Nursing News

Pay-for-Performance Incentives Increase Nurses’ Burden


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By Debra Wood, RN, contributor

February 11, 2011 - Hospital and nursing leaders indicate payors’ attempts to boost quality through performance-based incentives offer the potential to improve safety and quality, but they are concerned the policies will adversely affect the nursing workforce, increasing the burden and blame placed on direct-caregivers without improving staffing levels, work environments or salaries, according to a recent study.

Ellen T. Kurtzman, RN, MPH, FAAN
Ellen T. Kurtzman, RN, MPH, FAAN, encourages nurses to educate policymakers about the realities of their proposals, for government leaders to listen to the front-line caregivers, and for hospital executives to reward nurses when the hospital performs well on government metrics.

“There was a consensus that these types of incentive programs—pay for reporting and pay for performance—would not have a positive effect on the nursing workforce,” said Ellen T. Kurtzman, RN, MPH, FAAN, assistant research professor at the George Washington University School of Nursing in Washington, D.C.

Kurtzman and colleagues completed 75 analyzable interviews with unit nurses and hospital leaders, including chief executive and nursing officers and board members, in 25 acute-care facilities in 2008, inquiring about the effect of performance-based reimbursement incentives, such as The Centers for Medicare & Medicaid Service’s hospital-acquired conditions policy to not pay for preventable complications such as pressure ulcers. 

Both the leaders and the nurses overwhelmingly indicated that pay-for-performance incentives could result in improved patient outcomes and safety. Eighty-two percent of the leaders and 100 percent of the nurses thought the policies would significantly improve patient outcomes, and 88 percent of the leaders and 87 percent of the nurses thought they would significantly improve safety.

Major themes emerged from the interviews.

“There was universal acknowledgement of how much nurses matter,” Kurtzman said. “And there was a very strong reaction to whether or not nurses should be incentivized for better care.”

People were either strongly in favor or ethically opposed to nurse incentives, with no one on the fence. Both the leaders and nurses were skeptical that such a system could be made operational, with part-timers and float nurses. Some nurses may not want to help their peers if the patient is at high-risk for a poor outcome.

More than 22 percent of respondents cited the hard work associated with performance improvement and the changes within hospitals as they strive to become the best. An equal percentage of people mentioned concern about the financial effect of such incentives, acknowledging that losses in Medicare reimbursement could lead to nursing budget cuts and staff reductions.

Respondents brought up concerns about the burdens associated with incentive policies, such as the need for additional personnel, technology, training and documentation. Nurses raised the issue more than twice as often as hospital leaders, 24 percent compared to 10 percent, citing that documentation and complying with incentive policies took them away from bedside care.

Nurses also expressed concern about incentive policies potentially creating an environment where nurses would be blamed for hospital-acquired conditions. Eighty-six percent of nurses rated blame as a significant or very significant outcome, compared with 62 percent of the hospital leaders.

Cole Edmonson, MS, RN, FACHE, NEA-BC
Cole Edmonson, MS, RN, FACHE, NEA-BC, said nurses must work to qualitatively and quantitatively value the nursing profession.

Kurtzman found nurses tended to feel a “disconnect” between the work they do and the incentives. Nurses felt the policies had no influence on how hard they work and how well they care for patients.

“Even though the policies are intended to change people’s work behavior, the people we talked to saw it as unrelated,” Kurtzman said. “They didn’t relate [the care given] to the bigger policy issues.”

Cole Edmonson, MS, RN, FACHE, NEA-BC, chief nursing officer at Texas Health Presbyterian Hospital Dallas, who was not involved in the study, said his prime concern about the current payment structure is the inclusion of nursing in the traditional “room charge” and the inability to cost out or value the service.

“Performance-based payment systems may have a positive side as it highlights the need to understand and value the individual and collective contributions of the nursing profession on a range of outcomes,” Edmonson said.

The George Washington University-led study, funded by the Robert Wood Johnson Foundation, was part of a larger, two-year research project to examine the impact of performance measurement, public reporting, and performance-based financial payment policies on nurses. These findings are among the first to describe hospital stakeholders’ attitudes and perceptions of federal transparency and accountabilities policies on hospitals, nursing practice and the nursing workforce. 

The authors suggest that the information provides an opportunity to mitigate concerns as policymakers consider more elaborate incentive programs, such as offsetting threats to the nursing workforce, building a nonpunitive environment, strengthening nursing leaderships’ role and evaluating the effects of performance-based payments.

Kurtzman added that nurses could be effective in advancing governmental goals if they knew more about the process involved. She encourages nurses to learn more about proposed regulations and hopes the government will reach out to nurses, as direct caregivers, about whether and how new policies will work.

“On both sides, there needs to be more effort to think through the implications on the nursing workforce,” Kurtzman said. “We cannot keep adding on and adding on and thinking there isn’t going to be something that suffers. That will be patient care and to the people providing that care.”

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