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The relationship between registered nurses and nursing home quality: an integrative review (2008-2014).

IMPLEMENTATION OF THE Affordable Care Act has generated renewed interest in the quality and costs of health care provided to Medicare and Medicaid beneficiaries in skilled nursing facilities (SNFs), commonly referred to as nursing homes (NHs). Nursing home care is expensive; it is second only to acute hospital care for inpatient Medicare costs (Office of Inspector General [OIG], 2014). The increased focus on costs of care accrued by Medicare beneficiaries in NHs presents a valuable opportunity for registered nurses (RNs) to further demor "trate quantitatively the value they add to the capacity of the NH nursing skill mix to provide cost-effective and efficient quality care. Paraprofessionals (nursing assistants [NAs], certified nursing assistants, restorative nursing assistants, and licensed vocational/practical nurses [LVNs/LPNs]) have provided the majority of direct care to NH residents since 1965 (Institute of Medicine [IOM], 1996). Registered nurses increase the skill mix of this workforce. Skill mix refers to differences in education and licensure among nursing staff. It is unclear as to the benefits of this increase in skill mix with respect to costs and quality.

This integrative review is unique in that the RN is the sole focus of the review. By virtue of education and training, the RN is a key contributor to NH quality (Castle & Anderson, 2011; IOM, 2004). Researchers have reported a positive relationship between RN involvement in decision making and better clinical outcomes (Anderson & McDaniel, 1992, 1998, 1999). This is significant because effective care planning is based on the quality of clinical decision making (Centers for Medicare & Medicaid Services [CMS], 2013). Skills in care plan development, care planning, and coordination of care with interdisciplinary team members are codified as core RN competencies within RN state practice acts in the United States (American Nurses Association, 2010).

No prior review has examined the RN as a key contributor to the NH; yet research highlights the multifaceted role of the RN in NHs and their positive impact on residents, relatives, and staff (Heath, 2010). This review of research findings is made in an effort to advance the evidence-base supporting the proposition that RNs add value to NH residents' experiences both directly through the level of RN staffing and indirectly through the clinical leadership they provide to members of the nursing skill mix.


Over the past 18 years, three IOM reports have focused on nursing home quality. The 1986 report contained recommendations for fundamental changes in the federal government's oversight of NH care. Although specific RN staffing levels or nursing skill mix ratios were not proposed, the essential responsibility of professional and competent NH management (e.g., director of nursing [DON]), to create a positive work environment was emphasized (IOM, 1986). A review of studies summarizing the evidence base for a relationship-oriented management practice in NHs provides recent empirical support of this original recommendation (Toles & Anderson, 2011).

While the complexity of factors influencing achievement of quality services in NHs was acknowledged in a 1996 IOM report, specific recommendations for RN staffing were made. Committee members recommended that, by the year 2000, Congress would require a 24-hour presence of RN coverage; the use of geriatric nurse specialists and geriatric nurse practitioners hired in leadership and direct-care positions; a more structured approach to training of NAs; and greater emphasis placed on the educational preparation of new DONs (IOM, 1996).

Similar RN staffing recommendations were made in a 2004 IOM report. The authors recommended greater input of direct-care nursing staff into operational decisions (e.g., nurse staffing levels, skill mix, a redesign of work processes, and workflow to promote safety outcomes); study of factors contributing to nursing turnover; the 24-hour presence of at least one RN within a NH at all times; and implementation of staffing levels recommended in the Department of Health and Human Services (DHHS) report to Congress, "Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes" (IOM, 2004).

However, few IOM recommendations or those of an expert panel on nursing home culture (Burger et al., 2009) have become federal law, with one exception (Harrington et al., 2000). Since the passage of the Nursing Home Reform Act included in the 1987 Omnibus Budget Reconciliation Act, a RN has been required to either conduct or coordinate the completion of the Resident Assessment Instrument.

Currently, federal requirements for RN staffing in NHs remain low, even though resident acuity and complexity have increased substantially (Hirdes, Mitchell, Maxwell, & White, 2011). A facility is required to employ a RN as a DON. At least one RN must be on duty for no fewer than 8 hours per day, 7 days a week. In facilities with fewer than 60 residents, the DON may serve as the one RN on duty. Consequently, no requirement exists for facilities of 100 beds or more to employ an assistant DON or director of education. On evening and night shifts either an RN, LPN, or LVN is required (IOM, 2004). The national average of RN hours per resident day (HPRD) in 2014 was 0.47; the national average of direct-care staff horns per patient day in 2014 was 3.73 (American Health Care Association, 2014). These figures are in stark contrast to RN staffing in hospitals of over 10 horns per patient in a 24-hour period (Welton, 2007).

In the past 8 years, 10 literature or systematic reviews addressing extant NH quality and all nursing staffing levels and practices have been published (Backhaus, Verbeek, van Rossum, Capezuti, & Hamers, 2014; Bostick, Rantz, Flesner, & Riggs, 2006; Bryan et al. 2010; Castle, 2008a; Collier & Harrington, 2008; Dongjuan, Kane, & Shamliyan, 2013; Hodgkinson, Haesler, Nay, O'Donnell, & McAuliffe, 2011; Shin & Bae, 2012; Spilsbury, Hewitt, Stirk, & Bowwan, 2011; Streak, 2011). Findings have ranged from "a proven association between higher total staffing levels (especially licensed staff) and improved quality of care" (Bostick et al., 2006, p. 366) to "no consistent evidence found for a positive relationship between staffing and quality of care" (Backaus et al., 2014, p. 383). This disparity is largely based on differing assessments of the scientific rigor of the studies reviewed (Castle, 2008a; Spilsbury et al., 2011).


Search strategy. Combinations of key terms were used including registered nurse, nursing home, quality, nursing skill mix, RN scope of practice, quality of life, quality of care, deficiency citations, nurse staffing, work environment, and Minimum Data Set (MDS). Research studies and literature published in English between 2008 and 2014 were searched. Advanced practice nurse was excluded as a key term because the focus of this review was on the relationship of RNs practicing in the roles of DON, charge nurse, supervisor, MDS RN coordinator, clinical RN, and NH quality. While there is evidence use of advanced practice nurses has been associated with improved quality (e.g., reduction in avoidable rehospitalizations from NHs to acute hospitals), the authors believe it is important to focus on the RN staff infrastructure that exists in the majority of NHs (Boyd et al., 2014).

