Introduction

People need high-quality care to improve their health and gain trust in different contexts, regardless of the current healthcare system. Changing health needs, rising user expectations and new health goals are raising the level for healthcare systems to produce better outcomes and greater social value. To achieve this, it is necessary to optimize care processes by providing care that maintains and/or improves health, values its users and meets the population’s needs.(¹)

Costs associated with service provision are increasing, and the hospital area is the largest and most expensive for healthcare systems. Moreover, organizations have been pressured to balance their expenses by strategically reducing costs, without compromising quality, with actions that do not compromise patient satisfaction and experience.(²)

The sustained search for hospital care, with patients arriving at hospitals with more complex care demands and remaining hospitalized for longer periods, combined with the serious global socioeconomic repercussions of the COVID-19 pandemic,(³,⁴,⁵,⁶) have increased existing financial challenges.(⁷) With increasing demand and a large financial deficit in healthcare services, the greatest threat to their sustainability (recognized as an important and legitimate domain of health quality) is most often identified as financial constraints.(⁸)

Given the scarcity of resources allocated to the health sector in Brazil, it is important for institutional leaders to commit to the organizational management model, cost management and its impact on the different work processes. It has been confirmed that such commitment is essential to providing safe, efficient, effective and economically sustainable healthcare services.(⁹)

We emphasized that the participation of nurses who occupy different administrative leadership positions on the economic aspects necessary for the financial sustainability of daily hospital care is essential. Therefore, the present study was carried out to understand the meaning attributed by nursing division directors to hospital cost management.

Methods

Qualitative, exploratory-descriptive research, of the single case study type,(¹⁰) was structured according to the Equator Network’s COnsolidated criteria for REporting Qualitative research (COREQ) guidelines.(¹¹)

The research was carried out in the Nursing Department (ND) of a university hospital (UH) at a public university in São Paulo (which is part of the Brazilian Health System (In Portuguese, Sistema Único de Saúde – SUS), whose objectives have been consolidated through teaching, research and extension of its services to the community.(¹²)

The ND is linked to the UH superintendence and aims to coordinate, supervise and control the activities developed in nursing teaching, research and care. The ND has five divisions: 1) Clinical Nursing (covering Adult Intensive Care Units and Medical Clinic, Hemodialysis Service and Home Care Program); 2) Surgical Nursing (covering Surgical Clinic Units, Surgical Center, Central Sterile Supply Department and Day Hospital); 3) Pediatric Nursing (covering Pediatric and Neonatal Intensive Care Units, Pediatrics and Pediatric Emergency Room); 4) Obstetric and Gynecological Nursing (covering Obstetric Center, Rooming-In and Neonatal Unit); and 5) Outpatient Nursing (covering the Imaging and Endoscopy Outpatient Clinic, Adult Emergency Room, Basic Health Unit and Risk Stratification).(¹²)

The researcher responsible for this study worked at the UH (20 years) and is a professor (14 years) at one of the nursing schools of the aforementioned university. The University continually invests in strengthening academic-care links with the UH, aiming at excellence in nursing teaching, research and care. These goals are within the scope of its areas of activity and technical capacity, in the planning and operationalization of guidelines in nursing and in the definition of the principles that underpin nursing care. Thus, this study had the participation (for convenience) of the five division director nurses (DDN) working in the ND.

The researcher above previously consulted DDN (by telephone) about their interest and availability to participate in the study. All agreed to participate after project description (scientific initiation, SI) and objective presentation. Data were collected in a ND meeting room (11/22/2023) at the times indicated by them. Before the interviews began, an SI student collected data to characterize each participant. Then, the researcher in charge used an audio recording to conduct the interviews based on the guiding question: What meaning do you attribute to cost management in your professional practice? The interviews lasted an average of 16 minutes. Field notes were taken by a student during each interview.

The recorded interviews were transcribed by a student and their transcripts were returned to the participants who approved them without comments and/or correction. They were then coded using acronyms and submitted to content analysis, defined as a set of communication analysis techniques. Its objective was to obtain indicators that allow inferring knowledge regarding the conditions of production and reception of messages using systematic and objective description procedures. This process included the phases of pre-analysis, material exploration and content interpretation.(¹³)

The legal procedures established by Resolution 466 (12/12/2012), which approves the guidelines and regulatory standards for research involving human beings, were strictly followed. The research project was approved by the Research Ethics Committee of the proposing institution (Certificate of Presentation of Ethical Consideration 71870123.2.0000.5392) (Opinion 6.333.675).

