Any discussion of economics and economic valuing in what now is a globally connected health care delivery system is daunting talk, particularly to those among us who might prefer a focus on the art and science of care giving. Yet the nursing discipline is embedded in, and central to any discussion on the economic valuing and delivery of health care on many fronts. If this were not the case, one would have to seriously wonder, Why not? It is hard to imagine any serious health care venue consuming nursing resources in the United States or abroad - acute care, primary care, long-term care, home or public/community-based care, the military, informatics firms, pharmaceutical companies, and others - without seriously considering the value that nurses and nursing bring to bear on care or services outcomes.
Chang, Price, and Pfoutz (2001) describe economics as the science that studies how consumers, business firms, government entities, and other organizations make choices to overcome the problem of scarcity. Scarcity exists because there are not enough resources to satisfy all existing human wants and desires (p. 6). As they reflect on health care, they state that most patients and families do not have the necessary means to obtain all health services. This situation is complicated through the use of third parties (insurance companies and the government, for instance) who are involved as players in what would be, in parallel business entities, a relationship restricted to that between a buyer (patient) and seller (provider).
Those who embrace this edition of the OJIN: The Online Journal of Issues in Nursing will benefit in thinking about nursing's value contribution, present and future, to the health care system. The articles exemplify concepts espoused by Chang, Price, and Pfoutz (2001): (a) cost/quality valuation (what is the value of nursing interventions to patients or other aspects of the industry in the context of the outcomes produced?), (b) supply and demand (which influence salary, but also must link to career satisfaction and security), (c) awareness of markets (which asks who needs or will benefit from nursing's knowledge, skills, and abilities in the context of the discipline's social contract and emerging interests?), (d) service and product development and advancement (that link the full scope of nursing roles from basic to the highest levels of preparation with existing and new programs), and (e) pricing (where reimbursement for services and valuing of nursing contributions are in dynamic relationship).
As you peruse these articles, recall that economic value is dynamic, not a static process. Value is not the purview of the supplier of services (in this case, nurses), but rather is created in tandem with users of services (the patient or health system, dependent upon the unit of analysis). Economic value is but one way, albeit a very significant one, of valuing nurses and nursing. In traditional economic models the notion of the law of demand drives prices and value beyond the reach of users, giving access to those who can demand services preferentially. Among the challenges for the nursing discipline is the creation of fair value and economic reward for a discipline that extends itself to all aspects of society to be non-scarce in light of influencing the health and well-being of society, through which healthy workers emerge to constitute the backbone that feeds all other industries.
In the first article, Welton presents a robust discussion on the topic of mandatory hospital nurse staffing ratios, noting the various tensions that center on nursing's value as a commodity versus as a professional service provider. This article exemplifies the pricing concept noted above. Two articles follow that explain the relevance and use of the National Database of Nursing Quality IndicatorsTM (NDNQI)®, presented by authors Montalvo and also Dunton, Gajewski, and Klaus respectively. Using the NDNQI, both writers elucidate the importance of gathering and interpreting nurse-sensitive data when the unit of analysis is not at the institutional level, but rather at the unit level. Decision making suffers when the level of analysis is broader than the day-to-day issues being solved, and both authors present in different, but complementary ways, the value of nursing when it is considered from a non-macro level of analysis. Together, both Montalvo and Dunton, et al. directly address the concepts of cost/quality valuation of nursing and awareness of markets.
Jones and Gates model the economic concept of supply and demand by presenting the business case for nurse retention. Too often, retention is under-valued as an important contributor to the recruitment/retention equation; Jones and Gates aptly address the career satisfaction component of retention, including oft-overlooked roles of nurse leaders and faculty. VanHook concludes this edition of OJIN with a fascinating discourse and a challenge to reconceptualize the way nursing's value and impact are elucidated by using cost-utility analysis, whereby nursing has the opportunity to demonstrate its service and product outcomes by converting metrics to cost per adjusted- life years, or disability-adjusted life years. Stated simply, how does nursing care tie to adding value to life and living?
To summarize, economic concepts may be daunting, but absorbing the content of these five articles gives a needed voice to demystifying these concepts. Nursing is a practice discipline with a social contract to provide care; yet nurses are increasingly employed in settings that use nurses for products and services, a factor to be considered in value economics. The nursing discipline will advance when it has an increased pool of persons knowledgeable concerning economic concepts and the metrics used to capture value in a global health care arena. Economic value is expressed with indicators other than traditional care metrics, and new and improved models are emerging that capture nursing value. The fresh perspectives offered by these authors are a needed compendium to the economic literature.
The journal editors invite you to share your response to this OJIN topic addressing the Economic Worth of RNs either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles. Find out how...
Michael R. Bleich, PhD, RN, CNAA, BC, FAAN
Article published September 30, 2007
Chang, C.F., Price, C.A., & Pfoutz, S.K. (2001). Economics and nursing: Critical professional issues. Philadelphia, PA: F.A. Davis Company