The introduction of DRG funding and hospital nurses’ changing perceptions of their practice environment, quality of care and satisfaction: Comparison of cross-sectional surveys over a 10-year period

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Abstract

Background

As other countries which have introduced diagnosis-related groups (DRGs) to pay their hospitals Germany initially expected that quality of care could deteriorate. Less discussed were potential implications for nurses, who might feel the efficiency-increasing effects of DRGs on their daily work, which in turn may lead to an actual worsening of care quality.

Objective

To analyze whether the DRG implementation in German acute hospitals (as well as other changes over the 10-year period) had measurable effects on (1) the nurse work environment (including e.g. an adequate number of nursing staff to provide quality patient care), (2) quality of patient care and safety (incl. confidence into patients’ ability to manage care when discharged), and (3) whether the effects from (1) and (2) – if any – impacted on the nurses themselves (satisfaction with their current job and their choice of profession as well as emotional exhaustion).

Design and data sources

Two rounds of nurse surveys with the Practice Environment Scale of the Nursing Work Index (PES-NWI), five years before DRG implementation (i.e. in 1998/1999; n = 2681 from 29 hospitals) and five years after (i.e. in 2009/2010; n = 1511 from 49 hospitals). The analysis utilized 15 indicators as outcomes for (1) practice environment, (2) quality of patient care and safety, as well as (3) nurses’ satisfaction and emotional exhaustion. Multivariate analyses were performed for all three sets of outcomes using SPSS version 20.

Results

Aspects of the practice environment (especially adequate staffing and supportive management) worsened within the examined time span of 10 years, which as a consequence had significant negative impact on the nurse-perceived quality of care (except for patient safety, which improved). Both the aspects of the practice environment and the quality aspects impacted substantially on satisfaction and emotional exhaustion among nurses.

Conclusions

The DRG implementation in Germany has apparently had measurable negative effects on nurses and nurse-perceived patient outcomes, however, not as distinct as often assumed.

Section snippets

Background

The introduction of the DRG system represented the most visible and discussed reform of the German hospital sector within the last decades. The primary purpose for reforming the previous reimbursement system, which was based on budgets with per diem charges, was to create a more appropriate and fair resource allocation system by consistently defining and reimbursing all hospital services. While the DRGs as a patient classification system were introduced in 2003 (on a voluntary basis),

Objective

Given this still relative scarcity of empirical evidence especially regarding the impact on the nursing workforce (Fürstenberg et al., 2011, p. 536), we focus on this aspect by taking a 10-year perspective stretching from 1998/1999 (first survey wave) to 2009/2010 (second survey wave), i.e. from five years before the DRG introduction in 2004 to five years afterwards to find out whether we are able to confirm study findings in Germany and thus contribute to the current discussion on the

Method

Data of the International Hospital Outcomes Study (IHOS) (1998/1999) and of the RN4CAST study (2009/2010) were analyzed. The objective of both studies was primarily to determine the impact of nursing on hospital mortality, failure to rescue, quality of care, and patient satisfaction. To measure “nursing”, an elaborated nurse questionnaire was used at both times. The IHOS was performed in the USA, Canada, United Kingdom (England and Scotland) and Germany. In Germany, 2681 nurses working on

Results

In the 10-year period from 5 years before to 5 years after the introduction of DRGs, both the number of beds in acute and psychiatric hospitals as well as the average length of stay decreased, while slightly more patients were admitted (Table 2). As a result, fewer in-patient days were observed. As the number of physicians increased, their ratio to both admissions as well as in-patient days improved. In contrast, the number of nurses decreased, leading to more admissions per nurse but still an

Discussion

This study demonstrates significant changes in the practice environment, the quality of care as well as the satisfaction and emotional exhaustion of nurses in the 10-year period from five years before the implementation of DRGs to five years after. The practice environment deteriorated in all dimensions (except for the participation in hospital affairs), as did most aspects of quality of care (with the noticeable exception of patient safety), while dissatisfaction and emotional exhaustion

Conclusion

This study shows that certain examined aspects of the working environment have worsened in German acute hospitals within the time span of 10 years. This development can be partly attributed to the introduction of DRGs. Furthermore, given that nurse-rated quality is an useful indicator to highlight emerging deficits in service delivery without directly looking at mortality and complication rates, we were able to demonstrate that these changes have had substantial influence on the quality of care

Limitations of the study

It has to be taken into account that the present study bases on two cross-sectional surveys of different nurses in different hospitals which we used to study the longitudinal effects of the DRG implementation.

Acknowledgments

We thank the nursing directors, chief nurses, and nurses in the participating hospitals. The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007–2013) under Grant Agreement No. 223468. For more information on the RN4CAST project, please visit www.rn4cast.eu.

Conflict of interest: None.

Ethical approval: Ethical approval was obtained from the central ethical committee of the Berlin University of Technology.

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