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JHOM
26,2 A systems perspective on
nursing productivity
Nicola North
192 School of Population Health, The University of Auckland,
Auckland, New Zealand, and
Frances Hughes
Nursing Midwifery Office, Brisbane, Australia

Abstract
Purpose – Recent New Zealand reports have identified the nursing workforce for its potential to
make a significant contribution to increased productivity in health services. The purpose of this paper
is to review critically the recent and current labour approaches to improve nursing productivity in
New Zealand, in a context of international research and experience.
Design/methodology/approach – An examination of government documents regarding
productivity, and a review of New Zealand and international literature and research on nursing
productivity and its measurement form the basis of the paper.
Findings – It is found that productivity improvement strategies are influenced by theories of labour
economics and scientific management that conceptualise a nurse as a labour unit and a cost to the
organisation. Nursing productivity rose significantly with the health reforms of the 1990s that reduced
nursing input costs but impacts on patient safety and nurses were negative. Current approaches to
increasing nursing productivity, including the “productive ward” and reconfiguration of nursing
teams, also draw on manufacturing innovations. Emerging thinking considers productivity in the
context of the work environment and changing professional roles, and proposes reconceptualising the
nurse as an intellectual asset to knowledge-intensive health organisations.
Practical implications – Strategies that take a systems approach to nursing productivity, that view
nursing as a capital asset, that focus on the interface between nurse and working environment and
measure patient and nurse outcomes are advocated.
Originality/value – The paper shows that reframing nursing productivity brings into focus
management strategies to raise productivity while protecting nursing and patient outcomes.
Keywords New Zealand, Nursing, Human resource management, Management strategy, Workforce,
Productivity, Outcomes
Paper type Conceptual paper

Journal of Health Organization and
Management
Vol. 26 No. 2, 2012
pp. 192-214
q Emerald Group Publishing Limited
1477-7266
DOI 10.1108/14777261211230772
1. Introduction
Concerns about health sector productivity have arisen in the context of increasing
health care costs, largely driven by demand from ageing populations with a growing
burden of long-term conditions and supported by the growth of medical technology,
regarded as unsustainable (Organisation for Economic Co-operation and Development,
2009). In New Zealand (NZ) health is the second largest area of public spending
(Ministry of Health, 2008), and although reasonably efficient (based on an average cost
per discharge at $US4,900 compared to the OECD median of $US6,400), increasing
funding demands from the sector coupled with a weakening economic position have
led to an unsustainable fiscal position, with predictions that financial demand will
outstrip growth in available funding over the next decade. Concerns over demand and
expenditure have often been constructed as crises in NZ, given the relatively low GDP Nursing
and aspirations of its small, dispersed population for world-class health care productivity
(e.g. Upton, 1991; Ministry of Health, 2008; Ministerial Review Group, 2009).
Responding to perceptions of crisis, some government measures of recent decades
include incentives to improve efficiency, organisational restructuring and down-sizing,
health system reform (Gauld, 2000; 2003) and investment in primary health care
(including health promotion, prevention and early intervention) (Ministry of Health, 193
2000, 2001). Recent OECD and NZ reviews on the health sector focus on increasing the
productivity of the health sector (e.g. Organisation for Economic Co-operation and
Development, 2009; Ministry of Health, 2008; Ministerial Review Group, 2009).
The NZ Treasury in 2005 reported that in a three-year period hospital outputs had
not increased at the same rate as expenditure, based on outputs measured as
cost-weighted discharges (CWD). CWD covered only about 35-45 per cent of hospital
activity and no out-of-hospital activities (where many efficiency improvements can be
made) and measuring personnel costs (e.g. determining accurate full-time equivalents,
or FTEs) was limited by unreliable staff data (New Zealand Treasury, 2005). The
Treasury’s concern was that although efficiency had improved in some areas (e.g. day
cases and length of stay) and CWDs had risen, overall efficiency had declined and the
actual cost per CWD had risen. These increased costs were noted to have arisen
because of: “Changes in price, i.e. cost per input (e.g. cost per nurse); and changes in
productivity, i.e. CWDs per unit of input (e.g. discharges per nurse)” (p. 11). In the
period reviewed, 60 per cent of increased costs went on staff costs, with over half of
that increase spent on doctors and nurses (other contributors were uncosted clinical
supplies, outsourcing and infrastructure cost increases). Over the same period,
measured outputs (CWDs) per FTE nurse and per FTE doctor reduced – by 2.7 per
cent per annum for doctors and 1.8 per cent for nurses (New Zealand Treasury, 2005,
p.13). In other words, productivity (output per unit of labour input) had declined, and
costs per labour unit had increased. The report also noted that while this may have
been because of a decline in productivity, it could also be because doctor and nurse
resources were shifted to areas where activity was not measured (e.g. mental health).
A separate analysis commissioned by the conservative Business Round
Table (Maniparathy, 2008) reported an 8 per cent decline in labour productivity
(15 per cent for doctors and 11 per cent for nurses) and a rise in labour costs by 16 per
cent in a five year period, concluding that “The finding of a reduction of productivity is
consistent with the finding that the cost per unit of output increased” (p. 4).
The Ministerial Review Group (2009) echoed many of the concerns of the Treasury
analysis, linking strengthening of productivity with sustainability of the sector, and
focused on non-labour as well as labour strategies. Proposed non-workforce strategies
(Para. 104) included saving on bed days, through improved patient safety and service
quality improvements such as streamlining the patient journey. Though still seeking to
contain “wage inflation”, ways proposed to improve health workforce productivity
included moving from specialist to generalist and patient-centric models of care,
greater flexibility in work practices and improved job satisfaction (Paras 100-1). The
Organisation for Economic Co-operation and Development (2009, p. 105) highlighted
the difficulties for NZ in developing measures of productivity (unit inputs per output)
and efficiency (costs per output), both critical to the government’s pursuit of better
value for money, and made the more difficult by the poor quality of data and simplified
JHOM approaches that do not account for hard-to-measure health outcomes, economic growth
26,2 as population health improves and other, similar factors (Walker, 2009).
Concern about nursing productivity has emerged as a sub-theme in the broader
discourse of health services productivity because, as the single largest health
workforce, improved productivity will potentially make a significant contribution to
increasing productivity of health services (New Zealand Treasury, 2005; Ministerial
194 Review Group, 2009). That nursing is rightly a target of measures to improve health
sector productivity (Newbold, 2007) is neither new nor unique to NZ: writing about
American hospital productivity in 1990 Eastaugh (1990, p. 561) stated that: “Nurse
staffing patterns have come under increased scrutiny as hospital managers attempt to
control costs without harming service quality or staff morale”. Whether it is
reasonable, or even possible, to focus on a specific component of the health workforce
in the quest to improve sector productivity is an issue to be debated, and indeed
interdisciplinary productivity measures have been attempted (Moody, 2004). A more
pressing and pragmatic issue is to equip nursing unit managers and clinical leaders,
charged with transforming nursing skills to outcomes for patients, with the tools to
understand, measure and manage the productivity of nursing.
Many past and present approaches reflect the machine metaphor of organisations
(Morgan, 1980) in which nurses are units of labour, but underemphasise the intellectual
capital and skill embodied in nursing and its outcomes for patients’ health status and
for health systems. With reference to NZ, we consider approaches advocated to raising
the productivity of nursing. Drawing from recent research and analyses, we present
evidence that recent health systems and organisation level strategies to improve sector
efficiency and performance have had a negative impact on nursing workforce
productivity, both at organisational and national levels. As the negative consequences
were addressed through improved employment conditions, so nursing costs rose,
triggering another cycle of productivity improvement measures. In the light of ongoing
concerns in developed countries about the security of the nursing workforce and
drawing from notions of nursing as a capital asset, we propose a systems approach
that views nursing as a human capital asset, focuses on the interface between nurse
and working environment and measures patient and nurse outcomes.

