价值导向的护理实践：它是什么以及如何使其成为现实

分享智慧

共同成长

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Abstract

Nurses make decisions about the use of costly resources in countless care delivery settings 24 hours a day. Consequently, nurses are inseparably connected to not only the quality and safety of care, but to the cost-of-care as well. This article is Part 1 of a 6-part series on value-informed nursing practice. It describes the concept of ‘value-informed nursing practice’—practice that focuses not only on outcomes, but also on the cost of care—as a new way to envision nursing practice.

Browsing the inpatient admission list at the beginning of your shift, you notice that Mrs. X has been readmitted. Age 89, she is quite the character. You recall her calling herself, with glee, “The Noo Youk Goull,” insisting that she wear makeup and have her hair styled at all times! Today, however, Mrs. X is an unkempt, raw bundle of anxiety. You also recall Mrs. X's previous discharge planning focused on strategies to manage her relentless anxiety. As you enter her hospital room she is hyperventilating. She is tremulous. She remembers you: “I am having a heart attack this time, I am sure of it!” she implores. Looking at her heart monitor showing a normal sinus rhythm, you know that is not true. But, 12-lead EKG is standing orders, and it might calm her down… Plus, you have other patients to worry about, some of whom are very sick. Over the course of her 11 hour hospital stay, Mrs. X cycles in and out of hyperventilation and has three EKGs, all normal. When discharged, she and her family are relieved. “Everything was done for her,” they say. They are reassured by the number of tests. But you wonder whether the “everything” they are reassured by was too much.

 1

1This scenario is based on a true story experienced by one of the authors.

In health care, value is defined as the outcome of patient care provided, divided by the cost of resources used to achieve the outcome. High value care produces an improvement in patient outcomes while using the least amount of resources. Preventative care (e.g., vaccinations) is one example of high-value care. The vignette above, on the other hand, illustrates low-value care: multiple EKGs given to Mrs. X to calm her and her family's fears, tied up hospital resources with little to no improvement of Mrs. X's outcome. In the end, that element of Mrs. X's care was wasteful.

While low-value care care may seem innocuous—after all, no harm was done and Mrs. X and her family were reassured she was ok—provision of unnesessary, redundant services wastes valuable (and costly) health care resourses that could instead be used for other worthy causes. In our example, the repeat unnesessary testing made the equipment and technician time less available for other patients, potentially leading to delays in their diagnosis and treatment; while Mrs. X was occupying the room, an emergency room (ER) patient may have been waiting for an inpatient bed, and yet other patients may have been waiting for an ER bed. Aggregated across the U.S. health care system, such instances of wasteful use of health care resources add up to as much as $935 billion annually, with up to $286 billion being preventable through judicious use of resources. (

Shrank et al., 2019

) Instead of being wasted, this amount of money could provide full Medicaid coverage to all currently uninsured people in the U.S., or allow all U.S. hospitals to nearly double their nursing staff.

Because nurses make decisions about the use of costly resources in countless care delivery settings 24 hours a day, nurses are inseparably connected to not only the quality and safety of care, but to the cost-of-care as well. Additionally, nurses are the largest health profession—estimated 3.6 million in 2021—and among the highest-paid health professions. Consequently, we need a more comprehensive vision of nursing practice, one that holistically recognizes that nursing practice affects patients in two ways—directly, through care provided by a nurse to their patients, and indirectly, by tying up costly health care resources which could otherwise benefit the care of other patients. This article describes value-informed nursing practice—nursing practice that focuses not only on outcomes, but also on the cost of care (

Buerhaus & Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

)—as a new way to envision nursing practice.

