Nursing Home Staffing: Excellent Summary of the Problems, Compilation of Proposals for Improvement

A recent survey of literature and research provides an excellent summary and state of the world on the fundamental problem with nursing homes – too few qualified nurses.  Anyone who has both visiting a nursing home and has a working nose can attest to the critical need for quantity and quality of nursing care.

Though decidedly biased against nursing home management, the piece nevertheless compiles an excellent compilation of research, rules and arguments regarding nursing home staffing.

From the piece The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes, as published in Health Services Insight, a warning:

In 2015, the U.S. government proposed new nursing home regulations to strengthen the quality of nursing home care.20 Unfortunately, the proposed regulations do not change the federal staffing standard, even though the previous standards are considered too low, and resident acuity has increased dramatically since 1987.21 For example, the percent of total Medicare resident days classified as needing intensive rehabilitation and nursing care increased from 29 to 79 days between 2002 and 2013.21 Although resident acuity appears to be overstated because nursing homes have incentives for upcoding acuity to increase revenues,21 there is clearly increased association with early hospital discharge to nursing homes. Under the newly proposed regulations, nursing homes would be allowed to continue to set their own staffing levels without a higher federal minimum standard than the current requirement.

The paper makes a number of points based on existing research. A few snippets:

High nurse staffing levels and quality. Over the past 25 years, numerous research studies have documented a strong positive impact of nurse staffing on both care process and outcome measures. Over 150 staffing studies have been documented in systematic reviews, conducted primarily in the U.S. but also including studies in Canada, United Kingdom, Germany, Norway, and Sweden. The strongest positive relationships are found between RNs (with two to four years of training) and quality, which is stronger than the relationship between licensed vocational/practical nurses (LVNs/LPNs; who have less training than RNs) and quality. Total nurse staffing levels (which includes RNs, LVNs/LPNs, and certified nursing assistants [CNAs; with about two weeks of training]) are also related to quality.


Implementation of higher minimum staffing standards improves quality. Many studies have specifically identified the benefits of implementing higher federal and state staffing standards. The proportion of residents with pressure ulcers, physical restraints, and urinary catheters decreased, following the implementation of the U.S. Nursing Home Reform Act in 1987, in part, due to adoption of the 24-hour licensed nursing standard. Moreover, numerous studies have consistently shown that higher state minimum staffing levels (beyond the federal minimum requirements) have had significant positive effects on staffing levels and quality outcomes. In addition, higher state minimum RN and total nurse staffing have been shown to have a stronger effect on nursing home staffing levels than higher Medicaid payment rates.

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