Nursing and Health Sciences (2008), 10, 31–36

Research Article

Nurse staffing and cost of care in adult intensive care units

in a university hospital in Thailand
Petsunee Thungjaroenkul, rn, mecon, msc, phd,1 Wipada Kunaviktikul, rn, dsn,1 Philip Jacobs, phd,2
Greta G. Cummings, rn, phd3,4 and Thitinut Akkadechanunt, rn, phd1
1
Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand, 2Department of Public Health Sciences, 3Faculty of
Nursing, University of Alberta and 4Canadian Institute for Health Research and Population Health Investigator,
Alberta Heritage Foundation for Medical Research, Edmonton, Alberta, Canada

Abstract Decisions about nurse staffing levels in intensive care units (ICUs) should be guided by research to ensure
optimal outcomes. This descriptive correlational study in a large Thai hospital was designed to evaluate the
effect of nurse staffing levels on the costs of care, in terms of medical care cost per patient day and health
personnel cost per patient day, in ICUs. The costing data were collected prospectively from the records of 242
critically ill patients while the nurse staffing levels were extracted from hospital management reports. The
findings showed that a nurse staffing model with a higher number of registered nurses (RNs) led to an increase
in the health personnel cost per patient day. However, a greater number of RNs was associated with improved
patient safety and efficiency, thereby reducing the length of stay and the costs of care in the long term. This
study provides evidence to support decisions by hospital administrators concerning RN staffing levels.

Key words cost of care, critically ill patient, intensive care unit, nurse staffing.

INTRODUCTION et al., 2005; Tourangeau et al., 2007). Although increasing the

number of RNs also has been positively related to increasing
Restricted health-care funding, coupled with a nursing short-
hospital expenditure, it has not significantly affected hospital
age in Thailand, has created mounting pressure to decrease
profits. In contrast, greater non-RN hours have not only led
the number of full-time nursing positions, especially those of
to higher hospital expenditure but also to lower profits
registered nurses (RNs), and to replace professional nurses
(McCue et al., 2003). Furthermore, research suggests that
with unlicensed health personnel. Whether the size and skill
RNs are more productive than unlicensed health personnel
level of the current health-care workforce can adequately
because they can perform the entire range of nursing tasks
meet Thai patients’ needs has become a question of growing
without supervision. The displacement of RNs by unlicensed
concern. An increased caregiver workload and declining
health personnel to create a stratified workforce has not pro-
numbers of RNs might impact on the quality of patient care
duced cost savings and even has had an adverse effect on the
and safety.
quality of patient care (Brannon, 1996; Blegen et al., 1998;
Nurse staffing is the process used to determine and deploy
Welton et al., 2006).
the acceptable number and skill mix of personnel needed to
The available evidence on nurse staffing levels and cost of
meet the care needs of patients in a program, unit or health-
care focuses on general units in hospitals. However, little
care setting (Ellis et al., 2006). Staffing has been shown to
research on this topic relates to ICUs, which are the most
affect the outcomes of care for patients who were admitted
costly places to care for patients (Thungjaroenkul et al.,
to general hospital units, as well as to special units, such as
forthcoming). Additionally, most of these studies have been
intensive care units (ICUs). Researchers have found that
conducted in Western hospitals, which differ from those in
increasing the number of hours provided by RNs reduced
Thailand in terms of the competency of nursing staff, technol-
mortality and yielded cost savings resulting from a reduced
ogy, and diagnostic equipment. Consequently, studies in the
length of hospital stay (Needleman et al., 2003; Estabrooks
context of hospitals in Thailand might yield different results.
The aim of this study was to explain the relationship between
nurse staffing and the cost of care per patient day in ICUs in
Correspondence address: Petsunee Thungjaroenkul, Faculty of Nursing, Chiang
Thailand. The study provides information for hospital admin-
Mai University, 110 Intavaroros SriPhum, Chiang Mai 50200, Thailand. Email:
petsunee@mail.nurse.cmu.ac.th istrators in their efforts to improve the quality of care and
Received 16 January 2007; accepted 12 July 2007. allocate limited resources so as to optimize patient outcomes.