2. Meanings and applications of the concept of nursing productivity: an

overview
Labour productivity is a complex economic concept that is difficult to measure (Scott,
2006). The OECD on its website (Organisation for Economic Co-operation and
Development, 2007) defines labour productivity as “output per unit of labour input”
and is distinct from “unit labour costs [that] refer to labour cost per unit of output”.
Productivity improvement is different from efficiency gains; efficiency is explained as
“achieving maximum output from a given level of resources used to carry out an
activity” (Organisation for Economic Co-operation and Development, 2007). Labour
productivity is important because of its link with economic growth in an economy or
sector. The Organisation for Economic Co-operation and Development (2007) website
explains that: “The driving forces behind improvements in labour productivity are the
accumulation of machinery and equipment, improvements in organisation as well as
physical and institutional infrastructures, improved health and skills of workers and
the generation of new technology”, and that “high labour productivity is often
associated with high levels or particular types of human capital”. This point deserves Nursing
particular emphasis, as the health sector is characterised by its human capital productivity
intensity.
The discourse around improving labour productivity in health addresses both unit
labour costs and outputs per unit of input. Accounting for the lion’s share of labour and
its costs, medical and nursing workforces become targets of attempts to improve
productivity, particularly nursing as the largest clinical workforce and historically a 195
softer target for labour costs savings. Some literature on health workforce productivity
appears to conflate the concepts of labour productivity, labour costs and labour
efficiency in NZ (Maniparathy, 2008) and internationally. For example, productivity is
defined as “the ratio of the output produced by an organization divided by the
resources consumed” (Williamson and Johnston, 1988, p. 49). Holcombe et al. (2002,
p. 378) specify nursing productivity as: “The ratio of output (patient care hours per
patient day) to input (salary and benefits)”. Another author commented that “When
nurse wage inflation comes under control, nurses are less likely to protest at
productivity programs” (Eastaugh, 2002, p. 14). Thus strategies related to nursing
productivity are likely to target costs of nursing inputs, both in order to manage labour
costs as an end in itself and as a means to achieve labour productivity initiatives.
These strategies reflect what Moody (2004, p. 98) refers to as “traditional accounting
practices” in health management that view nurses as labour costs.
Strategies to improve nursing productivity (as opposed to reducing labour costs)
draw from management theory and focus on the relationship between unit inputs and
nursing outputs, for example through maintaining outputs for less labour inputs, or
increasing outputs with the same staff (see Williamson and Johnston, 1988; Moody,
2004). In the management discipline labour productivity has its genesis in
manufacturing, particularly in scientific management theory (Taylor, 1911).
Criticised as constructing an organisation in its pursuit of efficiency as a rational,
technical machine and its workers as labour units (Morgan, 1980), the machine
metaphor remains dominant but, in the view of some (e.g. Ehin, 1993; Grantham et al.,
1997) as no longer appropriate to contemporary knowledge-based economies and
organisations. However, the machine metaphor continues to dominate labour
productivity strategies, for example time-motion studies and work sampling endure,
the latter being advocated for use in nursing (Williamson and Johnston, 1988).
Scientific management theory underpins many of the recent “management fads”
(Gibson and Tesone, 2001) promising to improve efficiency and productivity generally,
such as business process re-engineering and process redesign, and the health sector in
particular, including the “productive ward” (Wilson, 2009) and “lean thinking”
(Ben-Tovim et al., 2008).
An increasing body of evidence links nurse productivity with workplace
characteristics, for example productivity is negatively related to high job stress but
positively related to staffing levels that enable RNs to provide quality care to patients
(Letvak and Buck, 2008). The ageing of the nursing workforce at a time of nursing
shortages has emerged as an important issue in creating a work environment to retain
older nurses (Schmalenberg and Kramer, 2008). In contrast to industrial approaches to
productivity improvement, these perspectives view the organisation as an organism
made up of interacting and interdependent parts, where the importance of satisfying
the psychosocial needs of the members is privileged (Morgan, 1980). A recent shift in
JHOM thinking about nursing productivity, that proposes viewing nurses as “capital assets”
26,2 in knowledge-intensive health service organisations, not only as costs, (Moody, 2004,
p. 98) supports strategies linking productivity with workplace characteristics. For
example, where nursing productivity is viewed as negatively influenced by costs
related to turnover, absenteeism and job stress (Pearson et al., 2006; Newbold, 2007),
the working environment becomes a focus of productivity improvement. Lending
196 weight to views that nursing is a capital asset, one analysis concluded that much of the
cost of employing a RN is saved because of the association between RN staffing and
reduced risk of complications for hospitalised patients, shorter lengths of stay reducing
demand for more expensive medical services, and that professional nursing makes an
economic contribution to society (Dall et al., 2009). Building on this, McGill Hall’s (2003)
theoretical framework for assessing productivity incorporates nursing’s intellectual
asset along with productivity indicators. These views have led to more sophisticated
approaches to measuring and managing nursing productivity, for example to support
decisions on skill mix. One example is the use of production economics that takes into
account both production functions of nursing and its cost functions, to determine the
most cost-effective staffing levels and skill mix without risk to patient outcomes
(Newbold, 2007).
The discourse on nursing productivity of the past two to three decades reflects three
broad approaches available to improve nursing productivity, summarised in Table I.
These approaches focus on input costs, outputs per nurse and the working
environment, respectively, and are expanded upon in the following sections.

