Resource allocation and resident outcomes in nursing homes: Comparisons between the best and worst

The purpose of this study was to identify patterns of resource allocation that relate to resident outcomes in nursing homes. Data on structure, staffing levels, salaries, cost, case mix, and resident outcomes were obtained from state-level, administrative databases on 494 nursing homes. We identified two sets of comparison groups and showed that the group of homes with the greatest percentage of improvement in resident outcomes had higher levels of registered nurse (RN) staffing and higher costs. However, comparison groups based on best–worst average outcomes did not differ in resource allocation patterns. Additional analysis demonstrated that when controlling for RN staffing, resident outcomes in high- and low-cost homes did not differ. The results suggest that, although RN staffing is more expensive, it is key to improving resident outcomes. © 1998 John Wiley & Sons, Inc. Res Nurs Health 21: 297–313, 1998     

Outcomes from the work of registered nurses working with older people in UK care homes

heath h. (2010) Outcomes from the work of Registered Nurses working with older people in UK care homes. International Journal of Older People Nursing 5 , 116–127 Aims and objectives. This research sought to illuminate the distinct contributions made by Registered Nurses (RNs) and Care Assistants (CAs) to outcomes for older people in UK (nursing) care homes and to identify the outcomes of their work. This paper reports on aspects relevant to RNs. Background. Older people living in long-term residential care settings around the world are among the most vulnerable individuals within their communities and those with the most complex needs. Nursing has historically been fundamental in the delivery of these services but, in some countries, the role of Registered Nurses in residential care is coming under increasing scrutiny, particularly in the context of escalating costs and funding restrictions, a questioning of the need for a 24-hour ‘health’ professional presence in a ‘social care’ service and a lack of evidence on the distinct contribution that RNs make to outcomes in these settings. Design. A multi-method qualitative interpretive approach, adopting a structure–process–outcome framework and grounded in the philosophical hermeneutics of Hans-Georg Gadamer (2003) . Methods. For Phase 1 of the study, RNs and CAs from care homes around the UK contributed examples of their work, which they identified as having made a ‘significant’ difference to older individuals. Phase 2 comprised researcher fieldwork (observations, interviews and documentary analysis) in three care homes around UK. Research participants included RNs, CAs, older residents, relatives, home managers and professionals working in the homes. Results. RN roles in care homes are broad and multifaceted. Distinct outcomes of RN work are consequent to their caring and their knowledge and skills developed through broad experience in a range of healthcare settings. Outcomes for residents from RN work include enhanced personhood and wellbeing, improved health and function, the prevention of problems/adverse outcomes and enhanced quality of life. RN outcomes have positive impact on relatives, staff and the homes in general. Conclusions. There is potential to reconsider the broad, ‘anything and everything’ nature of the RN role in care homes identified in the research. However, given the complex healthcare needs of the current resident population, the 24-hour RN presence is deemed essential.     

Expert nurse response to workforce recommendations made by The Coronavirus Commission For Safety And Quality In Nursing Homes

COVID-19 has exposed the longstanding internal problems in nursing homes and the weak structures and policies that are meant to protect residents. The Centers for Medicare and Medicaid Services convened the Coronavirus Commission for Safety and Quality in NHs in April, 2020 to address this situation by recommending steps to improve infection prevention and control, safety procedures, and the quality of life of residents in nursing homes. The authors of this paper respond to the Final Report of the Commission and put forth additional recommendations to federal policymakers for meaningful nursing home reform: 1) ensuring 24/7 registered nurse (RN) coverage and adequate compensation to maintain total staffing levels that are based on residents’ care needs; 2) ensuring RNs have geriatric nursing and leadership competencies; 3) increasing efforts to recruit and retain the NH workforce, particularly RNs; and 4) supporting care delivery models that strengthen the role of the RN for quality resident-centered care.     

The effect of registered nurses on nursing home residents’ outcomes,controlling for organizational and health care market factors

Despite cumulative and integrative evidence of registered nurse (RN) staffing on nursing home residents’ outcomes worldwide, few studies integrate the effects of residents’ case mix, healthcare markets, and nurse staffing on psychotropic-medication use and weight loss in Korea. This article examined the relationship between nurse staffing and residents’ quality-of-care outcomes, controlling for long-term healthcare market characteristics in Korea. Using a multilevel cross-sectional design, a disproportionate stratified random sampling was used. Of 87 nursing homes contacted, 60 agreed to participate. Weighted linear regression was used to test the hypotheses. RN hours per resident day (HPRD) had a statistically significant positive impact on reducing the number of residents with psychotropic medication (ß = − .331, p = .008). Greater RN HPRD positively marginally related to fewer residents with cognitive impairment (ß = − 0.201, p = .139). Higher turnover of RN staff related to decreased proportions of residents with weight loss (ß = − .331 p = .008). Policymakers should cautiously consider requiring mandatory nurse staffing in nursing homes in Korea, where it is still acceptable to have certified nurse aids as substitutes for RNs.     