Results

For the five DDNs, the mean age (53.4 years) and mean time since graduation (30.6 years), experience in a management position (18.8 years) and as an DDN (8.2 years) were calculated. They had doctoral degrees (4) and master’s degrees (1). The content analysis of interviews allowed us to construct the “Meanings attributed to cost management in nurses’ professional practice” category and three subcategories: (1) Access to content on cost management during the academic trajectory; (2) Perception of the association between nurses’ performance and cost management; and (3) Development of actions aimed at controlling hospital costs.

Meanings attributed to cost management in nurses’ professional practice

DDNs considered cost management to be an important task for nurses, regardless of whether they hold an administrative position or not. Considering finite resources, they reported that such knowledge helps to support the decision-making process regarding the inputs needed for safe and quality care as well as for the successful conduct of bidding processes. They also emphasized costs associated with material resources and nurses’ relevance using specific knowledge to help in qualified argumentation about the cost-benefit of their acquisition:

Subcategory 1: Access to content on cost management during the academic trajectory

Only two DDNs reported having had information about costs during their undergraduate studies; however, all highlighted contact with this topic at different levels during their (stricto and lato sensu) graduate courses:

Subcategory 2: Association between nurses’ performance and cost management

DDNs explained the favorable impact of the articulation between nurse managers (at different organizational levels) and care professionals. Articulation increases collective participation in decision-making according to the level of governance, increasing the rational use of materials, avoiding waste and stock formation:

Subcategory 3: Development of actions aimed at controlling hospital costs

DDNs exemplified strategic actions developed individually or jointly to minimize and/or control costs in healthcare units. Such actions ranged from facilitating access to information about new products available on the market and costs of materials consumed, including raising awareness among users about the need for rational use of inputs (according to patients’ clinical condition) and desired results, to using the institutional electronic decision support system:

Discussion

The DDN participating in this study attributed importance to knowledge about cost management to support nurses’ work, regardless of whether they hold decision-making positions in hospital organizations. This understanding was confirmed, but we emphasize that such knowledge is essential in management positions. It allows for supporting the efficiency and effectiveness of decision-making regarding the viability of different work processes that require a rational distribution of human, material, and structural resources. These are generally limited and maintained with restricted budgets, especially in public healthcare services.(¹⁴)

Nurses have been increasingly held responsible for making decisions regarding the structure, processes and outcomes of care at different levels of care, regardless of the legal nature (public, private or philanthropic) of healthcare services.(¹⁵) However, due to the limited financial amount allocated to health, healthcare professionals generally experience precarious working conditions in public hospitals in terms of physical structure, insufficient professionals and lack of beds.(¹⁶)

In this scenario, nurses’ qualified participation in the decision-making processes of UHs requires knowledge in addition to expertise in healthcare practice, as they are responsible for the sustainability of the teaching-research-care tripod. Additionally, their qualified participation requires the development of cost management skills for greater efficiency in the allocation of limited resources, thus avoiding waste and economic-care losses.(¹⁵)

Even considering that cost management is not restricted to material resource management, DDNs have repeatedly highlighted the importance of predicting and providing material resources, favoring the training of healthcare professionals and nurses. They should use knowledge of costs associated with their acquisition to encourage rational use, thus avoiding waste in the care process.

A narrative literature review (sample: 44 articles by nurses) showed the contributions and advances associated with production on the topic of cost management and knowledge translation. Some of the studies (63.6%) were conducted in Public Teaching and Research Hospitals (PTRH) funded by the SUS. The economic and financial results obtained provided a review of procedures or processes for a rational allocation of scarce resources, mainly material resources.(¹⁵)

UHs are responsible for the largest portion of SUS care, and it is estimated that they consume 70% of public spending. However, the worsening of the funding crisis has had an impact on the amount allocated to universities, and thus part of PTRH expenses have been covered by operating funds. Thus, managing costs is important for internal reinvestment and sustainability policies in the short, medium and long term.(¹⁷)

The shortage of physical resources, materials and qualified personnel can result in both the interruption of healthcare service provision and material and equipment purchase by professionals who are unaware of the appropriate specifications.(¹⁸)

Hence, we highlighted among the challenges related to specific knowledge that it is also necessary for nurses in management positions to improve their knowledge of current legislation to improve their participation in agreements and contracts between the organization they represent and the SUS funding bodies.

