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The Dollars and the Sense of Economics Interacting with Nursing Kevin D. Frick, PhD Contact Information: Associate Professor It was an honor to be asked to speak at the closing plenary session of the 2009 Southern Nursing Research Society annual meeting, for which the theme was “Interdisciplinary Research: A Road More or Less Traveled.” As a student of health policy for two decades with training in both health services research and economics, much of my career has been focused on trying to make interdisciplinary research the road more traveled, rather than less traveled. The opportunity to address the meeting’s attendees gave me a chance to share my vision of how to achieve this goal. I used the title “The Dollars and the Sense of Economics Interacting with Nursing” to underscore the importance of making effective use of the resources available to provide high-quality health care and to reflect the fact that the goal of my presentation was to provide a sense of how to go about this work. As a follow-up to the presentation, I have been given the opportunity to share some additional and slightly reorganized reflections in writing. Productive, truly interdisciplinary research combining nursing and economics has been a road less traveled historically because of the inherent challenges involved in achieving this objective. Economists, considered as a profession, are not known for offering the clearest, most intuitive explanations that would facilitate interdisciplinary collaboration. The remainder of this piece will discuss (1) what economists do—since even my collaborative colleagues have not always understood that before we have begun— (2) how to build an interdisciplinary research team, and (3) how the interests of nursing researchers and economists overlap. What Do Economists Do? Any attempt to describe an entire profession’s activities in one sentence will unavoidably lead to oversimplification. With that caveat, I would classify professional economic activities as falling into one of three categories along a continuum: (1) developing new theories to explain individual and organizational behavior, (2) testing those theories with empirical data, or (3) performing analyses of the expected outcomes of policy changes to facilitate policy recommendations. Along this continuum, developing and testing a theory are often part of the same project. Furthermore, the same project can include both empirical measurement and a prediction of what the results imply about how policy changes will affect the welfare of the population being studied. Once a policy is adopted, the outcome is rarely exactly what was expected. Additional theoretical advances often are needed to explain the new findings, and the entire process repeats itself. Consider the following example: Health economists helping with a study to encourage increased breastfeeding duration would (1) study potential economic reasons for short breastfeeding duration; (2) collaborate in developing a program to address the issues preventing longer duration, based on the findings from (1); (3) perform an evaluation of the new program; (4) make a recommendation as to whether to adopt the program or not, based on the findings from (3); and (5) observe whether the program resulted in the desired outcome, recognizing the need to return to (1) if it did not. A single economist may not perform all of these steps. A key take-home message is the recognition that while most economists have been trained to use the same tools, not all economists do the same thing. The tools that economists are trained to use are focused on a set of ideas that shape their entire way of thinking about the world. How can non-economists learn about what economists do and how economists think? There are formal classes in economics, health economics, and cost-effectiveness analysis. However, there are also ways of learning how economists think that do not involve formal coursework, which often focuses on graphs and equations more than on explaining the basic logic of economics. Most collaborators need to understand the logic of economics, rather than how to draw graphs and solve equations. For this reason, I would recommend the following books: The first is The Economic Naturalist, by Robert Frank. This book includes a series of short essays, mostly adapted from Professor Frank’s students’ writing, that illustrate the use of economic logic in everyday situations. The second is The Fattening of America, by Eric Finkelstein and Laurie Zuckerman. These authors present an accessible argument about how economic forces have reshaped the foods we eat and the time we spend on food preparation in ways that have led to increased average body weight in the U.S. population. A basic understanding of economics can be enhanced by reading a newspaper such as the Wall Street Journal or a magazine such as The Economist. When reading these publications, making a careful assessment of the arguments that are being put forward and the conclusions that are drawn about health policy will help increase a reader’s comfort level with the concepts of economics. In addition, there are blogs about economics. As an example, I have initiated one at http://economistlens.blogspot.com that applies economic reasoning to concepts in health and medicine on a near-daily basis. Several key points about how economists conceptualize the world can be summarized here. Economics is