The quality of nursing home care in Taiwan

This study describes the quality of care in nursing homes in Taiwan using demographic data, functional status measures, resident clinical care outcomes, and resident's ratings of satisfaction with nursing home care. Three hundred and eight randomly selected elderly residents in 13 nursing homes were interviewed through a structured interview process and demographic and medical information was collected from their nursing home records. Nursing home residents were younger and less functional than their counterparts in the United States. Stroke and dementia were the most common primary diagnoses and more than 27% of the residents had a history of urinary tract infections while more than 25% had been physically restrained within the past 3 months. There was no correlation between the number of nursing home staff per resident and the prevalence of selected clinical care outcomes. A moderate level of satisfaction with nursing home care was reported with acceptance of family visits and nursing home cleanliness rating highest, and loss of personal belongings and life as boring rating lowest. Level of satisfaction with nursing home care was positively correlated with the number of RNs and nursing assistants (NAs) on staff. Recommendations for improving the quality of nursing home care in Taiwan include increased recruitment of multidisciplinary professional and technical nursing home staff; restrictions in the use of restraints with development of alternatives; and use of standardized resident assessment, care planning, and evaluation tools. The authors recommend continuing education in geriatric nursing and continued nursing research focusing on identifying structure and process variables that affect clinical care outcomes and satisfaction with nursing home care.     

Are nursing homes adequately staffed? The silent epidemic of malnutrition and dehydration in nursing home residents. Until mandatory staffing standards are created and enforced, residents are at risk

Providing care to produce positive resident outcomes is an ethical duty of nursing home staff. Research has shown that inadequate staffing levels present an increased health risk to nursing home residents. Nursing home residents may experience dehydration and malnutrition caused by inadequate staffing. Continued research in the area of nutrition and dehydration in nursing home residents may positively influence changes in staffing levels at nursing homes. Currently, residents living in understaffed nursing homes and not receiving proper care are the victims. It is time for nurses to forcefully lobby for national mandatory nurse staffing standards.     

RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care

OBJECTIVE: A clear link has been demonstrated between lower nurse staffing levels in hospitals and adverse patient outcomes, but the results of studies of such relationships in long-term care facilities haven't been as clear. This study explored the time nurses spent in direct care and how it affected outcomes in long-stay (two weeks or longer) nursing home residents. METHODS: In a retrospective study of data collected as part of the National Pressure Ulcer Long-Term Study (NPULS), we analyzed data on 1,376 residents of 82 long-term care facilities whose lengths of stay were 14 days or longer, who were at risk of developing pressure ulcers but had none at study entry, and who had a Braden Scale score of 17 or less. Primary data came from residents' medical records during 12-week periods in 1996 and 1997. Dependent variables included development of pressure ulcer or urinary tract infection (UTI), weight loss, deterioration in the ability to perform activities of daily living (ADLs), and hospitalization. Independent variables included resident demographics, severity of illness, nutritional and incontinence interventions, medications, and nurse staffing time. RESULTS: More RN direct care time per resident per day (examined in 10-minute increments up to 30 to 40 minutes per resident per day) was associated with fewer pressure ulcers, hospitalizations, and UTIs; less weight loss, catheterization, and deterioration in the ability to perform ADLs; and greater use of oral standard medical nutritional supplements. More certified nursing assistant and licensed practical nurse time was associated with fewer pressure ulcers but did not improve other outcomes. CONCLUSIONS: The researchers controlled for important variables in long-stay nursing home residents at risk for pressure ulcers and found that more RN direct care time per resident per day was strongly associated with better outcomes. There's an urgent need for further research to confirm these findings and, if confirmed, for improving RN staffing in nursing homes to decrease avoidable adverse outcomes and suffering.     

