Transcript TITLE GOES HERE - University of Minnesota School of Nursing

Is there Evidence for Mandated Nurse
Staffing Standards for Nursing Homes?
Christine Mueller, PhD, RN, C, CNAA
Associate Professor
Center for Gerontological Nursing
University of Minnesota, School of Nursing
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Research Collaborators
•Robert Kane, MD, Professor and Minnesota Chair in
Long-term Care and Aging
•Greg Arling, PhD, Associate Professor, Cookingham
Institute, University of Missouri-Kansas City
Research Assistants
•Julie Bershadsky
•Theresa Lewis
•Diane Holland, MS, RN
Nurse Staffing/Nursing Time and Quality
Four research activities related to
staffing and quality in long-term care
facilities:
•Critical review of literature
•Analysis of States’ staffing standards
•Interviews of Minnesota stakeholders
•Analysis of Minnesota nurse staffing time and riskadjusted process and outcome quality measures
Critical literature review—Scope
•Relationship between nurse staffing and quality as
primary focus of the study
• 1977-2005
• 30 quantitative studies
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–
–
–
Adequacy of staffing data source and measures
Adequacy of care quality data sources and measures
Generalizability of study findings
Presence and strength of relationships
• 6 qualitative studies
– How staffing relates to processes of care and how the
processes affect the health status of residents
Critical literature review—Main Findings
•Data sources for staffing
• OSCAR (46% of studies)
– Accuracy issues
• Other state level databases, interviews
• One study observed time spent
•Staffing measures
• RN, LPN, NA, Total HPRD or ratio
Critical literature review—Main Findings
•Data sources for Quality
• 11 different data sources
•Quality measures
•Risk adjustment
•Summary of findings from studies
Quality Measure
High staffing/
better
outcomes
High staffing/
worse
outcomes
No
significance
Totals/
percent
Resident status
11 (38%)
1 (3%)
17 (59%)
29 (100%)
Health and
Functioning
32 (44%)
4 (5%)
36 (51%)
72 (100%)
Care Processes
18 (53%)
5 (15%)
11 (32%)
34 (100%)
Deficiencies
12 (40%)
0 (0%)
18 (60%)
30 (100%)
Composite measure
3 (50%)
1 (17%)
2 (33%)
6 (100%)
Other
4 (24%)
0 (0%)
13 (76%)
17 (100%)
Totals/percent
80 (43%)
11 (6%)
97 (51%)
188 (100%)
Stakeholder perceptions regarding staffing and
quality in long-term care facilities
Group Interviews
•13 group interviews
•212 persons
•Key organizations helped
facilitate interviews
Surveys
•114 respondents
•Family councils (4)
•Resident councils (4)
•RNs
•LPNs
•NAs
•Directors of Nursing
•Ombudsmen
•Administrators
•Union representatives
•Nurse practitioners
Two Primary Questions
•What are the greatest
concerns you have with
staffing in nursing homes?
•What is your advice to the
State about what should be
included in a staffing
standard for MN nursing
facilities?
Concerns of Stakeholders
•Lack of continuity of care
for residents
•Quality of staff
• Communication/English
fluency
• Lack of compassion;
negative attitudes
•Not enough nursing staff
•Lack of knowledge/training
needs of staff
•Management/supervision
•Turnover/retention
•Acuity needs of residents
changing
•Quality of care is
associated with staffing
• Examples after examples
Recommendations of Stakeholders
•More staff
• but no specific
recommendations for
ratios or HPRD
•Link staffing to acuity
•Associated with quality
•Training/education
•Management, leadership,
and supervision
•Positive work environment
that fosters staff
involvement in decision
making about the residents’
care and their work
Major Caveat: Support increased staffing
standards as long as their was the assurance of
financial support to meet the standards.
State Staffing Standards—Scope of work
Published in The Gerontologist
•Research questions:
• 1) What are the characteristics of state staffing standards in the U.S.?
• 2) Are state staffing standards associated with nursing staff hours per
resident day (HPRD), licensed HPRD and unlicensed HPRD?
•Obtaining staffing standard data
• 50 states plus District of Columbia (2004)
• Abstracting variables
•Obtaining actual staffing
• OSCAR (2004)
• 14,147 facilities in 50 states plus D.C.
•Creation of a data file for analysis
State staffing standards--Findings
•40 States have staffing standards over and above
the federal requirement
• 33 specify HPRD or ratio
– Median 2.35 HPRD (highest 3.6 HPRD)
• 33 specify additional licensed nurse staffing
requirements
• 7 require 24 hour RN staffing
•Actual Staffing (for each state)
• Licensed: 1.26 HPRD
• NA: 2.31 HPRD
• Total: 3.57 HPRD
Variables for analysis
•
Categorical staffing variables:
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No HPRD,  2.5 HRPD, >2.5 HPRD
Presence or absence of 24 RN staffing
Presence or absence of additional licensed staffing
Covariates
•
•
•
•
•
•
•
•
Size of nursing home
Type of Medicare/Medicaid certification
Percent of private pay residents
Hospital affiliation
Chain affiliation
Percent occupancy
Ownership
Resident acuity
State staffing standards—Findings (cont).
