STRATEGIES TO ENHANCE NURSING QUALITY: A PROPOSAL FOR HEALTH SYSTEM SUSTAINABILITYABSTRACT
Objective: to reflect on the relationship between the quality of nursing care and its costs through initiatives that strengthen the nursing profession.
Discussion: Advanced Practice Nursing improves access, coverage, and quality of care. Clinical Ladder Programs promote excellence and professional growth among nurses, with positive impacts on satisfaction and retention, and consequently, on the quality of care. Nursing-sensitive indicators allow for the monitoring of nursing-related outcomes and the impact of programs. Decisions regarding advanced practice and clinical ladder programs should consider opportunity costs and assess long-term cost-effectiveness. Solid evidence such as nursing-sensitive indicators and cost comparisons supports these decisions, including the optimization of nurse staffing.
Conclusion: investing in the nursing workforce prevents adverse events, improves satisfaction and quality of care, and reduces costs, achieving institutional sustainability and efficiency. Supporting decision-making with cost-effectiveness studies is essential for the incorporation of such nursing strategies.
DESCRIPTORS:
Nursing; Advanced practice nursing; Nursing care; Shared governance
RESUMEN
Objetivo: reflexionar sobre la relación entre la calidad de la atención de enfermería y los costos a partir de estas iniciativas que fortalezcan la enfermería.
Desarrollo: la Enfermería de Práctica avanzada mejora el acceso, la cobertura y la calidad de la atención. Los programas de escalonamento clínico promueven la excelencia y crecimiento de las enfermeras, con impactos positivos en satisfacción y retención y por ende en la calidad de la atención. Y los indicadores sensibles de cuidados de enfermería permiten hacer seguimiento de indicadores de enfermería y el impacto de los programas impartidos. La decisión sobre la práctica avanzada y programas de escalonamento clínico debe considerar el costo oportunidad y evaluar la rentabilidad a largo plazo. Evidencia sólida, como los indicadores sensibles de enfermería y comparativas de costos, permiten respaldar estas decisiones, como la optimización de la dotación de enfermería.
Conclusión: invertir en la fuerza laboral de enfermería previene eventos adversos, mejora satisfacción y calidad, y reduce costos, logrando sostenibilidad y eficiencia institucional. Justificar a los gestores que toman decisión, con estudios de costos, es esencial para la incorporación de estas estrategias propias de enfermería.
DESCRIPTORES:
Enfermería; Enfermería de práctica avanzada; Atención de enfermería; Gobernanza compartida
RESUMO
Objetivo: refletir sobre a relação entre a qualidade da assistência de enfermagem e seus custos, por meio de iniciativas que fortaleçam a profissão de enfermagem.
Discussão: A Enfermagem de Prática Avançada melhora o acesso, a cobertura e a qualidade do cuidado. Os Programas de Escalonamento Clínico promovem a excelência e o crescimento profissional das enfermeiras, com impactos positivos na satisfação, na retenção e, consequentemente, na qualidade da assistência. Os indicadores sensíveis à enfermagem permitem o monitoramento dos resultados relacionados ao cuidado e do impacto dos programas implementados. As decisões referentes à prática avançada e aos programas de escalonamento clínico devem considerar o custo de oportunidade e avaliar a relação custo-efetividade em longo prazo. Evidências sólidas, como os indicadores sensíveis à enfermagem e as comparações de custos, oferecem suporte a essas decisões, incluindo a otimização da alocação de profissionais de enfermagem.
Conclusão: investir na força de trabalho de enfermagem previne eventos adversos, melhora a satisfação e a qualidade do cuidado, e reduz custos, promovendo sustentabilidade e eficiência institucional. Fundamentar a tomada de decisão com estudos de custo-efetividade é essencial para a incorporação dessas estratégias próprias da enfermagem.