the study of the allocation of scarce resources. Economists generally believe that a market is well-suited for efficient resource allocation and will begin any discussion of new regulation by asking why it is necessary. The right evidence can convince most economists of the need for regulation in specific situations. This is particularly true in health care, which is not typically associated with efficient market operation. Economists studying health care will ask, for example, why particular personnel are used to produce certain types of care, why people who should seem to have an incentive to obtain a free flu shot do not, or whether a new imaging technology should be recommended for use for screening an entire population or just a subset of the population. All these questions involve assessing tradeoffs—the essence of economics. For questions involving the use of new technology, the literature often will include cost-benefit, cost-effectiveness, or cost-utility analyses. These analyses compare the costs and benefits of an intervention, treatment, or screening in a formalized way that allows policy makers to draw conclusions about whether the costs are worthwhile. Cost-benefit analyses require an analyst to place a monetary value on health and life. Cost-utility analyses often involve the concept of quality adjusted life years (QALYs), which are a non-clinical summary metric of morbidity and mortality that is useful for comparing treatments of different conditions or for assessing a treatment of a single condition that has multiple health effects. How to Build an Interdisciplinary Research Team The previous section’s focus on understanding what economists do is not meant to suggest that nurses need to understand economics, but the reverse does not apply. In fact, a good economist collaborator will either know or be interested in learning about nursing science. Thus, the first step in building an interdisciplinary research team is identifying an economist interested in nursing science. Beyond that, building an interdisciplinary research team is like building any other type of partnership in life: The relationship needs to be thought of as a “two-way street,” the partners need to understand each other, and both partners need to be willing to invest time in the partnership. Perhaps the fact that the collaborative relationship is a two-way street is obvious. However, I will be the first to admit that occasionally in my career I have found myself “lecturing” my colleagues about understanding my research expertise, rather than finding ways to engage them in sharing an interest in my research expertise—and asking the same from them in return. The best collaborative projects I have worked on with nursing researchers have been those for which my colleagues and I have both taken the time to learn about the other’s science. The key question is how much each member of the partnership needs to know about the other’s discipline and when it must be learned. In the previous section, I outlined some ways that nurse researchers can learn about economics. However, I should say that I do not expect my nursing science colleagues to become economists—any more than they expect me to become a nurse. Rather, I hope that they learn the way economists think about the world (for which I gave a brief synopsis above), how economists motivate their statistical (econometric) analyses differently from epidemiologists, and how economists structure their thinking about cost-effectiveness. All of this will not necessarily make nursing researchers ready to perform their own economic analyses but will prepare them to work effectively in a team with (and ask the right questions of) economics-trained collaborative colleagues. So, what should an economist be expected to know about nursing, and what is the best way to find the right economist with whom to collaborate? When I participate in a cost-effectiveness study in a clinical area in which I have not worked before, I like to say that I shouldn’t be asked to present a poster at the conclusion of the project unless I can at least pass a simple exam on the condition or describe the infrastructure in which my colleagues work. This does not have to be true at the beginning of the study, but it should definitely be true at the end of a study. An economist who does not understand a collaborating colleague will have just as much trouble giving an effective presentation and responding to questions about the presentation as would a nurse trying to answer economic questions without a firm understanding of the principles involved. Since an economist does not necessarily understand a clinical area or nursing science prior to a collaboration, nursing researchers must find ways to introduce economists to nursing. Just as I have recommended texts for introducing nurses to economics, nurses might consider texts that introduce economists to nursing. I have found Middle Range Theory for Nursing by Mary Jane Smith and Patricia Liehr to be particularly helpful. The objective should be to provide an economist with background information about nursing science, the clinical area in which a nurse researcher is working, and the organization of the system in which a nurse researcher works. With a plan in hand to engage the collaborating economist, what are the steps in choosing the right economist? First, as should be apparent by now, the old saying “Don’t judge a book by its cover” applies—don’t expect that