Nursing’s Growing Role

Rebecca Hendren, for HealthLeaders Media , July 13, 2010
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The U.S. Department of Veterans Affairs has committed to having at least one CNL at all its medical centers, across all settings, by 2016, and such is the popularity of the program that the VA expects to easily meet its target.

"In our hospital, we're using clinical nursing leaders to focus on quality measures," says Zastocki, "and how nursing can play a significant role in meeting national standards.

"We need to have continued development of clinical leaders in our hospital," Zastocki says. "We need someone who is a manager in a leader role, but also need a clinical leader role, too. They help to examine the intricacies of a patient's condition, help them prepare for transition to another care environment, and coordinate their care while they are here in the hospital. The combination leads to improved quality care measures."

Advanced practice nurses
The explosion of advanced practice nurses is a direct response to the need for nurses to play a greater role in healthcare. The ANA's Peterson says the growth of APNs is beneficial for healthcare. "We have a real shortage of primary care providers," she says. "Way too many people end up in emergency rooms with primary care needs. When healthcare needs are unmet, problems become more severe and require hospitalization, but we could have kept the person out of the hospital setting."

Peterson says hospital leaders should embrace APNs. "We think it's the right thing to do to increase access to care. We believe that an advanced practice nurse is an independent licensed practitioner. They should be allowed and be reimbursed for the care they provide."

Nursing associations point to the research that has been conducted over the past 40 years, saying it consistently demonstrates NPs deliver high-quality care. The American Academy of Nurse Practitioners states: "The body of evidence regarding the quality of NP practice supports that NP care is at least equivalent to physician care."

"What I find frustrating is there are decades of data looking at quality of effectiveness, yet we still continue to hear from detractors that 'we're not too sure about the role, so we need data on quality and effectiveness of this role,'" says Lisa Summers, CNM, DrPH, senior policy fellow in the department of nursing practice and policy at the American Nurses Association. "No other professional group has felt a need to produce a body of research of themselves as a professional group. No one asks about quality and effectiveness of dentists. What we need to do now is shift those research questions and say what is it about care provided by an NP that leads to lower prematurity rates? What is it about NP care that when caring for chronic hypertensive clients, they are more likely to stay on their medications? We need to look at what distinguishes the process of care."

APNs are at the forefront of nursing leadership in the acute care system and are working in expanded roles in physician offices and elsewhere.

"Using practitioners such as NPs and PAs allows doctors to do even more with the education and training they received," says Hassmiller, who then shares an anecdote familiar to families across the country. "My mother just had surgery and we only met the surgeon once, right before surgery, and he caught me in the hall afterward to say that the surgery went well. She was cared for [on behalf of the surgeon] by an office-based physician assistant ahead of time and then all follow-up care was provided by a nurse practitioner, with home care provided by a home healthcare nurse. Even the person who put my mother under anesthesia was a nurse anesthetist.

"We never thought anything was amiss with any of this. Everyone working together is what it took to get the job done. This is called collaboration and complementarity. This is how it should be. Physicians and nurses working together using all their skills to benefit patient care."

—Rebecca Hendren is an editor with HealthLeaders Media. She may be contacted at

Harnessing the Economic Power of Nursing

What is the economic value of nursing? Nurses make up the single largest sector of healthcare professionals, but the actual costs of nursing care are unknown because it is billed as room and board. That may soon change.

"Nursing is invisible at the payment and policy level," says John Welton, PhD, RN, professor and dean of the School of Nursing and Health Sciences at Florida Southern College. "We don't put a price on it so it has no economic value."

Welton and his colleagues have studied the potential of a nursing intensity billing model. He says we can't answer the question about nursing value until we start tracking who is caring for patients and how much nursing time and costs are expended for each patient. "We've been focused on nurse staffing and nurse-to-patient ratios for many years, but future research will look more closely at the individual relationships between nurses and patients regarding cost and quality," says Welton.

Part of the issue is that the complexity of patient care has increased. Hospitals are paid for procedures and continually implement more sophisticated medical technologies. This increases the need for registered nurses and the intensity of nursing care. In 1980, patients stayed 7.5 days and received 4.5 hours of nursing care every hospital day. By 2004, length of stay had decreased to 5.5 days, but time spent in nursing care had gone up to more than 10 hours. The increase in nursing time is due to sicker patients and a faster inpatient environment.

"The key problem is we don't know how much nursing care costs because payers average dollars across all patients without considering differences in nursing time and resources expended for different needs," says Welton. "We treat every patient the same in the billing system and charge it as a daily room rate. That hides the variability in nursing care hours and types of nurses caring for patients. And it creates a false impression about nursing care in the U.S. healthcare finance system."

An internal study by the Centers for Medicare & Medicaid Services reported in 2008 found the current accounting and billing practice was distorting the payment system.

Welton and his colleagues have been trying to change the way hospitals look at nursing costs. At the recent annual conference of the American Organization of Nurse Executives, a subsidiary of the American Hospital Association, Welton called for a substantial change in how hospitals and other healthcare institutions cost, bill, and reimburse nursing care. "We need to treat nursing care in a much more businesslike manner," argues Welton.

"Imagine you went into a grocery store and didn't know the price of any item," says Welton. "That's the way healthcare is set up now, but in the future we will be in a much more competitive environment with a much greater emphasis on value. So what is the added value that nurses bring to the bedside and what are consumers willing to pay for that care?"

Welton argues that healthcare executives need to know their true nursing costs on a per patient basis and to understand how nurses are assigned to patients. "There is an emerging accountability issue related to healthcare reform that nurses and executives need to pay close attention to," says Welton.

More experienced nurses with greater education and training should be caring for the sickest patients with the most complex problems. By capturing the nurses assigned to each patient using new real-time nurse scheduling and staffing systems, hospitals can become more efficient and effective by combining the nursing data with other clinical, administrative, billing, and discharge information.

"Why is healthcare stuck in a 1930s accounting and payment system?" asks Welton. "If we truly want to improve healthcare and get a better value for our dollar, we need to separate out nursing into its own cost center, then bill and reimburse for nursing care based on optimum value."

The benefit to healthcare executives for following this new approach is they get better information about how nursing care is delivered to different patients and will be able to benchmark performance across hospitals and other healthcare settings. Hospitals will be in a better position to know the relationship between true nursing costs and actual payment for service.

For payers and CMS, better information about nursing care could lead to a more equitable payment system that produces the best nursing value. Consumers will also benefit by knowing where the best nursing care is being delivered, and that could spur competition in nursing care quality that improves care outcomes and decreases costs.

"The bottom line is that it just makes good business sense to get better information about how nurses affect each patient, identify the costs per patient, examine how individual nurses improve outcomes of care, and then align the billing and payment to reflect best nursing care value," suggests Welton. "Ultimately, if we want to have a much safer and higher quality healthcare system at an affordable price, we have to engage nurses and incorporate them into the national healthcare finance structure."

Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at
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