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P. Nambisan1, M. Abahussain1,6, E.H. Duthie2, C. Galambos3, B. Zhang4, E. Bukowy5


1. Department of Health Informatics & Administration, College of Health Sciences, University of Wisconsin – Milwaukee, Milwaukee, USA; 2. Medical College of Wisconsin Division of Geriatric and Palliative Medicine, Milwaukee, USA; 3. Helen Bader School of Social Welfare, University of Wisconsin Milwaukee, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; 4. Educational Measurement, Department of Educational Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA; 5. Division of Geriatric and Palliative Medicine, MCW & Froedtert Hospital, Medical Director for the Lutheran Home and Clement Manor Nursing Home, Milwaukee, Wisconsin, USA; 6. Department of Ambulance Services, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia. Corresponding author: Priya Nambisan, Department of Health Informatics & Administration, College of Health Sciences, University of Wisconsin – Milwaukee, Northwest Quadrant Building B, Rm #6410, 2025 East Newport Avenue, Milwaukee, WI 53201-0413, Phone: (414) 251-0421, Office Ph: (414) 251-5217; Email: nambisap@uwm.edu

Jour Nursing Home Res 2021;7:55-61
Published online September 17, 2021, http://dx.doi.org/10.14283/jnhrs.2021.9



Background: The COVID-19 pandemic disproportionately affected the older adult population, especially those in nursing homes (NHs). However, there is also evidence that some NHs fared better than others. Objectives: This study examines a set of nursing home related factors to understand whether these factors are associated with the number of COVID-19 cases. Design: We combined three datasets from the Centers for Medicare & Medicaid Services (CMS) – the Star Rating Dataset, the Provider Information Dataset, and the COVID-19 Nursing Home Dataset. Setting and Participants: 4390 NHs that responded to the CMS survey. Methods: Data used is from the period of Jan 1–Dec 27, 2020 for all 12 Midwestern states. The measures used were self-reported information on ratings, staff shortages, PPE shortage, number of beds, Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA) hours per resident, star rating and ownership. Results: Of the 4390 NHs in 12 Midwestern states, high performing NHs were less likely to have more than 30 COVID-19 cases versus low-performing facilities for two of the CMS domains (health inspections, 520 NHs [27.6%] vs 1363 NHs [72.4%]; and staffing 773 NHs [41.1%] vs 1110 NHs [58.9%]). There was also a statistically significant association COVID-19 cases and star rating, NH ownership, NH size, RN, LPN, and CNA staffing in NHs (all p ≤ 0.01). NH ownership status persisted as a predictor of COVID 19 cases when controlled for NH size. Conclusions: Our study highlights two interesting findings. A) a statistically significant association between NH ownership structure and COVID-19 cases among residents – for-profit NHs had higher number of COVID-19 cases B) a statistically significant negative association between RN and CNA staffing and COVID-19 cases (i.e., more staffing hours of RNs and CNA correlated with a smaller number of COVID-19 cases) and a statistically significant positive association between LPN staffing and COVID-19 cases. We discuss ensuing policy implications for NHs.

Key words: COVID-19, Nursing homes, staffing hours, for-profit nursing homes.



The COVID-19 pandemic disproportionally affected the older adult population, especially those in nursing homes (NHs). According to a recent AARP report, an estimated 174,000 residents and staff of nursing homes and other long-term care facilities across the country died due to COVID-19 (1). Further complicating the situation, there are reports of under-reporting of nursing home deaths due to COVID-19 from many states (2). While many NHs were reporting COVID-19 cases to state and local public health departments, it was not until April 2020 that they started reporting to the CDC in a standardized format, which may have led to under or inaccurate reporting (3).
To understand how older adults can be protected in nursing homes, it is important to consider the characteristics that make some nursing homes more susceptible to the spread of COVID-19. In many ways, the COVID-19 pandemic has exposed the existing weaknesses of the nursing home system which provides care to some of the frailest and most vulnerable individuals in our society. Some researchers have called this pandemic a ‘case study of infection control’ (4) and studies delving into the factors that contributed to devastating outbreaks can provide critical insights into how this can be prevented in the future.
Nursing homes are prone to infectious outbreaks (e.g., seasonal influenza, norovirus) and there are several factors that make nursing homes highly vulnerable. These factors could range from high number of residents causing crowding, shared bathroom facilities, gathering/common areas to staffing shortages, frequent staff turnover, high resident-to-staff ratios, shortage of PPE, inadequate quality control and poor management (4, 5). In addition, NH residents are typically older adults with multiple chronic conditions such as diabetes, heart disease, pulmonary disease and other functional and cognitive disabilities including frailty (6, 7). Individuals with underlying chronic conditions were particularly vulnerable to contracting COVID-19 (8). Additionally, staff and caregivers in NHs are underpaid, do not get sick leave and move from resident to resident without adequate sanitation control or PPE (4, 9). Given that staff turnover rates are very high in nursing homes, training and maintaining sanitary protocols can also be challenging in this environment (4).
Using datasets available from CMS, which consists of self-reported data from NHs around the country on various factors, many studies (10–14) have reported findings on the factors associated with nursing homes and COVID-19 cases for various time periods in 2020. There have also been several single-state studies e.g. California (15), Connecticut (16) and West Virginia (17), that considered various factors such as star ratings, staffing, CMS quality indicators and PPE shortage. While data from CMS have been analyzed for NHs in Northeastern states (18) and for 30 States (11, 12), no studies have yet focused on NHs in the Midwestern states. Analyzing data from different regions is important as climate, COVID-19 prevalence, COVID-19 related policies and attitude of the population vary from region to region. Further, most existing studies have considered only a narrow time frame (few months in 2020), which may miss valuable information on recurrent NH outbreaks.
This study examines a number of factors such as nursing home ratings, quality of care, staff shortage, PPE shortage, and NH ownership structure (for-profit vs non-profit vs government) to understand whether these factors are associated with COVID-19 cases in NHs in Midwestern states for the entire year of 2020 (Jan 1 2020 – Dec 27 2020). More specifically, the research question that guided this study is: What are the factors that shape the incidence of COVID-19 cases in NHs in Midwestern states?