all economists are equally proficient at all tasks. A nurse researcher looking for collaborative opportunities should be able to describe what is needed and ask about the strengths and weaknesses a potential collaborators is perceived to have. Finally, a variety of simple steps can be employed to start the collaborative relationship on the most positive note possible. First, a researcher hoping to collaborate with an economist should seek that expertise as early as possible in the grant writing or research process. Second, the economist should not be expected just to perform analyses at the conclusion of the study but should be involved in the study design process, and particularly the planning for relevant data collection. Finally, the nurse researcher should not be afraid to ask questions and should be willing to answer the economist’s questions. No one looking for a positive collaborative relationship should be required to accept a colleague who is unwilling or unable to answer questions clearly. The research will only be improved by clear, concise communication. Overlapping Interests of Nursing Researchers and Economists While there are many potential areas of overlapping interest, this section will focus on three concepts to illustrate the point. First, nursing science is interested in whole-person measures. Economists who conduct cost-utility analyses are interested in the concept of health utility, which relies on multidimensional (or whole-person) measures of health-related quality of life. Economists also focus on the fact that health is not the only requirement for individual happiness. Community health nurses (and nurses in general) recognize that there are many aspects to what makes a patient happy that include, but are certainly not limited to, the condition for which a patient presents on a given day. Thus, nurses and economists can work more closely together on developing patient outcome measures that are more useful for assessing cost-effectiveness. Nurses have insight into what outcomes or aspects of outcomes are of interest to patients that are not captured well in existing measures; economists could profitably use these outcomes in policy-relevant analyses. Second, nurses practice as part of a care system. Care systems do not always provide care as efficiently as possible. Economists do not view efficiency as providing care with minimal resources so that quality is compromised; rather, they view efficiency as producing a specific level of quality at a minimum cost. Once this understanding has been established, the question of whether the quality that is produced efficiently is costing too much can be addressed separately. Nurses play a role in maintaining and improving the system and have the capacity to describe institutional intricacies to economist colleagues and thereby improve their analyses. A final example is workforce policy. While the paradigm of producing more hours of nursing services may be efficient, it has resulted in what is perceived as a shortage of nurses. Nursing researchers, nursing educators, and economists could profitably spend time together thinking about incentives for existing faculty, doctoral trainees, nurses, and nursing students as well as incentives for the organization of schools of nursing and medical care provision that could reduce the perceived shortage. Collaborative research efforts could then be undertaken to analyze the expected effects of those plans. Conclusion Barriers to developing strong interdisciplinary collaborative relationships are largely a function of the time that must be invested to develop a strong collaboration. Investing time is particularly difficult when it must occur prior to the availability of a funded grant. Also, the fact that not all potential collaborators are “right” for one another cannot be ignored. Despite the barriers, there are many opportunities for interdisciplinary collaboration between nursing researchers and economists. Nurses as a profession are called on to assess the relative costs and benefits of a variety of approaches to treating patients. Economists want to assess whether health is being produced efficiently, what the barriers to efficient production may be, and whether there is an effective way to change those barriers. Since health care in general, and nursing in particular, is not often characterized as a perfectly competitive market, economists find nursing services to be particularly interesting to study. Failure to make interdisciplinary research a road more traveled will limit interested economists’ understanding of the institutional details that describe the way in which and environment in which nurses work, and nurses lose valuable opportunities to benefit from technical analytic expertise that is timely and highly policy-relevant. In contrast, taking advantage of the opportunity to form interdisciplinary teams and to learn about other researchers’ approaches has the potential to result in research alliances that will improve research quality and make conclusions stronger. We would be well advised to recall the words the last stanza of Robert Frost’s “The Road Not Taken”: “Two roads diverged in a wood, and I—/I took the one less traveled by,/And that has made all the difference.” The opportunity to take the historically less-traveled road could make all the difference for the future of collaborations between nursing and economics.
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