Expert panel recommends minimum nurse staffing standards in nursing homes
(March 10, 2000 @ New York, NY) -- According to an article published in the February issue of the Gerontologist, current data shows that the average nurse staff levels in some of the nation's nursing homes are too low to assure quality care.
The article stems from an expert panel on nursing home care convened by the John A. Hartford Institute for Geriatric Nursing, Division of Nursing at New York University. Participants included leading nurse researchers and educators, administrators of long term care facilities, consumer advocates, health economists and health service researchers.
The authors report that older adults in nursing homes where nurse staffing is low have a greater incidence of health problems. The article also provides recommended minimum nurse staffing standards for nursing administration, professional education and direct caregiving by registered and licensed nurses
These findings are particularly relevant in light of a 1999 report from the U.S. General Accounting Office (GAO) which found that one third of California's nursing homes had seriously jeopardized the health and safety of its residents. Another 1999 GAO study of nursing homes in four states found that many institutions had caused actual or potential death or serious injury to residents.
"One of the major reasons that some nursing homes are still providing inadequate quality of care is that they provide inadequate levels of nursing staff," according to Charlene Harrington, PhD, RN, FAAN, lead author of the paper and Professor at the University of California, San Francisco, Department of Social and Behavioral Sciences.
"Caregiving is the central feature of a nursing home and needs to be improved in order to ensure high quality of care to residents," said Mathy Mezey, EdD, RN, FAAN, co-author of the study and Director of the Hartford Institute for Geriatric Nursing.
Data shows a positive relationship between higher nurse staffing and patient health
"Since detailed time studies have not been conducted on the amount of time that is required to
provide high quality of care to residents, expert opinion is currently the best approach to addressing
the problem of inadequate staffing," said Dr. Harrington.
Based on a review of the research studies on the relationship between nurse staffing in nursing homes, the panel reaffirmed the positive relationship between higher nurse staffing, particularly registered nurse staff, and resident outcomes. The experts also found that in nursing homes where nurse staffing was low, resident problems such as high urinary catheter use, low rates of skin care, poor feeding of residents, malnutrition, dehydration, starvation and low resident participation in activities were more frequent.
Nursing Management and Leadership are Central to Quality Care
Currently, registered nurses in nursing homes have substantially lower levels of education compared
to nurses in hospitals. Many nurses in nursing homes have no training in gerontology or chronic
disease management. Nursing management and leadership are central to providing high quality of care
in nursing facilities given the complex needs of residents. To address this issue, the authors
recommend that the Director of Nursing in nursing facilities should have a minimum of a Bachelor's
degree. The longer term goal would be that most nursing homes would have Directors of Nursing with a
BA degree and a Clinical Nurse Specialist (CNS) or a Nurse Practitioner (NP), with a specialty in the
care of the chronically ill and disabled and/or the elderly.
Specific Recommendations for Minimum Staffing Standards
The authors recommend minimum staffing standards for nursing administration, 24-hour RN supervision,
additional education and training, direct caregiver ratios (1 caregiver to 5 residents on days, 1:10
on evenings, and 1:15 on
nights and additional staff at mealtime), and licensed nurse ratios (1:15 on day, 1:20 on evenings,
and 1:30 on nights). The total recommended time is 273 minutes per resident day compared with 210
minutes on the OSCAR data and 250 minutes for the HCFA time studies with adjustments upward to take
into account resident care needs.
These minimum staffing standards can be used by state legislators, Congress and HCFA as elected officials and government agencies develop new legislation aimed at insuring quality care in our nation's nursing homes.
Better Staffing May Reduce Costs While Improving Patient Outcomes
A key barrier to adding more nursing personnel is the cost, especially to the government, which pays
a majority of the total nursing home expenditures in the U.S. The authors show how increased staffing
could affect cost savings by improving staff morale and productivity and by reducing the amount of
on-the-job injuries. Additionally, the costs of supplies and drugs may be reduced as residents have
more active and satisfying lives and have fewer complications and loss of functioning. Higher
staffing levels may also lower personnel turnover thus lowering costs associated with hiring and
training.
In addition to Harrington and Mezey, co-authors of the paper include Christine Kovner, PhD, RN, FAAN, Division of Nursing, New York University; Jeanie Kayser-Jones, PhD, RN, FAAN, UCSF professor of physiological nursing and medical anthropology; Sarah Burger, RN, MPH, National Citizens' Coalition for Nursing Home Reform; Martha Mohler, RN, MN, MHSA, National Committee to Preserve Social Security and Medicare; Robert Burke, PhD, Muse & Associates; and David Zimmerman, PhD, Center for Health Systems Research and Analysis, University of Wisconsin, Madison.
The John A. Hartford Institute for Geriatric Nursing at New York University, School of Education, Division of Nursing seeks to shape the quality of the health care that elderly Americans receive by promoting the highest level of competency if the nurses who deliver that care. By raising the standards of nursing care, the Hartford Institute aims to insure that people age in comfort and with dignity.
Journal
The Gerontologist