3. Reducing and containing costs of nursing inputs

Following a substantial pay increase for NZ public sector nurses in 2005, increased
labour unit costs and reduced nursing productivity in hospitals were reported (New
Zealand Treasury, 2005). As we will discuss in this section, during the previous two
decades the reverse was true: nursing costs decreased and nursing productivity
increased. However, these apparent gains came at a price. We suggest that negative
consequences for the nursing workforce and for quality of care (a non-labour approach
to improving productivity), may well outweigh short-term productivity gains in the
short term.
A global rise in health expenditure led to developed nations struggling with the
problems of containing the rising costs of health care (Blendon et al., 2002; Gauld, 2000;

Reducing/containing nursing Increasing ratio of nursing Nurse/work environment

input costs outputs per unit input approaches

Downsizing – fewer staff Process redesign (e.g. the Healthy workplace strategies
productive ward, lean thinking)
Outsourcing/casualisation – Configuration of nursing teams Reducing injury and absenteeism
reduced dependence on
permanent staff, lower fixed
Table I. costs
Management approaches Increased skill mix Nurse substitution Job satisfaction
to increase nursing Containing wage inflation, penal Nurse role extension Retention, reduced turnover
productivity rates, etc.
Kreible, 2001; Organisation for Economic Co-operation and Development, 1992) with Nursing
many undergoing a process of health reform. Underpinned by neoliberal economic productivity
theory and managerialism (Boston, 1991), NZ has the most restructured health care
system in the world (Gauld, 2003) and changes occurred more rapidly than in any other
developed country (Davis and Ashton, 2001). The major policy changes in NZ that
occurred during the 1990s included the introduction of managed competition,
population-based and capped global budgets, and the implementation of generic 197
management structures and practices into health services, with the aim of improving
efficiency (Scott, 1994; Ashton et al., 2005). As hospital care accounts for a large
proportion of health spending, restructuring was a major aspect of these reforms and
had a profound effect on the nursing workforce (Ministry of Health, 1998). At the same
time in NZ labour was deregulated through the Employment Contracts Act in 1991,
supporting employer determination of pay and reducing the role of trades unions,
reforms that reduced wage growth across all sectors including health. This legislation,
coupled with the Health and Disability Act, which was passed in 1993, “introduced
competition and contestability into the public service and the two statutes have been
instrumental in shaping the New Zealand nurses’ experience of employment” (Bickley,
1997, p. 304). Not until labour legislation was changed in 2000 were nurses able to
address concerns about deteriorated employment conditions.
As the largest clinical workforce and area of expenditure, nurses were affected by
restructuring that involved “reducing labour costs through changes to skill mix and
work practices and a reduction in management positions” (Duffield, 2007, p. 43). With
the introduction of generic management, traditional hospital administrative structures
were replaced by chief executive officers, and nurses in management positions were
replaced by generic business managers who assumed control over nursing budgets
(McCloskey and Diers, 2005). Flexible staffing to manage productivity (hours per
patient day and dollars per patient day) was a popular way to improve nursing
productivity and keep costs at or below budget (Anderson et al., 1991). Measures to
reduce expenditure directly impacting on nursing workloads included reducing
patients’ average length of stay (LOS), with increased patient turnover and acuity and
changes to skill mix including substitution (or extension) of RNs with unregulated care
givers (Shannon and French, 2005). In NZ public hospitals LOS decreased by 20 per
cent, medical and surgical nursing FTEs and nursing hours decreased by 36 per cent,
and skill mix increased 18 per cent (McCloskey and Diers, 2005).
The impacts on the nursing workforce of the combination of health reforms,
hospital restructuring and employment law changes were substantial and have been
highlighted in numerous government reports and reviews (e.g. Ministry of Health,
1998; Department of Labour, 2005). These reports highlighted that as nurses’
workloads increased, their pay stagnated, and employment conditions deteriorated and
nursing leadership was lost. By the end of the twentieth century a previously sufficient
workforce was demoralised and characterised by shortages, occupational dissociation,
and a decline in interest in nursing as a career reflected in falling numbers of graduates
added to the nursing register (Department of Labour, 2005; Buchan and North, 2009).
Other studies (Finlayson and Gower, 2002; McCloskey and Diers, 2005) found that
following these reforms and re-engineering there was:
.
a significant decrease in job satisfaction and ability to provide quality care;
.
a lack of nursing involvement in management changes;
JHOM .
a reorganisation of nursing career pathways and loss of senior nurses;
26,2 .
a lack of hospital-wide strategic workforce planning;
.
casualisation of the nursing workforce;
.
significant variations in the quality and availability of professional development
and education for nurses;
198 .
detrimental effects on the physical and emotional health of nurses; and
.
increased nursing turnover.

