Public Science Insights: Inadequate Nurse Staffing Standards in Nursing Homes

Posted Tue, Mar, 07,2017


A vast majority of nursing homes are in need of staffing reform. One of the most important underlying reasons for quality problems in many nursing homes can be traced to inadequate levels of nurse staffing. Many research studies have identified the positive relationship between nursing home care quality and nurse staffing levels and have shown the positive benefits of states enacting higher minimum staffing standards. The benefits of higher staffing levels, especially of RNs, include lower mortality rates; improved physical functioning; less antibiotic use; fewer pressure ulcers, catheterized residents, and urinary tract infections; lower hospitalization rates; and less weight loss and dehydration. In addition to staffing levels, the training and competency of nursing staff are critical factors in ensuring high quality of care.

The Nursing Home Reform Act of 1987 required nursing homes to have "sufficient staff" to meet the needs of residents but the federal standard is inadequate because it only requires one RN on the day shift and one licensed vocational or practical nurse (LVN/LPN) on the evening and night shifts regardless of the size of the facility. A 2001 CMS study recommended that nursing homes should have 0.75 RN hours per resident day (hprd), 0.55 LVN/LPN hprd, and 2.8 certified nursing assistant (CNA) hprd, for a total of 4.1 nursing hprd to prevent harm or jeopardy to residents. A recent simulation study found that a higher level of CNA staffing is needed, ranging from 2.8 to 3.6 hours per resident day depending on resident characteristics in order to provide basic care to residents.

Some experts have recommended even higher staffing standards (a total of 4.55 hprd) to improve the quality of nursing home care, with adjustments for resident acuity or case-mix. A number of organizations have endorsed the minimum of 4.1 hprd standard, including a least 30 percent by licensed nurses and 24 hour RN care (Institute of Medicine, 2004; American Nurses Association (2014), and the Coalition of Geriatric Nursing Organizations (2013) including the Consumer Voice). To date, however, the staffing thresholds identified in the 2001 CMS report and recommended by experts have not been adopted.

Although reported RN staffing and total staffing levels have steadily increased to 4.1 hours per resident day in 2014, half of nursing homes have low staffing (3.53 hprd or less) and at least a quarter have very low staffing (3.18 hprd or less). Most nursing homes (about 70 percent) are owned by for-profit companies and many by large for-profit chains (56 percent) that are owned by private investors and private equity companies. These companies use a strategy of keeping nurse staffing levels low, especially for RNs, in order to maximize profits. Only the non-profit and government operated nursing home have average staffing levels that meet recommended standards.

Policy makers have failed to adopt higher US staffing standards because they are concerned about the costs of implementing such standards. Generally, legislators have preferred to focus on market-based rather than regulatory strategies for improving quality. US nursing home industry's strong political opposition to establish higher standards have prevented legislative action. The federal and state governments need to adopt higher staffing standards and payment and regulatory strategies that will improve nursing home staffing and quality more generally. High quality of nursing home care requires adequate staffing levels.

Dr. Charlene Harrington is the co-author of the recently published paper The Need for Minimum Staffing Standards in Nursing Homes: Social, Political and Policy Factors in Health Services Insights in 2016.

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