During my 26 years of practicing nursing, I have frequently been baffled and frustrated by (and at odds with) administrators who seemed to lack compassion for others and make self-serving decisions that were detrimental to patients. As a clinician, I understood that administrators had to deal with nonclinical responsibilities such as budgets and staffing, but it often seemed as if they had forgotten that our ultimate goal was patient care.
Several years ago, I decided that administrators and clinicians do not speak the same language and that effective communication between these two groups would require a bilingual vocabulary. To this end, in 2003 I began taking prerequisite courses to obtain a master’s of business administration (MBA) and entered an MBA program in the fall of 2008. My experience thus far has persuaded me that more than language separates these groups; there is a fundamental difference in perceptual framework.
In my first MBA course, managerial economics, I noted a dramatic change in perspective from my undergraduate business courses, which addressed broad principles. The focus was overwhelmingly on two concepts: maximizing profit and minimizing cost. Although we learned various methods of processing and evaluating information, these two principles were the lens through which all topics and decisions were viewed.
Many years ago, hospital administrators were physicians and nurses. These individuals rose gradually through the ranks of their respective professions by demonstrating leadership, management, and clinical skills. As our health care system has become more complex, there has been a major shift toward hospitals and nursing homes being run by individuals trained in business, such as MBA programs.
Although clinicians try to provide the best possible service to every individual, their efforts are sometimes thwarted by limitations of time and other resources. To maximize the effectiveness of our working hours, learning to prioritize is one of the major tasks of nursing students and graduate nurses.
Chief executive and operating officers of health care organizations often have MBA degrees and are therefore educated to obtain the greatest possible profit margin (Kaplan, 2006; Knox, Blankmeyer, & Stutzman, 2004; Rivers, 2006). While providing health care value for patients and insurers and maximizing efficiency are important ingredients in profit maximization, the ideal or appropriate patient care is not always the most cost effective or profitable (Weech-Maldonado, Neff, & Mor, 2003). This creates a tension, and sometimes an incompatibility, between the profit-maximization imperative of business education and the optimal care values of nursing (Meliones, 2000).
I recently encountered a conflict between appropriate patient care and financial considerations. An elderly woman required passive range of motion for contracture prevention. Insurance covered only minimal care by physical therapy, and the nursing home administration was resistant to assume a greater level of caregiving without additional reimbursement. (An interesting side note to this is that contracture prevention, although not part of the nursing home’s protocol, is mandated by state law.) Providing such care is not necessarily cost effective.
Some might postulate that nurses can best address conflicts with administrators by working within systems to advocate for quality patient care. However, when the goals of profit maximization and improving the health of patients conflict, decisions are ultimately made by administrators, who prioritize profit. Therefore, nurses need to use individual and collective power to put pressure on organizations and society to not treat the health of individuals as a commodity, such as a house, car, or piece of furniture to be sold to those who can afford it.
As one of the most trusted (Harris Interactive, 2006; MilitaryConnection.com, n.d.; “Nurses Remain,” 2003) and largest (U.S. Department of Labor, Bureau of Labor Statistics, 2007) professional groups in the nation, nurses are in a unique position to influence the current discussion about the future of health care in the United States. Nurses need to educate people that the number one reason for bankruptcy in the United States—accounting for approximately 50% of filings—is exorbitant health care bills (Himmelstein, Warren, Thorne, & Woolhandler, 2005; “Medical Bills,” 2005).
Nurses should assume fiscal, political, and leadership roles that put external pressure on pharmaceutical companies, hospital systems, insurers, and other health-related agencies to balance profit with quality care. Specifically, serving on governmental regulatory or policy-making task forces or boards would be a beneficial strategy. In addition, nurses may use these same strategies to change expensive and onerous governmental regulations associated with the Minimum Data Set, Medicare, and Medicaid. Too often, these regulations create significant bureaucratic costs and do not result in improved patient care.
It would be overly simplistic and inaccurate to suggest or conclude that all administrators value profit to the exclusion of patient care, or that all clinical nurses are selfless martyrs; individual traits and values range across a spectrum. But it is important to understand that these groups come from different, and sometimes conflicting, educational perspectives.
Tension between administrators and clinicians is inevitable (Meliones, 2000). In such a work environment, mutual respect is necessary, and compromises are made by both sides. In the long term, however, there may be an irreconcilable difference between the goals of quality patient care and corporate profit. Trauma patients (Christensen, Nielsen, Ridley, Lecky, & Morris, 2008; “An Ounce of Prevention,” 2006; St. Peter, Calkins, Holcomb, Snyder, & Ostlie, 2008), burn cases (Griffiths et al., 2006; Mashreky et al., 2008), and chronically ill patients (Decker, Schappert, & Sisk, 2009; Paez, Zhao, & Hwang, 2009) are often money losers. Our societal priorities in health care remain ill defined and contradictory.
I believe the nursing model of “patients first” is superior to the MBA model of “profit first.” Although fiscal responsibility is necessary, the goal should be maximizing the health of our society, not increasing a pharmaceutical or hospital corporation’s stock value. As insiders within our evolving health care system, nurses have the opportunity to educate patients and others about the ways these conflicts influence them and to assume leadership roles in balancing patient care with profit.
Lisa L. Onega, PhD, RN, CNS
Professor, Clinical Nurse Specialist
Coordinator, and Graduate Coordinator
Radford University School of Nursing
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