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Home > Administrator > Office of Ombudsman > Federal Study on Nurse Staffing

Federal Study on Nurse Staffing in Nursing Facilities

Background: The Centers for Medicare and Medicaid Services (CMS), overseen by the Secretary of Health and Human Services, currently requires that each nursing facility provide 8 hours of care by a registered nurse and 24 hours of coverage by a licensed nurse per day. This regulation is the same for all nursing homes – regardless of the size of the facility or the number of residents it serves. For over a decade, Congress has asked the Secretary of Health and Human Services to report on establishing minimum caregiver to resident ratios and supervisor to caregiver ratios. Phase I of a report on nurse staffing ratios in nursing homes was released in July of 2000; Phase II was presented to Congress in March of 2002.

Purpose: This two-part federal study was designed to determine if nurse staffing ratios are appropriate and, if appropriate, to examine the cost and feasibility of minimum ratio requirements. Researchers were charged with seeking ratios to attain good or optimal quality outcomes as opposed to bad outcomes. In the first phase of the study, it was concluded that there are critical ratios of nurses to residents below which nursing home residents are at increased risk for quality problems. In the second phase of the study, researchers replicated the prior analyses with newer and better quality data, through focus groups, surveys and interviews at over 5,000 facilities in 10 states.

Key Finding: The Phase II Report, released in March of 2002, identified 4.08 hours of nursing care per resident per day as the threshold necessary to "improve outcomes and avoid selected problems" in long-term care residents. The total of 4.08 hours includes 2.78 hours per day of care by nursing assistants for each resident and 1.3 hours per day by licensed staff (including .75 from an R.N.) for each resident. It was noted that after these staffing thresholds are met, further increases in staffing would not be expected to add to quality.

The measures used by researchers to examine quality for long-stay residents involved five changes in health or behavioral status often cited in the scientific literature as related to staffing. Those measures included: activities of daily living (e.g., eating, dressing, toileting, bathing, walking etc); pressure ulcers; skin trauma (e.g., bruises, burns, cuts, skin tears); weight loss; and, resistance to assistance with activities of daily living.

Related Findings: In addition to increasing numbers of staff, retaining staff was identified as a critical factor in enhancing quality. High turnover/low retention was found to negatively affect quality of care for several reasons:

• familiarity with the resident and his/her needs is lessened
• continuity of care is compromised and vulnerable residents who do not cope well with change may decline
• turnover breeds additional turnover as staff feel overworked and lose morale.

Recruitment/Retention Efforts: Management practices and training for nursing staff provide opportunities to improve staffing. Specific suggestions include:

• Management: Positive management practices are associated with improved retention. According to researchers, best practices include:
• Clear and fair guidelines for staff
• Resources to allow easy implementation of standards
• Consistent follow-up and enforcement of standards by supervisors
• A culture which stresses respect and value of caregivers
• Willingness to delegate responsibility and hold staff and managers accountable
• Interest in spending time on the floor.

• Training: A commitment to ongoing training was identified as a critical factor in both recruiting and retaining staff. Points of consideration:
• More than 75 hours of training is necessary to give students time to absorb material covered in the classroom and increase clinical training
• Soft-skills such as communication, problem-solving, and cultural sensitivity must be added to curriculum requirements
• Career ladders, peer mentors, and support systems enhance the professionalism of nurses and provide opportunities for growth
• Linkages with community colleges, private schools, and other community-based trainers help ensure smooth transitions between classroom lessons and application to the nursing home.

Cost: The increased demand for nurses resulting from implementation of minimum staffing ratios would necessitate compensation increases between 2.5% and 7% for R.N.’s and between 10% and 22% (e.g. 86 cents to $1.89 per hour) for nurse aides. While acknowledging that these increases are substantial, the federal report nevertheless suggests "they are not so high as to preclude the possibility of implementing thresholds."

Next Steps: Two areas were identified by the federal staffing study as leading to improvement in nurse staffing – developing a reliable public reporting system of nurse staffing information and completing an analysis of costs/benefits associates with higher staffing. Effective January 1, 2003 all nursing home facilities will be required to post "in a clearly visible place" the number of nursing staff available on each shift.

Related Studies: The positive relationship between nurse staffing and quality of nursing home care has been identified in studies by the Institute of Medicine in 1996 and 2001 and in a report to the U. S. Health Care Financing Administration by Dr. Charlene Harrington of the University of California, San Francisco in 2000.

Minnesota Staffing Patterns

Background: Minnesota requires 2 hours of nursing care per resident per day – less than half of the 4.08 standard recommended in the federal study – and less than the 3.9 hours per resident per day currently reported as actual practice across the country. A review of January 2003 data from the Centers for Medicare and Medicaid shows that the state of Minnesota is in the bottom eight per cent of states in the average number of hours of nursing care provided per resident per day:

The 2001 Minnesota legislature mandated that a time study be conducted to determine whether staffing patterns are adequate for "providing quality care based on professional best practice and consumer experience." That study, originally mandated for completion by January 15, 2003, is now anticipated on January 15, 2004.

Review of Staffing Data: In partial fulfillment of requirements for a M.S. degree from Minnesota State University, Mankato, Jennifer Preus compared Minnesota averages to federal recommendations in the summer of 2002. Using the Nursing Home Compare website as a tool, charts were created presenting information for each Minnesota nursing facility. Each home was identified as a Boarding Care Home, Nursing Home Connected to a Hospital, or a Stand-Alone Nursing Facility, permitting analysis according to type of home.

When comparing ratios of individual Minnesota facilities with the ratios suggested by the federal staffing study, Ms. Preus reported that ninety-two percent of Minnesota facilities fell below recommended levels while eight percent of Minnesota facilities were found to staff at or above recommended levels.

Ombudsman Follow-Up: With the implementation of the federal requirement that nursing facilities post staffing information beginning on January 1, 2003, ombudsmen staff and volunteers will:

The State Ombudsman will participate in the advisory committee charged with overseeing the development of the time study report to the legislature due on January 15, 2004 referenced in the background section.

Tips for Consumers: The National Citizens’ Coalition for Nursing Home Reform Guide for Residents, Families and Caregivers suggests that families "trust your senses" of smell, taste, touch, hearing and sight to get a read on whether a facility has enough staff to provide quality care.

Questions to consider include:

1. Does the staff respond promptly to call lights or calls for help?
2. Are residents taken to the toilet when they ask or want to go?
3. Have staff worked at the facility long enough to call residents by name?
4. Are residents helped and encouraged to drink at mealtimes? Are they offered something to drink between mealtimes?
5. Are residents up and dressed and groomed every day?
6. Does the home look and smell clean?
7. Do staff spend time talking with residents?
8. Have the Administrator and Director of Nursing been at the facility for over a year?
9. Do residents seem relaxed and generally content?
10. Do nursing assistants
    1. Feel they have enough time to provide good care?
    2. Say they have a licensed nurse available to help when needed?
    3. Feel they have a choice about working overtime?