Searches included several databases: Cochrane Library, CINAHL, Pubmed, PsychINFO, Ovid, Google Scholar, and grey literature (e.g., government websites, reports, and texts). A total of 16,000 references were identified through database searching. Thirty-one records were identified in the grey literature. Duplicate citations were removed; the remaining 1,300 citations were reviewed and crosschecked with references used in selected literature reviews/systematic reviews (e.g., Backaus et al., 2014; Castle, 2008a; Collier & Harrington, 2008; Spilsbury et al., 2011). Any study previously cited in a review was removed from the search list to avoid duplication in reporting study findings; 175 full abstracts were reviewed, of which 133 full articles were printed. Sixty-six full texts were removed for a range of reasons (e.g., tool development, not including and/or reporting RN staffing levels, RN sample size, the individual numbers of RN and LPN/LVNs included in "licensed nurses" as a study variable, or failure to report RN-specific findings). Sixty-seven studies remained and were included in the review. This process is shown in Figure 1.

Characteristics of studies reviewed. The 67 studies reviewed used various types of designs: cross-sectional (n=33), mixed methods (n=3), longitudinal (n=13), qualitative (n=10), descriptive (n-6), and cohort (n=2) designs. Nursing homes or aged-care facilities representing six nations were included: United States (n=60), Canada (n=4), United Kingdom (n=2), Germany (n=1), Norway (n=1), and Sweden (n=1). The unit of analysis used in studies included nursing home administrators, RN roles (DON, RN MDS coordinator, charge or supervisory RN, and clinical RN), residents, NHs, and observational units (e.g., surveys, quarterly MDS assessments). Sample sizes varied widely including ranges of NHs sampled (1 to 11,611), residents (1,376 to 692,875), nursing home administrators (419 to 2,900), RNs employed in various roles (16 to 1,048), observational units (4,476 to 148,900), and 50 RN and LPN/LVN state practice acts and scopes of practice. In comparison with previously published reviews, there was an increase in the number of studies reviewed that focused on the impact of state and federal policies on minimal nurse staffing standards and RN staffing (n=8); used longitudinal designs (n=13) and qualitative and mixed methods (n=12); included the work environment or organizational culture as variables (n=6); and non-U.S. NHs (n=5).

Variables and measures of quality indicators and work environment. Most variables and measures of quality indicators were similar to those used in earlier reviews as shown in Tables 29. They included structural and process quality indicators; resident and employee outcomes; case mix, facility, and market variables; and the impact of policy changes (e.g., changes in federal or state minimum staffing levels and reimbursement rates). In recent years, researchers have included variables measuring the work environment and safety culture as shown in Table 5.

Data sources. Data sources used were similar to those used in earlier literature reviews and systematic studies (a summary of reviewed studies is available from the authors upon request). They included the Area Resource Files fn=15), MDS data other than quality indicators or quality measures (n=13), On-line Survey Certification and Reporting [OSCAR] (n=33), primary data (e.g., surveys, focus groups, interviews, direct observation, field notes) (n=32), quality indicators or measures from Nursing Home Compare (n=10), Automated Certification and Licensing Administrative Information Management Systems (n=l), or other sources.


Conceptual frameworks. Conceptual frameworks used to provide support for hypothesized relationships among key concepts and constructs related to RNs and NH quality were diverse. Donabedian's quality framework (Donabedian, 1992), complexity theory (Corazzini et ah, 2014), and Castle and Engberg's (2008) conceptual model were used most frequently (see Table 1). These frameworks reflect the complexity of factors influencing subjective and objective definitions and measurement of NH quality. These include factors such as nurse staffing level, nurse skill mix, ownership (e.g., structural); perceptions of teamwork, mutual respect, and open communication (e.g., process); and prevalence of pressure ulcers, urinary tract infections, falls, and deficiency citations (e.g., outcomes).

Structural quality indicators. Structural indicators of quality are stable characteristics, such as nurse staffing levels, resident clinical conditions, and facility demographics, such as ownership and size. Structural measures used to study the association of RNs and quality in NHs varied, as shown in Table 2 (agency RNs, RN staffing hours, nursing skill mix, professional jurisdiction, and RN retention intrinsic and extrinsic factors). Some resident characteristics were measured using case mix or acuity measures as shown in Table 6. Measurements for facility characteristics are shown in Table 7.

Registered nurse staffing continued to be measured in a variety of ways, with RN hours per resident day being the most frequently used (19 studies). Castle and Engberg (2008) and Castle (2009) measured agency RN (see Table 2).

Nursing skill mix was measured in 11 different ways (see Table 2). The two most frequently used measures were "number of RNs" and the "ratio of RNs to the sum of LPNs/LVNs and NA staff."

Process quality indicators. Process quality indicators are used to measure how care, or nursing work, is performed to produce experiences for residents and NH staff. Care processes used will differ based on resident characteristics, acuity, length of stay, and types and numbers of nursing staff included in the nursing skill mix. Care processes may be of a technical and directly observable nature, or of an interpersonal nature that requires both qualitative and quantitative methods to measure comprehensively. Measurement of relationships between RNs and their team members, or RNs and resident relationships, despite their profound influence on residents' quality of care, are not as easily measured (McGilton et al., 2012; Spilsbury et al., 2011). Because of this, they were not frequently included in studies (see Table 3).

Outcome quality indicators. The most frequently used outcome measures were those contained in government databases, including deficiency citations of various types from the OSCAR database (n=18), long-stay (n=25) and short-stay (n=9) quality measures derived from MDS data, other MDS-derived measures (n=4), and incidence or prevalence of pressure ulcers (n=5). Employee outcomes measured included turnover (n=7), retention (n=6), and RN intention to leave (n=l), intention to stay (n=l), and job satisfaction (n=l). Other outcome measures were derived from primary data (data observed or collected directly) (n=5) or Medicare databases (n=5).

