C L I N I C A L N U R S E S F O R U M

Joan BucklDepartment

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THE REAL COST OF CARING OR NOT CARING

Author: Joan Buckley, RN, Garden City, NY

Section Editor: Andrew D. Harding, MS, RN, CEN, NEA-BC, FACHE, FAHA, FAEN

The unpredictable conditions, fast pace, and need forimmediate decision making in emergency depart-ments have some nurses questioning their ability to

provide quality care to patients.1 In part because of theAffordable Care Act and the requirements imposed by theDepartment of Health and Human Services regardingMedicare and Medicaid reimbursement, facilities areincreasingly focused on medical errors, quality of care,and the reduction of medical costs, particularly in theemergency department.2 The impact of these changes hasall stakeholders examining the care given and the cost ofthat care at 3 different levels: the financial level (moneyspent), the physical level (patient outcomes), and theemotional level (satisfaction of the nurse and the patient).2

With greater than 40,000 nurses across the nation workingin emergency departments and nurses’ salaries representingmore than 50% of most hospital budgets, nurses’ salariesare an expense that hospitals review carefully when facedwith economic pressures.3 The implementation of evi-dence-based practice places the cost of care that patientsreceive from nurses as one of the most valuable items paidfor by health care consumers, with the rising cost closelyrelated to the growth of the gross domestic product, whichwas 17.9% in 2011.4 The awareness of health carespending by politicians and consumers supports the needfor researchers to explore the real cost of care as it relates tonurses’ caring and the effect on patient outcomes and thehealth care system.

The Financial Level

Pappas3 identifies caring nursing practice as the componentthat drives the overall value and quality of a facility, withvalue defined as the product of cost and quality; as such,nurses’ caring actions become the key components in theefficiency and economic success of health care organizations.

ey, Member, Nassau/Queens Chapter, is Assistant Professorof Nursing, Nassau Community College, Garden City, NY.

ndence, write: Joan Buckley, RN, 2165 Dogwood Ln, Westbury,E-mail: joan.buckley@ncc.edu.

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The cost of health care and changes that will continue tooccur as a result of federal initiatives, such as the AffordableCare Act, make it imperative that health care look at theresources that have been underutilized and will provideorganizations with the greatest return on investment.5

In a review of a meta-analysis of outcomes that involvedthe relationship between staffing ratios and outcomes byNelson,5 caring was not identified as an influential variableby the researchers Kane et al.6 Viewing this as an error,Nelson acknowledges the ability of the nurse to create acaring moment, which allows the nurse to connect, and inthat connected moment, a cumulative effect is created onthe patient’s and nurse’s internal healing that alters theoutcomes of the two. To define the “caring moment” andunderstand the importance of nurse caring in health care, itmust be understood that Jean Watson's view7 of “humancaring” explores ethical, ontological, and epistemic actionsthat will define the nurse and the patient at a specific timeand in a specific space, with new understandings that willoccur during health-wholeness-healing experiences.

The idea that caring is a factor that influences patientsand organizational outcomes is often underestimated, andthe lack of scientific analysis to explain the effect of oneindividual being taken care of by another is overlooked inmany discussions.5,8 In the study by Nelson,5 the greatestreturn on investment was identified as the nurse, and thisreturn on investment surpassed all other technology,pharmacology, or process improvements developed forhealth care. The nurse, acting as surveillance for health carefacilities, has the ability to identify factors that predisposepatients to preventable complications, such as a deteriorat-ing condition or change in mental status, which—if allowedto progress—could prolong a hospital stay and increase thecost of that admission for the facility.9

The Physical Level

Using the nursing effectiveness model of Irvine, Doran9

documented the influence of nursing care on patientoutcomes. This secondary analysis of cross-sectional data,collected in 1999, classified care according to the nurses’role in the activity: first, as independent functions andresponsibilities; second, as interdependent functions; andthird, as dependent functions (Table).10 Exploring thepatient’s perspective of nursing care, Doran11 found thatthere was a relationship between the patient’s level of

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TABLENursing functions

First: Independent functions and responsibilities aredescribed as actions that are performed by the nurseusing critical thinking and clinical judgment with noorder necessary.

Second: Interdependent functions are partially or totallydependent on the nature of the patient, the nurse, andother health care providers working together.

Third: Dependent functions relate to the nurse’s need foran order by the practitioner.

Buckley/CLINICAL NURSES FORUM

physical function before discharge and the positive ornegative response on the patient experience surveys, with norelationship between the nursing care and the paymentmethod. Doran11 examined independent nursing carefunctions, such as patient positioning, self-care assistance,and exercise promotion, for their impact on a patient’sphysiological and psychological condition on discharge andfound that a significant relationship existed.

In addition, Lucero et al9 used the same data to explorethe significance of nurse caring actions that focused onunmet nursing care needs and the connection between thecare environment and clinical outcomes. Nurse-sensitiveclinical outcomes identified in the research by Pappas3 werecalculated as the cost per case: medication errors at $334;falls at $648; urinary tract infections at $1,005; pneumoniaat $1,071; and pressure ulcers at $2,384. The significance ofthe study by Doran11 when compared with the study byPappas was the verification of a relationship betweenindependent caring actions of the nurse and the cost ofadverse events (outcomes) when intentional nurse caring isnot present.

