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Value and Payment Policy
August 10, 2020

Value-Informed Nursing Practice Can Help Reset the Hospital-Nurse Relationship

Author Affiliations
  • 1School of Nursing, School of Public Health, University of Michigan, Ann Arbor
  • 2College of Nursing, University of Rhode Island, Kingston
  • 3College of Nursing, Montana State University, Bozeman
JAMA Health Forum. 2020;1(8):e200931. doi:10.1001/jamahealthforum.2020.0931

As the coronavirus disease 2019 (COVID-19) pandemic continues to affect the country’s economic, political, social, and health care systems, it now appears to be disrupting the relationship between hospitals and nurses. Sharp decreases in revenues from curtailed diagnostic procedures and elective admissions led some hospitals and private medical practices to furlough nurses. From the perspective of many nurses, however, being furloughed was a reprehensible way to be treated. During the peak of the crisis, nurses came to work each day caring for patients and their families—often without adequate personal protective equipment. As one nurse commented, “It’s embarrassing. Everyone was like, ‘Come out of the woodwork: If you haven’t finished nursing school, we need you, and if you’re retired, we need you,’ and we’re like, ‘We’re laid off.’” The way that cost-cutting actions of some hospitals have affected nurses raises an eerie feeling that the hospital-nurse relationship has entered troubled waters.

To be sure, this is not the first time that hospitals reduced nurse employment to cut costs. During the managed competition era of 1990s, nurses reacted with nationwide protests, asserting that cost reductions were worsening quality of care and jeopardizing patient safety. Protests became so loud that an Institute of Medicine committee was established in 1995 to examine the quality of care and nurse staffing in hospitals and nursing homes.1 Nurses’ negative portrayal of hospitals also had an unintended effect by reducing the attractiveness of nursing as a career—each year between 1995 and 2000, enrollment into nursing programs decreased 4% to 6%.2 Today’s COVID-19 pandemic and hospitals’ furloughing of nurses once again risks creating a poor image of hospitals. This sentiment is already emerging, as captured in a recent New York Times opinion article titled, “Hospitals Got Bailouts and Furloughed Thousands While Paying CEOs Millions.” Efforts to reset the hospital-nurse relationship are needed to avoid damaging ramifications, including a contentious workplace and potentially decreasing interest in nursing careers.

A first step is for nurses and hospitals to pause and consider realities that underpin their interdependent relationship. For their part, nurses must acknowledge that the pandemic served a crushing blow to the hospital business model that relies on revenue from reimbursable services to cover costs. Because more than half of hospitals’ operating costs are labor related and nurses are among the highest-paid employees,3 cutting back on their employment—especially in areas with curtailed patient flow (diagnostics, elective procedures)—is an obvious way to quickly reduce costs. The economic strain enveloping many hospitals will linger until people feel safe and financially secure to use their services. Nurses and other hospital staff can anticipate that furloughs will continue.

There are realities about nurses’ increasing role in generating revenue that hospitals should appreciate. The transition to value-based programs that reward hospitals for providing high-quality care means that hospital leaders can no longer view nurses primarily as a costly labor input but rather as a key value-adding asset to producing high-quality outcomes4 and maximizing revenue.5 When the pandemic eases and hospitals get back to business, those who chose to save on short-term labor costs may find themselves struggling with quality and safety issues and a weakened, disloyal nursing workforce. Forward-thinking hospitals, those that prioritize their long-term relationship with nurses and support and retain them to the extent possible, will likely emerge as front-runners after the pandemic. How can we ensure that there are more forward-thinking hospitals and more nurses who understand their responsibility in strengthening the hospital-nurse relationship?

We believe that the path forward is for hospitals and nurses to embrace value-informed nursing practice. This means that nurses must focus not only on improving the quality and safety of outcomes, but also on decreasing the costs of resources used to produce outcomes. In other words, nurses must contribute to both aspects of the “value = outcomes/costs” equation. Nurses have tended to focus on the numerator, but this is no longer enough to secure their financial security and well-being. As a greater proportion of hospital revenue—and nurses’ long-term employment—becomes tied to hospital performance on value-based metrics,6 hospitals and nurses must work together to make value-informed nursing practice an intentional and unequivocal part of post–COVID-19 nursing in US hospitals.