© 2008 The Authors doi: 10.1111/j.1442-2018.2007.00334.x

Journal Compilation © 2008 Blackwell Publishing Asia Pty Ltd.
32
METHODS
Study design and setting
This was a descriptive correlational study with a prospective
collection of demographic and clinical data of patients admit-
ted to the Maharaj Nakorn Chiang Mai Hospital, a 1400-bed
university hospital in Thailand. After approval by the Ethics
Committee of the Faculty of Nursing, Chiang Mai University,
and the Institution Review Board of the hospital, our study
was carried out in three medical ICUs and one surgical ICU.
Intensive care was provided in these units by a team of criti-
cal care physicians, residents, medical students, RNs, practical
nurses (PNs), helpers (HPs), and respiratory therapists.
Data sources
Patient records were the primary source of data, selected by
purposive sampling using the following criteria: (i) patients
aged 15 years or older; (ii) patients admitted to one of three
medical ICUs or the surgical ICU; and (iii) patients that
stayed > 24 h in the ICU. The sample size of the patient
records was estimated based on a case-to-variable ratio of
~ 30-fold the number of independent variables for multiple
regressions (Tabachnick & Fidell, 1996). Thus, the total
number of patient records sought for the current study was
242, divided into 122 and 120 charts of medical patients and
surgical patients, respectively.
Two additional sources of data from the hospital records
were used. First, the assignment sheets of the ICU personnel
and the daily nurses’ reports between November 2005 and
May 2006 were obtained from each ICU. Second, the finan-
cial reports of the hospital for the financial year of 2005 were
obtained from the accounting department and the purchas-
ing department of the hospital.
Data collection
The data from all the ICUs were collected by research assis-
tants and were verified by the principal investigator. The
investigators attempted to control potential errors in the
data-collection process through inter-rater reliability training
at the start of the study and by providing guidelines for
collecting the data. The patient records were reviewed at
least every other day until the patients were discharged from
the ICU, or died. Individual patient information was assessed
during the first 24 h after admission and on the date of dis-
charge. This information included the patient’s age, sex, type
of ICU, admission diagnosis, levels of serum albumin, lym-
phocyte counts, length of ICU stay, date and time of dis-
charge, and discharge status. Physiological data to determine
the severity of the illness were recorded 24 h after admission.
For each day of stay, the daily nursing care hours were
assessed using the Therapeutic Intervention Scoring System-
28, developed by Miranda et al. (1996). We also assessed the
daily hospital charges for the resources used (excluding staff
time), including drugs, fluid infiltration, consumables (e.g.
syringes, tubes, catheters), laboratory and microbiological
analyses, diagnostic procedures (e.g. radiology), the equip-
© 2008 The Authors
Journal Compilation © 2008 Blackwell Publishing Asia Pty Ltd.
P. Thungjaroenkul et al.
ment used (e.g. infusion pump, ventilator), and life support
therapies (e.g. cut-down, cardiopulmonary resuscitation).
We reviewed the financial reports of the accounting and
purchasing departments in order to obtain information on
the total hospital operating costs, hospital revenue, and
hourly ICU personnel compensation. To assess nurse staffing
for each 8 h shift, we reviewed the assignment sheets of the
ICU personnel to capture the total number of RNs, PNs, and
HPs during each 8 h shift. The daily nurses’ reports also were
reviewed to obtain the total number of patients for each
8 h shift.
Data measurement
Two separate measures of the cost of care were used as the
dependent variables in the analysis: health personnel cost
per patient day (HC) and medical care cost per patient day
(MC). The HC was calculated by multiplying the daily
nursing care hours provided to individual patients by the
hourly ICU personnel compensation. The calculation of the
MC required the following two steps. First, the average hos-
pital charges of medical care for 1 day were computed by
totaling the daily hospital charges and then dividing this total
by the length of the ICU stay. Second, the MC was computed
by multiplying the average hospital charge for 1 day by the
cost-to-charge index, that is, expressed as the ratio between
the total hospital operating cost and the hospital revenue.
The nurse staffing levels were the major independent vari-
ables in the analysis. The nurse staffing levels were deter-
mined by the average ratio of RNs to patients on an 8 h
nursing shift and the average ratio of RNs to other nursing
staff (PNs and HPs) on an 8 h nursing shift.
The cost of care is clearly affected by a number of variables
besides nursing staffing levels. This might lead to either
under- or overestimation of this relationship between costs
and nurse staffing levels. To avoid this bias, other factors that
influence the relationship were included in the model as
control variables. The selection of such control variables was
based on a literature review of the relationship between
hospital costs and nurse staffing (Thungjaroenkul et al.,
forthcoming). The control variables included patient age,
nutritional status, type of ICU, day of admission, time of
admission, and the severity of the illness. The measures of
these variables were: (i) patient age in years during the first
24 h of admission to an ICU; (ii) nutritional status: the levels
of serum albumin and lymphocyte counts; (iii) the type of
ICU: whether or not the patient was admitted to a medical
ICU (Yes = 1, No = 0); (iv) the day of admission: whether or
not the patient was admitted to an ICU on a weekend day
(Yes = 1, No = 0); (v) the time of admission: whether or not
the patient was admitted to an ICU during non-office hours
(Yes = 1, No = 0); and (vi) the severity of the illness: the
degree of change in health status as a result of the illness or
injury, measured by using the Simplified Acute Physiology
Score (SAPS) II instrument, developed by Le Gall et al.
(1993). The range of possible SAPS scores was 0–163, with a
higher score indicating a greater risk of death. The formula
provided by Le Gall was used to indicate the predicted risk of
death.
Nurse staffing and cost of care 33

