Maureen Bisognano, MSN
Executive Vice President & Chief Operating Officer
Institute for Healthcare Improvement
Dear Maureen,
What are your thoughts on the current compensation system nurses work under and how it impacts the quality of care provided? What types of incentives and changes to the compensation system can be made to encourage and recognize nurses for making improvements in health care?
— Christine Lui, RN, Nursing and Health Systems Leadership Graduate Student, UCSF School of Nursing / IHI Open School Chapter Leader
Dear Christine,
You raise a complex and intriguing question — one bound to raise both intellectual and emotional issues. Often, salary is based on the “difficulty” of a job, and may include an assessment of the physical demands, the intellectual preparation needed, the complexity of decision making required, and the emotional burdens of a given job. In many positions, just one of these demands puts a job in line for a certain pay grade, but, in my opinion, nursing rates very highly in all these dimensions of work life. On any given day, nurses are moving equipment, moving patients, assessing life-threatening symptoms, and responding to and consoling a bereaved family member. Over the past decade, nursing salaries have increased in recognition of the ever-increasing complexity of the work and as a result of nursing shortages in many areas.
On the question of incentives to encourage improvement, I feel quite strongly that incentivizing individual nurses to provide higher quality of care is a bad idea. My preference is to pay nurses fairly (at or above the market rate for job categories and experience) and to decouple pay and performance. Processes are often broken in health care organizations, and the increasing complexity of care is not easily measured. For the most part, nurses work very hard, often butting up against institutional barriers, and they perform well. The few who don’t need to be dealt with directly, but withholding a pay increase is an ineffective strategy for motivating those who underperform. So how would I encourage and recognize nurses for making improvements? I’d offer growth opportunities for learning more, developing new skills, and then reward nurses who take on new responsibilities.
Consider the fictional case of Sarah — an experienced nurse of five years, who capably manages care for the patients and families in her ICU. She may be ready and excited about leading an improvement project to eliminate VAPs and decrease infections. Sending Sarah to a course to learn how to lead an improvement team, and supporting her visit to the best ICU in the US (based on ICU performance measures) to learn about improved processes will energize Sarah, allow her to grow new skills and competencies, and demonstrate institutional support for those staff willing to improve.
I’d recognize nurses with exceptional interpersonal skills in a different way. Consider another fictional nurse, Ben. Ben is a career ER nurse who always supports patients and families during moments of crisis and who provides a supportive shoulder for his fellow staff. For Ben, you might develop a different plan. Ben loves to coach others and is always asked to share how he developed his unique competencies. A good development plan for Ben might include attending a basketball coaching course. The plan might also include senior-level guidance and support for the development, by Ben, of a course for other professionals who need to develop the special skills demonstrated by Ben.
So, a few principles to consider:
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Most nurses already work as hard as they can, and paying incentives alone cannot produce better quality. Nurses deserve fair pay rates and logical and streamlined work processes. Time and resources to learn, managerial support for building new skills, and opportunities to develop learning and competencies, are all strong drivers of improvement. Many nurses tell me that getting outside their normal environments (at conferences, site visits, affinity group meetings, and in professional organizations) allows them breathing room to learn, and the necessary supports to build new skills.
Join the discussion: What do you think are the best incentives for nurses to improve care?
Maureen Bisognano oversees all operations, program development, and strategic planning for the Institute for Healthcare Improvement. She began her career as a staff nurse at Quincy Medical Center in Massachusetts.
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