Unfortunately, few nurses are socialized in the ethics of economic stewardship, and others will resist becoming conscious of the cost arm of the value equation, thinking it unseemly or even unethical. Yet, wasteful, redundant, low-value care erodes the bottom line of a patient care unit and quality of care. Nurses influence most aspects of health care operations, including cost, quality and safety, and information and technology, and they must take responsibility to call out waste and low-value care.

Nursing educators have a key role in preparing the new generation of value-informed nurses. Wise use of economic resources, along with quality improvement, must become a routine part of all nursing education courses, simulated learning, and students’ care planning for clinical assignments. Students should be taught to critically assess their impact on value creation and to revamp reflexive care that creates unnecessary or redundant care. Redesigning nursing education to emphasize elimination of low-value care throughout curricula is an essential step toward building value-informed nursing practice. Nurses must learn to create value-informed practice environments and can support other professions in this critical goal.

Moving forward, hospitals and nurses have an opportunity to use the COVID-19 pandemic experience to reset the hospital-nurse relationship. Hospitals must do their part to support value-informed nursing practice by, for example, using some of the Coronavirus Aid, Relief, and Economic Security (CARES) Act Provider Relief Fund to educate nurses on their critical role in creating value. Assurances from hospital leaders that cost savings are reinvested into quality and safety, and that reinvestment decisions are decentralized to nursing units, will improve nursing’s agency in decreasing low-value practices. Nursing education leaders should launch a national effort to educate nursing faculty on how to teach value-informed practice. To motivate these efforts, nursing regulatory bodies can incorporate value-informed practice in the entry-to-practice licensure examination. Intentionally acting together to embrace a new culture of value-informed nursing practice can promote a strong, sustainable relationship between hospitals and nurses.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Olga Yakusheva, PhD, School of Nursing, School of Public Health, University of Michigan, 400 N Ingalls, Ann Arbor, MI 48103 (yakush@umich.edu).

Conflict of Interest Disclosures: Dr Rambur reported holding a position at the University of Rhode Island, the Routhier Chair, endowed by the Routhier Foundation, which has not been involved in any aspect of Dr Rambur’s professional work, and serving on the Medicare Payment Advisory Commission (MedPAC). Dr Buerhaus reported receiving grants from the Gordon & Betty Moore Foundation; serving as a member of the National Academy of Medicine Committee on the Future of Nursing 2020-2030; and serving as chair of the National Health Care Workforce Commission created by the Patient Protection and Affordable Care Act in 2010; the commission remains unfunded. No other disclosures were reported.

Acknowledgments: Dr Rambur is a newly appointed member of MedPAC. The views expressed in the article are those of the authors and do not reflect the views of MedPAC.

Institute of Medicine (US) Committee on the Adequacy of Nursing Staff in Hospitals and Nursing Homes; Wunderlich  GS, Sloan  F, Davis  CK, eds.  Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? National Academies Press; 1996.
Buerhaus  P, Staiger  D, Auerbach  D.  The Nursing Workforce in the United States: Data, Trends, and Implications. Jones and Bartlett; 2008.
American Hospital Association. 2020 AHA hospital statistics: a comprehensive reference for analyses and comparison of hospital trends. Accessed August 6, 2020. https://www.aha.org/system/files/media/file/2020/01/2020-aha-hospital-fast-facts-new-Jan-2020.pdf
Yakusheva  O, Lindrooth  R, Weiss  M.  Nurse value-added and patient outcomes in acute care.   Health Serv Res. 2014;49(6):1767-1786.PubMedGoogle Scholar
Yakusheva  O, Lindrooth  R, Weiner  J, Spetz  J, Pauly  M. How nursing affects Medicare’s outcome-based hospital payments. Leonard Davis Institute for Health Economics, Robert Wood Johnson Foundation INQRI evidence brief. Accessed August 6, 2020. https://ldi.upenn.edu/brief/how-nursing-affects-medicare%E2%80%99s-outcome-based-hospital-payments
Medicare Payment Advisory Commission. Report to the Congress: Medicare and the health care delivery system. Accessed August 6, 2020. http://www.medpac.gov/docs/default-source/reports/jun20_reporttocongress_sec.pdf
1 Comment for this article
Citations for Broad Statements Would be Helpful
Francis Holt, PhD, RN |
The statements "Unfortunately, few nurses are socialized in the ethics of economic stewardship, and others will resist becoming conscious of the cost arm of the value equation, thinking it unseemly or even unethical" are quite broad. If there are supporting citations it would be helpful to include them.