价值导向的护理在实践中：它是什么以及如何使其成为现实

High value care produces an improvement in patient outcomes while using the least amount of resources. Preventative care (e.g., vaccinations) is one example of high-value care. The vignette above, on the other hand, illustrates low-value care: multiple EKGs given to Mrs. X to calm her and her family's fears, tied up hospital resources with little to no improvement of Mrs. X's outcome. In the end, that element of Mrs. X's care was wasteful.

While low-value care care may seem innocuous—after all, no harm was done and Mrs. X and her family were reassured she was ok—provision of unnesessary, redundant services wastes valuable (and costly) health care resourses that could instead be used for other worthy causes. In our example, the repeat unnesessary testing made the equipment and technician time less available for other patients, potentially leading to delays in their diagnosis and treatment; while Mrs. X was occupying the room, an emergency room (ER) patient may have been waiting for an inpatient bed, and yet other patients may have been waiting for an ER bed. Aggregated across the U.S. health care system, such instances of wasteful use of health care resources add up to as much as $935 billion annually, with up to $286 billion being preventable through judicious use of resources. (

Shrank et al., 2019

) Instead of being wasted, this amount of money could provide full Medicaid coverage to all currently uninsured people in the U.S., or allow all U.S. hospitals to nearly double their nursing staff.

Because nurses make decisions about the use of costly resources in countless care delivery settings 24 hours a day, nurses are inseparably connected to not only the quality and safety of care, but to the cost-of-care as well. Additionally, nurses are the largest health profession—estimated 3.6 million in 2021—and among the highest-paid health professions. Consequently, we need a more comprehensive vision of nursing practice, one that holistically recognizes that nursing practice affects patients in two ways—directly, through care provided by a nurse to their patients, and indirectly, by tying up costly health care resources which could otherwise benefit the care of other patients. This article describes value-informed nursing practice—nursing practice that focuses not only on outcomes, but also on the cost of care (

Buerhaus Co Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

)—as a new way to envision nursing practice.

The Economic Imperative

Given the low performance of the U.S. health care system and its exorbitant costs, the ongoing transition to value-based payment models was inevitable. For decades, a fee-for-service payment system incentivized overuse of human and other health care resources. Reimbursement based on the volume of services provided, with little regard for the patient outcome, created a clunky and unprecendlty costly health care system that eventually led to stagnating, even diminishing, health outcomes and unacceptable health disparities. Rising health care spending (currently 17.9% of the gross domestic spending or nearly 20 cents of every dollar spent in the U.S.) is a major problem facing U.S. individuals and families. The nation can no longer afford to ignore the true value of health care services, including costs, who pays for it, and how. Governmental and private payors are transitioning away from fee-for-service reimbursement and toward value-based payment, meaning that payments increasingly reflect quality and cost indicators; 40% of traditional Medicare, 30% of commercial payments, and 25% of Medicaid payments are made through some sort of value-based arrangements. The inclusion of cost considerations makes hospitals, nursing homes, and physician practices increasingly more accountable for both the quality and the cost of the services provided. Over the decade, nurses, too, can expect an increasing need to measure and improve the value of care in all practice settings, as cost, price, and provision of care will become increasingly transparent. Consequently, it is essential that nurses direct efforts toward controlling costs and improving the value of care. This shift means that nurses must learn to provide value-informed care that aligns with evolving payment systems, reduce waste and unnecessary costs, and better meet the needs of patients, families, communities, and the society-at-large.

What Does Value-Informed Nursing Practice Mean?

Value-informed nursing practice is practice that consistently incorporates the considerations of, both, the outcomes and the cost of resources required to achieve the outcomes, in clinical decision making.

Buerhaus Co Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

In our opening paragraph, value-informed nursing practice would be to directly address the root-cause of the situation, Mrs. X's anxiety. Practicing value-informed nursing care would, therefore, help to avoid a chain reaction of repeat unnecessary testing, while doing no harm to Mrs. X; in fact, Mrs X may have learned some calming techniques and used them at home, possibly preventing unnessesary future readmissions.

Practicing value-informed nursing care means that the nurse carefully assesses the situation with an eye toward using resources effectively and judiciously. In Mrs. X's case, even though following routine protocols may have been a time-saving choice for the nurse at that moment, a careful consideration of the full chain of potential downstream consequences, and costs, may have led to a different clinical decision—one that would reduce overall resource use and cost, and improve patient outcomes.