For instance, since January 2024, Law 14.133/2021 (Administrative Tenders and Contracts)(¹⁹) has become the only federal law that regulates and unifies tender and contract procedures. For its effective implementation, it requires public servant training, cultural change, improvement of control systems, and adaptation of systems and processes. In its application, legality, impartiality, morality, publicity, efficiency, effectiveness, public interest, administrative probity, equality, planning, transparency, segregation of functions, motivation, binding to the notice, objective judgment, legal certainty, reasonableness, competitiveness, proportionality, speed, economy, and sustainable national development were the principles used.(¹⁹)

As hospital budgets are tight and do not keep up with the increased demand for healthcare services, hospital managers are under pressure to seek strategies to reduce hospital costs associated with various material resources and improve their operational performance. In hospitals, the supply chain is composed of external suppliers (pharmaceutical companies, manufacturers and distributors), storage centers and points of use (healthcare units and services), and end users (patients). The external supply chain encompasses all transactions with suppliers, whereas the internal supply chain relates to all products and information flows.(²⁰)

Thus, we highlighted that effective hospital supply chain management provides significant opportunities for improving efficiency and reducing costs. It is distinct from other contexts due to its peculiarities (emphasis on patient safety, perishability, stochasticity, etc.). Therefore, to optimize its performance at different operational levels, strategic, tactical and operational decisions must be made in a collaborative and integrated manner.(²¹)

A recent study indicated the relevance of indepth knowledge and the appropriate use of material resources to identify, analyze and reduce waste. Waste generates costs, and financial resource consumption can be redirected to benefit other patients if avoided. The relevance of nurses and other nursing professionals in recognizing possible sources of waste and minimizing them with preventive measures was highlighted, thus contributing to the efficiency of processes and financial sustainability of organizations.(²²)

Some DDNs reported that cost management content was not taught during their undergraduate studies. When such an approach was provided later, it was superficial, being taught only after enrolling in graduate courses or specific courses on the subject.

Due to increasing costs associated with healthcare delivery, nurse leaders must enhance their financial skills to advocate for staff and patient needs while supporting the organizational mission, vision, and values. Since nurse managers are often responsible for designing, implementing, and monitoring budgets, sound financial planning must include collaborative efforts with the finance department. Thus, we understood that nurse leaders who are competent in financial and budgetary management are better prepared to handle the increasing challenges of managing costs, allocating resources, and managing teams.(²³)

We confirm that acquiring knowledge about cost management and its adequate application in healthcare and management practice requires personal and institutional investments to train nurses. Such investments should cover the financial aspects of providing healthcare services, considering the optimization of limited resources, its impact on access and equity for users, and maintenance of healthcare quality.(¹⁴)

On the one hand, nurses must commit to and invest in their continuing training, especially in relation to the acquisition of specific knowledge such as cost management. On the other hand, training and care institutions must also be involved in training on the economic and financial dimensions associated with the provision of safe and quality healthcare services.

Finally, this single case study was a carefully delimited investigation, clearly defined and with specificities of the topic in the real context where it occurs.(¹⁰) It allowed a better understanding of a specific process that occurs in the social context, showing the meanings of hospital cost management reported by DDNs.

Conclusion

For nursing division directors in the nursing department of the university hospital in question, the cost management process in different care contexts and decision-making levels is an essential tool for nurses’ performance. It underpins (a) decisions about the limited resources (human, material, structural and financial) needed to provide safe and quality healthcare services, (b) the successful conduct of bidding processes and (c) participation in negotiations with decision-making bodies responsible for the transfer of financial resources. Nursing division directors emphasize the need for adequate forecasting and provision of material resources to promote care safety, increase their efficient and rational use, thus contributing to minimizing financial losses.

Acknowledgements

This work was carried out with the support of the Brazilian National Council for Scientific and Technological Development (In Portuguese, Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPq).

References

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