The Economic Imperative

Given the low performance of the U.S. health care system and its exorbitant costs, the ongoing transition to value-based payment models was inevitable. For decades, a fee-for-service payment system incentivized overuse of human and other health care resources. Reimbursement based on the volume of services provided, with little regard for the patient outcome, created a clunky and unprecendlty costly health care system that eventually led to stagnating, even diminishing, health outcomes and unacceptable health disparities. Rising health care spending (currently 17.9% of the gross domestic spending or nearly 20 cents of every dollar spent in the U.S.) is a major problem facing U.S. individuals and families. The nation can no longer afford to ignore the true value of health care services, including costs, who pays for it, and how. Governmental and private payors are transitioning away from fee-for-service reimbursement and toward value-based payment, meaning that payments increasingly reflect quality and cost indicators; 40% of traditional Medicare, 30% of commercial payments, and 25% of Medicaid payments are made through some sort of value-based arrangements. The inclusion of cost considerations makes hospitals, nursing homes, and physician practices increasingly more accountable for both the quality and the cost of the services provided. Over the decade, nurses, too, can expect an increasing need to measure and improve the value of care in all practice settings, as cost, price, and provision of care will become increasingly transparent. Consequently, it is essential that nurses direct efforts toward controlling costs and improving the value of care. This shift means that nurses must learn to provide value-informed care that aligns with evolving payment systems, reduce waste and unnecessary costs, and better meet the needs of patients, families, communities, and the society-at-large.

What Does Value-Informed Nursing Practice Mean?

Value-informed nursing practice is practice that consistently incorporates the considerations of, both, the outcomes and the cost of resources required to achieve the outcomes, in clinical decision making. 

Buerhaus & Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

 In our opening paragraph, value-informed nursing practice would be to directly address the root-cause of the situation, Mrs. X's anxiety. Practicing value-informed nursing care would, therefore, help to avoid a chain reaction of repeat unnecessary testing, while doing no harm to Mrs. X; in fact, Mrs X may have learned some calming techniques and used them at home, possibly preventing unnessesary future readmissions.

Practicing value-informed nursing care means that the nurse carefully assesses the situation with an eye toward using resources effectively and judiciously. In Mrs. X's case, even though following routine protocols may have been a time-saving choice for the nurse at that moment, a careful consideration of the full chain of potential downstream consequences, and costs, may have led to a different clinical decision—one that would reduce overall resource use and cost, and improve patient outcomes.

A key part of value-informed nursing practice is being thoughtful about how a clinical decision in regards to one patient's care may impact the care of other patients. While nurses are not new to having to allocate their time among the many needs of their patients, it is important to remember that the downstream effects can impact patients beyond those directly assigned to your care. These other patients may experience their care delayed or lessened when the resources they need are tied up in the care to the patients immediately at hand. Though these other patients are ‘invisible’ to you at that moment, they are your colleagues’ patients and they may become your patients tomorrow, and so their needs and outcomes matter just as much as the patients’ directly in front of you right now. 

Eddy, 1996

) Value-informed nursing practice means being a judicious resource-user and using the smallest amount of resources required to achieve a desired outcome for your patients, as part of the ‘nursing lens.’ 

Buerhaus & Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

While discussing what value-informed nursing practice ‘is,’ it is equally important to stress what value-informed nursing practice ‘is not.’ Value-informed nursing practice does not, and should not, require that the nurse trades off the quality of care provided to a patient, in order to cut down the cost. In our vignette, addressing Mrs. X's anxiety without unnecessary testing likely would have provided the same or even better outcomes, given that the core problem of anxiety would have been more directly recognized and addressed. The primary objective value-informed nursing practice remains to deliver high-quality patient care, just doing so in a way that reduces or eliminates wasteful use of health care resources.

Currently, unnessessary testing and other overtreatment and/or low-value services constitue about 10% of the nearly one trillion dollar annual health care waste. (

Shrank et al., 2019

). The other two major sources of health care waste are administrative complexity (up to 35%) and care delivery and coordination failures (about 25%). (

Shrank et al., 2019

). Nursing already incorporates care coordination as part of nursing practice, with many research and quality-improvement efforts led by nurses to reduce coordination failures and streamline care processes (e.g., hospital-to-home tranisions, medication administration). However, addressing overtreatment, low-value care, and administrative complexity is not entirely in the nurses’ domain of influence and will require buy-in from administration and medicine. Nevetherless, nurses must begin to incorporate into their practice the responsibility to call-out low-value care and inefficient, cumbersome administrative processes that inhibit nurses' ability to provide coordinated, high-value patient care.

What Can Nurses Do To Make Value-Informed Nursing Practice a Reality?

