An ethical imperative: How nurses can be leaders in reducing overuse
Studies on overuse, or unnecessary care, often focus on the decisions that doctors make. But all clinicians on the care team may contribute to overuse, and are impacted by its downstream effects. Nurses in particular are among the most trusted profession in the US and have a lot to gain from reducing unnecessary care, yet this potential for nurses to lead the charge has gone largely untapped.
Three leading experts on nursing, value of care, and health policy share their insights on value-informed nursing and their visions for the future.
Betty Rambur, PhD, RN, FAAN is the Routhier Endowed Chair for Practice, Professor of Nursing, and Interim Dean of the College of Nursing at the University of Rhode Island. She serves on the state’s Cost Trends Steering Committee, the Technical Advisory Panel for Reimagining Nursing Initiative “Reducing Barriers to Value-based Care Payments in NP-led Primary Care,” and as a member of the Medicare Payment Advisory Commission (MedPAC).
Olga Yakusheva, PhD, MSE, FAAN(h) is Professor of Public Health and Nursing at the University of Michigan. She currently serves as a member of the Research Council of the American Nurses Association Enterprise, economic advisor to the American Nurses Association, and an independent consultant for American Nurses Credentialing Center.
Monica O’Reilly-Jacob, PhD, APRN, FNP-BC, FAAN is an assistant professor at the Boston College Connell School of Nursing. She leads “Reducing Barriers to Value-based Care Payments in NP-led Primary Care,” a pilot project of the American Nurses Foundation’s Reimagining Nursing Initiative and currently serves on the American Association of Colleges of Nursing’s Health Policy Advisory Council.
The views presented are the authors’ and do not necessarily represent those of any of their affiliations.
Lown Institute: We hear a lot about how the decisions that doctors make can drive (or reduce) overuse, but there are other clinicians involved in these care decisions. How do nurses impact overuse, both positively and negatively?
Olga Yakusheva: There are 4.6 million nurses working in the US, the largest clinical workforce in the country. Nurses provide the majority of direct hands-on patient care. While R.Ns don’t write orders like physicians do, there are many ways in which they can contribute to overuse of healthcare resources through their everyday practice— but nurses can also promote resource-wise clinical decision making. First, providers frequently give duplicative, redundant, even erroneous orders; if nurses follow such orders without questioning, this could result in wasteful low-value care, increase patient’s treatment costs, and even harm the patient setting off a domino effect of additional patient treatments and costs. Being a patient’s advocate means using a critical lens towards providers’ orders and implementing them in an efficient and coordinated way—something nurses do every day.
Nurses also play an important role in designing care processes, along with physicians and other health professionals. Being a key liaison between the healthcare organization and the patient and their family, nurses are uniquely positioned to know how to achieve the care patients really need. One nurse recently told me about her experience influencing her hospital’s end-of-life care protocol. After repeatedly observing the care of actively dying patients whose families were requesting everything that can be done to prolong life, she suggested to change the question that providers asked the patient’s family from “Would you like to continue life-support measures?” to “Would you like to continue treatments to postpone death?” Reframing the conversation helped achieve respectful, dignified end of life care for patients and families; it also reduced service use and costs. This is just one example of the power of value-informed nursing practice and leadership–there are many more and such examples, big and small, that happen every day.
Betty Rambur: Olga offers a great example. Overtreatment at the end of life that nurses perceive to be at odds with the patient’s wishes is a source of enormous moral distress for both student nurses and those in practice. It is also personal. My own father was offered dialysis when he was actively dying. I am forever grateful that I had been taught to reframe the conversation from “doing everything” to “will this help my father die more comfortably?” Well-intentioned families think they are doing the best for their loved one, only to later have to make a soul-splitting decision to end futile life support. In these scenarios, everyone feels like they have failed. We must do better than this.
Monica O’Reilly-Jacob: Olga & Betty make excellent points about bedside nursing in the acute care setting. Many advanced practice nurses (APNs) work in outpatient settings, where their decisions directly impact overuse, because they have the ability to order tests and treatments just like physicians. These settings often offer longstanding patient-provider relationships, engendering higher levels of patient-provider trust and effective shared decision-making around low-value care. In this way, the same approaches to de-implement low-value care among physicians will also hold true for NPs. It is important that de-implementation efforts are inclusive of all clinicians who have the authority to order services and potentially drive overuse.
What is the impact on nurses from waste and overuse (on work stress, moral injury, etc?)
