In this month's mailbag, I'm featuring just a few of the pieces that generated a lively debate this month, as readers offer their thoughts on subjects ranging from the role of nursing in the era of volume-based payment to the importance of preventive care in reining in health care costs to the growth of patient advocacy initiatives.

Richard Bogue's recent piece on the importance of nursing to hospital bottom lines in the era of volume-based payment — and the need for providers to work with and train nurses to get the most out of their contributions — elicited several responses, starting with this comment from Kathleen M. Mulcahy, R.N.

I am in full support of your recommendations, yet I want to bring one thing to your attention that you "misstated" in my view. Under the sections of suggestions to leaders, you mention collaboration with colleges to "train" nurses. Dogs are trained as well as the rare cat. Nurses are educated. If you wish others to recognize the incredible work and caring that nurses provide, treat them as professionals, use the word "nurse" to refer to the Registered Professional Nurse only. And provide them with sufficient registered nurses and support personnel, so nurses are with their patients and not running for meds or tracking down IV pumps or doing the work better suited to the UAP's in the hospital setting. I have been a RN for 39 years with more than 35 years in management positions, including both Director or Chief Nursing Officer. For patients to come first, leaders must put their nurses first. My motto: If you take excellent care of the nurses, they will be able to take excellent care of them and your patients.

Reader Jamie Kowalski also weighed in:

Another dimension that underscores the points made in your article is the impact the supply chain has on nurses' productivity and satisfaction, plus the quality of care provided. In 2009, I led a team that included Marquette University Colleges of Business and Nursing in a nation-wide survey of over 1600 critical care nurses and nurse executives. Over 70 percent were dissatisfied with how well the supply chain supported nurses, and how much time they spent on supply chain tasks instead of caring for patients (estimated at up to two hours per shift). They had a similar take on the supply chain's performance; it has a direct impact on the quality of care provided and patient safety.

And finally, Jo Harris had this take:

Upper management have incentives for nursing staff if you are one of the 'players' for management. The hardest-working, patient-centered advocate RN will not be the nurse that is promoted to take more classes or the nurse that management interviews for changes needed for better patient outcomes. The reason? Because they need those nurses at the bedside while the nurse "players" move up the chain.

H&HN Daily columnist Joe Flower's recent piece on the importance of preventive care in driving down overall U.S. health care costs also drew a spirited response, including this from a reader identified as Mike:

While Joe makes some good emotional points, he also continues in the same faulty logic that he criticizes — this is a problem that can be solved by others — namely, insurance companies, public health officials, etc. Look at the statistics. If three fourths of Medicare recipients have at least one chronic illness, and two thirds have multiple chronic illnesses, and the costs of treating chronic illnesses the current way we treat them is what is driving up costs, how does having more people insured help? All of those with Medicare are insured, right? What remains through all generational discussions is the individual responsibility for healthy choices, and a great role for government, businesses and hospitals to improve health literacy, such that individuals can understand how they can prevent the need for healthcare services (need in healthcare equals demand in economics, which outpaces supply or services, which increases price or cost, which currently is greater than bupkis.)

In response, Peter R. Lee offered this comment:

Thanks to Joe Flower yet again! He has been for a long time and is still a capable and articulate spokesperson for community change. He was one of the major voices that helped launch the Healthy Communities movement. This is another good article that I will share far and wide. One comment I would like to make, in part to respond to Mike since he is focusing on the insurance coverage only. The ACA has a significant contribution to community transformation, which is essential to prevention efforts! People get ill in their community and oftentimes the medical system mends the person only to send them back into the same community in which they became ill.

And finally, my recent video with Mei Kong, Assistant Vice President of Corporate Patient Safety of the New York City Health and Hospitals Corporation, on how hospitals can use patient advocacy programs to both educate and empower patients drew this response from reader Ron Hammerle:

Much easier said than done — for both patients and staff. Nurses and other hospital staff have often encountered severe criticism, push back and in at least some cases dismissal by hospitals for "speaking up" on patients' behalf. The challenge is even greater for patients, including even some who have physician spouse advocates. A recent experience makes the point. A highly trained nurse experienced a heart attack. When her neurosurgeon husband questioned the cardiac surgeon's intent to do quadruple bypass by citing radiological and clinical evidence to indicate doing a fourth vessel posed an unnecessary risk with unlikely success, the CV surgeon was offended. In the end, another member of his group concluded the neurosurgeon was correct. How much more difficult is it for patients without such medical knowledge or experience to "speak up" for themselves? Beyond the issue of effective patient advocacy (which is big in and of itself), many such experiences demonstrate the fallacy of truly informed consent in perhaps the majority of complex clinical and research encounters.