ICU Nurses’ Views on the Potential Design and Anticipated Consequences of a Hypothetical Pay-for-Performance (P4P) Program in Greece: An Exploratory Qualitative Study

Background In Greece, there is no pay-for-performance (P4P) program in ICUs. Evidence on ICU nurses' pre-implementation attitudes toward remuneration and hypothetical P4P design is scarce. Objective To elicit ICU nurses' hypothetical views on (a) the current remuneration system, (b) key design features of a potential ICU P4P scheme, and (c) anticipated consequences (benefits, risks, and unintended effects). Methods This is an exploratory qualitative study conducted using reflexive thematic analysis. ICU nurses meeting three eligibility criteria (bachelor's degree in nursing, ≥ three years' ICU experience, and written informed consent) were recruited via social media convenience sampling (June 2025). Nine nurses responded; seven were eligible and were interviewed via secure video conference (50-95 minutes; Greek). All participants worked in public hospitals across six Greek health regions. Two researchers independently double-coded all transcripts with third-party adjudication. A shared codebook, versioned analytic memos, and an audit trail supported rigor. Results Participants perceived pay as disproportionate to ICU intensity and workload and distinguished three facets of dissatisfaction: pay level (adequacy of the base salary), pay structure (seniority-graded pay misaligned with role/unit demands), and pay type (base-only salary lacking performance-linked elements). They expressed conditional openness to team-based P4P under safeguards: adequate staffing and information systems; a small set of clearly defined, locally feasible, nursing-sensitive indicators co-designed with the interprofessional ICU team (nurses and physicians); realistic, negotiated targets; transparent bonus criteria; and credible, transparent governance (independent auditing and clear accountability). Anticipated risks included gaming, crowding out, and interprofessional tension. Expected gains were modest and context-dependent rather than transformative. Conclusions Participants expressed conditional openness to team-based P4P only if specific safeguards are in place (adequate staffing and information systems; locally feasible, nursing-sensitive indicators co-designed with the ICU team; transparent governance and bonus criteria). These are baseline, pre-implementation attitudes from a small, self-selected, non-representative sample of ICU nurses with no P4P experience. They are subject to hypothetical response bias and the intention-behavior gap and should inform whether and how to pilot-test team-based incentives, rather than justify direct implementation or population-level claims.