Theories of caring and uncaring behaviors withinnursing are grounded in the idea that the lived nurse-patientexperience is characterized by a connection that empowersthe patient.12 Halldorsdottir12 discusses the influence ofpsychoneuroimmunology and the connection of theconsciousness (psyche), the central nervous system(neuro), and the body’s defense against external infectionand abnormal cell division (immunology) as it relates to thepatient. This means that there was a positive response ofthe immune system when the patient experienced caring inthe nurse-patient relationship and, as a result, healingoccurs. In a non-caring experience, patients feel disempow-ered and demoralized, which threatens their health further.13 What nurses as carers do and think and how they actgreatly impacts the quality of patient care administered andthe amount spent by a facility to provide that care.14

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The Emotional Level

In Notes on Nursing—What It Is and What It Is Not,Florence Nightingale wrote, “how immense and howvaluable would be the produce of her united experience ifevery woman would think how to nurse.”14 The produceNightingale referred to was caring, and it is through thecaring of the emergency nurse that the real cost of caringcan be understood.2 Caring is a moral ideal of nursing andis defined as an attitude, an intention, and a commitmentthat shows itself in the nurse’s behavior when directlyinvolved with the patient.8 Nursing care of the patient isthen the product achieved (positive or negative) when theemergency nurse attempts to meet the physical andemotional needs of a patient using objective data thathave been critiqued and questioned by the providers of carein the emergency department. In her writings, Todaro-Franceschi15 differentiates between the role of caregiver assomeone who provides care with learned skills and the roleof carer as someone who provides care with intentionalityand purposefulness. Through independent caring behav-iors, the nurse is able to assist patients as they strive toreach their own potential for health and healing.8,15 It isessential that emergency nurses focus on the uniqueindividual in a human-caring-healing relationship withdeliberate actions. The quality of patient care is importantto nurses and is a necessary prerequisite for theircontentment as professionals.15 Purposeful caring actions—the essence of nursing—enhances the quality of livingfor the patient and the nurse, as carer, and ultimately, thesavings are reflected in the financial portion of healthcare.15,16 Health care facilities need to look towardresearchers for insight and understanding into one of themost important pieces of the finances of the ever-changinghealth care system—the nurse.

REFERENCES1. Baldursdottir G, Jonsdottir H, Iceland R. The importance of nursing

caring behaviors as perceived by patients receiving care at an emergencydepartment. Heart Lung. 2002;31:67-75.

2. Frisse ME, Johnson KB, Nian H. The financial impact of healthinformation exchange on emergency department care. J Am Med InformAssoc. 2012;19:329-33.

3. Pappas SH. The cost of nurse-sensitive adverse events. J Nurs Admin.2008;38:230-6.

4. Fuchs V. The gross domestic product and health care spending. N Engl JMed. 2013;369:107-9.

5. Nelson JW. Measuring caring—the next frontier in understandingworkforce performance and patient outcomes. Nurs Econ.2011;29:215-9.

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6. Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nursestaffing and quality of patient care; evidence report/technologyassessment no. 151. Prepared by the Minnesota Evidence-basedPractice Center under Contract No. 290-02-0009. AHRQ PublicationNo. 07-E005. Rockland, MD: Agency for Health Research andQuality; 2007.

7. Watson J. Nursing as human caring science. In: Human Caring Science:A Theory of Nursing. Mississauga, Canada: Jones & Bartlett Learning;2012:17-33.

8. Tanking J. Nurse caring behavior. Kans Nurse. 2010;85:3-5.

9. Lucero RJ, Lake ET, Aiken LH. Nursing care quality and adverse eventsin US hospitals. J Clin Nur. 2010;19:2185-93.

10. Doran DI, Sidani S, Keatings M, Doidge D. An empirical testof the nursing role effectiveness model. J Adv Nurs. 2002;38:29-39.

11. Doran D, Harrison MB, Laschinger H. Relation between nursinginterventions and outcome achievements in acute care settings. Res NursHealth. 2006;29:61-7.

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12. Halldorsdottir S. A psychoneuroimmunological view of the healingpotential of professional caring in the face of human suffering. Int J HumCaring. 2007;11:32-66.

13. Bailey D. Framing client care using Halldorsdottir’s theory of caring anduncaring behaviors within nursing and healthcare. Int J Hum Caring.2011;15:54-66.

14. Nightingale F. Notes on Nursing: What It Is and What It Is Not. London:Harrison 59, Pall Mall; 1859.

15. Todaro-Franceschi V. Compassion Fatigue and Burnout in Nursing:Enhancing Professional Quality of Life. New York, NY: SpringerPublishing; 2013.

16. Douglas K. When caring stops, staffing doesn’t really matter. Nurs Econ.2010;28:415-9.

Submissions to this column are encouraged and may be sent toAndrew D. Harding, MS, RN, CEN, NEA-BC, FACHE, FAHA,FAENADHardingRN@Gmail.com

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