A key part of value-informed nursing practice is being thoughtful about how a clinical decision in regards to one patient's care may impact the care of other patients. While nurses are not new to having to allocate their time among the many needs of their patients, it is important to remember that the downstream effects can impact patients beyond those directly assigned to your care. These other patients may experience their care delayed or lessened when the resources they need are tied up in the care to the patients immediately at hand. Though these other patients are ‘invisible’ to you at that moment, they are your colleagues’ patients and they may become your patients tomorrow, and so their needs and outcomes matter just as much as the patients’ directly in front of you right now.

Eddy, 1996

) Value-informed nursing practice means being a judicious resource-user and using the smallest amount of resources required to achieve a desired outcome for your patients, as part of the ‘nursing lens.’

Buerhaus Co Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

While discussing what value-informed nursing practice ‘is,’ it is equally important to stress what value-informed nursing practice ‘is not.’ Value-informed nursing practice does not, and should not, require that the nurse trades off the quality of care provided to a patient, in order to cut down the cost. In our vignette, addressing Mrs. X's anxiety without unnecessary testing likely would have provided the same or even better outcomes, given that the core problem of anxiety would have been more directly recognized and addressed. The primary objective value-informed nursing practice remains to deliver high-quality patient care, just doing so in a way that reduces or eliminates wasteful use of health care resources.

Currently, unnessessary testing and other overtreatment and/or low-value services constitue about 10% of the nearly one trillion dollar annual health care waste. (

Shrank et al., 2019

). The other two major sources of health care waste are administrative complexity (up to 35%) and care delivery and coordination failures (about 25%). (

Shrank et al., 2019

). Nursing already incorporates care coordination as part of nursing practice, with many research and quality-improvement efforts led by nurses to reduce coordination failures and streamline care processes (e.g., hospital-to-home tranisions, medication administration). However, addressing overtreatment, low-value care, and administrative complexity is not entirely in the nurses’ domain of influence and will require buy-in from administration and medicine. Nevetherless, nurses must begin to incorporate into their practice the responsibility to call-out low-value care and inefficient, cumbersome administrative processes that inhibit nurses' ability to provide coordinated, high-value patient care.

What Can Nurses Do To Make Value-Informed Nursing Practice a Reality?

Adopting a value-informed lens as part of nursing practice will need significant support from nursing leadership, educators, and researchers. Moving toward value-informed nursing practice will require transformational, courageous and resilient nursing leadership at the highest level. As evidenced by the continued barriers to full practice authority for advance practice nurses, nursing leaders will have to be ready to confront the political power of both medicine and administration. Nursing leaders must speak about the importance of value-informed care; they must encourage and elevate nurses who identify ways to promote efficient use of resources and cost-containment; and they also must be ready to support and safeguard nurses against potential retaliation. Nursing units must be staffed appropriately to allow nurses the bandwidth needed for critical evaluation of resource use and the delivery of value-informed care. Lastly, nurse leaders must ally with hospital administration and medicine to ensure a transparent and fair distribution of financial gains from nurse-initiated or nurse-led cost-saving reousrce-use innovations, and reinvestments of these gains back to the unit.

For nursing educators, it is crucial that nurses more deeply understand the factors that contribute to the value of health care, as well as reimbursement and expenditures connected to nursing care. Cost and value competencies must be incorporated as foundational to professional nursing practice. The 2021 Entry-level Essentials now include cost and efficiency as key elements of nursing practice—this is a significant development and a first step toward value-informed nursing education (

Yakusheva et al., 2021

We will discuss the role of educators in more detail in Part 6 of this Series

Buerhaus Co Yakusheva, 2022

Nursing researchers need to study how nurses can contribute to waste- and cost-reduction through their everyday practice. Although a robust body of evidence demonstrates the contribution of nursing to quality and safety outcomes, the extent to which nurses can reduce unnecessary use of resources and costs is largely unknown. Among other glaring evidence gaps are nurse-led approaches to social determinants of health and nurse actions to reduce exorbitant environmental hospital waste. Nursing science should address these important, feasible research questions to help control health care spending, reduce costs and increase the value of nurses

Cohen et al., 2021

Conclusion

Value-informed nursing care is nursing practice that focuses not only on the outcomes but also on the costs of the care. Practicing value-informed nursing care means identifying and eliminating unnecessary, redundant, low-value care, and it requires practicing nurses, nursing leaders, nursing educators, and nursing researchers to work together to identify, scale-up, and disseminate innovative nursing practices to reduce waste, lower cost, and improve patient outcomes. In Part 2 of this series on value-informed nursing practice, we discuss the economic and policy drivers that necessitate the adoption of value-informed nursing practice.