DESCRITORES:
Enfermagem; Prática Avançada de Enfermagem; Cuidados de Enfermagem; Governança Compartilhada de Enfermagem
INTRODUCTION
Performance of healthcare services, clinical quality, and efficient care delivery are important attributes for the success and sustainability of healthcare institutions, and continuous monitoring is essential in times of restrictive healthcare budgets worldwide. According to the Institute for Healthcare Improvement (IHI), the sustainability of health systems is based on the following: improving patient care experience in terms of quality and satisfaction; improving population health through the prevention and management of chronic and prevalent diseases; increasing caregiver satisfaction with their professional well-being; and reducing per capita healthcare costs1. In Latin American countries, where health policies are generally centered on Universal Health Coverage (UHC) and, in Brazil, on the Unified Health System (SUS), where service provision is shared between the private and public sectors, sustainability also depends on adequate financing, public policies that promote balanced integration between coexisting systems, and efficient management of technologies and human resources2.
In this context, the balance between patient-centeredness, professional satisfaction and well-being, and the rational use of finite resources is a key element not only for the preservation of institutions but also an opportunity to redesign health services, highlighting the "value" of nurses. Nurses represent crucial human capital due to the relevance of their work and their significant presence in the health workforce. The knowledge, skills, and abilities inherent in nursing education significantly benefit organizations3-6. Nurses are the primary link between the patient and the health system, and their comprehensive, preventive, and health-promoting approach contributes to improving the quality of care and ensuring equitable, timely, and effective management, especially in the context of chronic diseases1.
Nursing represents nearly 60 % of all healthcare professionals worldwide, constituting the majority group in the health field and performing essential work functions at all levels of care1. Therefore, nurses play a crucial role in health promotion and the delivery of care to the population. Comprehensive actions such as disease prevention, care delivery to vulnerable populations, and treatment management can contribute to objectives such as reducing mortality and increasing access to quality health care, thus directly aligning with the goals of Sustainable Development Goal (SDG) 3 - Good Health and Well-being7.
Furthermore, these professionals influence the financial aspects of healthcare institutions. Evidence shows that an increased proportion of nurses is associated with improved outcomes and potentially reduced hospital costs, while decreasing the proportion of nurses results in worse outcomes and higher costs7-8.
Nurses can also indirectly contribute to sustainable economic growth by improving health indicators, supporting vulnerable populations, and helping to empower communities. Healthier people can be more productive and contribute to job creation in their communities, potentially reducing inequalities and promoting social inclusion, thereby positively influencing SDG 87.
Therefore, it is essential to understand the complex relationship between quality and costs in the field of nursing practice to provide solid evidence for healthcare managers and policymakers on the value of nursing care through the analysis of profession-specific health technologies. Over the years, different strategies have emerged to enhance the competencies and expertise of nursing professionals and demonstrate their impact on the relationship between the quality of care provision and costs. These technologies include Nursing-Sensitive Indicators (NSIs), Advanced Practice Nursing (APN), and Clinical Ladder Programs. Accordingly, this study aims to explore the relationship between nursing care quality and costs through the use of these strategies that strengthen nursing practice.
Performance of healthcare services, clinical quality, and efficient care delivery are important attributes for the success and sustainability of healthcare institutions, and continuous monitoring is essential in times of restrictive healthcare budgets worldwide. According to the Institute for Healthcare Improvement (IHI), the sustainability of health systems is based on the following: improving patient care experience in terms of quality and satisfaction; improving population health through the prevention and management of chronic and prevalent diseases; increasing caregiver satisfaction with their professional well-being; and reducing per capita healthcare costs1. In Latin American countries, where health policies are generally centered on Universal Health Coverage (UHC) and, in Brazil, on the Unified Health System (SUS), where service provision is shared between the private and public sectors, sustainability also depends on adequate financing, public policies that promote balanced integration between coexisting systems, and efficient management of technologies and human resources2.
In this context, the balance between patient-centeredness, professional satisfaction and well-being, and the rational use of finite resources is a key element not only for the preservation of institutions but also an opportunity to redesign health services, highlighting the "value" of nurses. Nurses represent crucial human capital due to the relevance of their work and their significant presence in the health workforce. The knowledge, skills, and abilities inherent in nursing education significantly benefit organizations3-6. Nurses are the primary link between the patient and the health system, and their comprehensive, preventive, and health-promoting approach contributes to improving the quality of care and ensuring equitable, timely, and effective management, especially in the context of chronic diseases1.
