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O.O. Omotowa1, L.C. Hussey2


1. Idaho State University School of Nursing, Idaho Fall, USA; 2. Walden University School of Nursing, Columbia, Maryland, USA. Corresponding author: Omotayo O. Omotowa, Idaho State University School of Nursing, Idaho Falls ID 83402, USA, omotomot@isu.edu, Telephone: 2082821117, Fax: 2082827966

Jour Nursing Home Res 2020;6:90-92
Published online October 9, 2020, http://dx.doi.org/10.14283/jnhrs.2020.24



Adequate nurse staffing levels are critical to nursing homes’ residents’ quality of care outcomes. The number of nurse staffing hours per resident day directly affects being with, and supervising residents’ activities in ways to prevent falls. Studies have shown some negative direct relationships between nurse staffing levels and occurrences of falls in nursing homes. The objective of this report is to examine the relationship between nurse staffing and occurrence of falls in nursing homes. Articles were search from nursing and health care databases such as CINAHL Plus, Academic Search Complete, Medline Complete, and ProQuest Nursing using different levels of nurse staffing, nursing homes, and long-term care. Information was also retrieved from the Center for Diseases Prevention and Control and the Centers for Medicare and Medicaid Services websites. Results showed that increased number of total nurses, increased licensed nurses, and increase ratio of registered nurses to certified nurse aids skill-mix were related to fewer numbers of falls. Falls are detrimental to nursing homes’ older adults’ quality of life. Adequate nurse staffing levels is imperative to maintain the dignity, wellbeing, and quality of life for vulnerable nursing homes’ residents.

Key words: Nursing homes, nurse staffing, falls.



Falls, an adverse event affecting quality of life and wellbeing experiences among nursing homes’ older adults, are an unfortunate common occurrence happening to a large number of this population every year in the United States. The occurrence of falls is reported to be happening to 50%-75% of the 1.4 million older adult nursing homes’ residents every year in the United States (1). Frailty and reduced physiological functionality predispose this population to increased danger of falling. In some cases, the older adult residents sustain injuries such open wounds, fractures, and traumatic brain injury that lead to functional disability, morbidity, poor quality of life, and/or eventual deaths (1-5).
Older adults residing in nursing homes experience worse outcomes and complication rates after falls and upon admission to the hospital when compared to their community counterparts (5-6). Impact of falls on the residents and their families continue to be a source of concern for all nursing homes health care stakeholders. In general, studies showed that causes of falls among the older adults population were mostly due to the presence of multiple diseases, cognitive impairment, increased mobility and physical activities, poly-pharmacy, urinary incontinence, unsafe gait/balance difficulty, weak body parts, malnutrition, limb impairment, decreased peak muscle power, and inadequate safety equipment (2, 4, 7, 8). In nursing homes, successful prevention of falls measures would involve assessment and identification of risk factors, especially the modifiable factors, and effective focused intervention activities (2, 9) by adequate number of higher skilled nurse staffing.
Some studies have revealed that nursing homes residents experience falls in different locations such as hallways, dining rooms, lounges, and the greater occurrences associated with fractures happen in the residents’ bedrooms and bathrooms (5, 10). Majority of the falls among residents happened during unknown activities (this implies that the staff was unaware of what and how happened when the falls occurred), followed by when walking and transferring; and, infrequently during reaching, sitting, and standing (5, 10). Residents were also found to fall during all hours of the day, with the most incidences happening in the early morning hours from 5 a. m to 8 a. m (5). This time window is when care delivery process is heightened and the need for nursing care and assistance by the older adults from nurses is usually higher.


The Relationship between Nurse Staffing Levels and Falls

Adequate nurse staffing levels are critical to nursing homes’ residents’ quality of care outcomes. Different levels of nurse staffing, skills-mix, and total nurses’ hours were studied as predictors of falls, with or without serious injuries, among the nursing homes’ residents (11-14). Researchers examined the impact of nurse staffing on falls incidences using total nurse (TN) hours per resident day (HPRD) and registered nurse skill-mix (11); registered nurse, registered nurse skill-mix, and certified nurse aide HPRD (14); and certified nurse aide and licensed nurse HPRD (13). These studies showed that insufficient number of nurse staffing HPRD, staffing to resident ratio, and inadequate registered nurse skill-mix affect the process and quality of care provided to the residents, including assessment, being with, caring for, and supervising their cares and activities for fall prevention. An overview of the studies reviewed is shown in Table 1.

