Balancing Quality Care and Cost Efficiency in Nursing Ethics

Introduction

As rising healthcare costs continue to pose problems for stakeholders in the health care industry, the question of how to solve this dilemma remains an elusive one. The trouble is that it is not just a question of cost—but also a question of how to balance quality care with efficiency of care in an industry where for-profit facilities seem increasingly to put profits before people, as opposed to putting people before profits. This is a tension that sits uncomfortably within a profession so inherently oriented toward helping those in need. While stakeholders understand that in order for professionals to provide quality care, and for patients to receive it, there must be some cost and some efficient system in place to expedite delivery, they must also recognize that a balance of quality and cost-efficiency must be achieved in order for the industry to remain viable over the long run (Sikka, Morath, & Leape, 2015). This paper discusses the problem of healthcare as an industry whose services have become nearly too expensive to be obtained by the people who need them most.

Background of the Key Ethical Issue

Provision 1 of the American Nurses Association (ANA) Code of Ethics states that "the nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems." As this is the first provision of the ANA Code of Ethics, it is worth focusing on—especially in light of the problem identified in this paper. It must be noted that the provision does not include a stipulation regarding the cost of care—that is, something like "so long as the patient can afford the expenses associated with the care received." Rather, the nurse's most prominent ethic within the Code is to demonstrate respect for every patient and to practice the art of nursing for every patient who comes for care. This ethical principle is critical to the nurse's sense of mission, self, and vision. Within it are the seeds of the Code's second and third provisions—namely that "the nurse's primary commitment is to the patient, whether an individual, family, group, or community" and that "the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient" (ANA, 2010).

The relevance of these three provisions within the ANA Code of Ethics to the issue of balancing quality care with efficiency of care is that each serves as a guide for how health care should be directed. Each puts the person at the center of the caregiving process. Not one of them mentions the for-profit nature of the industry today—mainly because the profit side of the business is not the nurse's concern. The concern of the nurse is to provide quality care for every patient; the nurse's concern is to put people before profits. This must be kept in mind by all stakeholders, for if the nurse is unable to fulfill this ethical provision for whatever reason—whether because healthcare costs have skyrocketed to the point where patients do not feel comfortable seeking care, or because healthcare facility administrators want care to be provided in a way that emphasizes maximizing profits instead of maximizing quality—the nurse and all other healthcare providers are very likely to experience low job satisfaction, as Sikka et al. (2015) point out in their study on the experience of providing care.

The ethical issue at play in the healthcare industry today is this all-important question of which should come first: the people or the profits? The latter should naturally flow from an appropriate level of attention given to the former—but in the highly corporatized business world of healthcare today, what gets deemed an "appropriate level of care" does not always correlate with the ethical provisions of the ANA Code of Ethics, primarily because effecting that correlation might cut into profits. Where there is no correlation, the healthcare provider is more than likely to feel dissatisfied in their role because the aim of the provider has been compromised. This is the essence of the ethical problem underlying the issue.

Scholarly Literature on the Quadruple Aim

Bodenheimer and Sinsky (2014) note that the Triple Aim of healthcare—"enhancing patient experience, improving population health, and reducing cost"—is a commonly accepted standard among healthcare practitioners, yet low patient satisfaction, poor health outcomes, and increased costs all appear to be the product of the current healthcare system (p. 573). In other words, far from achieving the aims that healthcare providers have in mind, the industry is actually seeing the exact opposite of what it intends to achieve. Sikka et al. (2015) propose a fourth aim: "improving the experience of providing care" (p. 608). This Quadruple Aim provides helpful context for the troubling situation in which the healthcare industry finds itself today: the experience of providing care has fallen to a standard below where it should be. Access to care is minimal for a substantial portion of patients; quality care is marred by nurse error, unaffordable treatment, high-cost prescriptions, and prescriptions that lead to addiction, among other problems (Kolodny, Courtwright, Hwang et al., 2015). The experience of providing care is falling short of what stakeholders expect.

Sikka et al. (2015) show that the poor experience is not limited to patients—it also affects providers: "the evidence that the healthcare workforce finds joy and meaning in work is not encouraging. In a recent physician survey in the USA, 60% of respondents indicated they were considering leaving practice; 70% of surveyed physicians knew at least one colleague who left their practice due to poor morale" (p. 609). Low morale among healthcare providers stems from a poor experience of providing care, and that poor experience is directly related to the problem of balancing quality care with cost-efficient delivery. In an industry increasingly focused on profits and costs, the importance of the patient-provider relationship is getting lost (Dowsett & Dowsett, 2015; Jennings, Clifford, Fox, O'Connell, & Gardner, 2015; Baummer-Carr & Nicolau, 2017). In order to provide an ethical solution that can help restore the balance between quality care and cost-efficiency, the research indicates that healthcare providers must be willing to put people before profits.

Ethical Principles Guiding the Issue

The ethical principles that guide this issue are that healthcare providers—and specifically nurses—are bound to provide quality care for every patient who comes to them, without regard for socioeconomic status. Implicit in this principle, which is explicitly stated in the ANA Code of Ethics' first three provisions, is the notion that nurses must deliver quality care wherever it is needed; people are the first priority of the nurse. This principle is, in today's healthcare industry, directly and inherently in conflict with the principle of business, which is to make money by minimizing costs. The problem and source of conflict is that in providing maximum quality care, the cost of that care cannot simply be quantified—at least not by a nurse who is truly dedicated to practicing the profession in accordance with the first three provisions of the ANA Code of Ethics. Unless the patient comes first in the practice of quality care, the nurse has no foundational reason to be there.

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