Nursing
and
Cost
Hospital
T
HE DECADE of the 1980s introduced many of us in 1 health care to a new phenomenon, namely, that of downsizing. While there were occasions where downsizing on the expense side was offset by a diminution of workload, in many instances those two variables did not operate in parallel. In fact, quite the opposite was often true. Expenses were expected to be reduced in the face of pressures to add new, resource-consuming programs. Unfortunately, there is every evidence that these kinds of financial constraints will continue for the foreseeable future, especially in light of our growing federal and state deficits. The cause of the pressures on health care are certainly well known. In spite of all efforts to date, the health care industry continues to take a larger and larger bite out of the economy each year. As Stuart Altman, the well-known health policy analyst, recently commented, if this trend continues unchecked our industry could one day actually consume more than 100 per cent of the gross national product. A facetious comment with a frightening message! It is probably safe to say that early cost-saving measures were beneficial in some respects. They drove us toward more efficient delivery systems and very likely reduced the cavalier attitudes that characterized some providers in the past. As time goes on, however, there will be fewer opportunities for fat trimming and some of the real meat will have to become involved. More than any other profession, nursing is adversely affected by a hospital’s efforts to contain costs. What is interesting to note is the number of people who hold a relatively naive view regarding this issue. In recent years more than a few hospital administrators, in describing their budget reduction measures, have proudly proclaimed that in spite of their need to make cuts in most departments, they had not cut nursing. More surprising is the fact that nurses themselves often will express the same view. This attitude shows a significant lack of understanding of the operation of these institutions and the role that nurses play in them. Many members of our profession have described the coordinator function of the professional nurse. I believe that MARGARET L. MCCLURE, RN, EDD, FAAN Executive Director of Nursing
Containment
the responsibility goes deeper than mere coordination and prefer the term “integration” (McClure & Nelson, 1982). In any case, to fully comprehend the delivery of patient care in any hospital is to understand that: (1) nursing forms an invisible kind of semipermeable membrane around patients through which all other care givers pass in order to render their services, and (2) the majority of professional and nonprofessional employees in the institution do not actually pass through that membrane, but instead deliver their services to nursing so that nursing can, in turn, deliver services to patients. As a result of this critical aspect of their professional role, nurses experience the impact of almost every reduction that is made in the hospital’s work force. In some cases the impact is direct and obvious because work that is normally performed by support personnel is transferred, wholly or in part, to nursing. For example, the elimination of certain respiratory therapists may require that nurses perform treatments during the hours that the therapists are not available. The nighttime closing of a department such as Central Service means that nurses must go to that area in order to secure the supplies they need for patients. There are, however, other instances in which the reduction of personnel in departments other than nursing has more subtle negative consequences. These cover the broad spectrum of all departments, involving professionals and nonprofessionals alike. The elimination of a pharmacist results in nurses spending additional time and energy in procuring medications; a reduction in the numbeer of engineers results in delays in the repair of equipment needed at the bedside. Nurses must either “make do” or attempt to borrow what they need from other departments. In the final analysis, then, it really does not matter where one cuts a hospital’s resources; eventually nursing feels the cut, sometimes even more than the departments directly involved. This fact brings into sharp focus the need for nursing to be represented at any table where hospital cost-containment actions are discussed. The decision making is difficult at best; however, it can only succeed if it is balanced, judicious, and informed by a thorough knowledge of the impact the outcomes will have on professional nurses and on their ability to effectively care for patients.
New York University Medical Center
Reference
550 First Ave New York, NY 10016
McClure M., & Nelson J. (1982). Trends in hospital nursing. In L. J. Aiken (Ed.), Nursing in the 198Os--Crises, opportunities, challenges. Philadelphia: Lippincott.
