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Is there Evidence for Mandated Nurse Staffing Standards for Nursing Homes? Christine Mueller, PhD, RN, C, CNAA Associate Professor Center for Gerontological Nursing University of Minnesota, School of Nursing Research Collaborators

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is there evidence for mandated nurse staffing standards for nursing homes

Is there Evidence for Mandated Nurse Staffing Standards for Nursing Homes?

Christine Mueller, PhD, RN, C, CNAA

Associate Professor

Center for Gerontological Nursing

University of Minnesota, School of Nursing

research collaborators
Research Collaborators
  • Robert Kane, MD, Professor and Minnesota Chair in Long-term Care and Aging
  • Greg Arling, PhD, Associate Professor, Cookingham Institute, University of Missouri-Kansas City

Research Assistants

  • Julie Bershadsky
  • Theresa Lewis
  • Diane Holland, MS, RN
four research activities related to staffing and quality in long term care facilities
Four research activities related to staffing and quality in long-term care facilities:
  • Critical review of literature
  • Analysis of States’ staffing standards
  • Interviews of Minnesota stakeholders
  • Analysis of Minnesota nurse staffing time and risk-adjusted process and outcome quality measures
critical literature review scope
Critical literature review—Scope
  • Relationship between nurse staffing and quality as primary focus of the study
    • 1977-2005
    • 30 quantitative studies
      • Adequacy of staffing data source and measures
      • Adequacy of care quality data sources and measures
      • Generalizability of study findings
      • Presence and strength of relationships
    • 6 qualitative studies
      • How staffing relates to processes of care and how the processes affect the health status of residents
critical literature review main findings
Critical literature review—Main Findings
  • Data sources for staffing
    • OSCAR (46% of studies)
      • Accuracy issues
    • Other state level databases, interviews
    • One study observed time spent
  • Staffing measures
    • RN, LPN, NA, Total HPRD or ratio
critical literature review main findings7
Critical literature review—Main Findings
  • Data sources for Quality
    • 11 different data sources
  • Quality measures
  • Risk adjustment
stakeholder perceptions regarding staffing and quality in long term care facilities
Group Interviews

13 group interviews

212 persons

Key organizations helped facilitate interviews

Surveys

114 respondents

Family councils (4)

Resident councils (4)

RNs

LPNs

NAs

Directors of Nursing

Ombudsmen

Administrators

Union representatives

Nurse practitioners

Stakeholder perceptions regarding staffing and quality in long-term care facilities
two primary questions
Two Primary Questions
  • What are the greatest concerns you have with staffing in nursing homes?
  • What is your advice to the State about what should be included in a staffing standard for MN nursing facilities?
concerns of stakeholders
Lack of continuity of care for residents

Quality of staff

Communication/English fluency

Lack of compassion; negative attitudes

Not enough nursing staff

Lack of knowledge/training needs of staff

Management/supervision

Turnover/retention

Acuity needs of residents changing

Quality of care is associated with staffing

Examples after examples

Concerns of Stakeholders
recommendations of stakeholders
More staff

but no specific recommendations for ratios or HPRD

Link staffing to acuity

Associated with quality

Training/education

Management, leadership, and supervision

Positive work environment that fosters staff involvement in decision making about the residents’ care and their work

Recommendations of Stakeholders

Major Caveat: Support increased staffing standards as long as their was the assurance of financial support to meet the standards.

