IMPROVING NURSING HOME RESIDENT OUTCOMES: TIME TO FOCUS ON MORE THAN STAFFING?
L.D. Kimmey, S.C. Stearns
Jour Nursing Home Res 2015;1:89-95
Background: Nursing home staffing characteristics have long been hypothesized to affect quality of care and resident outcomes. The current literature lacks a solid understanding of the magnitude of the effects that sufficient staff, low turnover, and good nursing oversight can have on outcomes that are important to residents and payers. Knowledge of the magnitudes of these effects is essential to evaluating future directions for long-term care research and policy. Objectives: This study estimates the effects of staffing components on the following resident outcomes: pain, pressure ulcers, and restraint use; falls; and emergency department use and hospitalizations. Design: Prior estimates of the relationship between staffing components and resident outcomes suffer from limitations including small samples and use of facility rather than resident-level data. This study allows for joint and non-linear effects of staffing characteristics on undesirable outcomes. We allowed for non-linear relationships by including squared measures of staffing hours per resident day and interactions between staffing levels and retention by type of staff. Our final models used logistic regression with sample weights calculated by the National Center for Health Statistics. Setting: Residents and facilities participating in the 2004 National Nursing Home Survey. Participants: The 2004 National Nursing Home Survey sampled 14,017 residents at 1,500 of the 16,628 nursing homes in the United States; facility and resident response rates were 81% and 96%, respectively. Exclusions for various criteria and missing data result in an analysis sample of 10,043 residents at 954 facilities. Measurements: We assessed three dichotomous outcome measures. The first measure combined reports of pain in the week prior to the survey, pressure sores at the time of the survey, or whether restraints were ever used for the resident. The second measure was a report of any fall in the 30 days prior to the survey, and third was any emergency department visits or hospital admissions in the previous 90 days. Key explanatory variables reflected staffing levels (ratios of staff hours per patient day and registered nurse bedside hours), retention (proportion of staff employed at least one year) and mix (ratio of registered nurses to licensed practical nurses and certified nursing assistants). Results: Moving from very poor to very good staffing improves predicted outcomes in plausible ways: pain, pressure sores or restraint use decline with higher certified nursing assistant hours and retention, 30-day fall rates decline with greater registered nurse oversight, and emergency department /hospital use decline with more registered nurse bedside hours. Conclusions: Both the absolute and relative effects of moving from very poor to very good staffing are limited in magnitude, demonstrating that broader approaches to improving nursing home quality are needed to ensure satisfactory outcomes for nursing home residents. Additional research is needed to better understand what components of facility administration and operation are most strongly associated with resident outcomes.
L.D. Kimmey ; S.C. Stearns (2015): IMPROVING NURSING HOME RESIDENT OUTCOMES: TIME TO FOCUS ON MORE THAN STAFFING?. The Journal of Nursing Home Research Science (JNHRS). http://dx.doi.org/10.14283/jnhrs.2015.18