Two recent NZ studies lend support to the risk that short-term and determined
measures to contain nursing input costs may actually reduce the productivity of the
health system. One study, part of a cross-country response to concern internationally
about global nursing shortages and nursing turnover (O’Brien-Pallas et al., 2006), set
out to measure the costs of nursing turnover at nursing unit level (North et al., 2005). In
2004-2005 a prospective 12-month study was conducted, involving randomly selected
medical and surgical wards in 11 public hospitals. The study produced detailed data on
the impacts of the productivity increases in nursing workforces at the micro (nursing
unit) level on nurse staffing practices and turnover. In participating units, occupancy
rates averaged 91.8 per cent, with some exceeding 100 per cent in a 24-hour period and,
according to unit managers, patient acuity was also high. Although skill mix was low,
with RNs predominant, data on RN (staff nurse) FTEs showed negative RN staffing
against budgeted levels, on average 2 1.88 FTE less than budget, with a range per
ward per month of 2 7.2 to þ 2.26. The reasons actual RNs tended to be lower than
budgeted included delays in filling vacancies and the deliberate practice to manage
costs as RN budget savings allowed unit managers to purchase other services
including RN substitution. During the 12 months in 19 wards a total of 192.6 FTE left
and 268 RNs joined the participating wards, giving an average of 13.4 new RNs per
year per ward (normal staffing was 25.8 FTE). RN turnover was also high with an
average per participating ward of nearly 40 per cent of its RN staff annually, and a
range over 12 months of 13 per cent to 73 per cent. Costs associated with induction of
new RNs and productivity loss during initial employment made the highest
contribution to turnover costs, closely followed by temporary cover costs.
The other involved a retrospective investigation of the impact of a national pay
increase for public sector nurses, where the majority of nurses are employed (Buchan
and North, 2009). The labour law reforms described above resulted in the historical
practice of determining nurses’ pay nationally being replaced with employer (and then
regionally) determined pay, followed by stagnation of wages and deterioration of
employment conditions (Department of Labour, 2005). In 2005 a national
multi-employer collective agreement (MECA) gave nurses and midwives employed
in the public sector an increase of 7 per cent (on average) along with improved
employment conditions. The impact of the MECA was assessed by examining
available labour market data over the period 2003 to 2007. Data assessed showed that
key labour market indicators (e.g. employment growth exceeding that of other
occupations, decline in vacancy rates and indications of a tightening of the labour
market) changed from negative to positive for the public sector – but not in other
sectors not party to the MECA – over the period covering implementation of the
agreement. In addition schools of nursing were surveyed, and reported an increase in Nursing
numbers of applicants for pre-registration nurse education (Buchan and North, 2009). productivity
To some extent the above measures to increase productivity by reducing labour
inputs and costs reflects the policies and ideologies of its time (1980s-90s), with some
approaches such as casualisation having since fallen out of favour. External to the
health sector and nursing, recent research has reported a negative relationship between
downsizing and labour productivity related to the impacts on employee morale and 199
because of damage to the organisation’s human capital, and advocates of downsizing
“best practice” incorporate mitigation measures (Iverson and Zatzick, 2011). Looking
back over the period of radical reform and hospital restructuring, nursing costs were
significantly reduced and productivity rose with higher patient acuity, shorter LOS
and increased patient:nurse ratios. However, negative impacts on the nursing
workforce arguably outweighed those gains. There is agreement in NZ and
international research (Aiken et al., 2001, 2002; Finlayson and Gower, 2002; Finlayson
et al., 2007) that nursing became an overworked occupation risking burnout and high
stress among nurses. It is not surprising, therefore, that subsequently employers
reported difficulty in filling RN vacancies (Department of Labour, 2005), attributed to
low numbers of applicants, high turnover, emigration of nursing skills and high
occupational detachment. Nursing productivity rose, a desired outcome for the payer
(the government) and for the employer (health services and hospitals). However, the
price paid by nurses, individual nurses and the nursing workforce as a whole, has been
enormous. McCloskey and Diers (2005) report that “in the chaotic environment created
in NZ by reengineering policy” (p. 1140) the relationships between changes in nursing
and adverse clinical outcomes were statistically significant. During that period of
change, the NZ nursing workforce changed from being characterised by sufficiency to
being marked by endemic staff shortages, high dissociation, declining interest in
nursing as a career and a growing reliance on international recruitment to meet
immediate workforce needs (Department of Labour, 2005; Zurn and Dumont, 2008).
A similar picture is found internationally. The aggregate response of nurses to
health reforms on an international scale has resulted in a severe shortage of nurses
worldwide (Heitlinger, 2003), with the links between job stress, turnover and shortages
becoming increasingly evident (Letvak and Buck, 2008). A systematic review found
evidence of strong correlations between increased productivity – through higher nurse
workloads (based on nurse: patient ratio) and staffing patterns (high skill mix) – and
poorer patient outcomes (Pearson et al., 2006). Significantly, industrial models of
productivity improvement and associated perspectives on the organisation of
personnel, skill mix, decision-making, product line management and work redesign
underpinned hospital organizational restructuring and process reengineering of the
past two to three decades (Shannon and French, 2005; Aiken et al., 2001). A key
implication of this growing and important body of nursing workforce research is that a
reduction in RN staffing levels, skill mix, professional experience and education
reduces the quality of patient care provided (Aiken et al., 2001, 2002; Shannon and
French, 2005). With improved quality of care a major non-labour strategy to improving
productivity (Ministerial Review Group, 2009), an overemphasis on reducing labour
input costs while increasing labour productivity can be counter-productive. The price
for increased nursing productivity and reducing input costs is, in the end, paid by
society through lower quality of care and poorer outcomes, and through having to pay
JHOM to replace those nurses, who are lost to nursing in NZ, in whose education the tax payer
26,2 has substantially contributed.

