Line Authority for Nurse Staffing and Costs for Acute Inpatient Care

By Liu, Chuan-Fen; Sharp, Nancy D. et al. | Inquiry, Fall 2009 | Go to article overview

Line Authority for Nurse Staffing and Costs for Acute Inpatient Care


Liu, Chuan-Fen, Sharp, Nancy D., Sales, Anne E., Lowy, Elliott, Maciejewski, Matthew L., Needleman, Jack, Li, Yu- Fang, Inquiry


There is little empirical evidence evaluating the effects of recent, widespread changes in nurse executive roles and nursing management structures on the costs of patient care. This retrospective cross-sectional study examined the relationship between line authority for nurse staffing and patient care costs (total, nursing, and non-nursing cost) using data from 124 Department of Veterans Affairs (VA) medical centers. After controlling for patient, facility, and market characteristics, nursing line authority was significantly associated with lower nursing cost per admission. Our results provide some evidence that a reduction in nursing line authority may adversely impact nursing costs.

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Nurse executive roles in many hospitals across the United States have changed dramatically over the past two decades. Widespread hospital reorganizations from traditional, functional, and discipline-based services to service line structures and interdisciplinary care teams (Conrad 1993; Shortell, Gillies, and Devers 1995; Parker, Charns, and Young 2001) have most often affected nursing management by decentralizing nursing administration and altering the scope of responsibility and authority of nurse executives (Bruhn and Howes 1986; Hesterly and Robinson 1988; Fine 1989; Fitzpatrick, McElroy, and DeWoody 2001; Miller et al. 2001; Norrish and Rundall 2001). Decentralization of traditional nursing services can also affect nursing supervision and reporting structures, staff nurse roles and workload, total number of nurse staffing, and nursing skill mix (Sovie and Jawad 2001; Sharp et al. 2006). A primary goal and criterion for evaluating the success of organizational change has been improved efficiency through cost reduction while maintaining high-quality care (Kizer, Fonseca, and Long 1997; Dudley and Raymer 2001; Thibodeau, Evans, and Nagarajan 2004). However, there is little empirical evidence evaluating the effects of changes in nurse executive roles and nursing management structures on the costs of patient care.

Advocates of decentralized structures argue that greater efficiency and economy can be achieved by organizing the delivery of care into patient-centered product lines or service lines and consolidating the reporting of related services to the same person or office (Zablocki 1997; Deaton 1998; Bazzoli et al. 2002; Kenagy and Christensen 2002; Nevers 2002). Efficiency is gained if timely decisions can be made by people who are most familiar with the products or services being produced (Bird 1988). Critics argue that service line organization does not eliminate functional management (Bowers and Taylor 1990), may create conflicts in lines of reporting, requires excessive management effort to gather the timely and accurate information needed to implement this concept (Alferevic, Kroman, and Ruflin 1987; Plarrtenberg 1988), and invests line authority in a service line manager who lacks the knowledge needed to make clinical and administrative decisions (Flynn 1991).

Service line organizations could include a variety of nursing management structures. For example, in the Department of Veterans Affairs (VA) health care system, nurse executive roles range from consulting on professional nursing practice to management of patient care delivery, including direct line authority for all patient care staff (Sharp et al. 2006). Findings from case studies suggest that nurse executives who maintain direct authority over the management of nursing services are able to respond to staffing needs in a timely manner (Hesterly and Robinson 1998; Flynn 1991). Shifting control of nurse staffing decisions away from a central nurse executive may decrease efficiency for the facility as a whole by creating new barriers to cross-service planning for staffing and to reassigning nurses from low to high census areas. Thus, changes in line authority for nurse staffing following hospital reorganization may have a positive or negative impact on patient care costs, but no evidence supporting either view has been published. …

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