简短翻译（请注意）

简短

看护每天 24 时长就在无数保健包含状况之中运使用价格昂贵的能源得出得出结论决定。因此，看护不仅与保健能量密度和公共安全众所周知，而且与保健可靠性众所周知。本文是关于更为重要性性理睬保健实证的 6 大多前传文章的第 1 大多。它刻画了“以更为重要性性为应运而生的保健实证”的表达方式——这种实证不仅重视结果，还重视保健可靠性——作为想法保健实证的一种新的方式为。

简短

在轮班开始时Flickr中风产妇剔除，您比如真是 X 外孙女已被重新的接纳。89岁的她，很有气质。你忘记她兴很高采烈地称呼自己为“Noo Youk Goull”，坚持要她化妆并随时推敲头发！然而，现今，X 外孙女是一个蓬头垢面、充满焦虑的原始人。您还忘记 X 外孙女此前的出院计划侧重于管理者她狡猾的焦虑的策略。当你离开她的手术室时，她正在过分导流。她颤抖着。她忘记你：“我这次肺癌心脏病了，我确定！” 她哀求。看着她的胸腔监护仪显示但就会的窦性心律，你知道那不是知道。但是，12 导联检测器是常规的，它似乎让她平静下来……另外，你还有其他产妇要恐怕，其之中一些产妇病得很重。在她 11 时长的中风期间，X 外孙女循环进出过分导流，并来进行了 3 次检测器公共安全检查，均但就会。出院后，她和丈夫都泽了再一。“一切为她完毕了，”他们真是。他们对探测的量沮丧急切。但是你想知道他们所急切的“一切”否太少了。

1 此情景基于其之中一位所作亲身经历的真实故事。

在保健之中，更为重要性性被定义为包含的病患保健结果总和使用做到结果的能源可靠性。很高更为重要性性保健可以在运使用最多能源的同时强化病患的外科手术视觉效果。持续性性保健（例如诊疗）是很高更为重要性性保健的一个举例。另一方面，右边的小片尾曲真是明了很低更为重要性性的保健：为 X 外孙女和她的丈夫来进行了多次检测器公共安全检查以平息她和她丈夫的恐惧，清空了疗养院能源，而 X 外孙女的结果近乎无法强化。终究，X外孙女的那份关怀是耗费的。

虽然很低更为重要性性的保健看起来无伤大雅——显然，无法造成任何伤害，而且 X 外孙女和她的丈夫确信她没事——但包含可能就会的、多余的一站式就会耗费难得的（且价格昂贵的）保健能源，而这些能源无论如何可以被运使用其他有更为重要性性的因素。在我们的示例之中，反复可能就会的探测使其他病患的设备和技术医护人员的等待时间降很低，似乎所致他们的病因和外科手术延误；当 X 外孙女清空卧室时，急诊室 (ER) 病患似乎一直在等待中风病床，而其他病患似乎一直在等待急诊病床。在整个American保健子系统之中，此类耗费保健能源的事件每年总计很高很高达 9350 亿美元，通过早先地运使用能源可以持续性很高很高达 2860 亿美元。(Shrank 等人，2019) 这笔借钱不就会被耗费，而是可以为American所有迄今无法保险的人包含进一步的 Medicaid 保险，或者让American所有疗养院的保健医护人员增高有约一倍。

