Home and Community Care Digest

Home and Community Care Digest 7(2) November -0001

Increasing Registered Nurse Staffing Resident-Time can Reduce Adverse Outcomes in Nursing Homes


The need for higher nurse staffing levels in nursing homes, especially skilled staff like registered nurses (RN), as a means to improve quality of care has received considerable attention in recent years from both policy makers and the public alike. This study examined the relationship between changes in RN staffing level and nursing skill mix on the changes in the rate of adverse outcomes (i.e., pressure sores and urinary tract infections) among long-stay residents in US-based nursing home facilities. The main finding was that increases in RN staffing tended to reduce the rate of both pressure sores and urinary tract infections. Policy makers considering strategies to improve quality of care in nursing homes, particularly with regards to pressure sores and urinary tract infections, may wish to consider increasing the RN staffing levels.
Background: The quality of care provided in nursing homes has been an ongoing issue of concern for both policy makers and the public. Recent focus has turned to potential relationships between nurse staffing levels and skill mix and quality of care, which has lead some researchers to advocate for higher staffing requirements and a more skilled staff mix in nursing homes. But until recently there has been insufficient high-quality evidence to support such recommendations. This study aims to fill the evidence gap by examining the registered nurse (RN) staffing-outcomes relationship in nursing homes.

Methods: This US study examined whether a change in RN staffing and skill mix leads to a change in outcomes in long-stay (> 90 days) nursing home residents in Medicare- or Medicaid-certified nursing homes in five states over the period 1997 to 2000. States were chosen based on reliability of data and geographic representation. Overall, the sample (n=399,206 resident assessments from 1,366 nursing homes) represented roughly 10% of nursing home facilities and residents across the US. Resident outcome measures included pressure sores and urinary tract infections, both of which are believed to reflect staffing-dependent aspects of care. Staffing was measured by intensity (RN hours per resident-day) and skill mix (RN staffing hours as a proportion of total nurse staffing hours, including RN, LPN and NA). The former is an indicator of the extent of RN expertise available for nursing home resident care, while the latter captures the extent to which supervision by RNs is available or pressure to shift tasks to less qualified nurses is reduced.

To uncover the true relationship between RN staffing time and resident outcomes, the study controlled for a number of individual- and nursing home facility-level factors that could impact the relationship in question and employed a statistical technique that minimizes bias in the estimates.

Findings: Greater levels of RN staffing (i.e., number of RN hours per resident-day) substantially reduced the rate of pressure sores, while nurse skill mix did not. Conversely, both greater levels of staffing and a more highly skilled staff mix were found to reduce the rate of urinary tract infections. Overall, the study finds that for the average nursing home facility, a 50% increase in RN staffing time per resident-day (roughly increasing from 0.35 to 0.525 hours per resident-day) would reduce the rate of pressure sores by about 66% and that of urinary tract infections by 45%.

This study accounted for the entire range of factors (e.g., circumstantial factors such as a budget cut during the study period) that may affect the outcome of interest by using a different (less rigorous) study method. Once these factors are accounted for, as was done in this study, a larger benefit is seen from RN staffing on these two key nursing home resident outcomes.

Conclusions: This study revealed that among long-stay nursing home residents in the US, increased RN staffing time improved resident outcomes, as measured by the rate of pressure sores and urinary tract infections. The study also found that the impact of nurse skill mix varied by the outcome: skill mix reduced the rate of urinary tract infections but not pressure sores.

The findings of this study are particularly important given the rigor of the statistical techniques used in the analysis, which account for many factors left out of other studies. This means that policy makers can have greater confidence in the findings reported in this study. However, it is important to note that the analysis focused on long-stay residents in nursing homes and that the findings may not pertain to post-acute care nursing home residents.

Reference: Konetzka RT, Stearns SC, Park J. The Staffing-Outcomes Relationship in Nursing Homes. Health Services Research. 2007; DOI 10.1111/j.1475-6773.2007.00803.


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