NML-ISSUE 6 VOL 2

REFRAMING THE VALUE OF NURSING AND MIDWIFERY IN HEALTHCARE SYSTEMS: CHALLENGES AND OPPORTUNITIES

By Nanyonga, R.C., and Kobukindo, T.K

Not too long ago, we celebrated the International Day of the Midwife and the Nurse (IDM and IDN), significant occasions that highlight the indispensable roles of nursing and midwifery professionals in healthcare systems worldwide. The two international days serve as important reminders to prioritize the support and recognition of nurses and midwives (NM) within comprehensive health system strengthening strategies on a global scale.

But how do we amplify advocacy when the value of nursing and midwifery care is not routinely accounted for or documented in some of the basic instruments such as hospital bills? I believe a pivotal aspect demanding NM leaders’ attention is the need to reframe the value of NM from an economic dimension (Dick et al., 2017) which requires the effective capture of the value of nursing and midwifery care through the appropriate costing of nursing and midwifery activities. This entails developing systems that allow organizations to not only track the several ways in which NM contributes to patients’ recovery and improves prognosis but also to quantify and allocate appropriate financial resources in acknowledgment of their education, experience, expertise, and organizational and societal contributions.

In this article, we argue that by accurately capturing nursing activities, organizations can gain insights into the diverse areas where nurses and midwives excel, including activities related to acquiring, deploying, and maintaining resources; activities related to transforming resources into services, and activities related to producing changes in patient conditions and impacting health and organizational outcomes (Dubois et al., 2013).

This data-driven approach not only illuminates nursing and midwifery impact but also provides a foundation for enhancing remuneration packages that reflect their level of skill, dedication, and positive influence on healthcare outcomes. Furthermore, prioritizing the appropriate cost of nursing activities fosters a culture of continuous improvement, encouraging ongoing enhancements in healthcare delivery and outcomes (Keepnews, 2011). It encourages investments in professional growth, advanced education, and innovative approaches, which are advantageous for patients, healthcare institutions, and the broader society.

Nonetheless, it's crucial to heed the wisdom shared by Keepnews (2011, p. 3) over a decade ago, emphasizing that while recognizing nursing's economic worth is important, it should not overshadow the core human values integral to nursing such as caring, compassion, respect, advocacy, and social justice. Put differently, our push to quantify the economic worth of NM activities should not minimize the fundamental values of empathy, care, and compassion inherent in these professions. As we celebrate these important occasions, it remains crucial to acknowledge the pivotal role that nurses and midwives play in shaping efficient healthcare systems and to adopt strategies that uphold and reinforce their indispensable contributions (WHO, 2022).

As noted, one way to capture nursing and midwifery care activities is through quality care metrics and billing. Hospital billing and reimbursement policies often reflect priorities and valuations, including Human Resources for Health (HRH). During a recent visit to a sick friend, one of us naturally found herself examining the hospital bill and was struck by the stark contrast in value allocation across billable items. For context, the itemized bill included 58 charges ranging from syringes, infusion sets, medication, theater fees, anesthetist fees, admission fees, hospital room charges, nursing care, procedure fees, and surgeons' fees. Nursing care was charged at just 15,000/- per day (around $4 for 24 hours). In contrast, the overnight admission (room) was billed at 200,000/($55), anesthetist fees for a major procedure at 800,000/−($218), and the Surgeons’ fee at 1,500,000/- ($409).

After reviewing several other hospital bills from different city hospitals, we found that the highest charge for 24-hour nursing care was 100,000/- ($27). While there is no intention to advocate for hospitals to increase their prices to reflect the value added by nurses, this discrepancy prompted reflection on the complex value distribution in our healthcare systems. If these bills are any indication, it becomes apparent that the true value added by nursing care is significantly undervalued. Nursing care encompasses a range of responsibilities beyond tasks, such as symptom recognition, safe medication administration, fall prevention, symptom alleviation, first aid administration, bedside care including safe practices to prevent bedsores and secondary infections for long-stay patients, counseling, referrals, and collaboration with healthcare teams. Nurses serve as frontline advocates, meeting patients' physical, emotional, and psychological needs. Recognizing nurses' crucial role in patient outcomes and healthcare quality, hospital billing policies should accurately reflect the value of nursing care through fair compensation and resource allocation. Revisiting value distributions can also lead to more equitable practices and a culture of appreciation for nursing professionals' expertise and impact (Keepnews, 2011).

Following the examination of the hospital bills, we discussed them with other nonmedical colleagues and asked what they thought of the perceived value of different items based on their prices. They all emphasized the high value of the doctors, and the room, followed by services like x-rays, lab tests, medications et cetera, placing nursing care at the bottom of the pile. This highlights a prevalent mindset favoring tangible, costly items over essential but intangible services like nursing care. It raises concerns about the eventual disconnect between recognizing the indispensable role of nurses and midwives and potentially undervaluing their contributions in practice. Given that this was a somewhat high-level facility, we wonder if the response would have been different in a lower-level facility, where the rooms were basic, x-ray machines were unavailable, access to hospital sundries was nothing short of a miracle, and the only available service is nursing care, would nurses be more valued and appreciated then?