Nursing represents nearly 60 % of all healthcare professionals worldwide, constituting the majority group in the health field and performing essential work functions at all levels of care1. Therefore, nurses play a crucial role in health promotion and the delivery of care to the population. Comprehensive actions such as disease prevention, care delivery to vulnerable populations, and treatment management can contribute to objectives such as reducing mortality and increasing access to quality health care, thus directly aligning with the goals of Sustainable Development Goal (SDG) 3 - Good Health and Well-being7.
Furthermore, these professionals influence the financial aspects of healthcare institutions. Evidence shows that an increased proportion of nurses is associated with improved outcomes and potentially reduced hospital costs, while decreasing the proportion of nurses results in worse outcomes and higher costs7-8.
Nurses can also indirectly contribute to sustainable economic growth by improving health indicators, supporting vulnerable populations, and helping to empower communities. Healthier people can be more productive and contribute to job creation in their communities, potentially reducing inequalities and promoting social inclusion, thereby positively influencing SDG 87.
Therefore, it is essential to understand the complex relationship between quality and costs in the field of nursing practice to provide solid evidence for healthcare managers and policymakers on the value of nursing care through the analysis of profession-specific health technologies. Over the years, different strategies have emerged to enhance the competencies and expertise of nursing professionals and demonstrate their impact on the relationship between the quality of care provision and costs. These technologies include Nursing-Sensitive Indicators (NSIs), Advanced Practice Nursing (APN), and Clinical Ladder Programs. Accordingly, this study aims to explore the relationship between nursing care quality and costs through the use of these strategies that strengthen nursing practice.
Nursing-Sensitive Indicators (NSIs)
Internationally, nursing services adopt indicators quantitative units of measurement to monitor and evaluate care provision and institutional activities. These data are used to assess process performance and improve outcomes over time9.
Nursing-Sensitive Indicators (NSIs) are used in different care contexts to portray the performance of nursing practices. They are objective and reliable criteria that link the quality of care with patient outcomes, distinguishing them from medical quality indicators9. NSIs were developed by combining Donabedian's conceptual model with discussions from the National Quality Forum (NQF) and the American Nurses Association (ANA)9. The combined conceptual model illustrates (Figure 1) the quality indicators in the field of nursing care and is composed of four categories: structure indicators, focused on the organizational structure; process indicators, focused on nursing interventions/processes; outcome indicators, focused on the nursing team; and outcome indicators, focused on the patient. According to Donabedian's proposal, these indicators are distributed along the structure, process, and outcomes axes, which exhibit dynamic behavior1.indicators, focused on the organizational structure; process indicators, focused on nursing interventions/processes; outcome indicators, focused on the nursing team; and outcome indicators, focused on the patient. According to Donabedian's proposal, these indicators are distributed along the structure, process, and outcomes axes, which exhibit dynamic behavior1.
Structure indicators refer to the organization of the team and the support provided for nursing practice, including the distribution, number, and qualifications of nursing professionals. This group includes metrics such as nursing work hours per patient per day, the ratio of nurses within the nursing team, the number of patients per nurse, and the qualifications of the nursing staff, among others10.
Process indicators reflect interactions between patients and care providers, as well as the functioning of specific care processes. They represent measures for assessing nursing care, including treatments and procedures, pain management, maintenance of skin integrity, and patient education10.
Outcome indicators are divided into patient outcomes and nursing staff outcomes. Patient outcome indicators reflect results associated with nursing care and include nosocomial infections, mortality, pressure injuries, patient and family satisfaction, falls, medication errors, length of hospital stay, and use of mechanical restraints, among others. Indicators related to nursing staff include job satisfaction, burnout, quality of care, and staff turnover10.
Evidence indicates that NSIs represent outcomes relevant to patient safety, quality of care, and the cost-effectiveness of nursing care11. Regarding structure indicators, a low proportion of nurses in the team and a high nursing workload have been associated with the occurrence of adverse events (AEs), longer hospital stays, readmissions, and patient mortality, as well as decreased professional satisfaction11. Heavy workloads may lead to unsafe care and omitted care due to time constraints. Too many activities may divert the professional's attention, increasing patients’ risk of experiencing AEs12-13.
Nursing staff shortages and heavy workloads have been associated with errors or failures in patient identification, documentation of medical history, inadequate supervision, falls, medication administration errors, pressure injuries, urinary tract infections, and mortality14.