Table 1
An overview of studies reviewed

Figure 1
Illustration of the relationship of nurse staffing levels/hours and occurrence of falls


Researchers found out that higher number of TN (certified nurse aide and registered nurse) staffing per 100 residents (12), increase registered nurse HPRD, increase staffing to resident ratio, and increase registered nurse to certified nurse aide skills-mix (14, 16) contributed to reduced fall rate. Findings also showed that consistent staffing and higher certified nurse aide, registered nurse, and licensed practical nurse HPRD (13, 16) were related to fewer number of fall incidences in nursing homes and facilities providing long term care services for the older adults. In determining the registered nurses and licensed practical nurses’ knowledge on eight causes of falls, Gray-Miceli, de Cordova, Crane, Quigley, & Ratcliffe (17) found that registered nurses had higher average knowledge scores than the licensed practical nurses, even though neither correctly identified all the causes of falls among the older adults. The authors considered registered nurses’ scores an indication of better performance in falls prevention (17); making increased registered nurse staffing level a positive factor in reduction of falls.
A few of the studies showed mixed outcomes of the relationships of nurse staffing and falls among the older adults in nursing homes or long term care facilities (13-15). A lack of statistically significant relationships were reported between occurrence of falls and nurse staffing levels or skills-mix; and all direct care nurse staffing HPRD including certified nurse aide, nurse aide, licensed vocational nurse, baccalaureate prepared registered nurse, trained feeding assistants, untrained staff, and trainees (11, 14-15). A mixed methods study on newly admitted short-stay nursing homes residents concluded that licensed nurses (registered and licensed practical/vocational nurses) were not significantly associated with falls (13). A study by Backhaus et al. (18) showed an increase in probability of falls among the older adults in somatic facilities (wards that provide care for residents with physical disabilities) that employed baccalaureate prepared registered nurses.
It is evident that inadequate nurse staffing hours and unlicensed nurse skills are detrimental to nursing homes older adults’ safe and quality of care processes and outcomes. Falls are increasingly prevalent among the older adult nursing homes’ residents due to their frailty, aging process, medical conditions, and vulnerability. Adequate and appropriate nurse staffing levels are necessary for avoidance of falls and maintenance of wellbeing, dignity (19), and quality of end of life for the nursing homes older adults.


Conflict of interest: The authors did not get financial support nor had an affiliation with any organization with any financial or non-financial interest in the subject matter discussed in this article.

Ethical Standards: This article does not violate any ethical standards. It does not involve one-on-one interaction with human or animal participants.



1. Center for Disease Control and Prevention. Home and recreational Safety: Important facts about falls, 2017. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
2. Álvarez Barbosa F, Pozo-Cruz B, Pozo-Cruz J, et al. Factors associated with the risk of falls of nursing home residents aged 80 or older. Rehabilitation Nursing 2016; 41(1): 16.
3. Cantalice Alves AH, Freire de Araújo Patrício AC, Fernan des de Albuquerque K, et al. Occurrence of falls among elderly institutionalized: prevalence, causes and consequences. Revista De Pesquisa: Cuidado E Fundamental 2016; 8(2): 4376-4386.
4. Damián J, Pastor-Barriuso R, Valderrama-Gama E, de Pedro-Cuesta J. Factors associated with falls among older adults living in institutions. BMC Geriatrics 2013; 13(6): 1-9.
5. McArthur C, Gonzalez DA, Roy E, Giangregorio L. What are the circumstances of falls and fractures in long-term care? Canadian Journal on Aging / La Revue canadienne du vieillissement 2016; 35(4): 491-498.
6. Botwinick I, Johnson JH, Safadjou S, et al. Geriatric nursing home falls: A single institution cross-sectional study. Archives of Gerontology and Geriatrics 2016; 63: 43-48.
7. Clancy A, Balteskard B, Perander B, Mahler M. Older persons’ narrations on falls and falling–Stories of courage and endurance. International Journal of Qualitative Studies on Health & Well-Being 2015; 10: 1-10.
8. Lannering C, Ernsth Bravell M, Midlöv P, Östgren C, Mölstad S. Factors related to falls, weight-loss and pressure ulcers – more insight in risk assessment among nursing home residents. Journal of Clinical Nursing 2016; 25(7/8): 940-950.
9. Kadono NA, Pavol MJ. Effects of aging-related losses in strength on the ability to recover from a backward balance loss. Journal of Biomechanics 2013; 46(1): 13–18.
10. Robinovitch S, Feldman F, Yang Y, et al. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet n.d; 381(9860): 47-54.
11. Backhaus R, van Rossum E, Verbeek H, et al. Quantity of staff and quality of care in Dutch nursing homes: A cross-sectional study. Journal of Nursing Home Research 2016; 2: 90-93.
12. Sandoval Garrido FA, Tamiya N, Kashiwagi M, et al. Relationship between structural characteristics and outcome quality indicators at health care facilities for the elderly requiring long-term care in Japan from a nationwide survey. Japan Geriatric Society 2014; 14(2): 301-308.
13. Leland NE, Gozalo P, Teno J, Mor V. Falls in newly admitted nursing home residents: A national study. Journal of the American Geriatrics Society 2012; 60(5): 939-945.
14. Shin JH, Hyun KH. Nurse staffing and quality of care of nursing home residents in Korea. Journal of Nursing Scholarship 2015; 47(6): 555-564.
15. Whitehead N, Parsons M, Dixon R. Quality and staffing: Is there a relationship in residential aged care. Kai Tiaki Nursing Research 2015; 6(1): 28-35. Retrieved from http://www.kaitiakiads.co.nz/research-journal/
16. Horn SD, Hudak SL, Barrett RS, Cohen LW, Reed DA, Zimmerman S. Interpersonal care processes, falls, and hospitalizations in green house and other nursing homes. Seniors Housing & Care Journal 2016; 24(1): 31-46. Retrieved from http://www.nic.org/analytics/publications/seniors-housing-care-journal/
17. Gray-Miceli D, de Cordova PR, Crane GL, Quigley P, Ratcliffe SJ. Nursing home registered nurses’ and licensed practical nurses’ knowledge of causes of falls. Journal of Nursing Care Quality 2016; 31(2): 153-60.
18. Backhaus R, van Rossum E, Verbeek H, et al. Relationship between the presence of baccalaureate-educated RNs and quality of care: a cross-sectional study in Dutch long-term care facilities. BMC Health Services Research 2017; 17(53): 171-179.
19. Centers for Medicare & Medicaid Services. (2015). Nursing home data compendium 2015 edition. Retrieved from https://www.cms.gov




