The Relationship Between Nursing Workload, Quality of Care, and Nursing Payment in Intensive Care Units

BACKGROUND: Nursing workload is highly associated with patient safety. It has been argued that the imbalance between nursing payment and nursing workload in Taiwan National Health Insurance (NHI)-covered intensive care units (ICUs) has resulted in the inadequate allocation of nursing manpower. However, limited empirical data are currently available to support this argument. PURPOSE: The aim of this study was to investigate the correlation between nursing workload, quality of care, and NHI-covered nursing payments in ICU settings. METHODS: This macrodata analysis study retrieved data from the existing ICU patient classification system, nursing quality monitoring system, and infection control monitoring system of a medical center in central Taiwan. Data on the Therapeutic Intervention Scoring System-28 (TISS-28) and non-TISS-28 scores, nursing hours, and nursing labor utilization rate were retrieved for the 23-month period beginning in January 2013 and ending in November 2014. The indices of care quality used in this study included incidence of falls, pressure sore density, incidence of restraint use, incidence of tube self-extraction, and infection density. RESULTS: A total of 92,442 data sets were collected from eight ICUs, with 61% of the direct ICU nursing hours categorized as TISS-28 and 39% categorized as non-TISS-28. Mean nursing hours totaled 12.5 hours. The direct nursing hours, the total nursing hours, the bed occupancy rate, the nursing hours calculated by patient classification system, and the nursing hours calculated by nurse–patient ratio were statistically, significantly correlated respectively with all of the care quality indices except for incidence of falls. The number of items of patient care in the patient classification records was greater than that of NHI-covered nursing payments. The NHI-covered nursing payment for every patient accounted for only 4.77% of the total medical expenses in the ICU. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Data from the patient classification database, quality monitoring database, and medical cost database indicate excessive nursing workload and underpayment from the Taiwan NHI program. Current nursing workload was significantly associated with care quality. This study provides empirical data for administrators to consider when revising nursing staffing and NHI payment policies.