that,

For the last two hundred years, Western culture has been an experiment to test the hypothesis that human beings can be totally fulfilled in an atmosphere of secular rationalism, technological efficiency, and material abundance alone. Evidence for the falsity of the claim that we can live without meaning daily pours into the psychotherapists’ offices. We see the anomie and emptiness symptomatic of the ethos with its disconnection from anything smacking of value, purpose, or the experience of the sacred.” (Jones, 1996, p. 75).

In other words, disconnecting totally from the spiritual nature of nursing is damaging not only to patients, but also to nursing personnel themselves. Rationalism and technology are not the only factors that figure into the nursing equation.

What many seem to struggle with is the understanding of the nature of the type of love a nurse may have for a patient, where it comes from, and how it affects both the nurse and the patients. Americans view love through soap opera emotions such as lust, or attachment to people or things, generally being confused or reticent when impersonal love is used in a caring context, a non-sexual compassionate caring for another. When people begin to understand their fundamental value and perhaps divinity, then caring for others can be accomplished with equity and equanimity. In caring for another, one cares also for oneself. This transcendent quality of non-judgmental caring has underpinned caring ideals for centuries, and is an act of spirituality, a sacred thing in itself (Sayer-Adams & Wright, 2000).

The true costs of not recognizing the nature of spirituality, compassion and understanding can be measured not only in an intangible human toll, but in the increased dollar costs of physical and emotional problems among nurses, leading to inefficiency and time lost. The value of recognizing the spiritual nature of nursing is, of course, hard to quantify, but nevertheless must be taken into consideration in assessing the overall cost-effectiveness of nursing services.

Summary and Conclusions

Challenges are being faced daily as health care systems restructure and reinvent themselves in a difficult and often painful effort to make more efficient use of their available resources. The health care reforms that have been introduced around the world, including privatization and the introduction of market-based approaches, have succeeded in bringing numerous new pressures to bear on health care systems and health care workers.

Primary care nursing was a reorganization that began in the late 1960s, gradually replacing other forms of nursing organization. Before then, team nursing was the accepted norm, and it effectively moved RNs out of direct patient care and into a managerial role. In contrast, primary care nursing assigns each RN to the overall care of five to eight patients, with the role of LPNs and aides diminished and subordinated to the authority of the primary RN.

Cost containment policies have essentially limited the amount of time patients may remain in hospitals and more acute care is required from nursing personnel. Ordinarily, the need to contain labor costs might result in using more lower-paid workers and minimizing use of more highly skilled and highly paid workers. However, the change in complexity and intensity of hospital care actually caused hospital administrations to attempt to eliminate from the mix any workers who were not capable of being flexibly utilized.

Nursing costs are notoriously difficult to track due to the fact that it is difficult to predict exactly how many and which type of workers will be required at any particular point in time. After RNs document patient needs, management uses this documentation to standardize patient care and to predict the right mix of nursing personnel that is required for any particular patient population. This system is widely used to measure productivity in the staffing of units on both a daily and monthly basis, as well as to make budgetary projections.

Nursing departments can trim the inefficiency associated with the seven top tasks performed by nursing personnel, with a focus on methods for trimming unneeded bureaucratic tasks. Other departments also can benefit from productivity improvement, with better scheduling systems for both staff and patients potentially enhancing productivity in radiology, respiratory therapy, and numerous other departments. A total quality-management program focuses on both external (e.g. patients, employers) and internal customers.

Hospitals need to annually reevaluate workload-driven staffing ratio, to ensure that they are in line with fiscal goals and shifts in payment rates, using “best-cost” standards from appropriate engineering studies. Down-staffing usually correlates with better-quality care, while staff-to-patient ratios can be reduced by over 15% in many cases. In departments with direct patient care responsibilities, it is clear that much of the bureaucracy, paperwork, and other useless units of activity should be eliminated.

