Systematic Review of Studies of Staffing and Quality in Nursing Homes

doi:10.1016/j.jamda.2006.01.024

Journal of the American Medical Directors Association

Volume 7, Issue 6, July 2006, Pages 366-376

https://doi.org/10.1016/j.jamda.2006.01.024 Get rights and content

Purpose

To evaluate a range of staffing measures and data sources for long-term use in public reporting of staffing as a quality measure in nursing homes.

Method

Eighty-seven research articles and government documents published from 1975 to 2003 were reviewed and summarized. Relevant content was extracted and organized around 3 themes: staffing measures, quality measures, and risk adjustment variables. Data sources for staffing information were also identified.

Results

There is a proven association between higher total staffing levels (especially licensed staff) and improved quality of care. Studies also indicate a significant relationship between high turnover and poor resident outcomes. Functional ability, pressure ulcers, and weight loss are the most sensitive quality indicators linked to staffing. The best national data sources for staffing and quality include the Minimum Data Set (MDS) and On-line Survey and Certification Automated Records (OSCAR). However, the accuracy of this self-reported information requires further reliability and validity testing.

Conclusions

A nationwide instrument needs to be developed to accurately measure staff turnover. Large-scale studies using payroll data to measure staff retention and its impact on resident outcomes are recommended. Future research should use the most nurse-sensitive quality indicators such as pressure ulcers, functional status, and weight loss.

Section snippets

Focus of the review

Under a consulting agreement with the Colorado Foundation for Medical Care, the authors conducted a systematic literature review of staffing measures linked to quality outcomes in nursing homes. The purpose of this literature review was to evaluate a range of staffing measures and data sources for long-term use in public reporting of staffing as a quality measure in nursing homes. Specifically, the Staffing Quality Measure (SQM) project, funded by the Centers for Medicare and Medicaid Services

Type of studies for inclusion

To ensure an inclusive investigation of staffing measures linked to quality outcomes in nursing homes, the authors used 2 methods to review the literature. First, a combined electronic literature search of 4 databases (Ageline, CINAHL, HealthSTAR, and MEDLINE) was conducted. The search was limited to research articles published from 1975 to 2003 in the English language. Key words of nursing homes, nursing staff, and quality of health care were combined and duplicates were removed. The

Methods

The research team carefully reviewed and summarized each article, extracted relevant content, and organized the information around 3 themes: staffing measures, quality measures, and risk adjustment variables. In addition, the sources of data for staffing and quality measures were also identified and summarized. Four summary tables identify each variable, how it was measured, and the frequency of that measure or data source found in previous studies. The first table reviews all staffing measures

Data source for staffing variables

Several sources of data were used in studies to obtain staffing information. Table 4 identifies the data sources from which staffing or control measures were obtained. Some instruments were specific to the state in which the studies were conducted and did not allow for easy comparison across other states. For example, all states require Medicaid Cost Reports for reimbursement purposes, but these vary from state to state as to the types of staffing information they require nursing homes to

Results

The results of this review are presented according to 3 major categories. Staffing Measures refer to various nurse staffing calculations used in the literature and range from staff ratios (number of staff per resident) to staff turnover rates. Quality Measures indicate a proxy measurement for quality care and are classified as either resident outcomes (eg, pressure ulcers or catheter use) or facility outcomes (eg, hospital admissions, mortality rates, or code violations). The third category of

Staffing measures

Staffing was examined using numerous methods with the most emphasis placed on staffing ratios. Almost half of the studies (42) used some measure of staff-to-resident or staff hours–to-resident ratio. Staff mix or staff utilization were also identified as significant variables to be studied. The type of staff (licensed or unlicensed) that interacted with the residents or the amount of time spent with them was often discussed.

Basically, there are 2 main staffing measures: (1) the ratio of staff

Quality measures

Quality is a difficult concept to capture directly; therefore, measures of quality are a proxy for quality, either as resident or facility outcomes. Certain resident outcomes indicate when substandard care is being provided, for example, accidents, fractures, and urinary catheterization place the resident at greater risk and may result in hospitalization. The absence or low incidence of these resident outcomes indicates that quality care is delivered.

Facility outcomes such as mortality rates,

Risk adjustment/control measures

Several variables have been used as covariates when studying the relationship between staffing and quality. These adjustments are made based on resident, facility, or economic characteristics (or a combination of these) to control for extraneous factors affecting quality.

Discussion

Based on the findings of this review, several questions arise regarding research on staffing and quality of care. The following questions offer a framework for the discussion of this issue.

1
Which procedure is the most reliable and accurate way to measure staffing?
Thus far, the literature is not helpful for addressing issues regarding how often staffing measures should be collected or over what time period the data should be collected. The majority of studies that used a measure of staffing

Conclusions

Future research should build upon the knowledge gained from previous research and should strive to validate the accuracy of staffing information available from national databases. More studies need to be conducted using the OSCAR database for staffing information and verifying its accuracy. Hours per resident per day (HPRD) seem to be the most accurate, albeit unverified, measure currently available to capture staffing levels for nationwide comparison. In addition to staffing levels, other

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: The analyses upon which this publication is based were performed under Contract Number 500-02-CO01, funded by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented.

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Original studySystematic Review of Studies of Staffing and Quality in Nursing Homes

Purpose

Method

Results

Conclusions

Section snippets

Focus of the review

Type of studies for inclusion

Methods

Data source for staffing variables

Results

Staffing measures

Quality measures

Risk adjustment/control measures

Discussion

Conclusions

J Health Econ

J Am Med Dir Assoc

Geriatr Nurs

Systematic reviewsGatekeepers of nursing knowledge

J Clin Nurs

On nursing home qualityA review and analysis

Med Care Rev

The relationship between nurse staffing in nursing homes and quality indicatorsA literature review

J Gerontol Nurs

Experts recommend minimum nurse staffing standards for nursing facilities in the United States

Gerontologist

Resource allocation and resident outcomes in nursing homesComparisons between the best and worst

Res Nurs Health

Relationship of nursing personnel and nursing home care quality

J Nurs Care Qual

Nursing staff turnover and retention in nursing homes

Nursing home staffing and its relationship to deficiencies

J Gerontol B Psychol Sci Soc Sci

Nursing facility staffing in the statesThe 1991 to 1995 period

Med Care Res Rev

Does investor-ownership of nursing homes compromise the quality of care?

Am J Public Health

Effects of nurse staffing on selected quality measures for long term residents derived from MDS

Effects of nurse staffing on hospital transfer quality measures for new admissions

Synthesis of findings on effects of staffing on quality of care

The relationship between nurse staffing levels and the quality of nursing home care

Effects of nurse staffing on nursing home quality measures

Nursing home quality, cost, staffing, and staff mix

Gerontologist

Relationship of nursing home staffing to quality of care

Health Serv Res

Nursing HomesQuality of Care More Related to Staffing than Spending

Nursing care quality in nursing homesCross-sectional versus longitudinal analysis

J Med Syst

Data sources of nursing home nurse staffing analysis, OSCARReliability and validity analysis

Data sources of nursing home nurse staffing analysisAssessment of OSCAR compared to Medicaid cost reports

Nurse staffing in U.S. nursing homes

Original study
Systematic Review of Studies of Staffing and Quality in Nursing Homes