Many organizations are reorganizing into service line structures, which have 3 inherent design components: planning, operations management, and marketing.1 This model is being promoted as an initiative to align resources to better address the needs of identified populations. Reflecting on this trend, the following question arises: "Why is nursing not a service line and will the value and benefit of nursing practice be lost in a service line design?"

Service Line Structures

Service line structures attempt to cross various disciplines to engage all necessary providers in the care of patients with a particular group of diagnostic codes. Reported benefits of this structure include focus, efficiency, improved communication, and optimal outcomes. But what happens to the patient who is not in a prioritized service line? How will leaders in an organization assure that patients in a product line receive consistent nursing care? Do we not have the same obligation to promote efficiency, quality, and focus for all patients regardless of whether they fall into a service line or not?

Services are often promoted and given resources based on the profitability of specific procedures or departments in service line structure. Will nursing need to generate revenue before it can be recognized similarly to cardiology or orthopedics as a priority service for the organization? Unfortunately, the mechanisms for reimbursement are not to the point where nursing cost and profit are identified (see the article by Watson in this issue). Fitzpatrick et al2 report that, often, in product line structures, centralized departments of nursing are eliminated. Dismantling nursing through a service line design can do little to contribute to collaboration and cooperation between multiple disciplines or to promote the delivery of quality care.

Nursing Leadership

The literature on service line structure advocates leadership opportunities for physicians; however, few advocate service line opportunities for nursing leadership.3 Nursing is the most visible, largest, and, in my opinion, the most important profession in a hospital. Why should we not advocate for nursing leadership in service lines as well? Nurses are integral to the coordination of care and services for patients. Care and coordination are selling points for service line structure; however, coordination is often referring to diagnosis-specific care and interventions and not integrated care across departments. The Nurse Executive Center's 2008 study, Envisioning the Future Nursing Organization, cites 3 common pitfalls of service line structure: inconsistent nursing practice across the institution, lack of a collective nursing voice in institutional decision making, and communication silos between service lines.4^(p113) Proactive, empowered nursing leadership can anticipate these pitfalls and ensure coordination and consistency for all patients.

I believe a hybrid approach to service line structure is more conducive to the delivery of quality patient care and nursing care. Nursing leaders accept responsibility for ensuring that standards are aligned with nursing practice guidelines and are in support of the mission of the organization and in the best interest of the patient. Developing a mechanism for nursing leaders to have a role and authority in the service line design is imperative. In addition to a service line executive, the nurse executive must be given organizational authority to set standards and enforce adherence to those practices necessary for patient safety and consistency in practice. Is a cardiac product line acceptable without attention to skin care assessment, respiratory assessment, and standards for medication safety?

I am advocating for nursing to continue to be a unique, identifiable entity in every hospital regardless of the organizational structure. Every nurse leader should advocate for this stance. Nursing services should report to a competent, strong, educated nurse leader who is able to articulate a vision and direction for the care delivered to patients and for the profession. Nurse leaders must be at the decision table to assure the continuity and consistency of care for all patients. In a service line environment, nurse leaders must establish and promote their role and value and the contribution of professional nursing to patient care services regardless of the service line the patient fits into.

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