Relationship of nursing home staffing to quality of care (original) (raw)
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Further Examination of the Influence of Caregiver Staffing Levels on Nursing Home Quality
The Gerontologist, 2008
Purpose: Weak empirical evidence exists showing that nursing home staffing levels influence quality of care. We propose that weak findings have resulted in many prior analyses because research models have underspecified the labor composition needed to influence care processes that, in turn, influence quality of care. In this analysis, we specified the nursing home labor composition by using staff stability, use of agency staff, and professional staff mix, in addition to staffing levels. Design and Methods: Data used in this investigation came from surveys of nursing home administrators (N = 6,005); Nursing Home Compare; the Online Survey, Certification and Reporting data; and the Area Resource File. Staffing characteristics, quality indicators, facility, and market information from these data sources were all measured in 2004. Results: The regression analyses showed that staffing levels alone were weakly associated with the six quality measures examined. However, when the regression models were more fully specified (by including agency staff, stability, and professional staff mix), staffing levels were generally associated with the quality measures (i.e., 15 of the 18 staffing coefficients were significant). Implications: Simply adding more staff may be a necessary but not sufficient means of improving nursing home quality. Some accounting for agency staff, stability, and professional staff mix is also needed.
Journal of Gerontological Nursing, 2012
The purpose of this study was to complete an integrated literature review of the relationship between staffing and quality outcomes in nursing homes. The majority of the reviewed studies showed better outcomes with higher nursing staff but depended heavily on cross-sectional observational studies and failed to differentiate RNs from other nursing staff. A total of 28 articles relating nurse staffing and quality outcomes were systematically reviewed and synthesized. However, each study examined different aspects of staffing and different resident or organizational outcomes, making determination of appropriate staffing levels difficult. The reviewed studies have not clearly defined the relationship between differing levels of nurse-staffing skill mix and specific structure, process, outcome, and composite indicators of quality. The inconsistent findings suggest that further research is needed in this area.
Caregiver Staffing in Nursing Homes and Their Influence on Quality of Care
Medical Care, 2011
Background: There is inconclusive evidence that nursing home caregiver staffing characteristics influence quality of care. In this research, the relationship of caregiver staffing levels, turnover, agency use, and professional staff mix with quality is further examined using a longitudinal analysis to overcome weaknesses of earlier research. Methods: The data used came from a survey of nursing home administrators, Nursing Home Compare, the Online Survey Certification and Reporting data, and the Area Resource File. The staffing variables of Registered Nurses, Licensed Practical Nurses, and Nurse Aides were measured quarterly from 2003 through 2007, and came from 2839 facilities. Generalized method of moments estimation was used to examine the effects of changes in staffing characteristics on changes in 4 quality measures (physical restraint use, catheter use, pain management, and pressure sores). Results: Regression analyses show a robust association between the staffing characteristic variables and quality indicators. A change to more favorable staffing is generally associated with a change to better quality. Conclusions: With longitudinal information and quarterly staffing information, we are able to show that for many nursing homes improving staffing characteristics will improve quality of care.
Quality of Care in the Nursing Home: Effects of Staff Assignment and Work Shift
The Gerontologist, 2004
The purpose of this study was to compare a variety of resident and staff outcomes across two types of staffing patterns, permanent and rotating assignment, and work shift. Although studies have examined these staffing patterns as part of multicomponent intervention packages, few studies have examined the isolated effects of staffing pattern by using an experimental design. Design and Methods: A between-groups comparison design was used to compare residents and certified nursing assistants (CNAs) from four nursing homes; two self-identified as using permanent assignment (PA) staffing and two as using rotating assignment (RA) staffing. Measures yielded data on verbal interaction among residents and staff, resident disruptive behavior, and specific aspects of resident-staff behavior during care routines. Other assessments included resident personal appearance and hygiene, expressed affect, and CNAs' job satisfaction, burnout, absenteeism, and turnover rates. A treatment fidelity check was conducted to confirm PA and RA staffing patterns. Results: Staffing patterns were significantly different between self-identified PA and RA nursing homes. Residents in PA nursing homes and on morning shifts received significantly higher ratings of personal appearance and hygiene. Rates of expressed sadness and interest among residents differed by staffing patterns and shift. However, these differences do not appear to be clinically significant. Although absenteeism was higher in PA nursing homes, these CNAs reported greater job satisfaction than CNAs from RA nursing homes. As expected, evening shifts across nursing homes had significantly higher turnover rates and significantly more resident disruptive behavior. Implications: Quality-of-care outcomes were similar among the two types of nursing homes, despite significantly different staffing patterns. Though staff permanency rates in PA nursing homes (50%) were twice that of RA nursing homes (26%), more research is needed to determine feasibility of higher rates of staff permanency (i.e.,. 50%) and effects on resident and CNA outcomes.