O.O. Omotowa1, L.C. Hussey2


1. Idaho State University College of Nursing, USA; 2. Walden University School of Nursing, USA. Corresponding author: Omotayo O. Omotowa, Idaho State University College of Nursing, USA, omotomot@isu.edu

Jour Nursing Home Res 2019;5:21-23
Published online May 27, 2019, http://dx.doi.org/10.14283/jnhrs.2019.4



Profit maximization is a significant factor affecting adherence to adequate staffing standards and actual staffing levels of nursing staff in many nursing homes in the United States. Studies have shown that inadequate nurse staffing is worse in the for-profit than not-for-profit nursing homes and, is adversely affecting resident care outcomes. The purpose of this report is to examine the literature and establish the impact of profit maximization on nurse staffing with a focus on the differences between for-profit, not-for-profit, and religious-based nursing homes in the United States. Databases such as CINAHL Plus, Business Source Complete, Medline Complete, Academic Search Complete, ProQuest Nursing, Allied Health Source, and Google Scholar were used as sources for information collection. Compared to other types of nursing homes, findings showed that for-profit nursing homes are doing better financially but worse on care outcomes. It is important that nursing homes regulators enforce strict adherence to staffing standards for optimal quality of care outcomes.

Key words: Profit maximization, nursing homes, nurse staffing, care outcomes.


Profit Maximization

In nursing homes, as in other organizations providing social and health care services, the goals for the enterprise may or may not include maximizing profit for the investors and shareholders. In accounting, maximization of profit translates to operating an industry at a level of surplus difference between total revenue and total cost or where the marginal cost is equal to marginal revenue (1-3). In accordance with the conditions underlying the economics of supply and demand, profit maximization occurs when the market is perfectly competitive, the entrepreneur has perfect knowledge of the market and is willing to assume risks, consumers are well informed, and production is made with a prospect of having surplus gain (4).
Maximizing profits in the United States (U.S) nursing homes (NHs) has involved adopting the strategies that focus on increasing revenue and containing operating costs and expenses (3). Nursing homes can increase their revenue and profit by engaging in upcoding business activities by providing additional services to patients or coding them as sicker, changing the mix of residents towards more profitable payers, and admitting residents that have profitable case-mixes (5). Increased use of ultra-high therapy Resource Utilization Groups and selling of stocks constitute other means by which NHs could increase revenue (6).
Health care labor cost incurred on staffing is the most expensive operating cost (2, 7). Therefore, decisions to increase profits and contain costs, among the U.S NHs, could involve reducing or maintaining lower nurse staffing levels, increasing patient-nurse staff ratio, reducing employee job benefits, and substituting cheaper lower skill staffers for higher skilled licensed nurse staffing that are more expensive (2, 6-11). These activities, according to these authors, have led to reduced quality in other areas of residents care.
Profit maximization is almost always the goal of business for the for-profit (FP) category of nursing homes (NHs) while the not-for-profit (NFP), especially the religious-based NHs, exist to provide value-based services (1, 3, 6, 7, 12). Nation-wide, the FP NHs are presumed to set output, input, quality, and residents case mix in order to maximize profits (12). Most of these NHs are publicly-owned by investors who have shares in the business and are expected to benefit from its profits and investments reward (1, 3) thereby adding the pressure of maximizing profits to the operators of the facilities.
The NFP NHs, on the other hand, are non-governmentally owned by religious, community groups or agencies and operated as nonprofit organizations (13). In the U.S, these facilities are precluded from an assignment of property rights; they do not have defined shareholders, and are not subject to the pressure of distributing profits (3, 7, 12). On the contrary, the NFP facilities are expected to use the profit derived from operation for the benefit of the clients (13). Effective performances of the not-for-profit religious-based NHs are measured by the outcomes in how well they provide services; take care and meet the immediate needs of customers (16).
In the United States, studies have concluded that FP NHs performed financially better than NFP NHs in operating revenue, operating profit margin, and total profit margin (1, 3). Harrington et al. (14) reported that Medicare profit margins in FP NHs were three times more than that of NFP NHs. Bos et al. (8) concluded, in their systematic review study on NHs financial performance, client, and employee well-being, that FP NHs had a better financial performance with higher profit margins and better efficiency than the NFP NHs. In situations that predispose FP NHs to the possibility of having reduced profits, profit maximizing decision would rather jeopardize the quality of care services and outcomes (1, 7, 8, 14). Profit making NHs are strongly inclined to choose the profit maximizing levels of quantity and quality of care (1, 2).