Table 1. A summary of the stepwise multiple regression model of logarithmically transformed medical cost per patient day (n = 216)

Step predictor R R2 R2 adjusted R2 change F change P df1, df2

1. Severity of illness (no. of points) 0.48 0.23 0.23 – 63.63 0.001 1, 215
2. Lymphocyte counts 0.54 0.29 0.28 0.06 43.00 0.001 2, 214
3. The average ratio of RNs to patients (%) 0.55 0.30 0.29 0.01 30.54 0.001 3, 213

RN, registered nurse.

Table 2. A summary of regression coefficients for the stepwise multiple regression model of logarithmically transformed medical cost per
patient day (n = 216)

Collinearity statistic
Variable B SE b t P-value Tolerance VIF

(Constant) 8.430 0.110 – 75.51 0.001 – –

Severity of illness (no. of points) 0.010 0.010 0.45 7.47 0.001 0.92 1.09
Lymphocyte counts 0.370 0.090 0.24 4.10 0.001 1.00 1.00
The average ratio of RNs to patients (%) -0.003 0.001 -0.10 -2.07 0.001 0.92 1.09

RN, registered nurse; VIF, variance inflation factor.

Statistical analysis median MC was Baht6019.5 (SD = 3810.0) or $US143.3

To assess the simultaneous effects of nurse staffing on the
cost of care in adult ICUs in Thailand, we specified a series of
ordinary least-square regression models. A P-value of < 0.05
was considered to be statistically significant. Two separate
sets of regression equations were specified. The first set
employed the MC as the dependent variable and the second
employed the HC as the dependent variable. The indepen-
dent variables of the two sets of analyses included nurse
staffing levels, patient age, severity of illness, levels of serum
albumin, lymphocyte counts, type of ICU, and the day and
time of admission. The data were used to test for the regres-
sion assumptions by using a residual analysis. The analysis
illustrated that the predicted model of the nursing personnel
cost per patient day fitted the regression assumptions but that
the model of the MC did not. A number of non-linear regres-
sions were utilized but only the results for the log regression
were presented as the best fit to predict the MC.
RESULTS
Demographic data
The patients’ age ranged from 15–93 years, with a median age
of 61 years (SD = 20.6). The percentage of males was 55.8.
The most common diagnoses included diseases of the respi-
ratory system (28.5%), the nervous system (17.8%), and the
digestive system (13.2%). Weekday ICU admissions com-
prised 63.2% of the study sample and 69% of patients were
admitted to an ICU during non-office hours. The median
severity of illness score for the first 24 h was 40 (SD = 23.5)
and the predicted risk of death at admission was 24.7%.
Approximately 32% of 242 patients had abnormal albumin
levels and 85.5% had abnormal lymphocyte counts. The
($US1 = Baht 42) in 2005 and the median HC was Baht1680.7
(SD = 584.3) or $US40.1, giving a total patient cost per
patient day of Baht7668.0 (SD = 4007.3) or $US182.6. The
median hours of care per patient was 21 h (SD = 8.7). The
median duration of mechanical ventilation for these patients
was 2 days (SD = 1.3). The median length of ICU stay was
4 days (SD = 2.2), with a range of 1–21 days. The death rate of
the ICU patients was 14.0%.
The effect of nurse staffing on the cost of care in
adult intensive care units
The effect of nurse staffing on medical care cost per
patient day
Stepwise multiple regression results indicated a model with
three predictors (severity of illness, lymphocyte counts, and
the average ratio of RNs to patients) that significantly pre-
dicted the MC (R2 = 0.30, R2 adjusted = 0.29, F(3,213) = 30.54,
P < 0.001) (Table 1).As shown in Table 2, the results specified
that greater severity of illness was associated with the MC
(b = 0.01, P < 0.001). The average ratio of RNs to patients was
negatively associated with the MC (b = -0.003, P < 0.001).
Patients who had an abnormal lymphocyte count were likely
to have a higher MC relative to those with a normal lympho-
cyte count (b = 0.37, P < 0.001).
The effect of nurse staffing on health personnel cost
per patient day
The HC was regressed on four independent variables (the
average ratio of RNs to patients, the average ratio of RNs
to other nursing staff, the type of ICU, and the day of

© 2008 The Authors

Journal Compilation © 2008 Blackwell Publishing Asia Pty Ltd.
34 P. Thungjaroenkul et al.