Medicaid payment rates, case-mix reimbursement, and nursing home staffing--1996-2004

OBJECTIVE: We examined the impact of state Medicaid payment rates and case-mix reimbursement on direct care staffing levels in US nursing homes. METHODS: We used a recent time series of national nursing home data from the Online Survey Certification and Reporting system for 1996-2004, merged with annual state Medicaid payment rates and case-mix reimbursement information. A 5-category response measure of total staffing levels was defined according to expert recommended thresholds, and examined in a multinomial logistic regression model. Facility fixed-effects models were estimated separately for Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nurse Aide (CNA) staffing levels measured as average hours per resident day. RESULTS: Higher Medicaid payment rates were associated with increases in total staffing levels to meet a higher recommended threshold. However, these gains in overall staffing were accompanied by a reduction of RN staffing and an increase in both LPN and CNA staffing levels. Under case-mix reimbursement, the likelihood of nursing homes achieving higher recommended staffing thresholds decreased, as did levels of professional staffing. Independent of the effects of state, market, and facility characteristics, there was a significant downward trend in RN staffing and an upward trend in both LPN and CNA staffing. CONCLUSIONS: Although overall staffing may increase in response to more generous Medicaid reimbursement, it may not translate into improvements in the skill mix of staff. Adjusting for reimbursement levels and resident acuity, total staffing has not increased after the implementation of case-mix reimbursement.     

Observing how RNs use clinical time in a nursing home: a pilot study

Registered nurses (RNs) working in nursing homes (NHs) are a scarce professional resource. Their responsibilities include direct (e.g., assessment, physical care, and medication administration) and indirect care (e.g., documentation, supervision, and other activities performed away from the resident to manage their care environment). The purpose of the study was to describe the direct and indirect care distribution of RNs working day shift in an NH. All RN care was observed, although RN care associated with pressure ulcer prevention as a clinical outcome was highlighted. Work sampling was conducted using a personal data assistant-based RN Observation Measure. RNs spent 59% of their time on indirect care. Little direct care could be linked with specific clinical categories relevant to pressure ulcer prevention. RNs are challenged to use RN clinical time more strategically.     

Nurse staffing and adverse events in hospitalized children

This study determined whether the number of hours of care provided by RNs was related to mortality and complications in hospitalized children. Administrative data (1996-2001) were used to examine discharges of 3.65 million pediatric patients in 286 general and children's hospitals in California. A greater number of resource-adjusted hours of care provided by RNs was related to significantly reduced occurrences of postoperative pulmonary complications, postoperative pneumonia, and postoperative septicemia; the positive impact of increases in nurse staffing was of greater magnitude at institutions providing fewer resource-adjusted hours of RN care. There was also evidence of an impact of increases in nurse staffing on urinary tract infections, but it was statistically significant only for institutions with higher resource-adjusted hours of RN care. There was no statistically significant relationship between RN staffing and mortality. More hours of care provided by RNs was associated with improved quality of care for hospitalized pediatric patients.     

The business case for nursing in long-term care

Lower nurse staffing in hospitals has been associated with adverse patient outcomes; results in nursing homes (NHs) are less clear. We examined the association between nurses' direct care time and outcomes in long-stay NH residents and potential cost savings from decreased adverse outcomes versus additional wages for adequate nurse staffing. Data were from the National Pressure Ulcer Long-Term Care Study of 1,376 at-risk residents from 82 NHs. Primary data came from medical records. Hospital, pressure ulcer (PrU) treatment, and urinary tract infection (UTI) costs were from national statistics or cost-identification studies. Time horizon was 1 year. More registered nurse (RN) direct care time/resident/day was associated with fewer PrUs, hospitalizations, and UTIs. Annual net societal benefit was $3,191/resident/year in high-risk NH units with 30-40 min of RN time/resident/day versus units with <10 min. Thus, after controlling for important variables, more RN time/day was strongly associated with better outcomes and lower societal cost.     

The effects of RN staffing hours on nursing home quality: A two-stage model

Objectives/background

Based on structure-process-outcome approach, this study examined the association of registered nurse (RN) staffing hours and five quality indicators, including two process measures (catheter use and antipsychotic drug use) and three outcome measures (pressure ulcers, urinary tract infections, and weight loss).

Setting/participants

We used data on resident assessments, RN staffing, organizational characteristics, and market factors to examine the quality of 195 nursing homes operating in a rural state of United States — Colorado.

Design/methods

Two-stage least squares regression models were performed to address the endogenous relationships between RN staffing and the outcome-related quality indicators, and ordinary least squares regression was used for the process-related ones. This analysis focused on the relationship of RN staffing to nursing home quality indicators, controlling for organizational characteristics, resources, resident casemix, and market factors with clustering to control for geographical differences.

Results

Higher RN hours were associated with fewer pressure ulcers, but RN hours were not related to the other quality indicators.

Conclusions

The study finding shows the importance of understanding the role of ‘nurse staffing’ under nursing home care, as well as the significance of associated/contextual factors with nursing home quality even in a small rural state.     

