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

Int J Nurs Stud. 2013 Feb;50(2):219-29. doi: 10.1016/j.ijnurstu.2012.07.008. Epub 2012 Jul 28.


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.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cross-Sectional Studies
  • Diagnosis-Related Groups*
  • Female
  • Humans
  • Job Satisfaction*
  • Male
  • Nursing Staff, Hospital / psychology*
  • Patient Safety
  • Quality of Health Care*
  • Workplace*