Salary or per diem? Which is best?
Non-salary has a place, but shouldn’t be the norm
As hospices try to cope with shrinking bottom lines and nursing shortages, many are looking for ways to reduce costs or creative measures to attract qualified nurses. One of the ways has been to pay nurses per diem or by the visit, rather than the traditional salary and benefits.
The financial impact can be significant, says Peggy Pettit, RN, senior vice president for patient/family services at Vitas Healthcare in Miami. In terms of money paid directly to nurses, the amount is about the same. But hospices can save 25% to 40% in benefits because they would no longer be obligated to pay for items such as health insurance and retirement savings plans.
Per diem basis might hinder relationships
But the savings can come at a price, says Pettit, whose company has studied the pros and cons of a per diem-paid nursing staff. In general, she says, a staff made up mostly of per diem nurses can have a detrimental effect on quality of care and productivity. Per diem nurses, who are paid by the hour for each day they work, often work fewer days than their salaried counterparts, which can hinder the bond established between nurse and the patient.
"We think quality is enhanced when you use full-time, salaried employees," says Pettit. "It is important to establish continuity of care. Full-time nurses are able to establish relationships with patients that some per diem nurses can’t, because they don’t see the patient as often or because they don’t see the same patients regularly."
But that doesn’t mean per diem nurses don’t have a place in hospices. While Vitas has chosen to keep most of its nursing staff on salary, it uses per diem nurses to fill gaps created by vacationing nurses and to provide continuous care, where demand is difficult to predict.
Haven Hospice in Atlanta employs 20% of its total nursing force using non-salaried nurses. It also uses a payment form more associated with home health agencies — per visit payment, which is based on the number of visits a nurse performs. The hospice, however, doesn’t use per visit nurses to reduce its costs. Instead, the strategy is part of the hospice’s attempt to attract qualified nurses and allow the hospice to increase its caseload.
"Some of our employees want benefits," says Metta G. Johnson, RN, BSN, OCN, ACRN, executive director and owner of Haven House. "Others want the flexibility of getting paid by the visit."
Need for continuing education
Whether the motivation is saving money or filling job positions, quality of care should be foremost in the minds of hospice leaders who are considering making similar moves.
Vitas officials believe a per diem-driven work force would be detrimental to overall quality. Instead, the organization chooses to balance its needs by using per diem nurses strategically. Despite the limited use of per diem nurses, there should be a program in place that routinely trains and educates per diem nurses to ensure quality of care does not decline, says Pettit.
As an example, per diem nurses should be exposed to the following topics:
• Organizational philosophy. Recently hired workers are schooled in the hospice philosophy and mission.
• Hospice basics. Nurses who have never worked in hospice need to become familiar with ideas such as the interdisciplinary team, palliative care, spiritual care, advance directives, and other unique tenets of hospice.
• Communication. New nurses are taught how to listen to patients and take clues from patient interaction.
• Death and dying. New hires are asked to explore their own feelings about death and dying, perhaps revisiting their own loss of a loved one.
• Stress management. The hospice stresses the importance of communication, not only for the sake of patient care but also for the mental well-being of its nurses. New nurses are taught the importance of using resources available through the interdisciplinary team, such as other team members who can provide additional support to the patient and alleviate the stress of having to support the patient on their own.
In addition to the above items, per diem nurses need continuing education and training in patient care, assessing emerging patient needs, and improved communication with other members of the interdisciplinary team, says Pettit.
While Johnson agrees that routine training is a must, she says diminished quality is not an issue among her non-salaried nurses. "We are very selective so that we can trust our staff," she maintains.
Johnson acknowledges the seeming contradiction between an incentive to squeeze in as many visits as possible under per visit payment and the mission of each hospice nurse visit to provide compassionate care irrespective of the time spent in the patient’s home. But she says her per visit nurses provide quality care that puts the patients’ needs ahead of the need to make more visits. Home health agencies have employed per visit payment to boost nurse productivity by encouraging them to take on as many visits as possible.
From a hospice perspective, a system that has nurses running from one visit to the next is not compatible with its mission. This is a principle not lost on Johnson. Rather than setting nurses loose to see as many patients in a day as they can, nurses are assigned a caseload much like salaried nurses are. While the incentive to make numerous and shorter visits is not eliminated, it is blunted by their caseload responsibilities. Like salaried nurses, per visit nurses are responsible for the case management of each of their patients, including spending the appropriate amount of time with each patient and his or her family.
To promote flexibility, per visit nurses at Haven decide on their caseload, taking on as much or as little as they feel suits them. In general, per visit nurse caseloads range from four to seven cases. It is the nurse’s responsibility to schedule visits for his or her assigned cases.
"It’s something you need to monitor," Johnson says of nurse visits. "But by and large, nurses want to be with patients, and there has to be that level of trust that your nurses want the best for their patients."
Better documentation skills
Although time spent with patients is a priority, there are other tasks in which per diem or per visit nurses must be proficient. A growing challenge for hospice nurses in general has been the increasing amount of documentation tied to reimbursement.
Pettit warns that non-salaried nurses need continued documentation training. Aside from basic training in proper documentation, Pettit advises training nonsalaried nurses to provide story-oriented documentation. "Per diem nurse documentation is often task-oriented," she adds "While they are very good at describing what services were provided, they don’t always provide the same depth as full-time nurses. They miss describing the big picture."
Because non-salaried nurses may not have the advantage of treating the same patients on a regular basis, they are at a disadvantage in developing skills to help them assess a patient’s emerging needs.
Both Johnson and Pettit agree that it would be ill-advised to convert a nursing staff from salary to per diem or per visit. Pettit fears such a hospice would be staffed by nurses whose loyalty and commitment might be lessened.
In that same vein, Johnson says nurses who want to work fewer than four cases could have questionable commitment. "If you have someone who wants to work sporadically, I don’t think that would work," she says.
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