Other characteristics associated with NH quality. The relationship of RNs and NH quality is complex, in part because many other macro and micro-system level variables exert an influence (see Tables 5-9). Examples included case-mix characteristics of residents, some of which are mutable or immutable, facility-level factors, market characteristics, the impact of legislative changes in NH staffing levels, state Medicaid rates, Medicare reimbursement rates, and geographic locations of facilities.

Findings of the relationship between RNs and NH quality. In studies using quantitative methods, higher RN staffing was associated with better resident care quality where the following indicators were examined: fewer pressure ulcers, better quality measures, lower restraint use, decreased probability of hospitalization, fewer deficiency citations, decreased mortality, and decreased incidence of urinary tract infections. Higher RN staffing was associated with better employee outcomes where lower NA and RN turnover were examined.

In NHs having a higher RN ratio to other nursing staff, the higher professional skill mix was associated with lower restraint use, perceived risk of malpractice losses, fewer dually eligible Medicare beneficiaries discharged to SNFs, licensed nurses spending more time with residents, and NHs with high Medicaid census. Less DON turnover was positively associated with lower levels of education, higher job satisfaction, lower nursing staff turnover, and increased NH occupancy. As shown in Table 5 in studies that examined the relationship between a better work environment, care processes, and outcomes, the following indicators were used: lower pressure ulcer rate, lower restraint use, having an administrator with a consensus leadership style, higher hierarchical values held in the NH, lower intent to leave, higher job satisfaction, and NHs with higher capacity for RN jurisdiction. Findings reported from studies using qualitative methods described RNs as negatively influenced by unsupportive work environments, poor leadership, low levels of teamwork and clinical leadership, poor communication, difficult relationships between members of the nursing skill mix, and greater organizational emphasis on compliance rather than quality.

The impact of changes in reimbursement rates and minimum staffing requirements on RN staffing, skill mix, and care quality were mixed (see Table 9). For example, Mukamel, Kang, Collier, and Harrington (2012) found a positive impact of anticipated changes in reimbursement rates and RN staffing levels. In contrast, others found negative or insignificant impacts. For example, Feng, Grabowski, Intrator, Zinn, and Mor (2008) reported that changes in state Medicaid rates and case-mix reimbursement in 48 states were associated with decreased RN HPRD. In another study, Feng and colleagues (2010) found no wage pass-through effect for RN HPRD. Chen and Grabowski (2014) reported that, although fewer RNs were fired relative to NAs, no significant changes in quality measures (Medicare-defined measures of the quality of care), other than contractures, and a reduction in severe deficiencies with minimum staffing regulations in California and Ohio were found.


Prior reviews identified several limitations in the research literature, including concern about data quality and accuracy, lack of standardized measurements of variables, a need for larger sample sizes, greater use of mixed methods and longitudinal designs, greater focus on nursing skill mix, and employee outcomes. While issues remain about data quality and lack of standardization of measurements, this review shows progress has been made in increasing the number of studies using larger sample sizes, qualitative and mixed methods, longitudinal designs, and measurement of the work environment and safety culture.

Most of the studies included in this review consistently reported higher RN staffing and higher ratios of RNs in the nursing skill mix are related to better NH quality. The strongest evidence supporting a causal relationship between higher RN staffing levels, higher RN ratios within the nursing skill mix, and quality indicators is found in several longitudinal studies (Castle & Anderson, 2011; Castle, Wagner, Ferguson, & Handler, 2014; Castle, Wagner, Ferguson-Rome, Men, & Handler, 2011; Kim, Harrington, & Greene, 2009; Konetzka, Steams, & Park, 2008; Lin, 2014), and the cohort study findings of Spector, Limcangco, Williams, Rhodes, and Hurd (2013). Given that a controlled experiment on RN HPRD and outcomes is not feasible or ethical, alternative methods must be found to more rigorously determine the causality of the relationship between increased RN staffing and increased NH quality. For example, Lin (2014) used the method of instrumental variables to estimate a causal relationship between increased RN HPRD and quality. Instrumental variables are used to address measurement problems, including omitted variable bias, measurement error, simultaneity, or reverse causality (Staiger & Stock, 1997). Lin noted no significant relationships were found between the RN HPRD and quality outcomes when the more common ordinary least squares regression model was used.

Some study findings were unexpected, and provide evidence of the challenges gerontological nurse educators and leaders face in increasing the skills of RNs currently working in NHs. For example, Castle and Engberg (2008a, 2008b) found that increased use of agency RNs was associated with higher quality. They suggested the clinical skill level of the agency RNs may be higher than that of the regular RNs included in the study sample. Directors of nursing with higher levels of education have shorter tenure (Decker & Castle, 2009).

Taken together, these findings suggest RNs practicing in NHs may be less well prepared clinically. This is consistent with the fact most RNs and DONs practicing in NHs have only an associate's degree or diploma-level education (IOM, 2004). The need for DONs and more RNs practicing in NHs to have a baccalaureate education is clear (Siegel et al., 2012). While the potential is there for RNs to have a significant impact on the quality of NH care, the NH tends to be a less-attractive career choice than other practice settings to many RNs. The nature of the nursing skill mix used, and its implications for RN practice, may contribute to this.

Gerontological nurse leaders and educators are therefore challenged to find ways to serve as educational resources to NHs. Evidence-based best practices known to enhance NH RN staff competencies exist (Bourbonneiere & Strumpf, 2008). Promising programs include peer mentoring, training to develop DON'S coaching and person-centered management skills, better orientation programs, and advanced practice nurse consultant visits to NHs (McGilton et al., 2012).