Adopting a value-informed lens as part of nursing practice will need significant support from nursing leadership, educators, and researchers. Moving toward value-informed nursing practice will require transformational, courageous and resilient nursing leadership at the highest level. As evidenced by the continued barriers to full practice authority for advance practice nurses, nursing leaders will have to be ready to confront the political power of both medicine and administration. Nursing leaders must speak about the importance of value-informed care; they must encourage and elevate nurses who identify ways to promote efficient use of resources and cost-containment; and they also must be ready to support and safeguard nurses against potential retaliation. Nursing units must be staffed appropriately to allow nurses the bandwidth needed for critical evaluation of resource use and the delivery of value-informed care. Lastly, nurse leaders must ally with hospital administration and medicine to ensure a transparent and fair distribution of financial gains from nurse-initiated or nurse-led cost-saving reousrce-use innovations, and reinvestments of these gains back to the unit.

For nursing educators, it is crucial that nurses more deeply understand the factors that contribute to the value of health care, as well as reimbursement and expenditures connected to nursing care. Cost and value competencies must be incorporated as foundational to professional nursing practice. The 2021 Entry-level Essentials now include cost and efficiency as key elements of nursing practice—this is a significant development and a first step toward value-informed nursing education (

Yakusheva et al., 2021

We will discuss the role of educators in more detail in Part 6 of this Series 

Buerhaus & Yakusheva, 2022

Nursing researchers need to study how nurses can contribute to waste- and cost-reduction through their everyday practice. Although a robust body of evidence demonstrates the contribution of nursing to quality and safety outcomes, the extent to which nurses can reduce unnecessary use of resources and costs is largely unknown. Among other glaring evidence gaps are nurse-led approaches to social determinants of health and nurse actions to reduce exorbitant environmental hospital waste. Nursing science should address these important, feasible research questions to help control health care spending, reduce costs and increase the value of nurses 

Cohen et al., 2021

Conclusion

Value-informed nursing care is nursing practice that focuses not only on the outcomes but also on the costs of the care. Practicing value-informed nursing care means identifying and eliminating unnecessary, redundant, low-value care, and it requires practicing nurses, nursing leaders, nursing educators, and nursing researchers to work together to identify, scale-up, and disseminate innovative nursing practices to reduce waste, lower cost, and improve patient outcomes. In Part 2 of this series on value-informed nursing practice, we discuss the economic and policy drivers that necessitate the adoption of value-informed nursing practice.

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摘要

护士每天 24 小时就在无数护理提供环境中使用昂贵的资源做出决定。因此，护士不仅与护理质量和安全密切相关，而且与护理成本密切相关。本文是关于价值知情护理实践的 6 部分系列文章的第 1 部分。它描述了“以价值为导向的护理实践”的概念——这种实践不仅关注结果，还关注护理成本——作为设想护理实践的一种新方式。

全文

在轮班开始时浏览住院病人名单，您注意到 X 夫人已被重新接纳。89岁的她，很有个性。你记得她兴高采烈地称呼自己为“Noo Youk Goull”，坚持要她化妆并随时梳理头发！然而，今天，X 夫人是一个蓬头垢面、充满焦虑的原始人。您还记得 X 夫人之前的出院计划侧重于管理她无情的焦虑的策略。当你进入她的病房时，她正在过度换气。她颤抖着。她记得你：“我这次心脏病发作了，我确定！” 她恳求。看着她的心脏监护仪显示正常的窦性心律，你知道那不是真的。但是，12 导联心电图是常规的，它可能会让她平静下来……另外，你还有其他病人要担心，其中一些病人病得很重。在她 11 小时的住院期间，X 夫人循环进出过度换气，并进行了 3 次心电图检查，均正常。出院后，她和家人都松了一口气。“一切为她完成了，”他们说。他们对测试的数量感到放心。但是你想知道他们所放心的“一切”是否太多了。

1 此情景基于其中一位作者亲身经历的真实故事。

在医疗保健中，价值被定义为提供的患者护理结果除以用于实现结果的资源成本。高价值护理可以在使用最少资源的同时改善患者的治疗效果。预防性护理（例如疫苗接种）是高价值护理的一个例子。另一方面，上面的小插曲说明了低价值的护理：为 X 夫人和她的家人进行了多次心电图检查以平息她和她家人的恐惧，占用了医院资源，而 X 夫人的结果几乎没有改善。到头来，X夫人的那份关怀是浪费的。