Employment of technicians to assist nurses in many tasks reduces wasted labor, enhances productivity, and therefore, improves cost-efficiency. Beyond the traditional technician tasks of obtaining vital signs and EKG results, patient transport, procuring supplies and equipment, procedural assistance, and paperwork, some hospitals have begun to utilize specialist technicians to dress wounds and to do other basic nursing functions. Progressive nurse managers should participate in careful studies designed to set the standards, study task-delegation feasibility, and set out the job descriptions for two to three levels of specialist technicians.

Software is available in the marketplace today to simplify the employee appraisal process and streamline the accreditation process, including medical-specific features with benefits for HR administrators, line managers and the entire organization, increasing efficiency and lowering costs. Such software has been implemented by numerous healthcare organizations seeking to streamline and automate the administration that is associated with the employee appraisal and accreditation processes.

New technology, such as sophisticated computerized systems, can provide nurses with accurate and precise physiologic measurements, providing a timely picture of the patient’s status and allowing rapid intervention if complications should develop. Some computer systems can even be programmed to administer blood, fluids, or drugs in small increments, based upon the computer’s periodic assessment of volume loss or changes in blood pressure. Automation helps nurses to accomplish timely interventions.

Most medication errors are the result of errors in management, rather than from patient factors such as allergic reactions. Unfortunately, even a very small error rate can have disastrous consequences in a modern hospital. To assist in the mitigation of this problem, nurses can establish data collection methods that accurately discover and describe the errors that do occur. The incidence of accidental injuries could then be reduced, resulting in major cost and timesavings.

Informed consent is a means of respecting the independent preferences of people who are seeking health care or participation in research projects. There seems to be a consensus today that informed consent is a process, rather than a single event consisting of completing an informed consent form. Informed consent is a useful tool for medical management, potentially changing outcomes at the bedside for the better. Having a system in place that provides consistency and reliability can mitigate the costs of obtaining and monitoring informed consent.

Most of the modern world of healthcare appears to have lost a sense of the sacred, in its often-hostile environments and organizations, in a feeling of “disconnectedness,” and in the apparent lack of reverence for life and human need in the face of cost controls. Nurses participate in countless acts of compassion on every shift. The true costs of not recognizing the nature of spirituality, compassion and understanding can be measured in increased costs of physical and emotional problems among nurses, leading to inefficiency and time lost. The value of recognizing the spiritual nature of nursing must be taken into consideration in assessing the overall cost-effectiveness of nursing services.

In conclusion, many factors can contribute to the creation of an effective nursing budget. As outlined in this paper, many various elements should be taken into consideration, from effective methods for obtaining informed consent, to recognizing the value of the compassion and spiritual connection with patients in the equation, to incorporation of more straightforward methods of cost-containment. Some of the major elements of cost-containment to improve nursing budgets include measuring nursing productivity, trimming inefficiencies in the top nursing tasks, cutting unnecessary bureaucratic tasks, improving scheduling systems, using total quality management techniques, reevaluating workload-driven staffing ratio, using “best-cost” standards from appropriate engineering studies, employing specialized technicians to handle many of the lower-level tasks, utilizing appropriate software to more efficiently accomplish certain repetitive tasks, incorporating technology where appropriate, and effectively tracking and mitigating medication and other treatment errors. All of these areas can be utilized to create more efficiency, which in turn contains costs and allows a better allocation of the resources provided by nurses in the acute care setting.

References

Abramson, S. (1980). Adverse Occurrences in Intensive Care Units. Journal of the American Medical Association 244 (14): 1582-1584.

Ahmadi, M. (1989). Traditional vs. Nontraditional Work Schedules. Industrial Management 31(2), 20-23.

Bennett, M. & Hylton, J. (1990). Modular Nursing: Partners in Professional Practice. Nursing Management 21(3), 20-24.

Beauchamp, T.L. & Childress, J.F. (1994). Principles of Biomedical Ethics, 4th ed. New York: Oxford University Press.

Bogner, M.S. (Ed). (1994). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates.

Caldwell, C., McEachern, J. & Davis, V. (1990). Measurement Tools Eliminate Guesswork. Healthcare Forum Journal 11(4), 23-28.

