Julie A.

Nelson
Nancy Folbre

Why a Well-Paid Nurse Is a

Better Nurse
I
N A RECENT ARTICLE TITLED “The es receive, along with their wage,
Executive Summary Economics of Vocation or from doing work that they “like”
䊳 Rebutting the argument by ‘Why Is a Badly Paid Nurse a or “feel a need to do.” The stan-
Heyes that lower wages attract Good Nurse?’” economist dard labor economics theory of
better, “vocationally called” Anthony Heyes (2005) argues that “compensating wage differentials”
nurses, the authors invalidate this a willingness to accept a lower posits that, all else equal, a person
position on several grounds in-
cluding existing research re- wage, all else equal, distinguishes will be willing to take a lower
garding the relationship between a “good” nurse from the “wrong wage for a job with characteristics
wages, retention, and patient sort.” Therefore, he argues, raising he or she prefers, than for a job
outcomes as well as forces evi- nurses’ pay would reduce the pro- with less-pleasing characteristics.
dent in the current nursing labor portion of nurses who have a voca- Drawing from this theory, Heyes
market. tion for it and result in a decrease asserts that someone with a “voca-
䊳 Simply put, the strength of in the quality of care. Lest such tion” for a service-oriented occu-
“vocation does guarantee skill” work be taken seriously — or tar- pation like nursing or teaching
and good nursing care hinges
heavily upon clinical and tech-
nish the reputation of all econo- will, all else equal, be willing to
nical knowledge. mists in the eyes of serious scholars enter that profession at a lower
䊳 In addition, Heyes projects the
of health care — this article, writ- wage than someone who does not
possible decisions of an indi- ten by two economists who have feel such a vocation.
vidual onto the entire labor studied the economics of occupa- So far, as an argument based
market, ignoring the possibili- tions with a “care” component on personal utility maximization
ty that some caring nurses (Folbre & Nelson, 2000), rebuts (and with the strong “all else
also need a well-paying job to Heyes’ argument. equal” clauses), the argument is
support their families. Heyes’ result is based on falla- relatively uncontroversial. The
䊳 Taking Heyes’ assertion to an cious reasoning and a disregard fallacious conclusions develop as
extreme, the best way to for considerable literature on qual- Heyes (a) fails to distinguish ade-
secure a fully “vocational”
workforce would be to rely ity of care, worker motivation, and quately between motivations and
solely on volunteers to deliver morale as will be discussed in this the quality of the job accom-
patient care. article. It also ignores actual nurs- plished, (b) uses a theory about
䊳 While Heyes asserts that high- ing shortages emerging in the individual behavior to make asser-
er wages “crowd out” good United Kingdom and many other tions about the characteristics of
nurses, he overlooks the evi- advanced industrial countries. the entire nursing labor market, (c)
dence that wages, when used There are many reasons to believe
as a form of recognition, can that higher salaries for nursing
“crowd in” good nurses.
would increase both the quantity
䊳 In reality, the lack of wage JULIE A. NELSON, PhD, is a Senior
and quality of nursing care. Research Associate, Global Development
incentives in the U.S. is one
factor leading to the labor and Environment Institute, Tufts
The “Bad Pay = Good Nursing” University, Medford, MA.
shortage and the need for
recruitment of foreign-trained Argument
NANCY FOLBRE, PhD, is a Professor of
nurses. Heyes models “vocation” as a Economics, University of Massachusetts,
“non-pecuniary benefit” that nurs- Amherst, MA.

