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The Clinical and Business Case for Improving Nurse Staffing in Long-Term Care
Dr. Eliopoulos is executive director, American Association for Long Term Care Nursing, Cincinnati, OH.
Those who have worked in long-term care settings over the past decade can attest to the fact that there has been an increase in the acuity and care needs of residents. Residents often have multiple conditions that require regular assessment to evaluate their status and identify changes. The treatments that are provided are more complex than ever and demand close monitoring for effectiveness and the presence of adverse reactions. The level of resident dependency in activities of daily living has increased to 4.1.1 The diversity of the resident population adds a new layer of challenges to assure care is individualized and appropriate. These are among the factors that create demands for greater numbers of nurses on staff. The average daily hours of nursing care provided per resident is 3.67 hours.2 Not only do many nurses working in nursing homes understand this to be insufficient to meet residents’ needs, but it falls below the average of 4.1 hours of direct nursing care per day that was deemed necessary to assure basic resident safety in a study by the Centers for Medicare & Medicaid Services more than a decade ago.3 Many directors of nursing (DONs) report that decisions affecting their staffing levels are made by persons in corporate offices, who are removed from bedside care, and often without consideration to the hours of care actually required by the current resident population.
The experience of the American Association for Long Term Care Nursing (AALTCN) has been that many DONs who are engaged in the Association’s DON certification program do not understand how to determine the hours of staffing required based on residents’ needs, nor are they involved in presenting staffing needs based on the actual hours of daily required care per resident when budgets are being developed. Not only are the current daily hours of nursing care insufficient to meet the growing demands of residents in most nursing homes, but the level of nursing staff is also inadequate. Only 10% of the nursing staff in nursing homes is comprised of registered nurses. Staffing of registered nurses averages 30 to 38 minutes per resident throughout a 24-hour period, which amounts to less than 2 minutes per hour, and it should be kept in mind that the reported registered nurse time includes nurses in administrative positions, not just those involved with direct resident contact.
Current regulations do not require a register nurse to be present at all times, however, according to licensure laws, the registered nurse is the only member of the nursing staff who can assess residents. With the high acuity and instability of many nursing home residents, regular assessment of residents’ conditions is required and can be needed any time during a 24-hour period. If a registered nurse is not present, the result is that either licensed practical/vocational nurses are forced to function outside their legal scope of practice by performing an assessment or residents are transferred to the hospital to have their conditions assessed.
The Consequences of Insufficient Staffing
There are risks and costs associated with insufficient hours of daily care and the lack of a 24-hour registerd nurse present in a nursing home:
• Poor outcomes. The lack of sufficient nursing staff to observe residents, complete tasks, identify personal needs and risks, and provide individualized care can result in a low quality of care, more complications, resident dissatisfaction, and poor survey results.4
• More rehospitalizations. Nursing homes with low ratios of RNs to total nursing staff have higher hospitalization and rehospitalization rates.5 In addition to the impact on residents, this can affect a facility’s revenue due to the reluctance of hospitals to refer patients to facilities that have a high readmission rate.
• Poor surveys. Several studies have demonstrated a correlation between staffing levels and quality of care and star ratings.6,7 Low quality can affect referrals for admission, and vacant beds do not generate revenue.
• Higher turnover and staffing costs. Insufficient staffing can cause staff to become dissatisfied and resign. High turnover is an expensive burden due to the costs associated with recruiting and orienting new employees, the need to depend on overtime and agency staff to provide coverage, and the lower quality of patient care, which may result in costly adverse outcomes. When all factors are considered, low staffing levels with few registerd nurses ultimately could be more expensive.8
Proposed Staffing Minimums
During this past year, the AALTCN has collaborated with the Coalition of Geriatric Nursing Organizations to promote regulatory changes to increase staffing in nursing homes. The recommendations are that there be a minimum of 4.1 hours of nursing care provided daily for each resident and that there be a minimum of one RN present in the nursing home at all times. The National Consumer Voice for Quality Long-Term Care, the leading advocate association for nursing home consumers, supports these recommendations as well.9 It is time that we realize that the so-called “rest home” of a half-century ago that cared for people who needed basic personal assistance has evolved into a complex clinical setting with individuals who require care and supervision that once occurred in hospitals. Staffing must reflect the needs of the population now served.
References
1. American Health Care Association. 2013 Quality Report. Washington, DC: American Health Care Association, 2012. www.ahcancal.org. Accessed March 20, 2015.
2. American Health Care Association. 2012 Quality Report. Washington, DC: American Health Care Association/The National Center for Assisted Living, 2012. www.ahcancal.org/quality_improvement/Documents/AHCA%20Quality%20Report%20FINAL.pdf. Accessed March 20, 2015.
3. Centers for Medicare & Medicaid Services. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Report to Congress: Phase II Final. Volumes I to III. Cambridge, MA: Abt Associations, Inc, 2001. www.allhealth.org. Accessed March 20, 2015.
4. Harrington C, Carillo H, Dowdell M, Tang P, Blank B. Nursing facilities, staffing, residents, and facility deficiencies, 2005 through 2011. San Francisco, CA: Department of Social and Behavioral Sciences at University of California-San Francisco, 2011. https://thenewsoutlet.org/media/documents/Nursing-Homes/Funding/Harrington-nursing-home-staffing-report.pdf. Accessed March 20, 2015.
5. Thomas KS, Mor V, Tyler DA, Hyer K. The relationship among licensed nurse turnover, retention, and rehospitalization of nursing home residents. Gerontologist. 2013;53(2):211-221.
6. Castle N. Nursing home caregiver staffing levels and quality of care: a literature review. J App Gerontol. 2008;27(4):375-406.
7. Public Release of the Five-Star Quality Rating System Three-Year Report, S&C: 13-44-NH [memorandum]. June 28, 2013. Accessed March 20, 2015.
8. Dorr D, Horn S, Smout R. Cost analysis of nursing home registered nurse staffing times. J Am Geriatr Soc. 2005;53(5):840-845.
9. Proposed minimum nursing staffing standards for nursing homes (adopted by the NCCNHR membership, November 1998). theconsumervoice.org/uploads/files/issues/Nurse-Staffing-Standards.pdf. Accessed March 20, 2015.