An analysis of the impact of nurse staffing was conducted on seven NSIs, examining a total of 3.2 million hospitalizations in 900 German hospitals over a five-year period. NSIs related to pneumonia and respiratory failure were significantly associated with nurse staffing levels, followed by pressure injuries. However, few significant effects were found on mortality and hospital readmission9.
In Chile, nurse staffing and various NSIs were evaluated through a survey of 1,652 nurses and 2,013 patients from 40 hospitals, along with an analysis of discharge data from 761,948 patients4. The findings showed that nurse staffing was significantly associated with all outcomes, including mortality, while the work environment was linked to patient experience and nurses’ quality assessments. Additionally, each additional patient assigned to a nurse increased the rates of mortality, readmission, and length of stay. Patients in hospitals with 18 patients per nurse, compared to those with 8 patients per nurse, were 41 % more likely to die, 20 % more likely to be readmitted, and 68 % less likely to survive. Researchers estimated that the savings from fewer readmissions and shorter hospital stays would exceed the costs of hiring additional nurses by $1.2 million and $5.4 million, respectively if average caseloads were reduced to 12 or 10 patients per nurse4.
The literature has reinforced the relationship between nursing staff well-being and the quality and safety of care in intensive care settings. A meta-analysis15 identified that burnout among nurses is significantly associated with a weakened safety climate, lower perceived safety, and an increased number of adverse events such as medication errors, falls, nosocomial infections, and omissions of care. Furthermore, burnout was linked to lower levels of user satisfaction and a negative perception of the quality of care provided by the nursing team. These findings indicate that continued exposure to burnout compromises both clinical outcomes and the perceived quality and safety of the healthcare environment. The associations remained consistent across different regions, levels of training, and clinical specialties, including critical care. This body of evidence reinforces the need to prioritize organizational interventions aimed at improving nurses' working conditions as a key strategy for enhancing clinical outcomes and institutional sustainability.
Advanced Practice Nursing
The World Health Organization (WHO) promotes Advanced Practice Nursing (APN) as a means to expand healthcare access and coverage, particularly for vulnerable and remote populations, and to strengthen health systems. Although APN was originally developed in response to a shortage of medical personnel, it soon evolved into a distinct career path for nurses16.
According to the International Council of Nurses (ICN), an advanced practice nurse “is a generalist or specialist nurse who has acquired, through additional graduate education (minimum of a master’s degree), the expert knowledge base, complex decision-making skills, and clinical competencies for Advanced Nursing Practice, the characteristics of which are shaped by the context in which they are credentialed to practice.16” The core competencies of APNs include management, leadership, collaboration, communication, consultancy, mentoring, education, and research16. The most common APN roles are Clinical Nurse Specialist (CNS) in acute hospital settings and Nurse Practitioner (NP) in primary care.
A Clinical Nurse Specialist (CNS) holds a master's degree specific to advanced practice and provides specialized healthcare services to particular patient groups or populations. In addition to direct patient care, CNSs contribute indirectly through education, research, mentoring of nurses and other healthcare professionals, leadership, and clinical management. They are distinguished by a systemic approach and play a key role in promoting continuous improvement within healthcare organizations17.
A Nurse Practitioner (NP), in addition to holding at least a master’s degree, develops competencies in patient assessment and diagnosis, treatment, management, and follow-up. As a result, NPs are autonomous and have a broader scope of practice. They dedicate more time to clinical activities compared to CNSs, with a focus primarily on individuals, families, and communities rather than on healthcare systems. Their level of autonomy and responsibility is determined by the context of their country or setting and by regulatory policies, which vary across nations17.
Evidence suggests that APN enhances the quality of care delivery, improves outcomes for patients with chronic diseases, optimizes the use of health resources, and increases user satisfaction17. High-income countries have reported more favorable outcomes with APN compared to usual care in both primary healthcare and hospital settings. Positive outcomes associated with APN include improved patient satisfaction, better physical functioning, and more effective blood pressure control18. In intensive care settings, APN has been shown to reduce ICU length of stay, treatment time, costs, and mortality, while also promoting higher patient satisfaction19.
