Introduction
The face of the nursing profession in the US is about to change. As it stands, the country’s healthcare system has many deficiencies, is exorbitantly expensive, and faces a cadre supply crisis. The number of patients is expected to grow in the next 20-30 years, while the number of recruited and trained nurse specialists will not be enough to accommodate them all. In the light of these events, nursing is to be transformed, with an emphasis on removing practice barriers, improving quality of care, and reducing expenditures.
Pay-for-Performance – an Emerging Trend in Healthcare Law
Healthcare in the US is evolving to better serve its customers and provide the highest value per dollar spent. The purpose of such a motion is to help reduce costs by increasing the quality of care, decreasing rehospitalization incidents, and providing healthcare workers with an incentive to perform well the first time. This trend has been encompassed in Medicare statutes and further implemented in various state laws, such as in New York (The Greater Buffalo United Accountable Care Organization), California Pay-for-Performance program. The introduction of levels of Value-based purchasing (VBP) as a means of reimbursing hospitals for the successful delivery of care (Mossialos, Wenzl, Osborn, & Sarnak, 2016).
These laws have a major effect on nursing roles and responsibilities. Nursing practice is shaped to deliver successful care in one go, with significant disincentives provided to prevent them from doing a poor job resulting in patients coming back for additional treatments. As a result, the demands towards effectiveness and nurse training are increased (Mossialos et al., 2016). In order to deliver a higher standard of care, healthcare professionals have to engage in practices of life-long learning, constantly adding to their existing skillset and updating their knowledge on the latest practices. Many nurses understand their critical role and responsibility for other peoples’ health and lives, which is why they have been entering universities to get additional education (IOM, 2016). The difference between a physician and a fully-trained nursing practitioner (NP) is getting thinner and thinner, which helps remove barriers to practice, which currently exist in various states.
Quality Measures, Pay for Performance, and Patient Outcomes
Pay for Performance has been a controversial issue since its introduction in 2010. In theory, it was supposed to increase accountability and incentivize healthcare providers to improve their standards of care. Bastian, Kang, Nembhard, Bloschichak, and Griffin (2016) report that Quality Blue, a P4P program implemented in Pennsylvania, helped reduce the incidence of central line-associated bloodstream infections by 3.13. The research, however, does not offer any information on the cost-effectiveness of the approach. Mendelson et al. (2017) mirror these findings, saying that while pay-for-performance has been associated with improved processes in nursing and ambulatory services, the consistency of such effects is unclear.
There are reports of negative effects of the practice on nurses and nursing practice as well. Gupta et al. (2018) state that the Medicare practice of rewarding or punishing hospitals based on readmission rates alone causes institutions to refuse difficult patients, who may require rehospitalization due to the sheer complexity of their situation. Roberts, Zaslavsky, and McWilliams (2018) agree, stating that negative reinforcement incentivizes nurses to refuse care for difficult patients, as treating those is considered a personal risk to one’s efficacy scores. These findings indicate that quality measures and pay-for-performance do not necessarily result in improved patient outcomes while shifting the expectations and responsibilities of nurses by punishing them in situations where treatment failure is likely. Based on these findings, it could be concluded that the existing applications of the program have unintended negative consequences on patients and nurses alike, while their benefits and cost-effectiveness remain ambiguous.
Nursing Leadership and Management Roles in Relation to Quality, Safety, and Diversity of Care
Since the release of the Future of Nursing: Leading Change, Advancing Health report in 2010 by the Institute of Medicine, there was a greater emphasis on nursing leadership and management roles in transforming the practice. Due to healthcare practices changing from traditional hierarchy to multidiscipline teams providing service, coordination and leadership became more valuable. Additional reasons include the ever-increasing influx of patients coupled with a shortage of nurses. In such dire conditions, leadership is required not only to effectively organize hospital work, but also to help reduce stress, burnout, and provide inspiration to fellow nurses. Lavoie-Tremblay, Fernet, Lavigne, and Austin (2016) report that leadership is associated with patient safety and quality of care. Namely, transformational and servant leadership styles resulted in moderate increases in the quality of care and reduction in nurse mistakes and hospital-acquired infections (Lavoie-Tremblay et al., 2016). At the same time, transactional and hierarchical leadership styles did not offer any substantial benefits but were associated with higher burnout and turnover rates among nurses.