由于看护每天 24 时长在无数保健包含状况之中决定运使用价格昂贵的能源，因此看护不仅与保健能量密度和公共安全密不可分，而且与保健可靠性众所周知。此外，看护是较大的健康职业——2021 年估算为 360 所到之处——并且是利润最很高的健康职业之一。因此，我们只能够对保健实证有一个不够进一步的熟识，从既有上熟识到保健实证以两种方式为负面影响病患——并不需要通过看护为病患包含的保健，以及间接通过清空价格昂贵的保健能源，否则有利于其他病患的保健。本文刻画了以更为重要性性为应运而生的保健实证——不仅重视结果，而且重视保健可靠性的保健实证（格林露西和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年)——作为想法保健实证的一种新的方式为。

经济发展未来将会

鉴于American保健子系统的很多余益和很高昂的可靠性，向基于更为重要性性的缴交方式为上的持续过渡时期是不太可能的。几十年来，按一站式收费的缴交子系统鼓励过分运使用人力和其他保健能源。基于包含的一站式量的缺席，近乎不再考虑病患的结果，成立了一个笨重且前所未见的价格昂贵的保健子系统，最终所致肥胖结果困难重重，甚至降很低，以及不可做的肥胖落差。不断增高的保健开支（迄今占国内总开支的 17.9% 或在American花费的每一美元之中的有约 20 美分）是American其所和家庭面临的主要情况。国家所再一忽视保健一站式的显然更为重要性性，包含可靠性、谁缴交以及如何缴交。和可靠性指标；40% 的传统习俗保健保险、30% 的商业缴交和 25% 的保健编列缴交是通过某种基于更为重要性性的亦需来进行的。可靠性再考虑心理因素使疗养院、疗养院和护士实证越来越多地对所包含一站式的能量密度和可靠性负责。在过去的十年之中，看护也可以预期在所有实证状况之中量化和提很高保健更为重要性性的只消费越来越大，因为可靠性、价格和保健包含将变得越来越光亮。因此，看护才就会努力依靠可靠性和提很高保健更为重要性性。这种转变假定看护才就会学就会包含与不断发展的缴交子系统保持一致的更为重要性性应运而生型保健，降很低耗费和可能就会的可靠性，并不够好地做到病患、亲属。

更为重要性性理睬的保健实证假定什么？

更为重要性性理睬的保健实证是在诊疗决策者之中自始至终再考虑结果和做到结果所只需的能源可靠性的实证。(格林露西和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年) 在我们的这段话段落之中，以更为重要性性为应运而生的保健实证将并不需要彻底解决这种情况的根本因素，即 X 外孙女的焦虑。因此，推行以更为重要性性为应运而生的保健将有助于避免反复可能就会的探测的有毒气体，同时不就会对 X 外孙女造成伤害；事实上，X 外孙女似乎早就学就会了一些让自己平静下来的擅长，并在家里运使用它们，似乎防止未来可能就会的再次康复。

实证更为重要性性理睬保健假定看护正确地指标情况，具体内容理论上和早先地运使用能源。在 X 外孙女的案例之中，尽管当时遵循常规方案对看护来真是似乎是一种节省等待时间的选择，但正确地再考虑潜在的北岸后果和可靠性的整个链条似乎所致不同的诊疗决定——一种可以降很低相比之下能源运使用和可靠性并强化病患预后的方法。

以更为重要性性为应运而生的保健实证的一个更为重要大多是再考虑关于一个病患保健的诊疗决策者如何负面影响其他病患的保健。虽然看护对于才就会将等待时间相应给病患的众多只消费并不一定熟悉，但更为重要性的是要做到，北岸负面影响似乎负面影响到并不需要相应给您保健的病患之外的病患。当这些其他病患只能够的能源被赶紧使用对病患的保健时，他们的保健似乎延迟或降很低。尽管此时这些其他病患对您来真是是“看不见的”，但他们是您威尔森的病患，他们明天似乎已是您的病患，因此他们的只消费和结果与您今日并不需要在您面前的病患一样更为重要性。

涡流，1996 以更为重要性性为应运而生的保健实证假定作为“保健摄像机”的一大多，已是早先的能源运使用者，并运使用最多的能源为您的病患做到预期结果。(格林露西和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年)在讨论更为重要性性应运而生的保健实证“是”时，同样更为重要性的是要强调更为重要性性应运而生的保健实证“不是”。更为重要性性理睬的保健实证不就会也不应建议看护权衡为病患包含的保健能量密度，以降很低可靠性。在我们的小片尾曲之中，在无法可能就会的探测的情况下彻底解决 X 外孙女的焦虑似乎包含完全一致甚至不够好的结果，因为焦虑的框架情况就会得到不够并不需要的熟识和彻底解决。以更为重要性性为应运而生的主要目标保健实证仅仅是包含很高能量密度的病患保健，只是以降很低或除去保健能源耗费的方式为这样做。迄今，可能就会的探测和其他过分外科手术和/或很低更为重要性性一站式约占每年有约 1 万亿美元的保健耗费的 10%。(Shrank 等人，2019）