Clark, D.A. & Clark, P.F. (2003). Challenges Facing Nurses’ Associations and Unions: A Global Perspective. International Labour Review 142(1), 29+.

Clark, P.E., Clark, D.A., Day, D.V. & Shea, D.G. 2001. Healthcare reform and the workplace experience of nurses: Implications for patient care and union organizing. Industrial and Labor Relations Review 55(1), pp. 133-148.

Deming, W. (1986). Out of the Crisis. Cambridge, MA: Massachusetts Institute of Technology Press.

Eastaugh, S.R. (1992). Health Economics: Efficiency, Quality, and Equity. Westport, CT: Auburn House.

Eastaugh, S.R. (1990). Hospital Nursing Technical Efficiency: Nurse Extenders and Enhanced Productivity. Hospital and Health Services Administration 35(4), 561573.

Eastaugh S.R. & Regan-Donovan, M. (1990). Nurse Extenders Offer a Way to Trim Staff Expenses. Healthcare Financial Management 44(4), 58-62.

Grant, S.E., Bellinger, A.C. & Sweda, B.L. (1982). Measuring Productivity Through Patient Classification. Nursing Administration Quarterly 6, 77-83.

Griffith, B. (1999). Competition and Containment in Health Care. New Left Review a (236), 24-52.

Grosskopf, S. & Valdmanis, V. (1987). The Measurement of Productive Efficiency. Journal of Health Economics 6(1), 89-97.

Halogen Software Product Features and Benefits, (2004). Retrieved May 18, 2004, from Halogen web site: http://www.halogensoftware.com/products/adwords/eappraisalhealthcare.php

ICN (International Council of Nurses). 2001. Outstanding African nurse, Sheila Tlou, delivers Virginia Henderson Lecture at ICN Conference. ICN Press Release, 12 June, Geneva.

Jones, J. (1996). In the midst of this path we call our life. London: HarperCollins.

Krall, L. & Prus, M.J. (1995). Institutional Changes in Hospital Nursing. Journal of Economic Issues 29(1), 67+.

Manthey, M. (1988). Primary Practice Partners: A Nurse Extender System. Nursing Management 19(6), 58-59.

Manthey, M. (1970). A Dialogue on Primary Nursing. Nursing Forum 9(4), 356-379.

Marram, G. (1977). Principles and Processes in Instituting the Change to Primary Nursing. In National League for Nursing, Primary Nursing: One Nurse-One Client Planning Care Together. New York: National League for Nursing.

Pope, G.C. & Menke, T. (1990). Hospital Labor Markets in the 1980s. Health Affairs 9, 127-137.

Powers, P., Dickey, C. & Ford, A. (1990). Evaluating an RN/Co-Worker Model, Journal of Nursing Administration 20(3), 11-15.

Prescott, P.A. (1986b). Use of Nurses from Supplemental Services: Implications for Hospitals. Nursing Administration Quarterly 11, 81-88.

Sayer-Adams, J. & Wright, S.G. (2000). Sacred Space: Right Relationship and Spirituality in Healthcare. Edinburgh: Churchill Livingstone.

Shorr, A. (1991). The Optimizer: Productivity Evaluation Methodology for Scheduling Staff with Linear Programming. Tarzana, CA: Shoff Associates.

Sinclair, V. (1988). High Technology in Critical Care: Implications for Nursing’s Role and Practice. Focus on Critical Care 15(4): 36-41.

Sugarman, J. (2003). Informed Consent, Shared Decision-Making and Complementary and Alternative Medicine. Journal of Law, Medicine & Ethics 31(2), 247+.

Walton, M. (1990). Deming Management at Work. New York: G.P. Putnam.

Wear, S. (1998). Informed Consent: Patient Autonomy and Clinician Beneficence within Health Care. Washington, DC: Georgetown University Press.

White, R. (1988). Political Issues in Nursing, Vol. 3. New York: John Wiley and Sons.

Zalumas, J. (1995). Caring in Crisis: An Oral History of Critical Care Nursing. Philadelphia: University of Pennsylvania Press.