虽然低价值的护理看起来无伤大雅——毕竟，没有造成任何伤害，而且 X 夫人和她的家人确信她没事——但提供不必要的、多余的服务会浪费宝贵的（且昂贵的）医疗资源，而这些资源本来可以被使用其他有价值的原因。在我们的示例中，重复不必要的测试使其他患者的设备和技术人员的时间减少，可能导致他们的诊断和治疗延误；当 X 夫人占用房间时，急诊室 (ER) 患者可能一直在等待住院病床，而其他患者可能一直在等待急诊病床。在整个美国医疗保健系统中，此类浪费医疗保健资源的事件每年总计高达 9350 亿美元，通过明智地使用资源可以预防高达 2860 亿美元。(Shrank 等人，2019) 这笔钱不会被浪费，而是可以为美国所有目前没有保险的人提供全面的 Medicaid 保险，或者让美国所有医院的护理人员增加近一倍。

由于护士每天 24 小时在无数护理提供环境中决定使用昂贵的资源，因此护士不仅与护理质量和安全密不可分，而且与护理成本密切相关。此外，护士是最大的卫生职业——2021 年估计为 360 万人——并且是收入最高的卫生职业之一。因此，我们需要对护理实践有一个更全面的认识，从整体上认识到护理实践以两种方式影响患者——直接通过护士为患者提供的护理，以及间接通过占用昂贵的医疗保健资源，否则有利于其他患者的护理。本文描述了以价值为导向的护理实践——不仅关注结果，而且关注护理成本的护理实践（比尔豪斯和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年)——作为设想护理实践的一种新方式。

经济势在必行

鉴于美国医疗保健系统的低绩效和高昂的成本，向基于价值的支付模式的持续过渡是不可避免的。几十年来，按服务收费的支付系统鼓励过度使用人力和其他医疗保健资源。基于提供的服务量的报销，几乎不考虑患者的结果，创建了一个笨重且前所未见的昂贵的医疗保健系统，最终导致健康结果停滞不前，甚至减少，以及不可接受的健康差距。不断增长的医疗保健支出（目前占国内总支出的 17.9% 或在美国花费的每一美元中的近 20 美分）是美国个人和家庭面临的主要问题。国家再也不能忽视医疗保健服务的真正价值，包括成本、谁支付以及如何支付。和成本指标；40% 的传统医疗保险、30% 的商业支付和 25% 的医疗补助支付是通过某种基于价值的安排进行的。成本考虑因素使医院、疗养院和医师实践越来越多地对所提供服务的质量和成本负责。在过去的十年中，护士也可以预期在所有实践环境中衡量和提高护理价值的需求越来越大，因为成本、价格和护理提供将变得越来越透明。因此，护士必须努力控制成本和提高护理价值。这种转变意味着护士必须学会提供与不断发展的支付系统相一致的价值导向型护理，减少浪费和不必要的成本，并更好地满足患者、家属。

价值知情的护理实践意味着什么？

价值知情的护理实践是在临床决策中始终考虑结果和实现结果所需的资源成本的实践。(比尔豪斯和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年) 在我们的开篇段落中，以价值为导向的护理实践将直接解决这种情况的根本原因，即 X 夫人的焦虑。因此，实行以价值为导向的护理将有助于避免重复不必要的测试的连锁反应，同时不会对 X 夫人造成伤害；事实上，X 夫人可能已经学会了一些让自己平静下来的技巧，并在家里使用它们，可能会防止未来不必要的再次入院。

实践价值知情护理意味着护士仔细评估情况，着眼于有效和明智地使用资源。在 X 夫人的案例中，尽管当时遵循常规方案对护士来说可能是一种节省时间的选择，但仔细考虑潜在的下游后果和成本的整个链条可能会导致不同的临床决定——一种可以减少总体资源使用和成本并改善患者预后的方法。

以价值为导向的护理实践的一个关键部分是考虑关于一个患者护理的临床决策如何影响其他患者的护理。虽然护士对于必须将时间分配给患者的众多需求并不陌生，但重要的是要记住，下游影响可能会影响到直接分配给您护理的患者之外的患者。当这些其他患者需要的资源被立即用于对患者的护理时，他们的护理可能会延迟或减少。尽管此时这些其他患者对您来说是“看不见的”，但他们是您同事的患者，他们明天可能会成为您的患者，因此他们的需求和结果与您现在直接在您面前的患者一样重要。