Even though nurses and midwives spend the most time with patients, organizations often overlook the revenue-generating potential of nursing care, viewing it as a liability rather than an asset. This mindset leads to disparities in how nurses are valued and compensated compared to other healthcare professionals. Subsequently, nurse leaders encounter challenges in advocating for fair pay and securing investments in and for nursing and midwifery. The traditional categorization of nursing care costs as fixed hospital overheads, for example, hinders the recognition of their true value. Similarly, health systems face challenges in correlating their established and growing quality care metrics in nursing and midwifery with both direct and indirect nursing care expenses. This situation inadvertently impacts workforce morale and complicates compensation negotiations.

Indeed, research demonstrates that traditional approaches fail to capture the value of nursing care in terms of:

Intangible Value: As noted, nursing care encompasses a range of responsibilities beyond direct patient care, including advocacy, education, and coordination of care. These aspects of nursing contribute immensely to patient outcomes and satisfaction but are often overlooked or undervalued when captured as fixed overhead costs.

Complexity of Nursing Work: Nursing work is multifaceted and dynamic, involving varying levels of intensity and complexity depending on patient acuity and care needs. Using simplistic metrics like hours per patient per day may fail to capture the nuanced nature of nursing care delivery.

Impact on Workforce Morale: When contributions are not properly recognized and valued, it can lead to frustration, burnout, and disengagement, ultimately affecting the quality of patient care. In many hospitals in Kampala, Uganda, for example, an expectant woman will typically see both a nurse/midwife and a gynecologist during each antenatal visit, and during delivery, both professionals are present. While the attending gynecologist receives a fixed fee of UGX 1,000,000, regardless of the outcome, nurses and midwives are not compensated based on their contribution but must rely on their regular salary. In contrast, other healthcare cadres receive payments based on the number of patients they attend to. This disparity in compensation contributes to feelings of underappreciation and impacts morale.

Negotiation and Advocacy: Without clear recognition of the true cost and value of nursing care, nurses have limited leverage when negotiating for competitive pay, benefits, and improved working conditions. As a result, many nurses in Uganda are forced to take on 2 to 3 jobs at different health centers just to make ends meet.

To address these challenges and foster a more equitable and sustainable approach, healthcare organizations must shift towards recognizing nursing as a profit center rather than just a cost center. This involves:

1. Implementing robust systems for capturing the full scope of nursing activities and outcomes, including both direct and indirect contributions to patient care and organizational success.

2. Engaging nurses and nurse leaders in decision-making processes related to resource allocation, staffing models, and performance metrics.

3. Investing in technologies and data analytics that enable accurate measurement and evaluation of nursing productivity, efficiency, and impact on outcomes.

4. Advocating for policies and practices that ensure fair compensation, professional development opportunities, and recognition of nursing expertise and contributions within the healthcare ecosystem.

As healthcare delivery evolves to prioritize team-based care, wellness, population health, care coordination, patient-centeredness, data analytics, and quality improvement, nurses are primed to drive and spearhead these transformative changes through various nurse-led services and interventions. (Salmond and Echevarria, 2017). Relatedly, as we continue to celebrate nurses and midwives globally, “mere accolades may not suffice” if there's a systemic gap between recognition and tangible support, especially in resource-limited settings like Uganda. There's a need for intentional actionable changes including revisiting remuneration policies, investing in professional development, improving working conditions, and fostering a culture of appreciation to truly elevate the status and compensation of nurses and midwives in healthcare systems. Our advocacy narratives must strive to make a compelling investment case for nurses and midwives to address these disparities and shift the paradigm toward recognizing their true value.

1. Dick, T.K., Patrician, P.A., & Loan, L.A. (2017). The Value of Nursing Care: A Concept Analysis. Nursing Forum, 52, 357–365.

2. Keepnews, D. M. (2011). Mapping the economic value of nursing. Commissioned by the WSNA Professional Nursing & Health Care Council Washington State Nurses Association, 6. Available at: https://cdn.wsna.org/assets/entry-assets/3215/economic-value-of-nursing-white-paper.pdf

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7. Clarke, I. (2019). Nursing Care Value: A Paradigm Shift in Healthcare Economics. Journal of Nursing Management, 27(5), 1063-1072

8. Institute for Healthcare Improvement. (2022). Nursing as a Profit Center: A Business Case for Investment in Nursing. IHI White Paper.

9. Dubois, C. A., D’Amour, D., Pomey, M. P., Girard, F., & Brault, I. (2013). Conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review. BMC Nursing, 12, 1-20. Available at: https://link.springer.com/article/10.1186/1472-6955-12-7

10. Lancet (2020). Unleashing the full potential of nursing. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32794-1/fulltext

Authors

Dr. Rose Clarke Nanyonga is an Associate Professor of Nursing Leadership, Management, and Policy and Vice-Chancellor at Clarke International University

Ms. Tracy Kobukindo Kamau is a Nurse & Public Health Specialist serving as Senior Manager of Education at Last Mile Health, where she supports efforts to strengthen the health system through the training of Frontline Health Workers, Community Health Workers, and Health System Leaders in Africa & Globally.