NURSING ECONOMIC$/May-June 2006/Vol. 24/No. 3 127

 neglects the impact of pay on A person drawn into nursing by husbands for financial support.
employee morale and retention, the emotional and relational tasks This pool of truly caring people
and (d) overlooks the empirical may not be effective in communi- who don’t need the money is
realities of current nursing short- cating a feeling of being “cared probably shrinking over time,
ages. for,” just as others who feel a however, given rising divorce
strong vocation to be poetic may rates and other changes in family
Motivations and Quality not ever successfully pen good structure. To the extent that nurs-
While vocation may be a nec- poetry. Heyes falls prey to a logi- ing education gets increasingly
essary condition for high-quality cal fallacy when he equates inten- technical and expensive, even
performance in many jobs, it is by tion with accomplishment. fewer people have the luxury of
no means a sufficient condition. making a decision to enter this
Vocation does not guarantee skill. Individual Analysis Is Not Market profession without worry about its
Someone who is effective in mak- Analysis financial implications.
ing patients feel truly “cared for” The theory of compensating People with real financial
provides higher quality care than wage differentials applies at the responsibilities for themselves
someone who performs his or her level of an individual, making the and their families, on the other
routines mechanically, all else choice of whether or not to supply hand, would find it difficult to
equal. The vast majority of nurses, his or her labor. The idea that gen- choose a low-wage nursing job, no
we believe, do provide such high- erally paying nurses low salaries matter how generous their hearts.
quality nursing or at least would is an argument that goes beyond Accepting such a job could mean
like to, if staffing levels and other the individual level to encompass putting the needs of their patients
employer policies would allow larger issues of market-level sup- before the needs of their own
them. But there are at least two ply. Regarding the available labor dependents. Caring, intelligent,
places for slippage between per- pool, Heyes assumes that the dis- organized, educated, and honest
sonal feelings of vocation and tribution of abilities and reserva- people with other options are not
quality of outcomes. tion wages among nurses with and only in demand for nursing, but in
First, nursing, has, unfortu- without vocation would be identi- demand for other occupations as
nately, long suffered from the cal, were it not for the vocation well. Higher wages elsewhere
stereotype that its practitioners factor. (The “reservation wage” is will, therefore, draw them out of
need only be motivated by love. the lowest wage that can be the low wage labor pool. This is
Some nurses complain that offered and still draw a worker not because they are “greedy,” but
patients, families, and fellow staff into a labor market.) Yet the rela- because in a modern economy one
treat them as unskilled, kindly tion between vocation and reser- needs income to pay for groceries
“angels” or “pillow-fluffers” rather vation wage should be a topic for and rent (The fallacious nature of
than skilled and caring profession- empirical study, not theoretical the equation of concern about
als. In judging quality of care, assertion. In fact, there is good money with “greed” is discussed
emotional competence is impor- reason to believe that nursing in Nelson, 1999). People with
tant, but should not be focused on applicants who have a full set of financial responsibilities (howev-
to the neglect of other medical, the emotional and other compe- er caring, competent, and voca-
technical, and organizational com- tencies that would enable them to tion-oriented they may be) must, if
petencies. The best nurses are those provide quality care will tend to they can, take jobs that pay wages
who combine both. Acquisition of have systematically higher reser- sufficient to support themselves
technical skills through nursing vation wages than lower-quality and their families.
education is, of course, generally applicants. So besides people who don’t
an expensive proposition in terms This comes from observing need the money, the other group of
of both time and money. Wage the two main sorts of workers who people in the low-wage pool will
rates that imply a low or negative may populate the low-wage pool. tend to be those who do need the
return on this initial investment First, As Heyes posited, some peo- money, but have no better alterna-
(especially if they create hardship ple are willing to accept low tives. These people may or may
in repaying educational loans) wages out of the goodness of their not be caring at all. In the case of
will discourage capable people hearts. These people must also, skilled nursing, these may be peo-
from entering this profession. presumably, have relatively low ple who can achieve the minimum
Second, people drawn to any financial responsibilities. Histor- skills to keep their job, but who
occupation by the opportunities it ically, nurses (along with pre- aren’t likely to move elsewhere
may offer for a particular kind of school teachers and other “caring” because they are on the lower end
self-expression may or may not professionals) were often young when it comes to such things as
actually be competent at even childless women, or married general intelligence, work habits,
those expressive aspects of the job. women who could rely on their and organizational skills. Or they