4. Increasing nursing outputs per unit input: current approaches

The period (described above) reflected a time when in NZ nursing input costs were
reduced and contained and at the same time productivity increased. If we accept that in
200 the long run this can be counter-productive in terms of nursing productivity, with
savings in employment costs outweighed by the exit of nurses from the NZ workforce
and risks to quality of patient care, then renewed intentions to raise nursing
productivity would require different solutions. Emerging candidates in NZ, both with a
focus on process, include the “productive ward”, and “reconfiguring nursing teams”.
The “productive ward” (along with the popular “lean thinking”)aims to raise
productivity by redesigning processes and so releasing nurse time for direct patient
care, while nursing team configuration focuses on the most productive mix of nurse
skill including RNs, second level nurses and unregulated carers. Associated with both
approaches is the process of identifying and eliminating non-nursing tasks, allowing
nurses to focus on the more technical and complex tasks.
NZ public hospitals have been funded to introduce the productive ward system (also
referred to as “releasing time to care”), with reported benefits in quality of care (as more
nurse time is made available), job satisfaction and lower turnover (O’Connor, 2010, p. 5).
Survey findings in the UK that only a small proportion of nurses’ time is spent with
patients because of the waste in time spent looking for things, fetching and
interruptions led to the productive ward initiative being designed and introduced into
the NHS. Based on lean methodologies developed at Toyota, the programme involves a
series of tools designed to support nurses in wards to review critically the processes of
care, identify and eliminate wasteful processes and so release time for direct patient
care (Wilson, 2009). The 15 modules provide a systematised approach to review
processes, and outcomes are regularly measured and compared with baseline
measures. A feature of the productive ward is that unlike externally driven
reengineering approaches, the staff team and its leadership take ownership of work
redesign and experiences show early promise of improving productivity: for example,
nurses spending 20 per cent more time with patients and less time on paper work,
handover and other unproductive activities (Wilson, 2009). However, the Productive
Ward has also been criticised for ignoring the health professional teams nurses work
with, particularly the medical profession, and a critical analysis of one component
concluded that “changes in structures do not lead to changes in behaviours” (Grant,
2008, p. 199). A broader application of “lean thinking” to make its way from
manufacturing to health services process redesign in Australia has reportedly shown
early promise. In the congestion and chaos characteristic of modern hospitals, “lean
thinking” is focused on the patient journey, and complex production processes are
redesigned in order to improve flow and reduce waste (see Ben-Tovim et al., 2008). This
initiative differs from the “productive ward” in that its application is wider than
nursing services in the ward or department, but it impacts on nursing as a participant
in redesigning projects, and as employees in the services that have been so redesigned.
Although the language in which these approaches are wrapped is palatable to nurses
with its emphasis on patient journeys, caring and nursing skill, the theoretical roots are
those same models of labour productivity underpinned by scientific management,
entailing work redesign, skill mix changes and process reengineering that had such Nursing
negative consequences for the nursing workforces of most developed countries. As productivity
relatively recent entrants to improving health productivity, and with the focus on work
processes(not outcomes) it is yet to be seen whether these initiatives will produce the
productivity improvements intended and be sustainable over time.
In contrast to process redesign, reconfiguring nursing teams focuses on the most
productive skill mix. Nursing teams have long been regarded as important vehicles to 201
deliver nursing services, because of the association with quality of patient care and
impacts on nursing satisfaction levels (Holcomb et al., 2002; O’Connor, 2010; Fasoli,
2010), and innovations need to be understood in the context of the history of nursing
models. Some reported models (referred to as ideal type models by Bach et al., 2008)
have utilised a mix of nursing skill including functional nursing and team nursing,
while others have required an all-RN workforce, such as primary nursing and total
patient allocation (e.g. Fasoli, 2010; Duong et al., 2010). RN-rich teams have their critics
for failing to bring promised patient benefits and for being expensive, and in addition
difficult to staff at a time of widespread nursing shortages (Duong et al., 2010;
Eastaugh, 1990). In this context team nursing is being promoted, in spite of it having
been seen by nurses in the 1950s (when it was first introduced) as a managerial drive
for control associated with efficiency and economy (Fasoli, 2010; Duong et al., 2010).
Team nursing espouses the principle of nurse extension, or nurse substitution (see
Eastaugh, 1990, 2002) linked in some research with poorer patient outcomes (e.g.
Pearson et al., 2006). However, in two studies team nursing has been attributed as
providing the highest level of nursing satisfaction and quality patient care (McGill Hall
and Doran, 2004), and an improvement in “staff satisfaction, recruitment and retention
of staff, reduction in sick leave, improved team spirit and a cleaner ward environment”
(Duong et al., 2010, p. 150). Other research has focused on the productivity of
professional practice models (PPM), models characterised by increased responsibility
and control by nurses over work processes, nursing unit operations, scheduling,
professional development and quality (Moody, 2004). While PPM was not shown to
achieve cost savings or improved nursing outputs, benefits including improved job
satisfaction, retention, and less absenteeism were reported, cost function contributors
to productivity (e.g. Pearson et al., 2006).
Minimising the time professional nurses spend on “non-nursing” tasks is attractive
to organisations seeking to improve nursing productivity, especially at times of
nursing shortages and rising costs, by using a scarce and expensive resource more
effectively (Thompson and Stanowski, 2009) and is a key element in both the
productive ward and nursing team configurations. It is also attractive to nurses if those
non-nursing tasks prevent nurses from completing core nursing tasks (see Aiken et al.,
2001). With this end in mind, Thompson and Stanowski (2009) reviewed research and
experiences of improving collaboration between nursing and support services
(including food services, patient transportation, environmental services and clinical
technology), and found that both nurse and patient satisfaction increased, quality of
care improved, and financial performance improved, but such initiatives needed to be
well managed and supported with shared decision-making and governance. They
concluded that “fundamentally, nursing should continue to focus on the clinical care
needs of their patients” (p. 82), and this raises questions regarding how “non-nursing”
tasks are defined. In the UK, USA, Australia and NZ, lower-paid, unregulated and
JHOM variably trained health care assistants (HCAs) or equivalent are substituted for
26,2 professional nurses, for example to relieve nurse shortages, reduce costs and release
nurses to focus on the more complex roles (Bach et al., 2008; Bosley and Dale, 2008;
Shields and Watson, 2008). Furthermore, HCAs (and similar unregulated assistants
and technicians) are emerging in services other than those where they have
traditionally been found, such as in residential aged care and home support. Their
202 presence in hospital secondary care services, perioperative care and more recently in
primary care, and with HCAs taking on observational and monitoring tasks for which
they are not trained (Alcorn and Topping, 2009; Bosley and Dale, 2008; Spilsbury and
Meyer, 2005) is causing consternation among some nurses who regard the trend as a
threat to the future of the profession (Shields and Watson, 2008).
Nurses’ principal concerns regarding substitution include nursing’s retreat from the
bedside into patient care management, blurring of roles and quality of care. Shields and
Watson (2008) warn that with nursing divesting itself of many tasks to HCAs, nursing
is also forfeiting opportunities for therapeutic interaction with patients. A UK study
found that nurses “abdicated”, not delegated, the nursing role to HCAs who
increasingly took on patient care, while nurses took on technical tasks no longer
carried out by doctors (Pearcey, 2008). Blurring of roles was highlighted in a survey of
surgical nurses (Alcorn and Topping, 2009) as HCAs increasingly took on tasks
symbolic of nursing, but of greater concern the survey found that while most
respondents agreed that they delegated and were professionally accountable for the
work of HCAs, a small but significant number disagreed (see also Spilsbury and
Meyer, 2005). In contrast, a US study found that though nurses were clear about
supervisory responsibilities for unregulated carers, they frequently were unable to
spend the desired amount of time due to other demands, and the study highlighted the
need for RNs to be formally prepared for the delegation and supervision as part of the
nursing role, rather than learn on the job (Siegel et al., 2008). Policy concerns focus on
variability in implementation: Bach et al. (2008) have found variation in nurses”
ideological positions regarding nurses” and HCAs’ roles, and this has allowed for wide
variation in how nursing teams are constructed by employers.
Reconfiguring nursing teams involving nurse substitution needs to be understood
in the broader context of health care teams generally, including medical shortages and
policy driving innovation, such as a patient-centred focus of workforce design and the
deliberate blurring of professional boundaries (e.g. Bach et al., 2008). Other established
health professions including medicine are also undergoing a process of divesting
themselves of tasks, for example to lower-paid and lower-educated physician
assistants working under supervision and to autonomous nurse practitioners (Cooper,
2007), regarded as a cost-effective approach to meeting growing demand for health
care. An important impetus for shifting role boundaries, as seen in the development of
nurse practitioners and nurse prescribing, is related to the move to primary health care
dominated health systems, a desire to improve service delivery and access especially
where doctors’ shortages prevailed, and to improve continuity of care and deal with
increased demand as populations age and the burden of chronic conditions grows
(Courtenay et al., 2006) but, as Cooper (2007) observes, in the US these are yet to
develop the capacity to relieve physician shortages. Debates parallel those related to
nurse substitution, for example focused on concerns about patient safety, confusion
over roles and changing the dynamics of teamwork (Baird, 2001). Furthermore, while
nurse extension may raise productivity of health services because of the lower cost of Nursing
nurses compared to physicians, shortages in nursing teams are unaffected and may be productivity
exacerbated.
Returning to the point that nurse substitution improves the productivity of nursing:
often for reasons of health professional shortages and increasing workloads, there
appears to be a movement of nursing simultaneously being extended (taking over
technical tasks doctors no longer want and taking on tasks to professionally extend 203
themselves) and substituted (by uneducated or minimally educated assistants), with
consequent blurring of roles and confusion about identity as a nurse (Bosley and Dale,
2008; Shields and Watson, 2008) and little evidence on impacts in patient care and
service benefits (Spilsbury and Meyer, 2005). Paradoxically, as nurses abdicate
traditional responsibilities, supervisory responsibilities move into the void formerly
taken up by direct patient care. Nurses remain overloaded (e.g. Siegel et al., 2008), but
when measures of labour productivity are applied, the workforce is possibly no more or
even less productive as much of this additional supervisory and training work is not
measured as hospital outputs (New Zealand Treasury, 2005). A second argument that
productivity may not improve arises from non-labour strategies to improve hospital
productivity, specifically improved quality of care (Ministerial Review Group, 2009).
Compromising quality of care and patient safety is at risk when HCAs “exceed their
remit” (being to assist RNs by attending to clerical and housekeeping duties and direct
patient care; see Spilsbury and Meyer, 2005, p. 72) by undertaking systematic
observations, monitoring blood glucose, wound care, medication administration,
running clinics and other roles without supervision (e.g. as reported by Bosley and
Dale, 2008 p. 119; Spilsbury and Meyer, 2005, p.75). These authors also report on
studies in the USA and the UK that substituting nurses with HCAs is not necessarily
cheaper or more cost-effective, and indeed any cost savings may be outweighed by the
added complexity of a higher skill mix and confusion over roles. While substituting
professional nurses with unregulated assistants may be well-intentioned as a way of
better using a scarce and expensive skill, or stretching that skill at times of shortages
and limited financial resources, and is often justified as freeing nurses to focus on
clinical needs of their patients, the issues generated may have the opposite outcome
from that intended.