Monica: Waste and overuse certainly contributes to moral injury and burnout. Nurses are often positioned between patients and ordering providers, and as such are responsible for both the implementation of care plans and the patient experience. In the context of unnecessary care ordered by providers, nurses are expected to execute redundant care orders and address patient frustration from cascades of unnecessary care. In the context of patient requests of low-value care (ie, low-value imaging and antibiotic use), nurses are expected to manage patient expectations and educate patients on the counterintuitive principle that more care is not always better. This paradox of dynamics around managing the patient experience of low-value care can most certainly sap the joy from work and lead to burnout.
“Imagine if more than $1 trillion dollars could be directed toward improving working conditions and staffing for nurses each year.”Olga Yakusheva
Olga: In addition to moral injury, waste and overuse have a significant and negative economic effect on nurses. Nurses across the US healthcare system, from primary care practices to nursing homes to hospitals, report being understaffed, underpaid, unsafe at work, and not adequately resourced to provide high quality care to patients and families. While it is true that healthcare organizations that employ nurses are frequently struggling to make their ends meet financially, there is large amounts of money and healthcare resources out there that can be used for nursing and many other good things. The problem is, right now they are simply being wasted. Studies show that for every $1 spent on healthcare, 25 cents are spent on redundant, duplicative, poorly coordinated care that does not help patients and may even hurt them.
Just imagine if a quarter of the $4.4 trillion healthcare expenditures were not wasted but instead saved and invested in making our healthcare system better. Imagine if more than $1 trillion dollars could be directed toward improving working conditions and staffing for nurses each year from now on. Namely, the two largest sources of waste are communication and care coordination, both are within the domain of nursing influence. By focusing on value-informed decision making, nurses have an opportunity to convert wasted resources into investments that can help sustain and grow the nursing profession.
Nurses are consistently one of the most trusted professions. How can nurses use this trust to help patients understand the harms of low-value care?
Betty: First, nurses themselves understand and personally experience the cascade of harm that can flow from low-value care. It is not benign in terms of physical and emotional health for the nurse or the patient and it certainly is not benign fiscally. That is why we consider value-informed nursing practice to be an ethical imperative. Next, nurses are developing the agency to act. This can be challenging in the hierarchical structure of many health care organizations, in which nurses are initially socialized to take and execute physician orders. This was not always the case. In the early 1900s, Lillian Wald’s model directly immersed nurses in the social context of people’s whole life, not just their illness. Nurse entrepreneurs in the 1900-1940 directly connected their work to those in need. Contemporary versions of these approaches are sorely needed.
Monica: For many years, nurses have been considered to be the most honest and ethical profession. More recently, we learned that the American public trusts nurses more than other professions to improve the health care system. This means that patients expect nurses to actually lead the charge in reducing health care waste rather than be along for the ride. It is really critical that we empower nurses from all levels of the hierarchy to confront harmful norms. From challenging unnecessary standing orders to developing system-wide initiatives – the public has decided that this is the new work of nurses. Nursing collaborations across institutions are essential to building momentum and promoting a high-value healthcare culture with national impact. We have roadmaps, such as a national collaborative of APRN-led initiatives to reduce low-value care by reducing neuroimaging, improve antibiotic stewardship and reduce routine labs, among others.
“The American public trusts nurses more than other professions to improve the health care system. This means that patients expect nurses to actually lead the charge in reducing health care waste rather than be along for the ride.”Monica O’Reilly-Jacob
I think one of the reasons nurses garner so much public trust is that they are perceived to be relatable, accessible, and altruistic. This certainly places them in a position of power and responsibility when it comes to educating the public about the potential harms of overtreatment. Within individual interactions and through more system-wide policies, nurses have enormous potential to de-implement low-value care and shift cultural norms. This will certainly not happen overnight; it is essential that nurses are well informed about the Choosing Wisely campaign and the consensus-based recommendations from 80 specialty societies on tests and treatments deemed unnecessary and overused.
Betty: Choosing Wisely can certainly contribute to waste reduction, if we take it far enough, and have the right things on the “never” list. I am particularly concerned about overscreening. We see other wealthy nations who do not do routine mammography yet have the same mortality outcomes we do, suggesting it is not the screening but the more precise treatments that are able to make a difference. Yet in the U.S. there is a relentless push for early and ongoing screening. People, including nurses, are socialized to believe that earlier screening is always better, when instead it often turns perfectly healthy people into patients. Patient and provider information hasn’t yet deeply shaped behavior. It would be very politically difficult, given that one person’s waste is another person’s revenue stream, but more effort should be given to the “effective but underused strategy for reducing low value care: stop paying for it.”
Does current nursing education teach about overuse enough? Where could we be doing better?