However, given no federal requirement exists for RNs to have specialized education in gerontological nursing upon hire and throughout their NH employment, it is likely concerns about cost will restrict the NH industry from widely embracing such programs. As initially highlighted, NH care is expensive; second only to acute hospital care for inpatient Medicare costs (OIG, 2014). Therefore, concerns about the costs of employing more highly skilled RNs and DONs who have the potential to positively influence members of the nursing skill mix will continue to influence NH industry hiring practices. Findings from studies that measured the impact of minimum state staffing requirements and changes in Medicaid and reimbursement rates demonstrate this concept.

Future Research

Legislation has recently been passed that should greatly enhance the quality of CMS NH data often used by NH researchers. A provision in the recently signed Improving Post Acute Care Transformation Act of

2014 (IMPACT) has the potential to improve the accuracy of the reporting of muse staffing levels, skill mix, and turnover data in NHs significantly. CMS is to implement quarterly electronic reporting of NH staffing information by the end of fiscal year 2016 that is auditable (PHI, 2014).

Studies that build on the work of researchers who have used conceptual frameworks that mirror the complexity of the NH practice environment are recommended. Examples of these include the adaptive leadership framework derived from complexity theory (Corazzini et al., 2014), Castle and Engberg's framework (2008), and Donabedian's (1992) quality framework. For example, Corazzini and colleagues (2014) used complexity theory to describe how adaptive leadership and technical practices are needed in the increasingly complex and dynamic NH practice environment if greater NH quality is to be achieved. Adaptive leadership, an approach believed to foster work environments supportive of person-centered care, emphasizes flexibility, rather than rigidity, in providing care that is responsive to resident preferences and values. Adaptive leadership, based on complexity theory, is a promising framework to use for further research of clinical supervision that is person-centered. Finally, researchers need to increase the use of economic frameworks to study the benefits of increasing the number and qualifications of RNs working in NHs with respect to costs and quality.

Continued use of mixed methods to study RN NH work is recommended. This approach increases the ability to more fully understand the directly observable and unobservable cognitive work of the RN, members of the nursing skill mix (IOM, 2004), and their interactions with one another that likely differ as RN staffing levels and the composition of the nursing skill mix varies. For example, a mixed methods approach is ideal for better understanding the mechanisms by which RNs add value to the nursing skill mix and enhance the resident's NH experience.

Two important mechanisms are nursing surveillance, or patient monitoring and coaching/person-centered supervision and management. Surveillance is defined as the ongoing acquisition, interpretation, and synthesis of clinical data for clinical decision making (IOM, 2004). It is different from assessment; it is an intervention that occurs over time, rather than a single point in time. Framed another way, surveillance involves visible and invisible care activities of the RN, or any nursing staff (IOM, 2004). Resident surveillance is used in providing both direct (nursing assessment, physical care, administration of treatments, and psychological care) and indirect care (documentation, supervision, management, and other activities performed away from residents but on their behalf to coordinate and manage the care experience and environment) (Dellcfield, Harrington, & Kelly, 2012).

Given the likelihood the RN presence in NHs will continue to be relatively limited, and most care will be provided by paraprofessionals, greater understanding of how nursing care delivery systems may increase their surveillance capacity is recommended. This is an urgent need given poor resident monitoring was cited as one of the three practices responsible for the preventable adverse events studied in the 2014 OIG report on Medicare beneficiaries.


Conducting research on the relationship of RNs and NH quality must continue, in spite of the persistent methodological challenges presented to researchers. For both the advancement of nursing as an applied science and the benefit of society at large, nursing researchers are challenged to better demonstrate how the increased presence of a registered nurse on each shift has the potential to enhance the cost effectiveness, efficiency, and quality of nursing homes. Nurse faculty and leaders are challenged to find ways that help nursing students recognize RN practice in a NH as complex, challenging, and a setting in which NH residents will benefit on both an individual and system level from their presence.


Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223-229.

American Health Care Association. (2014). Trends in nursing facility characteristics. Washington, DC: Author.

American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: American Nurses Association.

Anderson, R.A., & McDaniel, R.R. (1992). The implication of environmental turbulence for nursing-unit design in effective nursing homes. Nursing Economics, 10(2), 117-125.

Anderson, R.A., & McDaniel, R.R. (1998). Intensity of registered nurse participation in nursing home decision making. The Gerontologist, 38, 90-100.

Anderson, R.A., & McDaniel, R.R. (1999). RN participation in organizational decision making and improvements in resident outcomes. Health Care Management Review, 24, 7-16.

Backhaus, R., Verbeek, H., van Rossum, E., Capezuti, E., & Hamers, J.P.H. (2014). Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies, journal of the American Medical Directors Association, 15(6), 383-393.

Bourbonniere, M., & Strumpf, N.E. (2008). Enhancing geriatric nursing competencies for RNs in nursing homes. Research in Gerontological Nursing, 1(3), 171-175.

Burger, S.G., Kantor, B., Mezey, M., Mitty, E., Kluger, M., Algase, D., ... Rader,). (2009). Nurses involvement in nursing home culture change: Overcoming barriers, advancing opportunities. New York, NY: Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Bostick, J.E., Rantz, M.J., Flesner, M.K., & Riggs, C.J. (2006). Systematic review of studies of staffing and quality in nursing homes. The Journal of the American Medical Association, 7(6), 366-376.

Boyd, M., Armstrong, D., Parker, J., Pilcher, C., Zhou, L., McKenzie-Green, B., & Connolly, M.J. (2014). Do geronotology nurse specialists make a difference in hospitalization of long-term care residents? Results of a randomized comparison trial, journal of the American Geriatrics Society, 62(10), 1962-1967.

Bryan, S., Murphy, J.M., Doyle-Waters, M.M., Kuramoto, L., Ayas N., Baumbusch, J., ... McGregor, M.J. (2010) . A systematic review of research evidence on: (a) 24-hour registered nurse availability in long-term care, and (b) the relationship between nurse staffing and quality in long-term care. Vancouver, Canada: University of British Columbia.

Castle, N.G. (2008a). Nursing home caregiver staffing levels and quality of care: A literature review. Journal of Applied Gerontology, 27(4), 375-405.

Castle, N.G. (2008b). State differences and facility differences in nursing home staff turnover. Journal of Applied Gerontology, 27(5), 609-630.

