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
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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