Table 3. A summary of the stepwise multiple regression model of health personnel cost per patient day (n = 216)

Step predictor R R2 R2 adjusted R2 change F change P df1, df2

1. The ratio of RNs to patients (%) 0.41 0.17 0.17 – 44.02 0.001 1, 215
2. The ratio of RNs to other nursing staff (%) 0.53 0.28 0.28 0.11 42.07 0.001 2, 214
3. Type of ICU 0.55 0.30 0.29 0.02 30.71 0.001 3, 213
4. Day of admission 0.56 0.32 0.31 0.02 24.66 0.001 4, 212

ICU, intensive care unit; RN, registered nurse.

Table 4. A summary of regression coefficients for the stepwise multiple regression model of health personnel cost per patient day (n = 216)

Collinearity statistic
Variable B SE b t P-value Tolerance VIF

(Constant) 691.92 209.91 – 8.42 0.001 – –

The ratio of RNs to patients (%) 10.92 2.45 0.52 7.73 0.001 0.70 1.42
The ratio of RNs to other nursing staff (%) 8.07 1.86 0.38 5.94 0.001 0.79 1.26
Type of ICU 284.28 123.61 0.14 2.30 0.020 0.86 1.17
Day of admission 266.20 120.88 0.13 2.20 0.030 0.99 1.02

ICU, intensive care unit; RN, registered nurse; VIF, variance inflation factor.

admission). This model was highly significant (F(4,
212) = 24.66, P < 0.001) and explained 31% of the variance in
the HC (R2 = 0.32, R2 adjusted = 0.31) (Table 3). As shown in
Table 4, the data indicated that a higher average ratio of RNs
to patients was associated with an increased HC (b = 10.92,
P < 0.001) and the average ratio of RNs to other nursing staff
was positively associated with the HC (b = 8.07, P < 0.001).
Patients admitted to an ICU on a weekend had a lower HC
than patients admitted on a weekday (b = 266.20, P < 0.030).
The mean HC incurred for medical patients was higher than
that for surgical patients (b = 284.28, P < 0.020).
DISCUSSION
In this study, we conducted an analysis of ICU costs in a Thai
hospital, focusing on the effect of nurse staffing levels on two
financial outcomes. Our analysis showed that the average
RN-to-patient ratio had a significant negative association
with the MC and a significant positive association with the
HC. Our analysis suggests that increasing the number of RNs,
while contributing to increasing personnel costs, can benefit
hospitals and patients by preventing adverse events and sub-
sequent morbidity and shortening the length of hospital stay
(ANA, 2000; Tourangeau et al., 2007), thereby ultimately
reducing the total cost of ICU care. Moreover, these findings
suggest that ICUs can benefit from the full potential of RN
knowledge and skill, a finding that is congruent with studies
by Amaravadi et al. (2000), Bloom et al. (1997), Dimick et al.
(2001), and Rothberg et al. (2005). They found an increase in
RN caring activities was positively related to decreasing costs
in ICU care. The more positive financial outcome associated
with sufficient numbers of RNs in this study and other studies
might be related to the immediate availability of a RN to
evaluate and care for patients. The educational preparation
and the clinical experience of RNs can enhance their ability
to judge actual situations, detect changes in patient status,
as well as alter planned interventions in response to the
patient’s condition (Blegen et al., 2001). Furthermore, profes-
sional nurses could improve patient recovery by using proac-
tive management, weaning patients from ventilation, coping
with unpredictable events, and reacting promptly with inter-
ventions in the event of sudden deterioration (Archibald
et al., 1997; Kovner et al., 2002). Advances in technological
expertise in ICUs are not a substitute for properly trained
professionals providing direct patient care (Beckmann et al.,
1996; Buckley et al., 1997).
The skill mix, that is, the average ratio of RNs to other
nursing staff, had a significant relationship with health-care
cost per patient day (adjusted for the type of ICU and
average ratio of RNs to patients). It is not surprising that
higher RN-to-other nursing staff ratios contributed to
increasing health-care costs per patient day in this study.
This might be related to the difference between the mean
hourly cost for RNs and those for other nursing staff. In the
present study, the mean hourly cost for RNs was ~ 1.5-fold
that of other nursing staff, contributing to the positive asso-
ciation between skill mix and health-care cost per patient
day.
Increasing the number of RNs (to full-care provision by
RNs) increased the HC (b = -0.003, P < 0.001), but was also
associated with a decrease in the MC by 30%, suggesting that
cost savings may be attributed to the efficiency and effective-
ness of the care provided by RNs and, perhaps, to a lower
demand on consumable resources by RNs. Therefore, we
suggest that decisions about nurse staffing levels should be
based on sound evidence to ensure that the appropriate
number of skilled nurses is available to achieve safety stan-
dards and optimum patient outcomes.

