70 percent registered nurses. It was shown that, al-
though the acuity of hospitalized patients in-
creased, the average length of stay dropped from 9.2
to 7.3 days (Helt & Jelinek, 1988). Nursing produc-
tivity improved and quality of care scores increased
with the increased registered nurse staffing. The
higher costs of employing registered nurses was off-
set by the productivity gains, and the hospitals net-
ted an average of 55 percent productivity savings
(Helt & Jelinek, 1988).
Hospital administrators had made budgeting
and operating decisions based on the undocu-
mented belief that nursing care accounted for 30
percent to 60 percent of patient charges. However,
documented nursing research showed this assump-
tion to be in error. A study conducted at Stanford
University Hospital found that actual nursing costs
constituted only 14 percent to 21 percent of total
hospital charges (Walker, 1983). Similarly, the
Medicus Corporation funded a study in which data
were collected from 22 hospitals and 80,000 patient
records. Direct nursing care costs represented,
on average, only 17.8 percent of the Medicare re-
imbursement for each of the top 40 DRGs
(McCormick, 1986). In a study of Medicare reim-
bursement and operating room nursing costs,
nursing represented only 11 percent of the total
operating costs (Jennings, 1991).
By the time nursing researchers had demon-
strated the difficulty of costing out caring activities
with patient classification systems and the effective-
ness of registered nurse staffing on patient out-
comes, patient satisfaction, and mortality, the move
toward managed care had already started. With the
introduction of managed care and increased corpo-
ratization of health care, the economic environ-
ment was changing faster than nurse researchers
could document the impact of these changes on
clinical practice. In a managed care environment,
reimbursement to hospitals had been further con-
strained. As a response to shrinking operating
budgets, many hospital administrators have insti-
tuted registered nurse staff reductions or used unli-
censed nursing assistants to replace registered
nurses. As a result of these actions, the health-care
industry is now faced with a shortage of registered
nurses. According to statistics provided by the
Division of Nursing of the U.S. Department of
Health and Human Services (2000), over the next
ten years the demand for nurses will continue to
outpace the supply.
Economic Implications
of Bureaucratic Caring
Theory: Research in
Current Atmosphere
of Health-Care ReformInvestigation of the economic dimension of bu-
reaucratic caring is being explicated in part in nurs-
ing research studies. Findings from these research
studies have been valuable when linking the con-
cepts of politics, economics, caring, cost, and qual-
ity in the new paradigm of health-care delivery.
Although caring and economics may seem para-
doxical, contemporary health-care concerns em-
phasize the importance of understanding the cost
of caring in relation to quality.
Miller (1989, 1995), Nyberg (1989, 1990, 1991),
Ray (1981, 1987, 1989), Ray and Turkel (2000,
2001, 2003), Turkel (1997, 2001), and Valentine
(1989, 1991, 1993) have examined the paradox be-
tween the concepts of human caring and econom-
ics. It was a challenge for nurses to combine the
science and art of caring within the economic con-
text of the health-care environment. However, any
efforts to reshape the health-care system in our
country must take into account the value of caring.
Nyberg’s (1990) research findings indicated that
nurses were extremely frustrated over the economic
pressures of the past five years but that human care
was present in nurses’ day-to-day practice.
According to Nyberg (1989, p. 17), “[T]oday’s eco-
nomic environment constrains human care, but
nurses see human care as their responsibility and
goal.” Nurse executives agreed that care and eco-
nomics must be viewed as interdependent. One
nurse administrator proposed “caring as the mis-
sion of the hospital with economic and manage-
ment as supporting facets” (Nyberg, 1989, p. 14).
Although human care is the goal of nursing, eco-
nomics cannot be ignored.
Miller (1995, p. 30) used Nyberg’s Caring
Assessment Tool to evaluate nurses’ ability to care
on eight different pediatric nursing units in seven
Colorado hospitals. Although there were organiza-
tional differences, results showed a high correlation
of caring attributes among the various settings.
Interviews conducted with nurses indicated a con-
cern that their “ability to be caring was in jeopardy.”
Some of the responses they gave included “financial
pressure on the hospital distracts us from our372 SECTION IV Nursing Theory: Illustrating Processes of Development