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Policy

Impact of a financial incentive policy on Korean nurse staffing Y. Kim1

RN, PhD

& J. Kim2

RN, PhD

1 Associate Professor, Department of Nursing, Eulji University, 2 Assistant Professor, Department of Nursing, Gachon University, Seongnam, Korea

KIM Y. & KIM J. (2015) Impact of a financial incentive policy on Korean nurse staffing. International Nursing Review 62, 171–179 Aim: This study was designed to determine (1) the impact of policy on longitudinal changes in nurse staffing levels and (2) the characteristics of policy-responsive Korean hospitals. Background: A policy of varying nursing fees according to staffing grade by measuring the nurse-to-bed ratio has been implemented in Korean hospitals since 1999 with the aim of satisfying patient care needs and providing safe and high-quality nursing care. Methods: Nurse staffing hospital characteristics data were collected from Korean Hospital Nurses Association yearbooks for the period 1996–2011. The obtained time series nurse staffing data were analysed by assessing the nurse-to-bed ratio. Graphs were used to view nurse staffing trends in various nursing units by hospital type during the study period. Mixed repeated-measures modelling was used to analyse nurse staffing and hospital characteristics, with year categorized as a dummy variable. There were 585 and 1239 observations related to measurements of nurse staffing grade in 44 tertiary and 193 general hospitals, respectively. For measuring the nurse staffing grade in intensive care units, the number of observations for general hospitals was decreased to 1170. Results: Long-term nurse staffing in general and intensive care units was improved post-policy compared with pre-policy in both tertiary and general hospitals. Nurse staffing was improved more in Seoul than in other areas and was significantly better for hospitals with more beds for both hospital types. Conclusion and implications for nursing and health policy: Although the financial incentive policy implemented in Korea has had an overall positive result on nurse staffing, the effect was not assure in small-sized hospitals in rural area. A more refined method for calculating nurse staffing and increasing financial incentives relative to staffing grade is needed to improve hospital nurse staffing. Keywords: General Hospitals, Health Policy, Incentive Reimbursement, Longitudinal Studies, Nursing Staff, Personnel Staffing and Scheduling, Republic of Korea, Tertiary Care Centres, Trends

Correspondence address: Jiyun Kim, Department of Nursing, Gachon University, 1342 SeongnamDaero, Sujeong-Gu, Seongnam, Gyeonggi 461-701, Korea; Tel: +82-31-750-8822; Fax: +82-31-750-8859; E-mail: [email protected].

Conflict of interest: None declared. This manuscript has not been previously published and is not being simultaneously submitted elsewhere.

© 2014 International Council of Nurses

Introduction The adequacy of nurse staffing is related to the number of nursing hours per patient day (Donaldson & Shapiro 2010) and to nurses’ satisfaction (Tellez & Seago 2013). In addition, guaranteed nurse staffing reduces patient mortality (Tong 2011), working stress, nursing shortages and economic costs (Stanton