Castle, N.G. (2009). Use of agency staff in nursing homes. Research in Genontological Nursing, 2(3), 192-201.

Castle, N.G., & Anderson, R.A. (2011). Caregiver staffing in nursing homes and their influence on quality of care: using dynamic panel estimation methods. Medical Care, 49(6), 545-552.

Castle, N.G., & Engberg, J. (2008). Further examination of the influence of caregiver staffing levels on nursing home quality. The Gerontologist, 48(4), 464-476.

Castle, N., Wagner, L., Ferguson, J., & Handler, S. (2014). Hand hygiene deficiency citations in nursing homes. Journal of Applied Gerontology, 33(1), 24-50.

Castle, N.G., Wagner, L.M., Ferguson-Rome, J., Men, A., & Handler, S.M. (2011) . Nursing home deficiency citations for infection control. American Journal of Infection Control, 39(40), 263-269.

Castle, N.G., & Engberg, J.B. (2008). The influence of agency staffing on quality of care in nursing homes. Journal of Aging & Social Policy, 20(4), 437-457.

Centers for Medicare & Medicaid Services (CMS). (2013). Resident assessment instrument version 3.0 manual. Washington, DC: U.S. Government Printing Office.

Chen, M.M., & Grabowski, D.C. (2014). Intended and unintended consequences of minimum staffing standards for nursing homes. Health Economics. [Epub ahead of print] doi: 10.1002/hec.3063.

Collier, E., & Harrington, C. (2008). Staffing characteristics, turnover rates, and quality of resident care in nursing facilities. Research in Genontological Nursing, 3(3), 157-170.

Corazzini, K., Twersky, J., White, H.K., Buhr, G.T., McConnell, E.S., Weiner, M., & Colon-Emeric, C.S. (2014). Implementing culture change in nursing homes: An adaptive leadership framework. The Gerontologist. [Epub ahead of print]

Decker, F.J., & Castle, N.G. (2009). The relationship of education level to the job tenure of nursing home administrators and directors of nursing. Health Care management Review, 34(2), 152-160

Dellefield, M.E., Harrington, C., & Kelly A. (2012). Observing how RNs use clinical time in a nursing home: A pilot study. Geriatric Nursing, 33(4), 256-263.

Donabedian, A. (1992). Quality assurance. Structure, process and outcome. Nursing Standard, 7(11 Suppl.), 4-5.

Dongjuan, M., Kane R.L., & Shamliyan, T.A. (2013). Effect of nursing home characteristics on residents' quality of life: A systematic review. Archives of Gerontology and Geriatrics, 57, 127-142.

Feng, Z., Grabowski, D.C., Intrator, O., Zin,n J., & Mor, V. (2008). Medicaid payment rates, case-mix reimbursement, and nursing home staffing 1996-2004. Medical Care, 46(10), 33-40.

Feng, Z., Lee, Y.S., Kuo, S., Intrator, O., Foster, A., & Mor, V. (2010). Do Medicaid wage pass-through payments increase nursing home staffing. Health Services Research, 43(3), 728-746.

Harrington, C., Kovner, D., Mezey, M., Kayser-Jones, J., Burger, S., Mohler, M., ... Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the United States. Gerontologist, 40(1), 5-16.

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(2), 116-127.

Hirdes, J.P, Mitchell, L., Maxwell, C.J., & White, N. (2011). Beyond the 'iron lungs of gerontology': Using evidence to shape the future of nursing homes in Canada. Canadian Journal of Aging, 30(3), 371-390.

Hodgkinson, B., Haesler, E.J., Nay, R., O'Donnell, M.H., & McAuliffe, L.P. (2011). Effectiveness of staffing models in residential, subactue, extended aged care settings on patient and staff outcomes. The Cochrane Database of Systematic Reviews, (6): CD006563. doi:10.1002/ 2

Institute of Medicine (IOM). (1986). Improving the quality of care in nursing homes. Washington, DC: National Academies Press.

Institute of Medicine, Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes (IOM). (1996). Nursing staff in hospitals and nursing homes: Is it adequate? Washington, DC: National Academies Press.

Institute of Medicine (IOM). (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press.

Kim, H., Harrington, C., & Greene, W.H. (2009). Registered nurse staffing mix and quality of care in nursing homes: A longitudinal analysis. The Gerontologist, 49(10), 81-90.

Konetzka, R.T., Stearns, S.C., & Park, J. (2008). The staffing-outcomes relationship in nursing homes. Health Services Research, 43(3), 1025-1042.

Lin, H. (2014). Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach. Journal of Health Economics, 37, 13-14.

McGilton, K.S. Heath, H., Chu, C.H. Bostrom, A.M., Mueller, C., Boscart, V.M., ... Bowers, B. (2012). Moving the agenda forward: A person-centered framework in long-term care. International Journal of Older People Nursing, 7(4), 303-309.

Mukamel, D.B., Kang, T., Collier, E., & Harrington, C. (2012). The relationship of California's Medicaid reimbursement system to nurse staffing levels. Medical Care, 50(10), 836-842.

Office of the Inspector General (OIG). (2014). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries. Washington, DC: Department of Health and Human Services.

PHI. (2014). About. Retrieved from nursing-homes

Rahman, M., Grabowski, D.C., Gozalo, P.L., Thomas, K.S., & Mor, V. (2014). Are dual eligible admitted to poorer quality skilled nursing facilities? Health Services Research, 49(3), 798-815.

Shin, J.H., & Bae, S-H. (2012). Nursing staffing, quality of care, and quality of life in US nursing homes 1996-2011: An integrative review. Journal of Gerontological Nursing, 38(12), 46-53.

Siegel, E.O., Anderson, R., Calkin, J., Chu C., Corrazini K., Dellefield M.E., & Goodman, C. (2012). Supporting and promoting personhood in long term care settings: Contextual factors. International Journal of Older People Nursing, 7(4), 295-302.

Spector, W.D., Limcangco, R., Williams, C., Rhodes, W., & Hurd, D. (2013). Potentially avoidable hospitalizations for elderly long-stay residents in nursing homes. Medical Care, 51(8), 673-681.

