Elderly/Long-Term Care

Staffing level mix affects quality of care in nursing homes

Quality of care on four quality measures (QMs) changed when the mix of certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurses (RNs) in nursing homes changed, according to a new study by Gregory L. Alexander, Ph.D., R.N., of the University of Missouri. He analyzed the association between staffing-level mix at all Missouri nursing homes and differences in scores for 7 of 14 QMs downloaded from the Nursing Home Compare Web site in February 2004. Five of the QMs were the percentage of long-stay residents whose need for help with activities of daily living (ADLs) increased, who had pressure sores, or who became more depressed or anxious; and percentage of long-stay, low-risk residents who were incontinent or whose ability to move in and around their room got worse. The two other QMS were the percentage of short-stay residents who had moderate to severe pain or who had pressure sores.

Staffing levels for CNAs in the homes were much higher than either LPN or RN staffing levels, ranging from about 2 to nearly 3 hours per resident per day in some facilities. LPNs had nearly a 2 to 1 ratio of hours per resident per day compared with RNs, who spent a little less than one-half hour to less than 1 hour, depending on how well-staffed the facilities were.

As the level of RN staffing was held constant and number of CNA staff increased, and as the level of LPN staffing was held constant and number of CNA staff grew, the percentage of residents who were incontinent increased by about 5 percent. Similarly, more residents had greater need for help with ADLs, such as bathing and eating, when licensed nurses were available to assess their status. Also, the percentage of short-stay residents who had moderate to severe pain increased by about 10 percent in homes that had constantly lower levels of RNs (less than .30 hours per resident per day), who are needed to administer pain medications. When LPNs were staffed to provide more than 0.73 hours per resident per day and the number of CNAs was also increased, 3 percent fewer short-stay residents suffered from pressure ulcers. The study was supported by the Agency for Healthcare Research and Quality (HS16862).

See "An analysis of nursing home quality measures and staffing," by Dr. Alexander, in the July-September 2008 Quality Management in Health Care 17(3), pp. 242-251.

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