Long-Term Care
Nursing Leadership and Management
Research Reviews
The Relationship Between Nurse Staffing Levels in Nursing Homes and Quality Indicators: A Literature Review
M E Dellefield, 2000
Journal of Gerontological Nursing, 27(6), 14-28
The
current national crisis in nursing home staffing has been underscored
by claims that research has demonstrated a relationship between nurse
staffing and quality of care. Dellefield addresses that claim through
a systematic and thorough review of the literature on nurse staffing
and quality of care. Using Donabedian's Quality Framework, the variables
examined in each study are classified according to structure, process
and outcome indicators. Dellefield provides a succinct, clear overview
of Donabedian's Quality Framework and gives extensive examples of the
three types of quality indicators within the context of nursing homes.
A fourth type of quality indicator, the composite indicator, is identified
which combines both process and outcome indicators. The number and type
of deficiencies for a state survey is an example of a composite indicator.
Dellefield
reviewed 27 research studies that were conducted as early as 1977 and
as recently as 1999. Some of the studies used more than one type of
indicator. The dependent variable for 12 of the studies used outcome
indicators and 11 of the studies used composite indicators as the dependent
variable. There were 13 studies which used structural indicators as
either the independent or dependent variable. Only four studies used
process indicators as the independent variable.
The
findings from these studies on the relationship between quality (as
measured by different quality indicators) and nurse staffing were mixed
and inconsistent. The studies defined and measured the quality indicators
differently. The types of quality indicators used in the 17 studies
were limited and in some cases questionable as to whether they were
influenced by nurse staffing. The most frequently used structural indicator
was ownership of the nursing home. Outcome indicators were more varied,
however, even similar quality indicators (e.g. physical functioning)
were defined and measured differently between studies.
The
studies reviewed by Dellefield found that nurse staffing was defined
either as total nurse staffing hours or nursing staff skill mix or both.
The majority of studies explored the relationship between nursing staff
skill mix and quality indicators. Even within these two categories,
however, there was variation in how nurse staffing was defined and operationalized.
For example, one study identified skill mix as the percentage of direct
care staff that were RNs and another study identified skill mix as the
total number of licensed hours.
Dellefield
provides an extensive summary of the overall findings of these studies
and identifies clinical, research and policy implications of these findings.
She suggests that nursing homes may be motivated to evaluate the relationship
between their quality indicators and staffing given the recent implementation
of the investigative protocol on sufficient staff in nursing services
as a component of the standard nursing home survey process.
Dellefield
concludes, and rightly so, that based on the published research about
staffing and quality care, it may be premature to advocate for mandated
nursing staff skill mix to resident ratios. Rather, the literature provides
ample evidence to support advocating for a mandated minimum level of
total nursing care hours and then allowing providers to determine how
to configure the skill mix.
Clearly
more research in this very important area of concern to nurse leaders
in long-term care is needed. Researchers should be encouraged to identify
a common data set with consistent definitions of variables to use for
studies regarding nurse staffing and quality care. Nurse leaders in
long-term care should develop strategies to monitor quality care in
relationship to nurse staffing trends and patterns in their facilities.
Reviewed
by Christine Mueller, PhD, RN, Associate Professor, School of Nursing,
Center for Gerontological Nursing, University of Minnesota, July
2001.
Links
Return to: Academic Health Center : myU : U of M Home