However, analyzing studies and comparing results is complex, as ICU APNs receive heterogeneous training, display varying competencies, and operate under national policies that differ in how the role is incorporated. For this reason, a study has been initiated in Europe to identify the skills and competencies an ICU APN should possess, grouping them into four pillars: advanced clinical practice, knowledge, leadership, and research (Chart 1)20. In Latin America, the development of this role is still incipient, with no regulatory or legislative mechanisms, officially recognized degrees, or specific master’s programs currently in place for its implementation.
In addition to establishing regulations for this practice, it is vital to develop a care model based on shared governance, involving collaboration and interaction with physicians and other professionals to overcome existing controversies regarding the development of an expanded role for nurses and address concerns regarding the perceived medicalization of the nursing profession. This includes the development of standards, protocols, and educational programs, with clearly defined interprofessional boundaries and roles21.
Studies such as RN4CAST, conducted in hospitals across four large states in the United States, have shown that a higher proportion of APNs on the nursing staff not only improves clinical outcomes but also enhances patient and nurse job satisfaction4. Furthermore, Medicare spending was significantly lower than the national median in hospitals with more APNs. Hospitals with more than 3 APNs per 100 beds spent an average of 5 % less per Medicare beneficiary than those with fewer than 1 APN per 100 beds. Additionally, patients in hospitals with higher APN-to-bed ratios had a lower likelihood of death, shorter hospital stays, and fewer readmissions.
Regarding the cost-effectiveness of the implementation of APN in various healthcare settings, results have shown that APN provides similar or superior effectiveness compared to conventional medical care in several clinical indicators, such as blood pressure, serum lipid levels, patient satisfaction, and quality of life in Primary Health Care (PHC)22. Overall, findings on cost-effectiveness are not conclusive, and the studies highlight several limitations, such as the wide variability in how the cost-effectiveness of APN is assessed18,22-23. However, evidence suggests that APN may positively influence long-term cost savings in the care of patients with chronic diseases by improving adherence to medical treatment, increasing attendance at follow-up visits, and promoting healthy lifestyles through longer consultations with a patient-centered approach and health education, resulting in better-informed patients18-19. Furthermore, the findings indicate that APNs have similar rates to physicians in ordering laboratory tests, diagnostic procedures, and referrals to specialists18,23.
Clinical Ladder Programs
The incorporation of Clinical Ladder Programs has been adopted in some countries as a strategy to promote the development of professional competencies, as well as to improve satisfaction and retention among nursing professionals24.
Clinical Ladder Programs are formal initiatives that promote excellence in clinical practice by recognizing nurses based on specific criteria related to clinical performance, continuing education, leadership, and research skills24. These programs function as healthcare technologies and innovations that reward nurses for their qualifications, competencies, research, and leadership abilities, positively influencing critical thinking and knowledge development in nursing practice. They also contribute to improved nurse satisfaction, higher staff retention rates, and better patient health outcomes. Conversely, the absence of Clinical Ladder Programs and limited opportunities for professional development have been identified as contributing factors to nurses’ job dissatisfaction and intention to leave their positions25.
The objectives of Clinical Ladder Programs are to (i) foster the professional growth and development of nurses, (ii) provide career opportunities for nurses who demonstrate advanced nursing knowledge and skills, (iii) promote autonomy and responsibility while remaining in a direct care role, and (iv) improve the recruitment and retention of nurses, ultimately leading to better patient care outcomes and a positive impact on healthcare organizations26.
Clinical Ladder Programs are based on Benner's Novice-to-Expert Theory, which was inspired by the Dreyfus Model of skill acquisition. The model proposes five stages of proficiency: novice, advanced beginner, competent, proficient, and expert. Benner adapted this framework for nursing, identifying five categories specific to the profession.
The success of these programs in improving clinical nurse satisfaction and retention was variable in the early years. However, as existing programs matured and incorporated improvements, participation in and acceptance of Clinical Ladder Programs increased26. Key improvements included clear delineation of performance expectations based on advancement levels, recognition of advanced practice, and acknowledgment of performance.
The job satisfaction of nurses who participated in Clinical Ladder Programs was positively and significantly correlated (r = 0.323; p < 0.01), and negatively and significantly correlated with turnover intention (r = -0.317; p = 0.01)27. When Clinical Ladder Programs incorporated mentoring, turnover decreased by nearly 75 %, and burnout decreased by 4 % among ICU nurses28.