Three datasets were combined from the Centers for Medicare & Medicaid Services (CMS): 1. Star rating; 2. Provider information and 3. COVID-19 nursing home reported cases. The period examined is from Jan 1 – Dec 27, 2020, for the 12 Midwestern states in the population set (Illinois, Indiana, Iowa, Kansas, Michigan, Missouri, Minnesota, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin). This time period includes one year of data for the analysis, providing a more longitudinal picture of what occurred in nursing homes during the COVID-19 pandemic. Our sample size consisted of 4390 free-standing NHs, after removing cases with missing values.
We combined COVID-19 NH cases data with CMS and provider information. The provider information includes star ratings in three domains (health inspection rating, quality measure rating, staffing rating) and the star ratings range from one(low) to five (high). The health inspection domains are based on the three most recent standard surveys for each nursing home that result from any complaint investigation during the recent three years. The quality measure rating is based on indicators to describe the quality of care given in each nursing home. These measures address a wide range of functioning and health status in multiple care areas. The staffing domain is based on self-reported data from the nursing homes on the number of hours worked by their nursing staff, including Registered Nurse (RN) + Licensed Practical Nurse (LPN) + Certified Nursing Assistants (CNA) hours and the number of residents in the facility.
Drawing on a recent study, we grouped nursing homes into three categories (19) based on the number of COVID-19 cases: those with (a) 10 cases or fewer, (b) 11 to 30 cases, and (c) more than 30 cases. Other measures used were self-reported information on ratings, overall star rating (1 to 5-star facilities), staff shortages, PPE shortage, number of beds, occupancy rate, and ownership status (profit, non-profit, government), and nursing staffing level hours per resident per day (RN, LPN, CNA). Ordinal logistic regression was used to examine the association between nursing home characteristics and incidence of COVID-19 cases.
Descriptive analyses in Table 1 show COVID-19 cases, Midwestern states, and NH characteristics. Three separate ordinal logistic regressions were conducted to examine the three domains associated with COVID-19 cases and assess the odds of high-performing facilities (4- or 5-star facilities) having more than 30 cases vs 11 to 30 cases vs 10 or fewer cases relative to low-performing facilities (1- to 3-star facilities). These factors were compared with reported resident COVID-19 cases and the statistical significance was tested between NHs having more than 30 cases vs 11 to 30 cases vs. 10 or fewer cases of COVID-19. Statistical measures used were ANOVA for nominal variables, Spearman r for ordinal variables, and Pearson correlation tests for continuous variables.
Further analysis to understand the impact and effect of NH ownership structure on COVID-19 cases was done using the ANCOVA analysis to control for NH size.
All statistical analyses were performed by SPSS V. 27, and two-sided p values were considered significant at p<0.01.



Of the 4390 NHs in 12 Midwestern states, when we compared the low-performing facilities and high performing NHs, the high performers were less likely to have more than 30 COVID-19 cases for two of the CMS performance domains (health inspections, 520 [27.6%] high performers vs 1363 [72.4%] low performers; and staffing 773 (41.1%) vs 1110 (58.9%) (see Tables 1 & 2). Table 1 shows the number of nursing homes in each Midwestern state for each CMS domain, classified into high-performing and low-performing.

