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It is appropriate to consider both emergency physician and nurse productivity together since they are interrelated. And to some degree, emergency physician and nurse productivity each depend upon the productivity of the other. Both in turn depend upon the level of hospital administrative resource allocation, the responsiveness of lab and radiology, and the availability of inpatient beds and the consulting/admitting medical staff. It should be clarified at the outset that nurse staffing budgets are often driven by volume, yielding hours per patient visit (HPPV). The budgeted allowances for nursing fulltime equivalents (FTEs) typically include “nonproductive” time (vacations, jury duty, bereavement, education time, staff meetings, etc). These factors are in addition to direct and indirect patient care time, which assumes uniform individual productivity.

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Historically emergency department (ED) staffing levels have been based on hours per patient visit that assume that a physician is a physician and a nurse is a nurse. However, there are wide variations in the productivity of individual physicians and nurses, which would seem to invalidate this still current practice. A better way is necessary to measure individual productivity and how it is impacted by the level of support from all of the other resources necessary to achieve a targeted level of productivity. There have been several recent developments that bear on both physicians' and nurses' productivity. In this chapter, some of these developments will be discussed to trace the evolution of emergency physician and nurse productivity evaluation up to and including the current state-of-the-art.

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Given that an individual's motivation is intimately related to his or her productivity, it is necessary to expound briefly on the subject of motivation. In his book, The Surprising Truth About What Motivates Us, author Daniel Pink1 summarizes research that suggests, “money is a motivator for purely mechanical tasks but as soon as some level of cognitive processing is required to complete the task, money is secondary to other factors.” This fact likely underlies the effectiveness of productivity-based compensation for emergency medicine providers when productivity is measured in terms of how completely each case is documented. There is little or no cognitive processing required to follow a template and to fill in all of the requested data points. On the other hand, money has proven to be a poor motivator when encouraging emergency physician group governance involvement and leadership activities.

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Hospitals have not embraced productivity-based ED nursing compensation to date. Among the reasons for this are

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  • Nursing productivity is more difficult to measure since there is generally not a one-to-one relationship between an ED patient and a single ED nurse.
  • The precedent of productivity-based nursing reimbursement would affect the entire hospital.
  • Very few successful models have been demonstrated.

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This raises the question, when considering nursing motivation, what are these “other (motivational) factors” to which Daniel Pink refers?

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Autonomy, mastery, and purpose are the nonmonetary “other factors” that motivate all people. ...

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