Spilsbury, K., Hewitt, C., Stirk, L., & Bowman, C. (2011). The relationship between nurse staffing and quality of care in nursing homes: A systematic review. International Journal of Nursing Studies, 48, 732-750.

Staiger, D., & Stock, J.H. (1997). Instrumental variables regression with weak instruments. Econometrica, 65(3), 557-586.

Streak, J. (2011). Staffing models in aged care: A systematic review. Adelaide, Australia: Joanna Briggs Institute.

Toles, M., & Anderson, R.A. (2011). State of the science: Relationship-oriented management practices in nursing homes. Nursing Outlook, 59, 221-227.

Welton, J. (2007). Mandatory hospital nurse to patient staffing ratios: Time to take a different approach. Online Journal of Issues in Nursing, 12. Retrieved from http://www.nursing dicals/OJIN/TableofContents/Volumel22007/ No3Sept07/MandatoryNursetoPatientRatios.html

MARY ELLEN DELLEFIELD, PhD, RN, is Research Nurse Scientist, VA San Diego Healthcare System (VASDHS), San Diego, CA.

NICKOLAS G. CASTLE, PhD, MHA, is Professor, Department of Health Policy & Management, University of Pittsburgh, Pittsburgh, PA.

KATHERINE S. McGILTON, PhD, RN, is Associate Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.

KAREN SPILSBURY, PhD, RN, is Professor, Department of Health Sciences, University of York, Heslington, York, United Kingdom.

NOTE; The views expressed in this article are those of the authors, and not necessarily those of the Veterans Health Administration.

Table 1.
Summary of Conceptual Frameworks/Models Used in Reviewed
Studies of the Relationship of RNs and NH Quality

                                                        Number of
Framework/Model                                          Studies

Castle and Engberg Staffing Framework                       2

Competing Values Framework                                  1

Complexity Theory/Science/Complex Adaptive Systems          4

Donabedian's Quality Framework                              7

Flerzberg, Mausner, Snyderman Concepts of Intrinsic         1
Motivation, Self-Growth, Job Satisfaction

High-Reliability Organizations (Mindfulness)                1

McGilton, Bowers, Boscart Model of Intention to Stay        1
among Nurses in Long-Term Care Work Environment

Nursing Organization and Outcomes Model                     2

Organizational Culture (Safety Culture)                     2

Professional Jurisdiction                                   1

Random Utility Maximization Model                           1

Resource-Based Organizational Theory                        1

Standard Economics Model                                    2

Stressors and Workplace Support Model of Turnover           1

Theory of Chain Growth                                      1

Theory of Planned Behavior                                  1

Turnover Theories                                           2

Table 2.
Summary of Structural Quality Indicators Used in Reviewed Studies of
the Relationship of RNs and NH Quality

                                                             Number of
Variable                  Specific Measure                    Studies

Agency RNs      Agency registered nurses (RNs) as                2
                percentage of all RNs all facilities or
                only facilities using agency staff

                Full-time equivalent (FTE) agency                1
                RNs/100 beds

                RN agency (number RNs used in past year          1
                as percent of regular staff)

                RN agency staff                                  1

RN Staffing     RN hours per resident day (HPRD)                19
                FTE RNs/100 residents                            6

                FTE RNs/resident                                 3

                FTE RNs                                          3

                RN daily hours/bed                               2

                RN HPRD = RNs + directors of nursing             1

                RN productive hours (full and part-time,         1

                RN hours/resident                                1

Nursing Skill   FTE RNs/total nurses                             1
                Licensed staff (RN + licensed practical          1
                nurse [LPN]) as percent of total nursing

                Percent RNs of total nursing staff               1

                RN FTEs/LPNs + nursing assistants (NAs)          1
                full-time, part-time, and temporary

                RN FTEs/RN + LPN + NA FTEs                       1

                FTE RNs full time in permanent                   1
                positions/total number of workers
                (including unfilled positions)

                RN/LPNs + NAs                                    5

                Number RNs                                       4

                Percent RNs                                      1

                RN staffing hours as proportion of total         3
                staffing hours

                RN HPRD/LPN HPRD                                 1

Professional    DON prepared at BSN level; other RNs in          1
Jurisdiction    facility prepared at BSN level; specialty
                certification of DON; specialty
                certification of other RNs in facility;
                RNs in facility have graduate degree;
                presence of APNs in facility; proportion
                of nursing staff that are RNs

RN Retention    Flexible scheduling, paid personal day,          1
Extrinsic       retirement, paid sick days, health
Factors         insurance, Alzheimer's unit, parenteral
                nutrition services, nursing HPRD,
                administrator tenure in months, DON
                tenure in months, RN wage ratio

RN Retention    Recognition, conference money, attendance        1
Intrinsic       awards, career ladder, tuition money,
Factors         career development

Table 3.
Summary of Process Quality Indicators Used in Reviewed Studies of the
Relationship of RNs and NH Quality

                                                             Number of
Variable                     Specific Measure                 Studies

Antipsychotic   Percent of residents receiving                   2
Drug Use        antipsychotic drugs

Consistent      Same caregivers consistently caring for          2
Assignment      the same resident almost every time they
                are on duty

Leadership      Four-item Nurse Manager Ability,                 1
Relationships   Leadership, and Support of Nurses
                subscale of the Revised Nursing Work
                Index (NWI-R)

Long-Stay       Percentage of;
Measures        Residents with increased need for help           1
                with daily activities

                Residents with physical restraint use            2

                Residents who had a catheter inserted and        5
                left in bladder

RN Care         Average RN direct care time/resident day         7
                Percent of RN time engaged in specific           1
                type of care activity

Resident        Six-item support relations subscale of           2
Relationships   Person-Directed Care Scale (PDCS)

Work            Work Group Cohesion Scale                        1
                Work Group Identification Scale (WGIS)           1

Table 4.
Summary of Outcome Quality Indicators Used in Reviewed Studies of the
Relationship of RNs and NH Quality