。保健耗费的另外两个主要似乎是管理者举例来说（很高很高达 35%）以及保健一站式包含和相互配合最终（约 25%）。(Shrank 等人，2019）。保健早就将保健相互配合作为保健实证的一大多，许多研究课题和能量密度改进工作由看护他组织，以降很低相互配合最终和一般化保健流程（例如，疗养院到家庭的过渡时期、药物管理者）。然而，彻底解决过分外科手术、很低更为重要性性保健和管理者举例来说情况并不一定完全属于看护的负面影响范围，只能够管理者和自然科学管理机构的支持。尽管如此，看护才就会开始在他们的实证之中纳入负有，即呼吁很低更为重要性性保健和很多余、繁琐的管理者流程，这些流程就会抑止看护包含相互配合的、很高更为重要性性的病患保健的能力。

看护可以做些什么来使更为重要性性理睬的保健实证已是现实？

在保健实证之中有别于更为重要性性应运而生的视角只能够保健他组织、教育工所作和研究课题医护人员的大力支持。迈向以更为重要性性为应运而生的保健实证将只能够最很高级别的变革性、勇敢和有弹性的保健他组织。正如很高级观念工所作看护进一步观念工所作司法权的持续障碍所证明了的那样，保健他组织者才就会做好面对自然科学和管理者管理机构的政治权力。保健他组织者才就会谈论更为重要性性理睬保健的更为重要性性；他们才就会鼓励和起用那些发现方法来促使能源理论上能用和可靠性依靠的看护；他们还才就会做好支持和保护看护免受潜在的威吓。保健单位才就会装备前提的医护人员，以使看护能够获得对能源运使用来进行更为重要指标和包含更为重要性性理睬保健所只需的频宽。先前，看护他组织才就会与疗养院管理者管理机构和自然科学管理机构结盟，以确保光亮和平等地相应由看护发起或由看护为首的节约可靠性的能源运使用新的颖所带来的公司财务获利，并将这些获利再投资回单位。

对于保健亦然来真是，看护不够系统地地了解负面影响保健更为重要性性的心理因素以及与保健相关的缺席和开支至关更为重要性。可靠性和更为重要性性能力才就会作为专业保健实证的典范。2021 年入门级全面性今日将可靠性和可靠性作为保健实证的更为重要表现形式——这是一项更为重要性发展，也是迈向更为重要性性理睬保健教育的第一步

（Yakusheva 等人，2021 年）。我们将在本前传的第 6 大多（格林露西和雅库舍瓦，2022）。

保健研究课题医护人员只能够研究课题看护如何通过日常实证为降很低耗费和可靠性得出得出结论助益。尽管有大量结论声称保健对能量密度和公共安全结果的助益，但看护可以在多早先上降很低可能就会的能源和可靠性运使用在很早先上是有可能的。其他明显的结论落差包含以看护为为首的肥胖观念决定心理因素方法和看护为降很低过很高的状况疗养院耗费而采取的行动。保健科学应彻底解决这些更为重要性的、可行的研究课题情况，以尽力依靠保健开支、降很低可靠性并提很高看护的更为重要性性。

（科恩等人，2021）。

得出结论

更为重要性性理睬保健是一种保健实证，不仅重视结果，还重视保健可靠性。实证更为重要性性理睬的保健假定标识和除去可能就会的、多余的、很低更为重要性性的保健，它只能够观念工所作看护、保健他组织者、保健亦然和保健研究课题医护人员携手努力，标识、扩展到和传播新的颖的保健实证，以降很低耗费、降很低可靠性并强化病患外科手术视觉效果。在本前传关于更为重要性性理睬保健实证的第 2 大多之中，我们讨论了只能够有别于更为重要性性理睬保健实证的经济发展和国策驱动心理因素。

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