•Facility HPRD staffing varied a great deal more within than
between states.
• Staffing standards per se accounted for only a small proportion of
between-state variance in facility staffing levels (11% of total HPRD).
• Medicaid payment rate and facility-level covariates did a much better
job of accounting for between-state variance (70% of total HPRD)
•Facilities in states with low HPRD standards had the lowest
average total, licensed, and aide HPRD
•Facilities in states with high HPRD standards had highest total,
licensed and aide HPRD;
•Facilities in states with no standards were in between.
Staffing Standards analysis--Implications
•Introducing a high HPRD staffing standard may increase facility
staffing; But, how high?
•A low standard may have no affect or even a dampening effect.
Some facilities may treat staffing standard minimums as if they
were maximums, and lower their staffing accordingly
•Other facility characteristics, such as management style or labor
market conditions, not measured in our study may explain some of
the variation that was not accounted for in this study.
Nursing Time and Quality
•Limitation of other studies
• Staffing and quality assessed at the facility level
•Our study addressed this limitation
• Data included nursing time that could be associated with
– specific residents
– specific nursing units
• Resident and unit risk adjusted quality measures/
indicators at the resident level
• Accounted for resident acuity and staffing at the unit level
Research Questions
•Is there a positive relationship between nursing time
(nursing resource used) and quality related outcomes/
measures? Is more staff time associated with better
quality indicators? Is the association causal?
•If quality related resident outcomes are positively
associated with more nursing resources, what is the
nursing resource/quality threshold, that is, what amount
of nursing resource use will provide no further
improvement in quality outcomes?
Nursing Resource Use & Care Quality Model
Unit
Quality
Unit
Staffing
Unit
Acuity
Resident
Resource
Use
Resident
acuity/risk
Care
Processes
Care
Outcomes
Staff Time Study
•43 Minnesota LTC facilities
•68 nursing units
•2,506 residents
•40 conventional units
•18 special care (dementia)
units
•Staff time data collected over
48 hour period
•Resident specific time
•Non-resident specific time
•MDS assessments for each
resident
Variables
Staff time (RST and NRST)
•RN
•LPN
•NA
•Therapy
•Social services
•Activities
Quality indicators/measures
•5 Process measures
•7 Outcome measures
•Risk adjusted
Control variables
•Resident acuity
•Unit acuity
•Unit type
Resident-Level Direct Care Times as Predictors of
Process and Outcome Measures
Quality Indicator/Measure
Direct Care Minutes/Day
RN
LPN
NA
Restraints (P)
ns*
ns
1.25**
Psychotropic medications (P)
ns
ns
ns
Range of motion training (P)
ns
ns
1.14
Toileting training (P)
ns
ns
1.16
ADL Skill training (P)
ns
ns
ns
Loss of function in basic daily activities (O)
ns
1.13
0.93
Incidence of decline in range of motion (O)
ns
ns
ns
Worsening of bowel or bladder incontinence (O)
ns
ns
1.06
Worsening behavior (O)
ns
ns
ns
Worsening depression or anxiety (O)
ns
ns
ns
Weight loss (O)
ns
ns
ns
Worsening pain (O)
ns
1.22
ns
•Non-significant result; only results significant p> .05 are shown as actual odds ratios
** odds ratio associated with a 15 minute/day increase in care time
Unit-Level Direct Care Times as Predictors of Process
and Outcome Measures
Quality Indicator/Measure
Direct Care Minutes/Day
RN
LPN
NA
Restraints (P)
ns*
ns
ns
Psychotropic medications (P)
ns
ns
ns
Range of motion training (P)
ns
2.15**
ns
Toileting training (P)
ns
ns
ns
ADL Skill training (P)
ns
ns
ns
Loss of function in basic daily activities (O)
ns
ns
ns
Incidence of decline in range of motion (O)
ns
ns
ns
Worsening of bowel or bladder incontinence (O)
ns
1.52
0.81
Worsening behavior (O)
ns
ns
ns
Worsening depression or anxiety (O)
1.54
ns
ns
Weight loss (O)
ns
ns
ns
Worsening pain (O)
ns
ns
ns
•Non-significant result; only results significant p> .05 are shown as actual odds ratios
** odds ratio associated with a 15 minute/day increase in care time
Strength of the Evidence?
•Support from literature is marginal
•Use of staffing standards requires caution
•No support for the relationship between nurse staffing
time and quality measures
•While stakeholders believe staffing and quality are
related, they are unable to identify staffing ratios or
HPRD that would result in desired quality.
What are the questions we should be asking?
•Quality may be more of a function of the way nursing
care is organized and delivered—
– Continuity of care provider fostering the nurse-resident
relationship
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Expertise of direct care staff
Staff morale and teamwork
Facility or unit management practices
Leadership and supervision
Care related technology
Availability of support staff
Our Recommendations
•Premature to propose specific staffing standards
•Rather, establish incentives to allow facilities to be
more creative and apply cost-effective solutions to
address staffing factors
•Quality based Medicaid payment system
• Reward higher quality of care
• Give facilities flexibility for channeling resources
•Need research to see if this approach improves quality
•Focus research on other factors that might influence
quality
Thank you!
Questions?