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Nurse staffing patterns have come under increased scrutiny as hospital managers attempt to control costs without harming service quality or staff morale. This study presents production function results from a study of nurse output during the period 1997-2000. The results suggest that productivity varies widely among hospitals as a function of staffing patterns, methods of organization, and the degree of reliance on nurse extender (NE) technicians. NEs can enhance the marginal value product of the most educated nurses as the registered nurses (RNs) concentrate their workday around patient care activities. The results suggest that nurse extenders free RNs from the burden of nonnursing tasks. Key words: productivity, hospital productivity, nurse productivity, productivity measures.
ACCORDING TO Peter Drucker, productivity is the first test of management's competence. (1) A hospital manager should get the greatest output for the least input effort, better balancing all factors of care delivery to achieve the most with an optimal level of quality. A number of exogenous factors can affect productivity. For example, nurse staff flexibility is enhanced during tight low-wage inflation periods. In the 1990s, hospital-based nursing experienced a wage deflation. When nurse wage inflation is under control, nurses are less likely to protest productivity improvement programs. In the 1990s, nurse wages deflated 0.4 percent annually, whereas comparable professions increased by 1.1 percent annually. (2) Hospital nurse productivity did not improve in the 1980s. In the 1980s, nurse wages inflated 2.3 percent annually, while comparable professions (e.g., teachers) increased by only 2.0 percent. Recent barebones reimbursement policy changes, such as the Balanced Budget Act of 1997, have had a major effect on the profession.
The hospital nursing profession is undergoing a major transformation. Task delegation and the allocation of nurses within the hospital have become major medical economics issue. Nursing department employees represent 62 percent of the hospital employees and 36 percent of hospital expenses. (3) Hospitals have increased their employment of full-time registered nurses (RNs) per 100 patient days by 49 percent in the period 1993-1999. The report of the Secretary's Commission on Nursing indicates that the hospitals reporting the most severe RN shortages have been the leaders in replacing licensed practical nurses (LPNs) with more expensive RNs. (4) Alternative labor input, in the form of the technician nurse extender (NE) is an increasingly popular approach to alleviating the problem of the inadequate nurse staffing level. A careful empirical study has not yet been done to assess the degree to which employment of NEs and efficient task delegation to clerks can enhance department productivity and free nurses to perform their unique clinical activities. In theory, however, NEs can intensify the marginal value product of the most educated nurses, as RNs are able to concentrate their workday around the most severely ill patients.
Hospital nursing has undergone a number of major organizational shifts, from functional nursing in the 1940s to team nursing in the 1960s to primary nursing in the 1980s. The 1960s' innovation of team nursing set the experienced RN as team leader, working with nursing aides and LPNs. The team leader delegated much of the patient care to the team members and planned the care each patient received during that specific shift. Team nursing had the financial benefits of cost effectiveness and the positive and negative aspects of any task-oriented system. Hospital administrators liked team nursing's focus on centralization of control, while nurse educators desired a new system that would focus on autonomy of the Bachelor of Science in Nursing (BSN)-trained RN (and maximize reliance on RNs, while decreasing employment of LPNs.) (5)
Primary nursing became popular in the 1980s, as nursing focused on the need for autonomy and the evolution of a knowledge-based professional practice. Primary nursing involves decentralization of the nursing unit and the …