The Gerontologist, 2007
Purpose: Residential care/assisted living facilities have become an alternative to nursing homes for many individuals, yet little information exists about staffing in these settings and the effect of staffing. This study analyzed the intensity and skill mix of nursing staff using data from a four-state study, and their relationship to outcomes. Design and Methods: We obtained longitudinal data for 1,894 residents of 170 residential care/assisted living facilities participating in the Collaborative Studies of Long-Term Care. Descriptive statistics assessed the levels of direct care staff (registered nurse, licensed practical nurse, personal care aide). Regression analyses evaluated the relationship between two staffing measures (intensity measured as care hours per resident and skill mix measured as the percentage of total care hours by licensed nurses), facility characteristics, and four health outcomes (mortality, nursing home transfer, hospitalization, and incident morbidity). Results: Care hours per resident decreased with facility size (economies of scale) only for very small facilities and increased with dementia prevalence (case-mix effect). Licensed staff accounted for a greater proportion of total hours in nonprofit settings. Health outcomes did not vary by total care hours per resident, but hospitalization rates were significantly lower in facilities with higher proportions of skilled staff hours; this effect was stronger as dementia case mix increased. Implications: Current staffing levels for the outcomes analyzed meet most residents' needs. Reduced hospitalization in relation to greater use of licensed staff suggests that increased use of these workers might result in reductions in acute care expenditures.
Nurse Staffing Patterns and Quality of Care in Nursing Homes
Health Care Management Review, 2004
Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care. N ursing homes are experiencing significant financial challenges because of constrained revenues and rising costs. In response, nursing homes may consider restructuring their staffing patterns in an effort to control costs such as by reducing the number of registered nurses (RNs). 1-3 Nevertheless, it is generally believed that more RNs are necessary to ensure the quality of care received by nursing home patients. 4-7 Furthermore, evidence is increasingly supporting the role of nurse staffing in the quality of care. 8-10 A recent study of nurse staffing in hospitals identified a definitive link between nurse staffing and mortality rates. 11 To date, however, research into the link between nurse staffing structures and quality of care in nursing homes has produced inconsistent and contradictory results. 5,6,12-14 Such results may arise from differences in conceptual frameworks, methods, data, data quality, and adjustments for case-mix intensity. 5,6,15 The Institute of Medicine called for more research into the relationship between staffing structures and outcomes of patient care. 6,7,14 Using Donabedian's structure-process-outcome (SPO) framework that was developed in the 1960s and the resource-based view of the firm, 16 this study considers the direct and indirect effects of staffing (RN staffing mix and full-time RN-staffing) on patient outcomes. RN staffing mix is defined as the proportion of RNs relative to other nursing staff. 17 Full-time RN staffing is the proportion of RNs who are full-time, permanent employees of the nursing homes as opposed to part-time RNs or contract RNs supplied by nurse staffing agencies. CONCEPTUAL FRAMEWORK Health services research into the effect of nurse staffing on the quality of patient care outcomes has primarily used Donabedian's SPO quality framework. 4-6,18 Within this framework, structural indicators of quality include staffing patterns and organizational characteristics that
Journal of the American Medical Directors Association, 2014
Background: The relationship between nurse staffing and quality of care (QoC) in nursing homes continues to receive major attention. The evidence supporting this relationship, however, is weak because most studies employ a cross-sectional design. This review summarizes the findings from recent longitudinal studies. Methods: In April 2013, the databases PubMed, CINAHL, EMBASE, and PsycINFO were systematically searched. Studies were eligible if they (1) examined the relationship between nurse staffing and QoC outcomes, (2) included only nursing home data, (3) were original research articles describing quantitative, longitudinal studies, and (4) were written in English, Dutch, or German. The methodological quality of 20 studies was assessed using the Newcastle-Ottawa scale, excluding 2 low-quality articles for the analysis. Results: No consistent relationship was found between nurse staffing and QoC. Higher staffing levels were associated with better as well as lower QoC indicators. For example, for restraint use both positive (ie, less restraint use) and negative outcomes (ie, more restraint use) were found. With regard to pressure ulcers, we found that more staff led to fewer pressure ulcers and, therefore, better results, no matter who (registered nurse, licensed practical nurse/ licensed vocational nurse, or nurse assistant) delivered care. Conclusions: No consistent evidence was found for a positive relationship between staffing and QoC. Although some positive indications were suggested, major methodological and theoretical weaknesses (eg, timing of data collection, assumed linear relationship between staffing and QoC) limit interpretation of results. Our findings demonstrate the necessity for well-designed longitudinal studies to gain a better insight into the relationship between nurse staffing and QoC in nursing homes.
Nursing Staffing and Quality of Life in Western New York Nursing Homes
Western Journal of Nursing Research, 2014
This study investigated the relationship between nurse staffing and quality of life (QOL) in Western New York State nursing homes. This was a crosssectional, correlational study. The independent variables were hours per resident day (HPRD), skill mix, and turnover rate of nursing staff. The outcomes were measured using the self-reported QOL instrument. No coefficients were statistically significant with registered nurses' (RNs) HPRD. Certified nursing assistant (CNA) HPRD had a statistically significant positive impact on the spiritual well-being domain. There was a statistically negative relationship between the amount of licensed practical nurse (LPN) HPRD and food enjoyment; and the ratio of more RNs to fewer LPNs and CNAs had a statistically significant negative influence on the meaningfulactivity, food-enjoyment, and security domains. The turnover of RNs had a statistically negative relationship with the sum of each domain. None of the coefficients was statistically significant with LPN turnover.