5. Nurse/work environment approaches

There are significant limitations to approaches to improving nursing workforce
productivity so far considered with their emphasis on reducing costs per nurse unit
and increasing outputs per nurse unit. An important limitation concerns the sheer
difficulties in measuring nursing productivity (e.g. Moody, 2004; Newbold, 2007; Dall
et al., 2009), in that much of what nurses do cannot be quantified and measured and is
characteristically non-routine and highly variable (Williamson and Johnston, 1988).
Another drawback is that these approaches do not take account of the human
characteristics of the nurses themselves. The view that a nurse is a unit of labour to be
manipulated in the interests of improving productivity (implicit in organisational
efforts to improve efficiency and reduce nursing labour costs, and at work process level
to improve nursing labour output), does not acknowledge nursing as a
“labour-intensive, skill rich” occupation (Newbold, 2007, p. 121) and fails to take
account of the diversity of a given nursing workforce and the influence on productivity
JHOM of the working environment. These approaches also under-emphasise nursing role
26,2 extension and blurring between traditional medical and nursing roles (discussed
above) as both professions grapple with shortages and patient-centred design of health
care teams takes centre stage. A small body of research is shifting the focus from the
nurse to the interface between nurse and work environment in a quest to improve
nursing productivity and draws from the evidence to emerge from the impacts of
204 industrial models on nursing and patient outcomes.
Research that relates nursing productivity with work environments has found that
low productivity, poor work environments, nursing shortages, low job satisfaction and
low quality of patient care tend to be related (e.g. Pearson et al., 2006). In contrast, using
an Essentials of Magnetism (EOM) instrument, Schmalenberg and Kramer (2008)
found that hospitals meeting magnet hospital characteristics are consistently shown to
be productive and satisfying working environments. The EOM measures eight process
dimensions:
(1) Support for Education;
(2) Nurse-Physician Relationships;
(3) Working with Clinically Competent Peers;
(4) Clinical Autonomy;
(5) Control over Nursing Practice;
(6) Perceived Adequacy of Staffing;
(7) Patient Centred Values; and
(8) Nurse Manager Support Index.

The authors stress that a “productive and satisfying work environment is a

multidimensional, integrated phenomenon” (p. 8) and that each of the eight dimensions
is positively related to overall job satisfaction and to quality of care; the presence of
just some dimensions is not sufficient.
In their systematic review, Pearson et al. (2006) refer to positive working contexts as
“healthy work environments”, and environments with high nursing workloads
(measured as patient:nurse ratios) are good for neither patients or nurses. Much of this
research has come from the USA, but a large-scale study in the UK also supported this
premise: Rafferty et al. (2007) found that hospitals with the lowest patient:nurse ratios
consistently had better patient outcomes (measured as patient mortality), and nurses
who were less dissatisfied showed lower burn-out scores and were less likely to report
that patient care was deteriorating. Other research has shown high workloads and
nursing shortages to be associated with low productivity. In Tehran, where there are
recognised nurse shortages, a study into burnout (measured using the Maslach
Burnout Inventory) and productivity (measured using a specially designed instrument)
found a significant negative correlation between productivity and the emotional
exhaustion and the depersonalisation subscales, but a significant positive correlation
between productivity and personal accomplishment (Nayeri et al., 2009). Using the
same instrument, a survey in 1999 involving over 1,000 NZ nurses found that about a
third of all nurses showed advanced burnout, rising to almost half of nurses in the
41-45 age group (Hall, 2001), rates not as high as in some other countries but with
qualitative data highlighting a sense of being under-valued and having little control
over work. Adding support for the link between job stress and productivity, Nursing
O’Brien-Pallas et al. (2004) reported that injury claim rates and lost time rose with productivity
working overtime (increased job stress), and declined with positive nurse-physician
relationships (associated with reduced job stress).
Managers also need to address personal characteristics impacting on productivity
such as:
.
gender (illustrated in productivity decline with a feminised medical workforce; 205
see, for example, Weizblit et al., 2009);
.
age (where productivity declines in the fertile years and as a workforce ages; see,
for example, Letvak and Buck, 2008); and
.
health and disability (e.g. musculoskeletal conditions; Escorpizo et al., 2009, and
demonstrated in cost-of-illness studies).

Letvak and Buck (2006) related work productivity (measured in their study as an
expression of work impairment based on absenteeism, presenteeism, work
productivity loss and activity impairment) with the working environment and
individual nurse characteristics. Factors associated with decreased productivity
included: age, total years working as a nurse, quality of care provided, total job stress
score, having had a work injury, and having a health problem (p. 162). Addressing the
work environment to reduce stress, support nurses’ ability to provide high-quality care,
and to improve job satisfaction were seen as important to retain the demographically
ageing nursing workforce.
Research relating productivity with the work environment highlights relationships
among workload, job stress and productivity. When individual nurse characteristics of
a predominantly female and ageing workforce are taken into account, opportunities to
improve productivity are found in reducing job stress and burnout, reducing intention
to leave and turnover, and creating working conditions that enhance the ability to
provide good quality care and improve job satisfaction. Improved productivity could
be mediated in two ways:
(1) by reducing error and complications for patients (non-labour approaches); and
(2) by retaining satisfied nurses in the workforce.