The Relationship between Profit Maximization and Nurse Staffing Standards/Levels

The impact of maximizing profit, which is characteristic of the U.S FP NHs, has been studied in relation to nursing staffing levels in NHs. Prioritization for profit maximization in NHs has been reported to be significantly correlated to lower nurse staffing levels, serious staffing quality related deficiencies, and poor care outcomes in other areas of quality measures (6, 7, 9-11). Figure 1 shows the illustration and interrelatedness of profit maximization, staffing standards, and care outcomes in nursing homes.

Figure 1
Illustration of profit maximization, staffing standards, and care outcomes


Examining the effect of profit status and chain affiliation in Ontario long-term-care homes, Hsu et al. (11) found out that, despite the complexity of needs and the rise in proportion of residents who needed care services, the FP facilities had marginal to lack of growth in registered nurse staffing level and higher use of cheaper, less skilled, support care workers. Hsu et al. added that the religious organizations had more direct care nursing hours than the FP organizations. In a similar study, over 2003-2009 period, by Harrington et al. (1), the profit maximizing chain of twenty-two nursing homes in California was found to have increasing high resident acuity (44-67% of total residents) and 34-44% revenue increase than other NHs. In these NHs, nurses’ staffing hours were lower than the state required 3.2 total nursing hours for one-third of the total days during these years of study. These culminated in sixty-two annual or complaints surveys and several staffing-related deficiency citations throughout the twenty-two facilities.
In most cases, registered nurses hour per resident day has been shown to be compromised when administrators are required to maximize profits within the context of compliance with staffing standards (1, 2, 7). Registered nurses’ staffing level, the most important but more expensive nursing skill category, and their ratio in staffing skill-mix were found to be at a lower level in FP maximizing NHs compared to NFP NHs (1, 2, 6, 7, 10, 11; 15). Likewise, these authors concluded that total nursing staff hour per resident day was, also, generally reduced in the U.S FP nursing homes.
Harrington et al. (7) and Harrington et al. (1) stated that all for-profit chains and other for-profit nursing homes in the U.S had a lower number of total nurses’ hour per resident day than their counterpart nursing homes operators. In response to nurse staffing standards and levels, FP NHs had lower staffing levels for all types of nurses (15). In their study on the relationship between ownership, staffing, and quality in Indiana using the U.S Center for Medicare and Medicaid Services’s five-star rating system, Gichungeh and Kim (10) concluded that 35.9% of FP NHs received “above average” and “much above average” compared to 66.1% overall nurse staff rating received by the NFP NHs.
There are few studies that reported exceptions to reduced nurse staffing hour per resident day in the U.S FP NHs. Harrington et al. (7) found a higher total nursing hour per resident day in the FP NHs when there was an increasing percentage of residents who had limitations doing activities of daily living. Gichungeh and Kim (10) reported no difference in LPN staffing levels in the two categories of NHs and McDonald et al. (9) reported no conclusive evidence of a significant relationship between FP NHs and staffing-related deficiency citations. Bos et al. (8), found a study that failed to find differences in staffing levels between FP and NFP NHs.


Conflict of interest: There is no conflict of interest, financial or otherwise, involved in this study.

Ethical standard: This article does not involve human/animal participants.



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