128 NURSING ECONOMIC$/May-June 2006/Vol. 24/No. 3

may enter the nursing profession 1998). But that article focused on they are perceived to be acknowl-
because of preferential visa treat- the supply of caring labor as a edging” (1998, p. 444, emphasis in
ment or the fact that a subsidized whole, emphasizing the impor- original). That is, if compensation
education program offered them a tance of changing gender norms is structured such that it shifts the
way into a skilled occupation. and the need for a new social con- perceived locus of control outside
These workers are willing to tract. It did not argue against pay- the worker, vocation can be damp-
accept a low wage for nursing ment of higher wages for care ser- ened or extinguished. But if the
because their opportunity costs (in vice work. If one took Heyes’ argu- remuneration is understood as an
terms of jobs foregone) are low. ment to the extreme, the only way acknowledgment and appreciation
While in the case of registered to get a fully vocational nursing of the worker’s own intrinsic moti-
nurses the “low wage pool” has a labor force would be to rely on vations, it can strengthen such
floor related to skill and educa- volunteers. By neglecting the fact motivations.
tion, the implications of low- that even highly vocationally ori- Such research suggests that
wage-pool issues are especially ented people need to support overly regimented work and pay-
dramatic in the case of lesser- themselves, he fallaciously leaps ment structures that treat nurses as
skilled health aides. Nursing from a individual-level analysis of “just a pair of hands” that have to
homes and home health care agen- the propensity to take a certain be manipulated into producing the
cies, for example, often are forced wage, all else equal, to unrealistic maximum number of shots and
to draw on the absolute lowest- and unfounded conclusions about completed paperwork can, indeed,
wage pool of workers to get mini- the population of the pool of lead to reduced feelings of voca-
mum-wage aides and orderlies. workers who are available for tion. But the problem is not with
People with very low education work at low wages. payment itself. If high pay is given
levels, recent immigrants, and in such a way that nurses feel
non-English speakers are often Crowding Can Be “In” as Well as respected and rewarded for their
hired into these low-status, heavy “Out” care and professionalism, feelings
lifting, and often unpleasant jobs. Heyes twice (2005) cites the of vocation can be reinforced and
On rare (but frightening) occa- work of Bruno Frey on the issue of expanded. Akerlof’s (1982) concept
sions, people may be attracted to “crowding out” of “intrinsic moti- of gift exchange between employ-
health care occupations, whether vations” (such as vocation) by ers and workers is relevant here:
well or ill-paid, primarily because remuneration (identified as an Nurses frequently make a gift of
they offer easier access to drugs or “extrinsic motivation”) (Frey as care to their patients, as well as
opportunities for abuse. cited in Rabin [1998], Frey providing them with the benefit of
In addition to the earlier argu- [1993]). The “crowding out” story their extensive technical training
ment about the significant skills was made most famous by and expertise. But if that gift is not
necessary for nursing, we can also Richard Titmuss’s (1971) study of recognized, and honored, they may
add an argument based on the blood supply. It has been shown begin to withdraw it.
labor pool. Because skilled, car- that, in some cases, paying people “Crowding in,” or comple-
ing, and able people need decent to do something they might other- mentarity between intrinsic and
wages, it is quite possible — wise do voluntarily can drive out extrinsic motivation, can also be
though empirical study would be their impulses to do the activity explained in terms of endogenous
needed to establish this definitive- for their own pleasure, other’s ben- preferences. Following standard
ly — that higher wages would efit, or other internally supplied neoclassical assumptions, Heyes
attract a higher proportion of truly reasons. While Heyes’ own argu- takes nurse’s preferences and
caring, quality, skilled workers. A ment does not hinge on the crowd- “vocation” as exogenously given.
reasonably high wage can make it ing-out wage-motivation link, this While he allows that poor working
possible for a caring (feeling) per- story gives, of course, further conditions may lead to low morale
son to choose to train for an occu- apparent reinforcement to Heyes and to vocationally oriented nurs-
pation that includes a significant idea that paying nurses well is bad es leaving their jobs, he does not
caring (activity) component. policy. allow for the fact that the level of
Certainly, higher wages would at The more complete story, respect or lack thereof that nurses
least give nursing educators and however, is that intrinsic motiva- find expressed in their paycheck
managers a broader pool to choose tions may be either “crowded out” may change their level of intrinsic
from; it is unreasonable to sup- or “crowded in” by remuneration. motivation. For instance, a hospi-
pose that quality of care is com- Frey actually found that external tal administrator who explained to
pletely unobservable by them. motivations like pay “crowd-out his nursing staff that, after reading
Heyes cites an article that one intrinsic motivation if they are per- Heyes’ article, he had decided to
of us co-authored in support of his ceived to be controlling and they pay them less, is likely to notice a
argument (Folbre & Weisskopf, crowd-in intrinsic motivation if reduction in both morale and

NURSING ECONOMIC$/May-June 2006/Vol. 24/No. 3 129

 retention. Nothing undermines greater demands in environments “Why Is a Badly Paid Executive a
altruistic preferences more than in which they have little control Good Executive”? $
the fear that they will be taken over the quality of care (Aiken,
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