                                                             Number of
Variable                            Specific Measure          Studies

All-Cause Mortality and       Resident mortality/                1
Hospitalization               hospitalization occurred
                              during outbreak period
                              compared with non-outbreak
                              period of reported
                              norovirus in nursing homes

Burnout                       Nine-item emotional                1
                              exhaustion subscale of
                              Maslach Burnout Inventory

Contractures                  Percent of residents with          1

Deficiency Citations          Health deficiencies found          1
                              during the inspection; 100
                              per resident

                              Life and safety                    1
                              deficiencies found during
                              the inspection; 100 per

                              Quality of care                    1

                              Sum of numeric scores for          1
                              each deficiency

                              Total deficiencies found           1
                              during the inspection; 100
                              per resident

Deficiency Citation for       F-Tag 444 (staff hand              1
Hand Hygiene                  washing after direct
                              resident contact)

Deficiency Citation for       F-Tag 441 (the facility            1
Infection Control             must establish and maintain
                              an infection control
                              program designed to provide
                              a safe, sanitary, and
                              comfortable environment and
                              to help prevent the
                              development and
                              transmission of disease and

Deficiency Citations for      F-Tag F221 and F323                1
Physical Restrains and        combined
Restrictive Side Rails

Hospitalization Risk          Ambulatory care-sensitive          1
                              conditions (ACSCs);
                              additional NH-sensitive
                              avoidable conditions
                              (ANHACs); NH "unavoidable"
                              conditions (NHUCs)

Incontinence                  Proportion of residents            1
                              with incontinence without
                              toileting plan

Intention to Leave            DON intention to leave (12         1
                              and 24 months)

Intention to Stay             Self-report of likelihood          1
                              of staying at facility for
                              next 5 years

Job Satisfaction              Job Satisfaction Scale             1

Leadership Style              Jerrel-Slevin management           1

Long-Stay Quality Measures    Percentage of:

                              High-risk residents with           4
                              pressure ulcers

                              Low-risk residents with            3
                              pressure ulcers

                              Low-risk residents with            2
                              loss of bladder or bowel

                              Residents who spent most of        3
                              their time in bed or in a

                              Residents with urinary             4
                              tract infection

                              Residents with                     4
                              moderate-to-severe pain

                              Residents more anxious and         2

                              Residents with decreasing          3
                              ability to move in/around

                              Average number of                  1
                              complaints per nursing home
                              per quarter

                              Number complaints from             1
                              division of health service

Malpractice Paid Losses       Malpractice paid losses or         1
                              no malpractice paid losses

Nursing Home Complaints       Number of complaints in            1
                              North Carolina

Pressure Sores                Number of residents with           1
                              pressure sore within last
                              14 days

                              Percent of residents with          2
                              pressure sores

                              Incidence of pressure sores        2

Quality of Life               Section F Minimum Data Set         2

                              Six domains: environment,          1
                              personal attention, food
                              enjoyment, engagement,
                              negative mood, positive

Reason for Discharge          Percentage of residents            2
Comparing Hospitalization     hospitalized, recovered/
or Nonhospitalization         stabilized died in nursing
Prior to Nursing Home         home, discharged to another
Admission                     long-term care setting, or
                              other setting

RN Satisfaction               Nine-item scale (Aiken,            1
                              Clarke, Sloane, Lake, &
                              Cheney, 2008)

RN Retention                  RN staff employed during           1
                              the period, not including
                              DON or agency

                              Total number RNs employed          1
                              over 10-month period 2010

                              Mean tenure of DON                 1

Serious Deficiencies          G or higher level of               4

Short-Stay Quality            Percentage of residents            2
Measures                      with delirium

                              Percentage who had                 2
                              moderate-to-severe pain

                              Percentage with pressure           2

                              Lost too much weight               3
                              malpractice claims

Threat of Litigation          Lagged 2-year moving               1
                              average of the
                              county-level number of
                              total deficiency citations

Total Defiency Citations                                         6

RN Turnover                   Administrator self-report          1
                              of RN turnover

                              Administrator self-report          1
                              of voluntary and
                              involuntary turnover
                              (percent RNs leaving
                              nursing home within 6 and
                              12 months)

                              Percent FTE RN turnover in         1
                              2007; staff who left
                              employment during past
                              quarter/total number

                              Percent FTE RN turnover in         1
                              past quarter; (total number
                              of RN turnover (departure
                              for 1 year as percentage of
                              total nursing positions)

                              Administrator self-report          1
                              of percent RNs employed
                              more than 1 year

                              Number of regulated nurses         1
                              who terminated employment
                              over the past 12 months/
                              total number of nurse FTEs

                              RN stability (percent RNs          1
                              who worked 5 years or more)

Urinary Tract Infection       Urinary tract infection            1
                              within last 30 days

Workplace Injuries            Lost days away from work           1
                              (including cases away from
                              work and cases with only
                              restricted work activity)

Table 5.
Summary of Contextual Characteristics Used in Reviewed Studies of the
Relationship of RNs and NH Quality
                                                             Number of
Variable                           Specific Measure           Studies

Competing Values Measure    Competing Values Framework           1
                            question related to group
                            culture, developmental
                            culture, market culture,
                            hierarchical culture

Nursing Home Work           Staff cohesion; self-managed         1
Environment                 teams; formal teams;
                            consistent assignment

Perceived Patient Safety    Average percent positive             2
Culture                     score for the 12 domains of
                            the Nursing Home Survey on
                            Patient Safety Culture

Practice Environment        Practice Environment Scale of        2
                            the Nursing Work Index

Table 6.
Summary of Case Mix/Resident Acuity Characteristics Used in Reviewed
Studies of the Relationship of RNs and NH Quality

                                                             Number of
Variable                          Specific Measure            Studies

Acuity Index               OSCAR data for a range of ADL         2
                           dependencies and special
                           treatment measures for all

Average Score for Three    Give score of 1 for low need          4
ADLs                       for assistance with ADLs, 2
                           for moderate assistance, and 3
                           for high need for assistance
                           with ADLs