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& Rutherford 2004). In Korea, better nurse staffing was found to be associated with not only a lower occurrence of pneumonia and sepsis but also a lower mortality in surgical patients (Kim et al. 2012). There is also evidence that adequate nurse staffing in Korea is related to a higher cognition level regarding patient safety and safe nursing activities (Nam & Choi 2011). Obtaining adequate nurse staffing is a policy focus in many countries aimed at ensuring a high quality of care and patient safety. Many efforts have been made to increase nurse staffing. Implementing an explicit policy for nurse staffing, such as mandated nurse-to-patient ratios, has been shown to increase nurse staffing in Californian hospitals regardless of hospital characteristics and unit types (Burnes et al. 2007; Donaldson & Shapiro 2010; Feng et al. 2008; McHugh et al. 2012; Serratt et al. 2011). Workforce planning by the UK National Health Service that included targets for nurses and midwives increased the numbers of staff nurses (Buchan 2004). A new national pay award for nurses in New Zealand also increased the numbers of staff nurses, reduced difficulties in recruiting and filling vacancies and increased application rates to schools of nursing (Buchan & North 2009). However, because there is no single magic bullet policy, a long-term and sustainable solution for maintaining adequate nurse staffing needs to be developed (Buchan & Aiken 2008). Moreover, such policy interventions need to be designed specifically for the health system in each country. The National Health Insurance (NHI) system in South Korea is unique in that it has a single insurer, the National Health Insurance Corporation (NHIC), and covers almost all of the population (Chun et al. 2009). This almost universal coverage has applied since July 1998 due to the implementation of a gradual coverage extension policy. In 2011, 50 908 000 people in Korea were covered by the NHI (i.e. 96.9% of Koreans) and the remainder (i.e. 1 609 000; 3.1% of Koreans) were medical aid beneficiaries (Kim & Kang 2013). There are three main types of hospital in Korea named tertiary hospitals, general hospitals and hospitals. In brief, general hospitals are institutions with a minimum of 100 inpatient beds and provide secondary healthcare services in major areas, such as internal medicine, surgery and paediatrics, whereas tertiary hospitals are general hospitals that provide advanced medical care, treat severely ill-referred patients and are involved in training healthcare personnel. Hospitals are relatively small institutions with 30 or more beds. The intention of policies and regulations in hospitals should be to ensure a high quality of patient care and should include improving the adequacy of hospital nurse staffing. Medical law in Korea covers nurse staffing and requires a prescribed number of hospital nurses. For inpatient care in hospitals, two nurses should care for every five inpatients, regardless of the shift, unit

© 2014 International Council of Nurses

[e.g. ward, intensive care unit (ICU) or emergency room (ER)] or hospital characteristics. However, this regulation has failed to ensure that hospitals comply with this requirement. For example, an accreditation survey conducted in 2006 found that 51% of general hospitals with fewer than 360 beds did not comply with this regulation (Lee et al. 2007). This failure may be attributable to no penalty being applied when the minimum level of nurse staffing is violated. Therefore, the mean number of practicing nurses per 1000 people in the Korea population (4.2) is very low compared with other Organization for Economic Cooperation and Development countries (9.6) (OECD 2009). In an attempt to solve this problem, a new incentive policy for nurse staffing was developed and implemented by the Korean government in 1999, namely the nursing fee differentiation policy (NFDP) on nurse staffing levels (Ministry of Health & Welfare 2006). The main objective of this policy was to improve the quality of nursing care services by motivating hospitals to increase their nurse staffing levels and encouraging them to stop or reduce the delegation of nursing care to the patients’ family members or paid caregivers (Kim 2007). The NFDP on nurse staffing levels involves a reimbursement system that takes into account nurse staffing rather than being a regulation system. Under this programme, nursing services routinely provided for the fee that inpatients pay in hospitals are paid as a part of the hospitalization fee. The inpatient fee in Korea is divided as follows: 40% for medical care, 25% for nursing care and 35% for hospital management (Kim 2007). In order to calculate nurse staffing, the mean number of beds used over 3 months is divided by the mean number of nurses in a ward over the same period. The total number of beds in a hospital includes those in general inpatients wards, maternity wards and open psychiatric wards, and excludes the ER, nursery, delivery room, ICU, closed psychiatric wards, artificial kidney room and isolation patient care (Kim 2007). The total number of nurses includes nurses working in general inpatient wards and those applying intravenous therapy. It is possible to substitute parttime registered nurses (PTRNs) with full-time registered nurses in nurse staffing calculations (Kim 2007), with the substitution ratio differing according to the PTRNs’ working hours per week, location and hospital type (e.g. tertiary hospitals, general hospitals and hospitals) (HIRA – Health Insurance Review & Assessment Service 2012). Nurses working in administrative departments, hospice care nurses and family nurses are not taken into account in the differentiation fee regulation. In 1999, six nurse staffing grades were implemented for all types of hospital, and the new policy extended this to a sevengrade fee system for general hospitals in 2007. At that time the ratio calculation was included only for general care units, and

Nursing fee differentiation policy in Korea

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Table 1 Differentiated inpatient and ICU nursing fees according to staffing level Inpatient fee

ICU fee for adult care

Tertiary hospital

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9

General hospital

Staffing

Additional fee

Staffing

Additional fee

Impact of a financial incentive policy on Korean nurse staffing.

This study was designed to determine (1) the impact of policy on longitudinal changes in nurse staffing levels and (2) the characteristics of policy-r...
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