Transformational leadership in particular proved to have a positive effect on improving the diversity of care and diversity training in other nurses. Perez, Nichols, and Quinn (2018) reported that transformational leaders inspire individuals to understand and respect other cultures, methods of treatment, and religious beliefs more effectively. They also help reduce tensions in multiracial teams in an event of conflict or disagreement. Thus, the newly emerging nursing leadership and management roles help respond to the emerging trends in the promotion of patient safety, diversity, and quality of care.
Emerging Trends
According to the recommendations and predictions in the IOM report, the main trends in modern western medicine would include the decrease in nursing barriers, a drastic increase in the geriatric population, and a continuous shortage of nursing professionals. In the next 5 years, the number of geriatric patients in the US is bound to increase by about 10 million, while the shortage of nursing cadres will increase by 100,000 (IOM, 2016). This would put additional strain on the existing workforce and will require optimization of time and delivered care. In order to save space, time, and money, a greater emphasis will be placed on prevention and outpatient treatment. The emergence of telenursing as a means of communication between patients and healthcare professionals demonstrates this trend. In order to be more responsive to patient influxes, nurses will likely switch to floating week schedules as means of optimizing time, resources, and expenses (IOM, 2016). Digital technology and robotics will be widely implemented to substitute for nurse shortage.
In addition, the concept of pay-per-quality will be further refined to ensure the maximum amount of value for patients while overcoming the restrictions placed on nurses as a result (IOM, 2016). It is possible for the existing quality programs to deliver more concrete results, which would be recorded and thoroughly researched. It is likely that it will not be applied for certain groups of patients with diseases that may require a plethora of diverse treatments, with monitoring and rehospitalization a distinct possibility. Such exceptions will allow nurses and doctors to treat difficult-scenario patients without fearing retribution for events outside of their area of control (IOM, 2016). At the same time, the next five years will likely see an evolution of existing methods of treatment, making certain conditions easier to predict, treat, and support.
References
Bastian, N. D., Kang, H., Nembhard, H. B., Bloschichak, A., & Griffin, P. M. (2016). The impact of a pay-for-performance program on central line–associated blood stream infections in Pennsylvania. Hospital Topics, 94(1), 8-14.
Gupta, A., Allen, L. A., Bhatt, D. L., Cox, M., DeVore, A. D., Heidenreich, P. A.,… & Fonarow, G. C. (2018). Association of the hospital readmissions reduction program implementation with readmission and mortality outcomes in heart failure. JAMA Cardiology, 3(1), 44-53.
Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
Lavoie‐Tremblay, M., Fernet, C., Lavigne, G. L., & Austin, S. (2016). Transformational and abusive leadership practices: Impacts on novice nurses, quality of care and intention to leave. Journal of Advanced Nursing, 72(3), 582-592.
Mendelson, A., Kondo, K., Damberg, C., Low, A., Motúapuaka, M., Freeman, M., Kansagara, D. (2017). The effects of pay-for-performance programs on health, health care use, and processes of care: A systematic review. Annals of Internal Medicine, 166(5), 341-353.
Mossialos, E., Wenzl, M., Osborn, R., & Sarnak, D. (2016). 2015 international profiles of health care systems. Canadian Agency for Drugs and Technologies in Health.
Perez, A., Nichols, B., & Quinn, W. V. (2018). Growing diverse nurse leaders: The current progress of the future of nursing campaign for action. Nurse Leader, 16(1), 38-42.
Roberts, E. T., Zaslavsky, A. M., & McWilliams, J. M. (2018). The value-based payment modifier: Program outcomes and implications for disparities. Annals of Internal Medicine, 168(4), 255-265.