Case Mix                   Average ADL dependency score          1
                           of residents in three ADLs
                           (eating toileting,
                           transferring to and from bed)
                           and percent of new cognitively
                           impaired residents

                           Number of residents in the            1
                           nursing home who can perform
                           ADLs independently

                           High ADL dependence                   1

                           ADL index, special care index,        1
                           percent residents on admission
                           having pressure ulcer, and
                           contractures; percent
                           depressed with psychiatric
                           diagnosis and dementia

                           Late loss ADLs and Cognitive          1
                           Performance Scale

                           Composite of ADLs and average         1
                           Texas Index of Level of Effort

                           CMS composite score based on          1
                           all residents

                           Resource utilization group            1
                           (RUG) classifications
                           converted to numbers; 23
                           categories with each group
                           used as a control variable

                           Percent of residents with             1
                           pressure sores, contractures,
                           and restraints on admission

                           Physical case mix (ACUINDEX           1
                           and percent of residents who
                           are bed and chair bound) +
                           mental health case mix
                           (percent of residents with
                           dementia, depression,
                           psychiatric illness other than
                           dementia, and developmental

Cowles Acuity Index        Staffing HPRD/ACUINDEX [The           4
                           weighted sum of proportion of
                           residents with need for
                           special treatment (STINDEX)
                           and dependencies in ADLs

Level of ADL Dependence    High ADL dependence for a             1
                           resident needing assistance
                           with all three ADLs (bathing,
                           dressing, eating) or required
                           assistance transferring in and
                           out of chair

Limited ADL Index          Proportion of residents with          1
                           ADL limitations in four areas
                           (toileting, transferring,
                           incontinence, eating)

Measure of Resident Need   Percent Medicare residents/           1
                           total residents + number of
                           medications and catheters/
                           resident + number of pressure
                           ulcers + ADL needs/resident

                           Number of residents with              1
                           limitations in ADLs

RUGS III                   RUGs case mix index derived           1
                           from Minimum State Set data

Resident Acuity            Weighted sum of ADL index and         1
                           special treatment index

                           Percent residents with                1
                           limitations in ADLs and
                           percent receiving

Resident Care Needs        Facility average case mix             1

No Case Mix Reported in                                         30
Studies Using Mix of
Quantitative Methods

Table 7.
Summary of Facility Characteristics Used in Reviewed Studies of
the Relationship of RNs and NH Quality

                                                       Number of
Variable                                                Studies

Average Census                                             3
Average Length of Stay                                     2
Facility Size                                              2
  Large = more than 150 beds; medium = 50-150 beds;
  small = less than 50 beds
Gender/Ethnicity of Residents
  Percent residents who are male                           1
  Percent residents who are Black                          2
  Percent residents who are Hispanic                       1
Location in Hospital                                       6
Medicaid Reimbursement Rate                               16
Medicaid Bed Hold Policy                                   1
Medicare Reimbursement Rate                                1
Membership in Chain                                       29
Occupancy Rate                                            22
  For-profit, not-for-profit, governmental                39
Ownership Change                                           1
Private Paid Days                                          1
Payer Mix
  Percent Medicare residents                              21
  Percent Medicaid residents                              30
  Percent private pay                                     12
  Medicare paid days                                       1
  Medicaid paid days                                       1
Presence Nurse Practitioner/Physician Assistant            3
Rural Location                                             1
Specialty Unit/Program                                     5
Total Beds                                                30
Urban Location                                             5

Table 8.
Summary of Market Characteristics Used in Reviewed Studies of the
Relationship of RNs and NH Quality

                                                             Number of
Variable                         Specific Measure             Studies

Market                   Average income (log)                    1

                         Average per capita income              10

                         Competitiveness of RN wage              1

                         County unemployment rate                5

                         Percent poor in market                  2

                         Female employment rate                  3

                         Hospital wage index                     6

                         Herfindahl-Hirschman Index             15

                         Medicare managed care                   3
                         penetration rate

                         Weekly wages                            1

Bed Supply               Number of nursing homes in              4

                         Average number of empty beds in         9

                         Number of nursing home                  2
                         beds/1,000 elderly

                         Excess nursing home beds                1

Elderly Population       Number of elderly in county             4

                         Population aged 85 years and            3

                         Size of senior population (log)         1

                         Population density                      2

Healthcare Workforce     Physicians per 1,000 persons 65         1
                         years and older

Number of RNs in 1,000                                           1

Table 9.
Summary of Policy Change Characteristics Used in Reviewed Studies of the
Relationship of RNs and NH Quality

                                                             Number of
Variable                            Specific Measure          Studies

Impact of California          Medicaid payment rate in           1
Medicaid Reimbursement for    2008 calculated by state
Nursing Homes                 for each facility

State Medicaid Wage           Medicaid wage pass-through         1
Pass-Through                  to nursing homes variable
                              with baseline:
                              pre-adoption; year of
                              adoption; first year after
                              adoption (with policy still
                              in effect); second or
                              subsequent years after
                              adoption (with policy still
                              in effect); and policy

Medicaid Nursing Home         Annual state-average               1
Reimbursement                 Medicaid per diem rate,
                              inflation-adjusted to 2004

                              Use of case-mix payment            1
                              system in a given state and
                              year California law
                              specifying minimum nurse
                              staffing requirements

Minimum Staffing Standards    California law specifying          2
                              minimum nurse staffing
                              requirements As total
                              direct-care hours with same
                              weight to RN, LPN, and
                              certified nursing assistant
                              (CNA) hours

                              Ohio law specifying minimum        1
                              nurse staffing requirements
                              as total direct-care hours
                              with same weight to RN,
                              LPN, and CNA hours

                              Changes made between 1998          1
                              and 2001 in 16 states to
                              implement or expand
                              staffing standards in
                              excess of federal
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Author:Dellefield, Mary Ellen; Castle, Nickolas G.; McGilton, Katherine S.; Spilsbury, Karen
Publication:Nursing Economics
Geographic Code:1USA
Date:Mar 1, 2015
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