Nurses and hospital leaders have mixed attitudes toward performance-based incentives as a way to improve outcomes and lower costs, according to a recent survey study. Although survey respondents held generally favorable views of incentive programs as a means of improving the safety and quality of care, they expressed concern that such programs would increase "the burden and the blame for nurses without corresponding improvements in staffing levels, work environment, salaries, or turnover."
Researchers led by Ellen T. Kurtzman, an assistant research professor at the George Washington University School of Nursing, analyzed 75 open-ended interviews conducted in 24 U.S. hospitals from June to October 2008. Respondents also filled out short surveys. The interviews and questionnaires focused on the perceived effects of performance-based incentives on hospitals and nurses, with a particular emphasis on Medicare's hospital-acquired conditions policy, which went into effect in October 2008.
Twenty-four interviewees were unit nurses, including staff nurses and managers. Among the hospital leaders interviewed were 45 hospital executives and eight board members.
Hospitals were carefully chosen to include a wide range of institutional characteristics, such as size, ownership, and location, and included hospitals in states that report nursing performance, hospitals that have Magnet status, and hospitals whose nurses are members of labor unions.
The results indicated that the respondents saw performance incentives as "a mixed blessing, with potential benefits for patients but potentially serious, negative consequences for nurses." The two most common interview responses, both mentioned by approximately 22% of respondents, focused on the various beneficial effects of incentives on the quality of care and concerns about the financial impact of incentives, such as possible cuts in staffing and greater workloads. The researchers noted that "nearly all respondents recognized the hospital-acquired conditions rule's likely impact on increasing the complexity of admissions assessments and, predictably, the documentation burden."
The question of whether nursing performance should be linked with incentives evoked some strong emotions. "On the whole, people thought it was a reasonable idea to pursue. I thought I was going to find much more opposition to it," Kurtzman said. But she also noted that a small number of respondents—predominately staff nurses—had the most negative reaction to the idea. "Those people said, 'Hey, listen: I already get paid to deliver high quality. To suggest that more money is going to change what I do is, frankly, insulting.' They were morally opposed to the idea."
Although nurses and hospital leaders strongly agreed that nurses are essential to the success of incentive programs, Kurtzman said both groups "thought that when there were penalties, the blame would fall on nurses. That was a very strong finding and should be troubling to the nursing community."
To ensure favorable outcomes while protecting nurses from negative consequences of incentive programs, the researchers made several recommendations: invest in education, infrastructure, information and decision-support technology, and additional staff; strengthen collaborative teamwork to make work environments less punitive, more egalitarian; empower nurses to take leadership roles in policy development and implementation; and assess costs and benefits.
In discussion, Kurtzman wasn't afraid to sound a warning, saying that the incentive strategy "will fail, unless it takes into account a workforce of three million people who are prepared to deliver higher quality care."—James M. Stubenrauch