Thinking “outside the box”

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Much evidence supports that having more nurses leads to better patient outcomes. However, why is nurse staffing still lacking in practice? Previous studies on the nursing workforce have, so far, focused on determining “more nurses and better patient outcomes.” However, a controversial debate on the cost‐effectiveness of hiring more nurses still continues (Aiken, Cimiotti, Sloane, Smith, Flynn, & Neff, 2011). When it comes to nursing workforce policy‐materializing in practice, the inconclusiveness of nursing efficiency is considered to be one of the critical reasons for the failure to narrow the gap between the ideal and the real. How can we fix this two‐sided coin? The bottleneck is impeding us from moving forward from a “volume‐driven” to “value‐driven” healthcare delivery system. There is no more time for delay. We need to rethink this issue from a different angle.
To improve both the “efficiency” and “quality” of care, relentless and sustained small‐scale changes by multidisciplinary team‐led care delivery redesign operations are necessary to make a real difference (Bohmer, 2016). Such changes can transform the healthcare delivery system to be more value‐driven, justifiable and more effective. It is particularly critical that such operations build upon evidence‐based, informed shared decision‐making rationales among all parties comprising our healthcare delivery system. However, these rationales are absent from the current literature. Knowledge without a foundation in science might lead to muddled policy‐making.
A typical example is the Korean Ministry of Health & Welfare's “Comprehensive Nursing Care Services (Korean‐CNCS),” which refers to integrated nursing care services provided by professional nursing personnel only, without caregivers or carers. In Korea, there is a tradition that family member(s) or a hired carer(s) stays with the patient while he or she is in the hospital. However, it was discovered that the practice made effective and efficient infection control impossible. The care tradition was one of the reasons behind the 38 fatalities (a lethality rate of 20.4%) caused by the Middle East respiratory syndrome coronavirus in 2015 (Kim, 2015), whereupon the inception of the Korean‐CNCS began to emerge as the key solution.
The Korean‐CNCS first looked to satisfy everyone. Hospitals can use government grants to hire more nurses and provide better qualitative care including infection control. Caregivers can also lessen the burden of time as well as the physical and emotional stresses from exhaustive caring. In addition, caregivers can benefit from an insured caring cost from the Korean National Health Insurance Corporation. However, surprisingly, in February 2017, the Korean government retracted the original plan to expand the Korean‐CNCS to the whole country by 2018 (Shin, 2017). Why?
The number of nurses per 1,000 inhabitants in 2014 was 5.6 for Korea, which was about half the average of countries in the Organization for Economic Cooperation and Development (OECD) and even less than one‐third of Switzerland's 17.6 (OECD 2017a). Korea already has a significant shortage of nurses in practice; and what is worse, the Korean‐CNCS seems to make nurses’ working conditions more difficult. Four of five new nurses left their jobs because of the much heavier workloads caused by the Korean‐CNCS (Chae, 2016). In fact, the majority of newly hired nursing staff hold temporary positions (Kim, 2016). Furthermore, the Korean‐CNCS caused inequity in access to healthcare when urban hospitals absorbed the nurse staffing of local hospitals to get more government grants, which eventually led to the closure of the only emergency center in a certain rural area (Kim, 2017).
Bohmer's (2016) report shows that financial incentives actually did not lead to real change. Increasing the quota of nursing school entrants was also fruitless in meeting the demand of nurse staffing in practice (Shin, 2017).
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