© 2008 The Authors

Journal Compilation © 2008 Blackwell Publishing Asia Pty Ltd.
Nurse staffing and cost of care
Higher RN-to-other nursing staff ratios were not related to
the MC in this study. This finding was consistent with an
analysis of health personnel data from 583 hospitals, which
found that higher percentages of RNs were not related to
hospital costs (Bloom et al., 1997). From these results, one can
infer that a higher ratio of RNs to non-RNs decreases the
need for additional non-RN staff and that hospital costs will
remain unchanged, even with more RNs providing patient
care. Although other nursing staff are employed to assist RNs
in performing non-nursing duties, the majority of direct
patient care activities remain within the scope of RNs. There-
fore, the greater use of other nursing staff might not reduce
the amount of time that RNs spend performing ICU-related
activities. In contrast, some research suggests that the work-
load of RNs increases with the employment of unlicensed
assistant staff due to requirements for supervision and the
correction of errors (Mackinnon et al., 1998). Thus, within
ICUs, RNs might be more productive than unlicensed assis-
tant staff because they can perform the entire range of
nursing tasks without supervision.
The effect of nurse staffing on the MC was statistically
significant (based on the regression model) but it explained
only 29% of the variance: this means that 71% of the vari-
ance was influenced by factors not measured in this study.
The effect of nurse staffing on the HC was also statistically
significant but, again, it explained only 31% of the variance,
leaving 69% unexplained. Certainly, the severity of the
illness would have contributed to the larger portion of the
variance of medical care cost (23%). The remaining vari-
ances might be explained by other factors influencing
patient outcomes. Organizational factors, such as nursing
leadership, nursing unit environment, provider characteris-
tics, and processes of care, can influence patient outcomes
(Marek, 1997; Wong & Cummings, 2007). Further study is
needed to include these factors in costing models to increase
the power of prediction.
Despite the unexplained variance in the costs of care, our
results support the notion that improved nurse staffing can
have multiple downstream effects by benefiting patients
through better health outcomes and benefiting hospitals and
the health-care system by reducing the patient length of ICU
stay and the resulting costs. The findings of this study are of
particular importance to hospital administrators, who must
balance the two mandates of ensuring quality of care and
fiscal accountability. Staffing decisions fall into both domains
and staffing models must correspond to the needs of patients.
Sicker patients need more knowledgeable and skilled nurses
for safer, more efficient, and expeditious care. Moreover,
medical patients almost always cost more than surgical
patients as they tend to have more complex needs, are typi-
cally older, have multiple co-morbidities and, therefore, have
a longer length of stay – these patients clearly need experi-
enced RNs.
This study did not investigate the inter-relationships
among nurse staffing, patient safety, and costs of care in the
ICUs. Further research that evaluates the linkages among
these variables is needed to increase our understanding of
the relationship between nurse staffing and the costs of care
in ICUs.
Journal Compilation © 2008 Blackwell Publishing Asia Pty Ltd.
35
In conclusion, the study predicts that the overall costs of
care in ICUs are reduced with greater RN staffing. This might
be because RNs’ knowledge and skill levels lead to efficient
and effective nursing care, as well as less demand on consum-
able resources. Although skill mix models with higher levels
of professional nursing staff have higher health personnel
costs, these are offset by improved patient outcomes result-
ing from the decreased incidence of nosocomial infection
(Hugonnet et al., 2007), pressure ulcers (Lichtig et al., 1999;
Unruh, 2003), and patient falls (Sovie & Jawad, 2001; Dunton
et al., 2004). These, in turn, reduce the hospital and ICU
length of stay and overall costs of care over the long term.
Therefore, we posit that if hospital administrators use higher
ratios of RNs to non-licensed personnel, they will better
achieve their objectives of quality patient outcomes and cost
containment in ICUs.
ACKNOWLEDGMENTS
The authors wish to thank the administrators and the heads
of departments at Maharaj Nakorn Chiang Mai Hospital,
Chiang Mai, Thailand, for their cooperation and assistance
throughout the data-collection process. We also would like to
thank the Ministry of Education in Thailand, University
Mobility in Asia and Pacific program, and the Faculty of
Nursing, Chiang Mai University, for providing financial
support.
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