涡流，1996 以价值为导向的护理实践意味着作为“护理镜头”的一部分，成为明智的资源使用者，并使用最少的资源为您的患者实现预期结果。(比尔豪斯和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年)在讨论价值导向的护理实践“是”时，同样重要的是要强调价值导向的护理实践“不是”。价值知情的护理实践不会也不应该要求护士权衡为患者提供的护理质量，以降低成本。在我们的小插曲中，在没有不必要的测试的情况下解决 X 夫人的焦虑可能会提供相同甚至更好的结果，因为焦虑的核心问题会得到更直接的认识和解决。以价值为导向的主要目标护理实践仍然是提供高质量的患者护理，只是以减少或消除医疗保健资源浪费的方式这样做。目前，不必要的检测和其他过度治疗和/或低价值服务约占每年近 1 万亿美元的医疗保健浪费的 10%。(Shrank 等人，2019）

。医疗保健浪费的另外两个主要来源是行政复杂性（高达 35%）以及医疗服务提供和协调失败（约 25%）。(Shrank 等人，2019）。护理已经将护理协调作为护理实践的一部分，许多研究和质量改进工作由护士领导，以减少协调失败和简化护理流程（例如，医院到家庭的过渡、药物管理）。然而，解决过度治疗、低价值护理和行政复杂性问题并不完全属于护士的影响范围，需要行政和医学部门的支持。尽管如此，护士必须开始在他们的实践中纳入责任，即呼吁低价值护理和低效、繁琐的管理流程，这些流程会抑制护士提供协调的、高价值的患者护理的能力。

护士可以做些什么来使价值知情的护理实践成为现实？

在护理实践中采用价值导向的视角需要护理领导、教育工作者和研究人员的大力支持。迈向以价值为导向的护理实践将需要最高级别的变革性、勇敢和有弹性的护理领导。正如高级执业护士全面执业权限的持续障碍所证明的那样，护理领导者必须准备好面对医学和行政部门的政治权力。护理领导者必须谈论价值知情护理的重要性；他们必须鼓励和提拔那些发现方法来促进资源有效利用和成本控制的护士；他们还必须准备好支持和保护护士免受潜在的报复。护理单位必须配备适当的人员，以使护士能够获得对资源使用进行关键评估和提供价值知情护理所需的带宽。最后，护士领导必须与医院管理部门和医学部门结盟，以确保透明和公平地分配由护士发起或由护士主导的节约成本的资源使用创新所带来的财务收益，并将这些收益再投资回单位。

对于护理教育者来说，护士更深入地了解影响医疗保健价值的因素以及与护理相关的报销和支出至关重要。成本和价值能力必须作为专业护理实践的基础。2021 年入门级要点现在将成本和效率作为护理实践的关键要素——这是一项重大发展，也是迈向价值知情护理教育的第一步

（Yakusheva 等人，2021 年）。我们将在本系列的第 6 部分（比尔豪斯和雅库舍瓦，2022）。

护理研究人员需要研究护士如何通过日常实践为减少浪费和成本做出贡献。尽管有大量证据表明护理对质量和安全结果的贡献，但护士可以在多大程度上减少不必要的资源和成本使用在很大程度上是未知的。其他明显的证据差距包括以护士为主导的健康社会决定因素方法和护士为减少过高的环境医院浪费而采取的行动。护理科学应该解决这些重要的、可行的研究问题，以帮助控制医疗保健支出、降低成本并提高护士的价值。

（科恩等人，2021）。

结论

价值知情护理是一种护理实践，不仅关注结果，还关注护理成本。实践价值知情的护理意味着识别和消除不必要的、多余的、低价值的护理，它需要执业护士、护理领导者、护理教育者和护理研究人员共同努力，识别、扩大和传播创新的护理实践，以减少浪费、降低成本并改善患者治疗效果。在本系列关于价值知情护理实践的第 2 部分中，我们讨论了需要采用价值知情护理实践的经济和政策驱动因素。