By Beth A. Brooks, PhD, RN, FACHE
How do we quantify the value of nursing in healthcare delivery? It is one of the most persistent questions in nursing, and a growing body of research keeps trying to answer it with ever more sophisticated models. I read that work with genuine interest. But I keep returning to a more basic issue that all of those models step around: we still do not directly measure much of what nurses actually do.
That gap is not an accident. It is built into the way nursing was absorbed into the business of healthcare.
A Problem We Inherited
Nursing did not start as a cost center. A century ago, nurses were often paid directly by patients and their families. As care moved into hospitals, nursing was folded into the institution’s finances. When insurance and later Medicare arrived, nursing was tucked inside the hospital room charge and bundled with other routine services.
That structure never went away. Nursing care is still financially invisible, buried inside facility charges and never broken out on its own in reimbursement data. Bundling decides how a service gets paid. It says nothing about whether the work was performed, or by whom.
Attribution Is Not Reimbursement
Any mention of paying for nursing separately tends to trigger the same reaction: healthcare will cost more. That worry has frozen the conversation for decades. But it confuses two different things. Measuring who performed the work is not the same as changing how the system pays for it.
This distinction matters, because the evidence has been sitting in plain sight for a long time. By the early 1990s, researchers studying CPT-coded services in hospitals found that a large share of billable clinical work was being done by nurses, even though those services were billed under physicians according to the rules of the day. The system assigned value through codes and sent the dollars accordingly, while nurses did much of the actual work. We named the problem. We just never chased it down.
More recent research points the same direction. When you look directly at nursing interventions, they explain a meaningful share of the variation in hospital costs, while the traditional severity-of-illness measures we rely on add surprisingly little. Care happens through interventions. Costs follow the work. And nurses perform a great deal of that work. Yet we keep reaching for proxies that miss it.
The Starting Point We Already Have
Here is the part I find hard to let go of. The healthcare system already owns a tool for defining clinical work and attaching value to it. CPT codes define the work. Relative Value Units assign the value. Dollars follow.
I am not proposing that we rewrite reimbursement. I am talking about attribution. If a service is performed and already carries a defined economic value, that value should be credited to whoever performed it. Attribution does not raise the cost of care. It raises the clarity of who is creating value.
CPT codes will never capture everything nurses do. Much of nursing is cognitive, coordinative, and relational, and tools like the Nursing Interventions Classification represent that work far better. But CPT codes still cover a substantial number of discrete clinical tasks that nurses perform every day, which makes them a practical place to start.
Take something as ordinary as administering a blood transfusion. It is a defined clinical service with real economic value. Nurses perform it constantly. And it is not attributed to nursing in any meaningful way. The system recognizes the service. It does not recognize who delivered it.
None of this is simple to fix. It means connecting clinical documentation, coding frameworks, and financial systems in ways most organizations have not attempted. But difficult is not the same as unnecessary.
Why We Keep Circling It
Much of the profession’s energy, including excellent work published in our leading journals, has gone toward downstream value: quality scores, patient outcomes, cost avoidance. That work matters. But it has left a simpler question largely untouched, which is attributing the directly observable nursing work that is already tied to existing value structures. So we keep approaching value indirectly, through new frameworks, new data models, and new payment schemes, when a more immediate option already exists.
The system can define work and assign value to it. We have simply never pointed that capability at nursing.
I was skeptical enough that this might be too obvious to be true that I took it to the executive vice president and chief financial officer of a major health system. Over lunch, I asked him what I was missing. Why don’t we do this?
His answer was immediate. No one has asked.
That is the opportunity. Not a new model. Not a new payment system. Just the willingness, finally, to ask.
Adapted from Beth A. Brooks, “Nursing’s invisible revenue problem: And the simple fix we keep ignoring,” Nursing Outlook 74 (2026), 102799. https://doi.org/10.1016/j.outlook.2026.102799