Currently, hospitals that have adopted Clinical Ladder Programs continue to refine them and reduce barriers to participation, fostering a new understanding of their impact on nursing practice, job satisfaction, and motivation to engage in the programs.
Regarding financial investment, given that higher-level nurses earn higher salaries, it is important to assess the feasibility of incorporating them into the institution and justify this approach as an investment rather than an expense. Likewise, estimating the percentage of nurses that could be employed at each level is essential to project the potential increase in the salary budget. Initially, this strategy may appear counterproductive to efforts aimed at containing healthcare costs; however, in the long term, increased healthcare efficiency and improved patient outcomes lead to institutional savings especially considering that patient health indicators such as adverse events, readmissions, and length of hospital stay have a significant impact on healthcare costs5,6. Furthermore, cost studies indicate that savings from reduced turnover justify the salary increases associated with promotion programs29.
Moreover, financial incentives are not the only rewards that Clinical Ladder Programs aim to offer in attracting, retaining, and motivating talent. In addition to monetary compensation, total rewards include intangible benefits such as a positive work environment and quality of life, opportunities for professional advancement and recognition, work flexibility, teleworking, and flexible hours. Together, these elements create a value proposition designed to maximize employee commitment and engagement26.
Studies have shown that participation in Clinical Ladder Programs increased job satisfaction by 21 % and reduced turnover by 8.9 %28. Other researchers have evaluated the institutional cost-benefit of maintaining such programs, reporting an investment of $215,508 in a Clinical Ladder Program involving 295 nurses an annual investment of approximately $730 per nurse which was significantly lower than the estimated cost of $82,000 to replace a nurse who resigns30.
A review comparing nurse turnover rates and costs across four studies conducted in the United States, Canada, Australia, and New Zealand used the Nursing Turnover Cost Calculation Methodology (NTCCM) tool and found that a significant proportion of turnover costs were attributed to temporary replacement, regardless of the country. These findings highlight the importance of nurse retention31.
Turnover costs were higher in Australia ($48,790) due to termination and replacement expenses for temporary staff. Costs were nearly 50 % lower in the United States ($20,561), Canada ($26,652), and New Zealand ($23,711). The low nurse turnover associated with Clinical Ladder Programs is directly linked to Sustainable Development Goal 8, which promotes decent work and economic growth particularly by supporting job stability and economic efficiency32. Reduced turnover lowers the costs of recruiting and training new staff, allowing limited resources to be redirected to other areas of the organization.
In short, according to hospitals with decades of experience, fostering an organizational culture that supports the implementation of Clinical Ladder Programs and ensuring the presence of committed nurse leaders are essential to the success of these programs26.
CONCLUSION
Evidence indicates that investing in the quantity and quality of nursing human resources is a preventive measure against adverse events, readmissions, and unnecessary prolongation of hospital stays. Additionally, it can foster a quality work environment and greater job satisfaction, reduce turnover, and lower care-related costs, thereby enhancing a hospital’s organizational productivity and profitability.
However, the adoption of strategies such as the integration of Advanced Practice Nursing (APN) or Clinical Ladder Programs in practice requires healthcare institution leaders to make decisions within the constraints of limited budgets, taking into account opportunity costs that is, the value of the alternative foregone when choosing one option over another. Evidence-based decision-making presents a challenge for managers and policymakers at the organizational level, while also testing nursing leaders' ability to advocate for health innovations and technologies such as those discussed in this article. In addition to demonstrating the effectiveness of interventions and programs in improving clinical outcomes, patient and family safety, and satisfaction, it is essential to justify their cost-effectiveness. This enables decision-makers to adopt a broad value-based perspective when prioritizing financial resource allocation, considering the magnitude of benefits, the quality of the evidence, the impact on equity, budgetary implications, and organizational consequences of incorporating Clinical Ladder Programs, APN, and adequate nurse staffing. In the current context, nurses play a critical role in implementing strategies and technologies, strengthening health systems, and promoting economic and social development thereby making unique contributions to achieving the targets of SDG 3 and SDG 8.
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NOTES
Edited by
The data that support the findings of this study are available from the corresponding author, upon reasonable request.