Betty: Imagine the change that would occur if the 5.2 million nurses in the U.S. unified their efforts and joined like-minded others to stop overuse and its harmful effects! It has been our mission (Olga, Monica and Betty) to make this happen. The nursing program accreditation criteria on quality and safety recently have expanded to include cost and appropriateness, but there is a long, long way to go. Students are socialized to the profession in settings that are largely fee-for-service and so are most faculty, so low-value care is often normalized. Yet from the very first courses, students can be taught to ask about the value of what they do and see done by others. Cost and cost-effectiveness education should occur in the context of patient/person/family care, not reserved for the capstone leadership courses. Post clinical conferences should, by default, always include such discussions. Then, tracing how saved resources could be redirected to the upstream social determinants of health offers a powerful connector between the immediate student-patient interaction and broader health influences. Students quickly grasp that almost every condition they see in a clinical situation is just one step away from upstream social factors; understanding “how the money works” offers students a new and powerful tool for action. Nurses who are fluent in finance and resource allocation models as well as clinical practice could transform the system; I expect they would also experience more career satisfaction.
Monica: As we mentioned before, the clinical decisions of NPs directly impact overuse, and, thus, it is critical that the principles of value-informed nursing practice are threaded throughout graduate curricula. In fact, in the most recent national guidelines for graduate nursing education, cost-effective care was more prominent than ever before. Renewed efforts to highlight the NP role in reducing waste is welcomed. While NPs are rooted in the nursing model of care, with an emphasis on high-value activities such as prevention and patient education, they often adopt the ordering behaviors of their colleagues. Preparing emerging NPs within the framework of value-informed nursing practice will help to reduce waste over time.
MedPAC does a lot of work on value-based care. Are there payment model innovations you’re excited about that have the potential to move the needle?
Betty: I am always excited about value-based models, especially those that are not built on a fee-for-service chassis because fee-for-service inevitably will lead to overuse. We currently have this untenable situation in which physician care and procedures are revenue generators, yet nursing care is considered a cost and therefore something to contain. This is paradoxical given that when a person is hospitalized it is because they need nursing care…otherwise they would be treated in an outpatient setting. A focus on value as the quotient of outcomes divided by cost, is important, but does not fully capture the contribution of nurses in current quality measurement approaches. So much of what is valuable to society is in the “care” domain, not the “cure” domain, yet our traditional payment models have focused on the latter. I am particularly excited about the new Guiding an Improved Dementia Experience (GUIDE) model because it recognizes and aims to address caregiver burden and the totality of the family experience.
“We currently have this untenable situation in which physician care and procedures are revenue generators, yet nursing care is considered a cost and therefore something to contain.”Betty Rambur
Monica: Yes! That’s a great example of a nurse-led initiative that has become a gold standard. The GUIDE model was, in part, inspired by a NP-led primary care practice designed specifically for patients living with dementia. To me, it’s fascinating that the Center for Medicare and Medicaid Innovation Center looked to NPs to develop a patient-centered, value-based model, yet NPs are often excluded from participating in value-based contracts. We are currently leading a pilot project to prepare NPs who are independent practice owners for value-based payment. The type of care they provide is well aligned with value-based care, but they often don’t have the infrastructure to capture and report their quality measures. While NP practice owners are a relatively small group, they are growing in numbers and hold promise in performing well under value-based care. Including these practices in these new models will be a benefit to all.
In particular, what do you think about CMS’s new global budgets model for states?
Betty: I have been a long-time proponent of all-payer, all setting, total cost of care models, so this is certainly an important step. “All setting” is important, or costs spill out to settings and services that are not within the target or cap. The 11-year time horizon for the model is also important; real change takes time. This is a voluntary program, which may make sense, given the transformation needed, but I am also a proponent of immersion in risk-bearing, value-based models as a condition of participation in Medicare. If the 1983 Prospective Payment System and DRGs had been voluntary, it would still be a controversy under discussion. Instead, the mandatory nature of the payment redesign, whereby hospitals assumed financial risk for length of stay, resulted in provider behavior change with nearly neck-snapping alacrity: change the payment model incentives and system redesign will follow.
Olga: We should also not overlook how the existing payment models may be unintendedly, but adversely, influencing the quality of nursing care. While the IPPS and DRGs have been in place for decades, these models have been criticized for disincentivizing health care organizations from investing more in nursing. Nursing wages already account for over a third of most organizations’ operating budget, so high-quality nursing does not come to organizations at a cheap price. Value-based pay-for-performance incentives are intended to reward high quality and cost savings; yet, accounting for only 1-2% of the DRG operating payment, value-based incentives pale in comparison to the expenditures it would take most organizations to improve the quality of nursing care. By comparison, in other industries product quality accounts for 30-35% of the price. Payment rates and performance incentives under the current payment models need to be better aligned with the economic models of healthcare organizations that employ nurses.