The effect of LPN reductions on RN patient load

OBJECTIVE: This study explores the effect of licensed practical nurse (LPN) reductions on registered nurse (RN) staffing. BACKGROUND: RN staffing is usually evaluated by assessing RN/patient and RN/nursing staff ratios. Using these measures, researchers generally have not found deterioration in RN staffing. Despite differences in roles, RNs and LPNs frequently share a substantial amount of patient load. Given reductions in LPNs, adequate RN staffing can be assessed more completely by looking at the changes in the staffing of licensed nurses (RNs and LPNs combined). METHODS: This study measures the percent change in RN, LPN, and licensed nurse staffing from 1991 to 2000 in 185 to 215 Pennsylvania hospitals. Paired sample t tests measure the significance of change from year to year and for the period overall. RESULTS: A 29% reduction in LPNs during the years 1991 to 2000 affected RN staffing through an increase in licensed nurses' patient load and a slight decrease in skill mix. When adjusted for acuity, both RN and licensed nurse patient load increased significantly. CONCLUSIONS/IMPLICATIONS: These results help explain the perception that hospitals are understaffed. Future research and managerial decision-making should consider the adequacy of licensed nurse staffing, and its impact on cost, performance, and quality.     

The influence of registered nurse staffing on the quality of nursing home care

The purpose of this study was to determine the extent to which registered nurse (RN) staffing patterns influenced nursing home quality. Based upon extensive literature review, a model for nursing home quality was developed. Using data from reports of 455 Medicare-certified skilled nursing facilities, structural, process, and outcome factors thought to influence quality were entered into the model and analyzed using ordinary least squares regression. A small, though statistically significant, proportion of the variance in quality nursing home care was explained by the equation. A positive, significant relationship existed between nursing home quality and the ratio of RN hours to licensed vocational nurse (LVN) hours per resident day.     

Licensed caregiver characteristics and staffing in California acute care hospital units

PURPOSE: Concerns about declining quality of care and nurse staffing shortages led to legislation mandating minimum nurse-to-patient ratios in the state of California. Although research finds that better registered nurse (RN) staffing results in higher quality of care, little evidence exists on which to base specific nurse-patient ratios. The authors describe the results of a California survey characterizing licensed caregivers, identifying staffing levels by unit type, and describing how staffing levels vary across hospital types. METHODS: A stratified random sample of general acute care hospitals was surveyed to collect cross-sectional data on hospitals' nursing workforce and staffing practices and to assess the impact of potential patient-to-nurse staffing ratios. All academic medical centers; rural, private, and city/county hospitals; and hospitals affiliated with a large group-model health maintenance organization (HMO) were eligible for inclusion. RESULTS: Eighty hospitals were surveyed, representing all major metropolitan areas in the state. Acute care hospitals in California have diverse nursing staffs with variations in education, experience, and employment status. Considerable variations in skill mix were identified, with the proportion of RNs ranging from 30% to 84%, depending on the unit type surveyed. CONCLUSIONS: As states struggle with an anticipated critical shortage of RNs, these results have several implications for health and education policy. Future studies of this type will be needed to evaluate the impact of anticipated changes in the regulation of nurse staffing.     

The development and testing of a questionnaire to measure complexity of nursing work performed in nursing homes: NCCQ-NH

The quality of care in nursing homes has improved over the last 2 decades; however serious problems persist. Although staffing levels are a primary concern, studies show that ineffective management structures may be a contributing factor to poor quality care. Evidence suggests that the complexity of work performed within the organization is an important consideration in developing effective management structures. The purpose of this article is to describe the development and initial testing of an instrument to measure the complexity of nursing work in nursing homes. A sample of 168 nursing personnel (RNs, LPNs, CNAs) from 7 nursing homes participated in the study. The results of measures to determine the reliability and validity were generally acceptable for a new scale. A modified version of the original scale can be used to provide scientific evidence on which to base the design of management structures in nursing homes.     

Nursing resources on the nursing unit and quality of patient care.

This article deals with the relationships between nursing resources and quality of patient care. The following relationships were found: (1) the quality of the nursing care plan was negatively related to the number of part-time student nurses, full-time Aides, part-time Registered Nurses (RN), and full-time RNs; (2) the quality of the nursing record was negatively related to the number of part-time RNs and full-time student nurses; and (3) the quality of the nursing care at the bedside was negatively related to the number of full-time student nurses and number of patients on the ward; and (4) the total quality of nursing care was negatively related to the number of full-time student nurses, part-time RNs, part-time student nurses, full-time Aides, and full-time RNs. The results were discussed in terms of the effects various nursing resources have on the performance of the RN.