6. Towards a systems approach to nursing productivity

Shifting the focus from the nurse as a unit of labour to the nurse in interaction with
her/his working environment reflects a systems approach to increasing nursing
productivity. Systems theorists conceptualise the organisation as a dynamic entity
comprised of inter-dependent parts, in open interaction with its environment as it
transforms inputs to outputs (Kast and Rosenzweig, 1972). A system is conceptualised
as comprising inputs that are processed into outputs and outcomes with a feedback
loop into the process. In addition, a complex system comprises many sub-systems. A
change in one part will affect other parts, whether intended or not, and conversely,
change in one part may not have the desired effect if other parts are ignored (Broedling,
1999), for example illustrated in negative impacts on patients and the nursing
workforce of high patient:nurse ratios (Rafferty et al., 2007). By using a systems
approach to frame nursing productivity, productivity is conceptualised not as a thing
of itself, but as a part of a whole complex system, with each part influencing and
JHOM influenced by the other parts in a cyclical and iterative fashion. It also takes account of
26,2 the principle of homeostasis, another tenet of systems theory – measures to raise
productivity that focus on one part in isolation from the whole tend to fail because
system dynamics work to return to the pre-change state (Broedling, 1999). A key
dilemma facing nursing managers is how to increase nursing productivity without
creating unintended consequences for the nursing workforce and poor patient
206 outcomes.
There is a growing recognition of nursing (and health care) as knowledge-based
work (McGill Hall, 2003; Newbold, 2007; Grantham et al., 1997), by which the product
(health status) is an outcome of the application of cognitive processes and
knowledge-based competencies, evident in the deepening of nursing roles and
expansion into medical territory. Conceptualising nursing as knowledge work
challenges cost-accounting approaches to productivity improvement based on nurses
as units of labour and as costs to the organisation (Moody, 2004), and places an
economic value on nursing (Dall et al., 2009). The non-routine, non-repetitive nature of
nursing work involving the nurse in “cognitively thinking about, evaluating for,
collaborating with, and actively serving and negotiating human health needs” (Moody,
2004, p. 101) questions the basis for patient-related nursing work being cut up into bits
and distributed among substitutes, because the context for knowledge-based work is
the nurse-patient interaction. Using this approach, the nurse is privileged as a capital
asset, not a labour cost, to the organisation. McGill Hall (2003) advocates reframing
nursing productivity “in relation to the knowledge, skill and competency embodied in
the discipline of nursing” (p. 18).
A systems approach will focus on nursing as a sub-system, but will also cast the
spotlight on its interaction with other sub-systems and the context of the
organisational system. To begin with the nursing sub-system: when nurses are
valued as essential assets to enable the health organisation to conduct its business,
strategies to improve productivity would measure and give a value to nursing capital
and measure the costs to the organisation (and the wider nursing workforce) of the loss
of that capital. Thus one element of a systems approach is to measure the intellectual
capital of nurses as inputs into the nursing sub-system and the wider organisation and
health system. The transformation of that capital asset into outcomes for patients and
health systems is central to productivity improvement; nursing work would need to be
measured, as a second main element. A third element refers to the outcomes of nursing
for patients and health systems. Each element is now expanded with reference to the
NZ context.
A method of inventory and valuation of the nursing capital asset, as the primary
input to the system, would include measures of formal education, continuing education
and professional development, clinical and leadership experience, cultural and
linguistic capital. In NZ, nursing competencies are enshrined in the Health
Practitioners Competency Assurance Act 2003 and administered by the Nursing
Council (Nursing Council of New Zealand, 2009 p. 5), including clinical and cultural
competencies, and offer a framework for measuring nursing capital. Thus, in addition
to registration status and qualifications, a nurse’s clinical skills and clinical leadership
will receive a value. Present measures of hospital productivity (New Zealand Treasury,
2005) at best count nurses, and do not discriminate among nurses’ competencies. The
complexity of measuring nursing’s capital asset is illustrated in cultural safety and
competency. The education and practice of nursing has for some time been influenced Nursing
by cultural safety, an approach that emerged in NZ during the 1980s as a way of productivity
ensuring that the views and norms of the indigenous Māori people, who make up
nearly 15 per cent of the population, were incorporated into nursing practice with
power shared between nurse and consumer, so as to reduce inequalities between
Māoris and the general population (Ramsden, 1993). Pacific peoples contribute a
further 7 per cent to the population and Asians (9 per cent) are the fastest growing 207
ethnic group (Statistics New Zealand, 2006); cultural competency offers a framework to
support nurses in being responsive to population diversity (de Souza, 2008). Thus, a
culturally competent nurse has a greater value to the organisation that input measures
should capture. Modifiers of nursing capital are those factors that may reduce
productivity, and need to be managed in order to retain nursing knowledge; these
include age, diversity, medical conditions, impairments and personal responsibilities
(e.g. family) that reduce nurses’ availability.
The process of managing the resource of nursing knowledge so that it is effectively
translated into health status needs to be understood and managed, and shifts the focus
from the nurse as a unit of labour to the interface between nurse and work environment
(where the nurse-patient encounter takes place). Newbold (2007, p. 127) refers to
nursing as a “bundle of services, all of value to the end user, so a multiproduct
production function may be needed”. Other researchers have developed inventories
and data sets of nursing interventions available for quantification, making nursing
work more visible (Moody, 2004, p. 101). Moody identifies many measures and
instruments available to assess the productivity of nursing teams that could be
selected and validated for use in particular contexts, such as staffing levels, skill mix,
staffing practices including nurse substitution and extension, nursing practice models,
job satisfaction, organisational commitment and ability to provide quality care. Where
nursing teams include HCAs who need to be supervised, then supervisory work also
needs to be measured. Process innovations such as the “productive ward” have found
that as little as 30 per cent of nursing time is spent on direct patient care (Wilson, 2009),
supporting the case for identifying and reducing (e.g. through work redesign) the 70
per cent of time spent unproductively, such as in searching for things and dealing with
interruptions. Considerations of the work environment on the production function of
nursing would, based on research evidence (see previous section), particularly focus on
such dimensions as workload, control over clinical work and work design, leadership
and job stress. A feature specific to NZ is the Safe Staffing Healthy Workplaces
(SSHW) Unit (DHBNZ, n.d.; Buchan and North, 2009), and would contextualise
measures to assess the work environment as supportive of nursing productivity. The
SSHW Unit is an innovative response in NZ to concerns among nurses about staffing
levels and the ability to provide safe care to patients. Developed in partnership between
public sector hospitals and the nurses’ union as an alternative to approaches such as
fixed nurse:patient ratios (Newbold, 2007), the SSHW Unit aims to assure patient safety
and satisfaction, support staff well-being and hospital efficiency.
Nursing productivity is measured in its outcomes. Nurse outcomes are those
measures of productivity loss (the cost function) that include work-related illness and
injury, absenteeism, presenteeism and turnover. Although many of these data are
collected by organisations and health systems, they are seldom included in
productivity calculations. The true measure of nursing productivity lies in improved
JHOM health outcomes for patients (taking account of patient acuity and LOS), measured as
26,2 nursing sensitive outcomes. In addition are the hard-to-measure less tangible outcomes
for patients and family such as emotional wellbeing, pain being managed, physical and
cultural safety, self-management strengthened and supported in healthy practices
(e.g. nutrition, quit smoking). A third outcome of nursing and one that is even more
elusive to measure is outcomes for health systems, including avoiding
208 ambulatory-sensitive hospitalisations, self-managing patients and reduced demand
on health services, improved quality of care, improved efficiency. Measuring
productivity narrowly as nursing input compared with cost-weighted hospital
discharges (New Zealand Treasury, 2005) clearly does not take account of nursing
knowledge transformed into patient recovery and wellness. Finally, a feedback loop
explicitly links outcome measures with input and process measures, and will allow
managers to make decisions that raise nursing productivity without creating
unintended consequences for the nursing workforce and patient outcomes.

