This issue's theme, "Bending the Cost Curve Without Doing Harm," emphasizes the need for balance in weighing the tremendous pressure to contain costs against the Hippocratic oath. The challenge of doing no harm has never been more difficult than it is today.
Health care-related expenses increased an estimated 3.9% in 2011 and consumed 17.9% of gross domestic product, relatively the same level as that seen in the previous 2 years.1 However, America continues to spend more on health care than any other country in the world.2 While we acknowledge that our nation cannot continue to allocate such a significant percentage of the gross national product to taking care of its people, nurse executives find themselves at the intersection of cost cutting and quality care. It is a tricky place to be. Some days, it seems that the Hippocratic oath could be on the chopping block too.
However difficult these decisions, nurse leaders have access to advanced business intelligence tools to "fast forward" through multiple cost-cutting scenarios before making a final choice. These scenario-based modeling exercises represent only a first step toward decision making, not an end result. Nurse leaders need to understand the wide-reaching impact associated with each of the final decision choices on the quality of care in their organizations and on the staffs who deliver that care. The consequences reach far beyond the balance sheet.
With such critical results hanging in the balance, nurses are making these sweeping trade-off decisions without the single most fundamental, keystone of knowledge. What is the value of nursing care? Despite considerable research, however, no one has been able to determine the value of nursing care. Attempts to come up with an economic price tag or other value indicator have come up short. In fact, there has been no agreement on the universal meaning of the term "value of nursing." Some theoretical foundation for such a discussion has been created, and it was this foundation that drove a recent discussion with nurse executives about how to measure and set the profession's value.
As technology experts predict the impact of "big data" to be as sweeping to global business as the prevailing winds of a tsunami, some are predicting that the most valuable data of all will come from health care. Even today, electronic health records are amassing mountain ranges of data ready to be sliced, diced, and julienned with "big data" tool sets. What insights are lurking there that could revolutionize the way we practice nursing? Will these tools allow us to see, often for the first time, the relationships between clinical interventions and outcomes over populations disparate and alike? Might, finally, the value of nursing care be revealed?
For the past decade, a heated public policy debate focused on what some call the "ultimate battle" of cost versus quality-the use of nurse-to-patient staffing ratios as a preeminent determination for quality of care. Massachusetts rejected the ratios popularized in California and took a new tack of demonstrating and documenting exactly how care was delivered in its hospitals. This effort showed that staffing to deliver quality patient care involved a thorough consideration of a complex series of interrelated conditions and factors. This complexity dispelled the belief that a single indicator, such as the nurse-to-patient staffing ratio, could serve as the lone, deciding quality benchmark. On the basis of this experience, there remains much to be learned to determine how to effectively reduce the cost of nurse staffing without negatively affecting patient care.
No discussion of health care costs can overlook the fiscal impact associated with the continuation of that taboo practice-defensive medicine. Despite it care-related and fiscal impacts, defensive medicine continues, especially in emergency departments. This pervasive practice, which permeates health care facilities of all sizes and specialties, adds millions to the nation's health care costs. Could it be that current economic pressures, combined with evidence-based medicine and aggressive hospital policies, might finally curtail this phenomenon?
In every industry, quality suffers when a workforce is unable to deliver optimal performance for any reason. But when physical demands and stress put workers' health at risk, the cost of resolving the causation come into play. The health care industry is no different. Specifically, what can be done to mitigate health- and stress-related risks for nurses? A series of new studies zero in on the positive effects associated with specific interventions, evidence-based practices, and programs that delivered results. While progress in protecting the health of nurses has been made, there remains a need for more research into how to improve and protect the health and safety of the nursing workforce-especially in light of projected shortages.
Nurse leaders charged with managing a sea of personalities in their workforces strive to gain optimal job performance from each. As nursing workforces become more diverse, the complexity of the challenge escalates as well. The nurse leader's empathy plays an instrumental role in determining how effective individual nurses will be in their organizational responsibilities. One recent study, which used a standardized emotional intelligence testing tool to gauge nurse leaders' emphatic component, linked leaders' higher empathy scores with their teams' improved job performance.
In addition to being a key to obtaining improved performance from their teams, nurse leaders with emotional intelligence can be highly effective in combating a common barrier to optimal performance: bullying. This negative behavior is no longer contained on the playground; its increasing frequency in the workplace is a cause for alarm. Health care organizations, which attract high levels of intelligence and will, can serve as breeding grounds for this negative and damaging behavior. Confronting bullying behavior, an emotional minefield for many leaders, often goes unaddressed. Simply put, organizational leaders often lack the strategies and tools needed to recognize, manage, and avert negative behavior, which often begins with bullying and advances from there. However, evidence taken from research into bullying in other workplaces suggests that one of the keys to confronting negative behavior early centers on developing emotional intelligence.
Rounding out the cost versus quality discussion is the rarely discussed but important issue of executive succession. A clear succession plan ensures a smooth transition-for the facility, the nursing organization and the nurse who work in that facility. Long before a nurse executive, leader, or manager departs an organization, careful consideration to her or his departure must be given. Once that plan has been put in place, nurse executives need to mentor and coach emerging nurse leaders to ensure a transition that appears smooth and effortless. Succession planning, an activity long practiced in business, has yet to make its way to the nursing ranks with any consistency. However, the building of a "deep bench" of nursing talent, beginning at the managerial level and continuing through the executive ranks, is an antecedent for organizational continuity.
It will take all of these strategies and more to bend the cost curve while preserving the quality of patient care. Submit your own innovations, case studies, and research to Nursing Administration Quarterly (NAQ) for consideration.
Finally, let us give a standing ovation to Barbara J. Brown, EdD, RN, CNAA, FAAN, FNAP, for her decades of purposeful contribution to give shape and form to the practice of nursing leadership. Most importantly, she founded NAQ when no one else would give a nod to nursing leadership. Dr Brown was a lone voice advocating for nurses to take the charge of the business of patient care with clarity, compassion, and grace. For that she deserves our thanks.
Personally, I must thank Dr Brown for the opportunity to explain how a burgeoning movement called nursing informatics would come to turn the practice of nursing on its ear by delivering evidence-based data to the point of care. She encouraged my writings, recognizing the specific domain of knowledge would be core to nurse administration leadership's future.
Finally, I would like to add a personal welcome to Dr Kathleen Sanford as she takes the reins of this standard-bearing publication. All of us in nursing can rest assured that Kathy will continue NAQ's long-standing dedication to nursing leadership, quality, and innovation. Kathy brings a wealth of knowledge, skills, and leadership from her time as the president of the American Organization of Nurse Executives and now as a key nurse executive in one of America's largest multihospital organizations. In a private conversation with Dr Brown, I asked her how she chose Kathy. She told me,
Roy, of all the nurse executives that I know, Kathy Sanford is and will always be a nurse executive's friend. She weathered the time I have known her all these years to become a beacon of exemplar leadership for patients and the profession. I put my trust in her to take NAQ to another level and mission for us all in executive leadership.
With Barbara's endorsement and the profession's backing, I raise my glass, hold my hand up high, and toast you, Dr Sanford, knowing NAQ's successes will continue with you at the helm. We all look forward to this new era of patient care leadership. It was my pleasure to be your first guest editor, thank you, and God speed.
-Roy L. Simpson, DNP, RN, DPNAP, FAAN
Vice President, Nursing
Cerner Corporation
Kansas City, Missouri
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