I wonder if the pay-per-visit nurse compensation model causes poorer outcomes for vulnerable patient populations and/or moral distress among home healthcare nurses. In the pay-per-visit system, more visits equal more money. This creates a potential conflict-of-interest: the nurse's financial goals versus giving each patient the time needed to achieve optimal health outcomes. This compensation model creates tension between quantity of care and quality of care. The Code of Ethics for Nurses is one of my favorite nursing documents (American Nurses Association, 2015). It reminds me of the nursing values and core principles I committed to when I became a nurse. The Code identifies nurses' professional integrity versus nurses' economic self-interest as a key potential conflict-of-interest. It stresses that such conflicts must be resolved with the patient's best interests guiding decision-making.

The inherent conflict-of-interest found in pay-per-visit compensation could lead to unintended (and usually unconscious) inadequate care for minority and vulnerable patients. A systematic review of disparities in home healthcare found that minority patients suffer from the same inequities that patients suffer in other settings (Narayan & Scafide, 2017). Minority and other vulnerable patients may need more time to achieve equitable outcomes. One potential cause of disparities is that nurses, eager to make as many visits as possible, don't invest adequate time in the care of vulnerable patients (Narayan & Mallinson, 2022). Examples include:

* patients who do not speak English, because interpreted conversations take longer;

* patients who have low health literacy, because they need extra explanation during teaching;

* patients with inequities in social determinates of health, because ameliorating deficits through additional nursing interventions and social work/community referrals takes additional time;

* minority patients who have different values and lifestyles, because more time is needed to assess and understand the patient as a person so a care plan can be individualized to the patient's needs and preferences (Narayan & Mallinson, 2022).

Moral distress is the emotional state nurses experience when they know the ethically right thing to do but the nurse experiences pressure to take a different action (American Association of Critical-Care Nurses, n.d.). The Code of Ethics calls nurses to provide excellent nursing care that goes beyond the Outcome and Assessment Information Set assessment to perform a nursing assessment of the physical, cognitive, emotional, social, and cultural factors that may affect the patient's ability to reach optimal outcomes. It means establishing a trusting, caring relationship with the patient.

How can nurses resolve this conflict-of-interest in their own practice? How can they assure that patients who need more time and effort to achieve goals get the time they need? How can nurses experiencing moral distress in the pay-per-visit system resolve their conflict-of-interest? I believe that home healthcare nurses and administrators need to have a thoughtful discussion about the pay-per-visit system.

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