7. Conclusions
Concerns about efficiency and productivity of the nursing workforce in NZ were raised
during the 1980s/1990s and have emerged again in the past few years. As the single
largest health workforce whose improved productivity will potentially make a
significant contribution to increasing productivity of health services, nursing is rightly
a target (New Zealand Treasury, 2005; Ministerial Review Group, 2009). Unlike in
previous decades, NZ now has the benefit of experience to inform the present pursuit of
improved nursing productivity, as a sub-set of health sector productivity. It is
important that NZ takes account of those past experiences to avoid a repeat of poor
nursing workforce outcomes following reduced nursing labour costs and increased
workload as nurses (conceptualised as labour units and costs to the organisation) bore
the brunt of health system restructuring (Cook, 2009). The relationship between high
labour productivity and high levels of human capital (Organisation for Economic
Co-operation and Development, 2007) is important for its implications that a key to the
quest for higher productivity lies in investment of human capital. This is an important
observation as health ministries and grapple with the challenge to raise productivity in
the human capital intensive health system and services in economically straitened
times.
In the light of ongoing concerns in developed countries about the security of the
nursing workforce, and drawing from notions of nursing as a capital asset, we have
proposed a systems approach to nursing productivity. Reframing nursing productivity
to privilege the intellectual capital of nursing and its outcomes for patients and health
systems holds promise for capturing the true productivity of nursing as a capital asset,
and offers strategies to raise productivity while protecting nursing and patient
outcomes. A systems approach would take account of nursing capital, focus on the
interface between nurse and work environment (where the nurse-patient encounter
takes place), reflect systems thinking (Moody, 2004, p. 102; McGill Hall, 2003) and, as
Newbold (2007, p. 127) advocates, specify and measure cost and production functions.
The system as described in previous pages is conceptual and yet to be developed
through research, and any such investigation would need to establish its utility for
managers as well as the validity of its measures. Much of the research and strategies
on nursing productivity have been driven by economic and management theories, and
for nurse managers and clinical nursing leaders to understand and apply these theories Nursing
is a particular challenge. Not only are these approaches to a large extent theoretically productivity
and technically inaccessible to nurse managers; they consistently reduce nursing to
units of labour with associated costs and fail to account for nursing as a skilled
workforce in knowledge-intensive clinical contexts that better reflect managers’
experiences. The approach would need to make sense to and be usable by nursing
leadership and managers responsible for outcomes of nursing services, and incorporate 209
a feedback system to enable informed decisions on the nursing resource. We contend
that the model of nursing productivity espoused by the organisation or system
influences management behaviour: pressure to reduce costs and/or raise outputs per
nurse input is likely to lead, for example, to higher patient-nurse ratios and nurse
substitution. The approach we advocate is more likely to lead to investment in nurses
and nursing leadership through education and professional development, retention
strategies, reducing nurses’ stress and identifying and reducing processes wasteful of
nursing skill.
Measurement of the capital asset embodied in nursing, and the translation of that
knowledge into health outcomes for patients through nursing services is, as in
medicine (Scott, 2006), a challenge to nursing workforce managers and researchers
alike (Moody, 2004). Although the approach is yet to be researched and established in
practice, there is an implicit focus on hospitals as a context for nursing, reflecting
available measures that have been largely developed in hospital settings. A systems
approach would need to be sensitive to specific contexts, such as aged care and mental
health, and to nursing in community contexts, often working in advanced roles with
patients with complex conditions, as well as to acute hospital care. A limitation of a
focus on the nursing sub-system is that nursing is part of the wider health system and
this also influences nursing productivity (indeed, Kast and Rosenzweig, 1972, p. 454,
are critical of a tendency to practice sub-systems thinking while preaching a general
systems approach). How a nursing sub-systems approach to nursing productivity can
respond to broader developments in the health system is challenging but must not be
ignored. For example, while extension of nursing into traditionally medical territory
(e.g. through nurse-led clinics and prescribing) may not improve productivity of the
nursing sub-system based on measures specific to nursing, as doctors are freed up to
focus on more complex cases and shortages relieved, such developments are likely to
improve the productivity of the health system.

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Further reading
Nursing Research (2008), Nursing Research, 1, January/February, pp. 2-13.

About the authors

Nicola North is Associate Professor in Health Management in the Health Systems Section of the
School of Population Health and Director of the Master of Public Health programme at the
University of Auckland. She began her working life as a nurse and has maintained a significant
interest in nursing workforce issues through academic studies in health management and social
anthropology and a university career mainly in health systems and health service management.
Nicola North is the corresponding author and can be contacted at: n.north@auckland.ac.nz
Dr Frances Hughes is Facilitator, World Health Organization, Pacific Islands Mental Health
Network, and Adjunct Professor, University of Technology – Sydney, Australia, and University
of Technology – Auckland, New Zealand. A 2001-2002 Commonwealth Fund Harkness Fellow in
Health Care Policy, she was formerly Chief Advisor for Nursing in New Zealand’s Ministry of
Health. During her tenure she was responsible for leading nursing policy initiatives in New
Zealand, including nurse prescribing, primary health care nursing, and nurse practitioners.

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