state staffing standards scope of work
State Staffing Standards—Scope of work

Published in The Gerontologist

  • Research questions:
    • 1) What are the characteristics of state staffing standards in the U.S.?
    • 2) Are state staffing standards associated with nursing staff hours per resident day (HPRD), licensed HPRD and unlicensed HPRD?
  • Obtaining staffing standard data
    • 50 states plus District of Columbia (2004)
    • Abstracting variables
  • Obtaining actual staffing
    • OSCAR (2004)
    • 14,147 facilities in 50 states plus D.C.
  • Creation of a data file for analysis
state staffing standards findings
State staffing standards--Findings
  • 40 States have staffing standards over and above the federal requirement
    • 33 specify HPRD or ratio
      • Median 2.35 HPRD (highest 3.6 HPRD)
    • 33 specify additional licensed nurse staffing requirements
    • 7 require 24 hour RN staffing
  • Actual Staffing (for each state)
    • Licensed: 1.26 HPRD
    • NA: 2.31 HPRD
    • Total: 3.57 HPRD
variables for analysis
Variables for analysis
  • Categorical staffing variables:
    • No HPRD,  2.5 HRPD, >2.5 HPRD
    • Presence or absence of 24 RN staffing
    • Presence or absence of additional licensed staffing
  • Covariates
    • Size of nursing home
    • Type of Medicare/Medicaid certification
    • Percent of private pay residents
    • Hospital affiliation
    • Chain affiliation
    • Percent occupancy
    • Ownership
    • Resident acuity
state staffing standards findings cont
State staffing standards—Findings (cont).
  • Facility HPRD staffing varied a great deal more within than between states.
    • Staffing standards per se accounted for only a small proportion of between-state variance in facility staffing levels (11% of total HPRD).
    • Medicaid payment rate and facility-level covariates did a much better job of accounting for between-state variance (70% of total HPRD)
  • Facilities in states with low HPRD standards had the lowest average total, licensed, and aide HPRD
  • Facilities in states with high HPRD standards had highest total, licensed and aide HPRD;
  • Facilities in states with no standards were in between.
staffing standards analysis implications
Staffing Standards analysis--Implications
  • Introducing a high HPRD staffing standard may increase facility staffing; But, how high?
  • A low standard may have no affect or even a dampening effect. Some facilities may treat staffing standard minimums as if they were maximums, and lower their staffing accordingly
  • Other facility characteristics, such as management style or labor market conditions, not measured in our study may explain some of the variation that was not accounted for in this study.
nursing time and quality
Nursing Time and Quality
  • Limitation of other studies
    • Staffing and quality assessed at the facility level
  • Our study addressed this limitation
    • Data included nursing time that could be associated with
      • specific residents
      • specific nursing units
    • Resident and unit risk adjusted quality measures/ indicators at the resident level
    • Accounted for resident acuity and staffing at the unit level
research questions
Research Questions
  • Is there a positive relationship between nursing time (nursing resource used) and quality related outcomes/ measures? Is more staff time associated with better quality indicators? Is the association causal?
  • If quality related resident outcomes are positively associated with more nursing resources, what is the nursing resource/quality threshold, that is, what amount of nursing resource use will provide no further improvement in quality outcomes?
slide20

Nursing Resource Use & Care Quality Model

Unit Quality

Unit Staffing

Resident Resource Use

Unit Acuity

Care Processes

Care Outcomes

Resident acuity/risk

staff time study
43 Minnesota LTC facilities

68 nursing units

2,506 residents

40 conventional units

18 special care (dementia) units

Staff time data collected over 48 hour period

Resident specific time

Non-resident specific time

MDS assessments for each resident

Staff Time Study
variables
Staff time (RST and NRST)

RN

LPN

NA

Therapy

Social services

Activities

Quality indicators/measures

5 Process measures

7 Outcome measures

Risk adjusted

Control variables

Resident acuity

Unit acuity

Unit type

Variables
resident level direct care times as predictors of process and outcome measures
Resident-Level Direct Care Times as Predictors of Process and Outcome Measures
  • Non-significant result; only results significant p> .05 are shown as actual odds ratios
  • ** odds ratio associated with a 15 minute/day increase in care time
unit level direct care times as predictors of process and outcome measures
Unit-LevelDirect Care Times as Predictors of Process and Outcome Measures
  • Non-significant result; only results significant p> .05 are shown as actual odds ratios
  • ** odds ratio associated with a 15 minute/day increase in care time
strength of the evidence
Strength of the Evidence?
  • Support from literature is marginal
  • Use of staffing standards requires caution
  • No support for the relationship between nurse staffing time and quality measures
  • While stakeholders believe staffing and quality are related, they are unable to identify staffing ratios or HPRD that would result in desired quality.
what are the questions we should be asking
What are the questions we should be asking?
  • Quality may be more of a function of the way nursing care is organized and delivered—
      • Continuity of care provider fostering the nurse-resident relationship
    • Expertise of direct care staff
    • Staff morale and teamwork
    • Facility or unit management practices
    • Leadership and supervision
    • Care related technology
    • Availability of support staff
our recommendations
Our Recommendations
  • Premature to propose specific staffing standards
  • Rather, establish incentives to allow facilities to be more creative and apply cost-effective solutions to address staffing factors
  • Quality based Medicaid payment system
    • Reward higher quality of care
    • Give facilities flexibility for channeling resources
  • Need research to see if this approach improves quality
  • Focus research on other factors that might influence quality
slide28

Thank you!

Questions?