Copyright 0 199 1 by W, B. Saunders Company 8755/7223/91/0701-0003$3.00/O
4
Jogma
of Professional
Nursing,
Vol 7, No
1 (January-February),
1991:
p 4
and
Cost
Hospital
T
HE DECADE of the 1980s introduced many of us in 1 health care to a new phenomenon, namely, that of downsizing. While there were occasions where downsizing on the expense side was offset by a diminution of workload, in many instances those two variables did not operate in parallel. In fact, quite the opposite was often true. Expenses were expected to be reduced in the face of pressures to add new, resource-consuming programs. Unfortunately, there is every evidence that these kinds of financial constraints will continue for the foreseeable future, especially in light of our growing federal and state deficits. The cause of the pressures on health care are certainly well known. In spite of all efforts to date, the health care industry continues to take a larger and larger bite out of the economy each year. As Stuart Altman, the well-known health policy analyst, recently commented, if this trend continues unchecked our industry could one day actually consume more than 100 per cent of the gross national product. A facetious comment with a frightening message! It is probably safe to say that early cost-saving measures were beneficial in some respects. They drove us toward more efficient delivery systems and very likely reduced the cavalier attitudes that characterized some providers in the past. As time goes on, however, there will be fewer opportunities for fat trimming and some of the real meat will have to become involved. More than any other profession, nursing is adversely affected by a hospital’s efforts to contain costs. What is interesting to note is the number of people who hold a relatively naive view regarding this issue. In recent years more than a few hospital administrators, in describing their budget reduction measures, have proudly proclaimed that in spite of their need to make cuts in most departments, they had not cut nursing. More surprising is the fact that nurses themselves often will express the same view. This attitude shows a significant lack of understanding of the operation of these institutions and the role that nurses play in them. Many members of our profession have described the coordinator function of the professional nurse. I believe that MARGARET L. MCCLURE, RN, EDD, FAAN Executive Director of Nursing
Containment
the responsibility goes deeper than mere coordination and prefer the term “integration” (McClure & Nelson, 1982). In any case, to fully comprehend the delivery of patient care in any hospital is to understand that: (1) nursing forms an invisible kind of semipermeable membrane around patients through which all other care givers pass in order to render their services, and (2) the majority of professional and nonprofessional employees in the institution do not actually pass through that membrane, but instead deliver their services to nursing so that nursing can, in turn, deliver services to patients. As a result of this critical aspect of their professional role, nurses experience the impact of almost every reduction that is made in the hospital’s work force. In some cases the impact is direct and obvious because work that is normally performed by support personnel is transferred, wholly or in part, to nursing. For example, the elimination of certain respiratory therapists may require that nurses perform treatments during the hours that the therapists are not available. The nighttime closing of a department such as Central Service means that nurses must go to that area in order to secure the supplies they need for patients. There are, however, other instances in which the reduction of personnel in departments other than nursing has more subtle negative consequences. These cover the broad spectrum of all departments, involving professionals and nonprofessionals alike. The elimination of a pharmacist results in nurses spending additional time and energy in procuring medications; a reduction in the numbeer of engineers results in delays in the repair of equipment needed at the bedside. Nurses must either “make do” or attempt to borrow what they need from other departments. In the final analysis, then, it really does not matter where one cuts a hospital’s resources; eventually nursing feels the cut, sometimes even more than the departments directly involved. This fact brings into sharp focus the need for nursing to be represented at any table where hospital cost-containment actions are discussed. The decision making is difficult at best; however, it can only succeed if it is balanced, judicious, and informed by a thorough knowledge of the impact the outcomes will have on professional nurses and on their ability to effectively care for patients.
New York University Medical Center
Reference
550 First Ave New York, NY 10016
McClure M., & Nelson J. (1982). Trends in hospital nursing. In L. J. Aiken (Ed.), Nursing in the 198Os--Crises, opportunities, challenges. Philadelphia: Lippincott.
Copyright 0 199 1 by W, B. Saunders Company 8755/7223/91/0701-0003$3.00/O
4
Jogma
of Professional
Nursing,
Vol 7, No
1 (January-February),
1991:
p 4