Table 1
Characteristics of High-Performing vs Low-Performing Nursing Homes Across 3 CMS Performance Domains in the Order of Number of Nursing Homes in Each State

Table 2
Association Between Nursing Home Ratings of Health Inspections, Quality Measures, and Nurse Staffing Domains with COVID-19 Cases


Table 3 provides the distribution of NH COVID-19 cases in each of the Midwestern States, with Ohio having the biggest share of NH COVID -19 cases and South Dakota having the lowest.
Illinois by far and away had the most large sized NHs. Ohio had the most NHs overall and was the state with the most medium sized facilities. Interestingly, as a percent of total beds, Missouri had the highest percent of middle sized NHs.

Table 3
State wide Distribution of Nursing Homes with COVID-19 Cases in Descending Order Based on the “All COVID-19 NH Cases”

* n = 4334; Data not available for 56 NH


NHs with high ratings on health inspection and nurse staffing were less likely to have more than 30 COVID-19 cases vs facilities with 11 to 30 and vs facilities with 10 or fewer cases than were low-performing NHs (OR, 0.68; 95% CI(.567-.823; P = <.01), (OR, 0.48; 95% CI(.418-.557; P = <.01). There was no significant association between high- vs low-performing NHs in the quality measures domains with COVID-19 cases.
While PPE shortages was a major concern in the early part of 2020, this study did not find any statistically significant impact of PPE on the incidence of COVID-19 cases (Table 4). There was no statistically significant association between self-reported staff shortages and COVID-19 cases.

Table 4
Nursing Home Characteristics, Covid-19 Factors, and Star rating

** p<0.01, * p<0.05, ***p<.001; *. Correlation is significant at the 0.05 level (2-tailed); **. Correlation is significant at the 0.01 level (2-tailed); CV-Corona Virus; P values measures whether nursing homes of residents with COVID-19 cases using ANOVA for nominal variables, spearman r for ordinal variables, and Pearson correlation tests for continues variables; Ownership P value = ANOVA; Overall star rating P value = spearman r


Ownership of NHs (for-profit vs. not-for-profit vs. government) also showed a statistically significant (p<.001) association with incidence of COVID-19 cases (See Table 4). The data shows that for-profit NHs had more COVID-19 cases than not-for-profit and government owned. In this dataset, 60.4% were for-profit, 7.8% were government owned and 31.8% were not-for-profit nursing homes. In the category of NHs with less than 10 cases 53.2% were for-profit, 9.7% were government and 37.1% were not-for- profit. Whereas in NHs with over 30 cases of COVID-19, 67.9% were for-profit, 6.6% were government owned and 25.4% were not-for-profit. This could be because there are more for-profit nursing homes than government owned and non-profit.
To further understand the ownership effect, an ANCOVA analysis was performed to control for NH size measured by number of beds. The results of ANCOVA (see Table 5) clearly show a statistically significant (F=20.1** p<0.01) association between ownership and COVID-19 cases after controlling for number of beds. We did a post hoc analysis (Bonferroni comparison) for NH ownership and found that there is statistically significant difference between for-profit vs government (mean difference 6.82** p< 0.01) and statistically significant difference between for-profit and non-profit (mean difference 3.77** p< 0.01) and there was no significant difference between not-for-profit and government ownership (mean difference -3.05 p=.09). This additional analysis indicates that for-profit NHs were significantly different from both government-owned and non-profit NHs, when it came to the number of COVID-19 cases.
COVID-19 cases also increased with the number of beds in the nursing homes. NHs with over 30 COVID-19 cases had an average of 114.8 beds, whereas NHs with less than 10 COVID-19 cases had only 70.9 beds on average. This association is statistically significant (p<.01) (See Table 4). However, there was a statistically significant but small negative correlation between occupancy rate and COVID-19 cases, NHs with less than 10 COVID-19 cases had slightly higher occupancy than NHs with over 30 cases of COVID-19. The average occupancy rate was 65.8% and there was not much variance in this when compared based on COVID-19 cases. There was also a low negative correlation between number of beds and occupancy rate r=-0.155 p<0.01(data not shown).
There was also a statistically significant (p<.01) association between star ratings of NHs and the incidence of COVID-19 cases (Table 4). The data shows there were fewer nursing homes with 5-star rating in the over 30 COVID-19 cases. Of the NHs that had 1-star rating 57.6% had more than 30 COVID-19 cases, whereas only 29.5% of NHs that had 5-star rating had more than 30 COVID-19 cases. Similarly, only 19.4% NHs with 1-star rating had less than 10 cases of COVID-19 while 39.1% of NHs with 5-star rating had less than 10 cases of COVID-19.
While there was no significant association between self-reported staff shortages and COVID-19 cases, staff hours per resident of RN and CNA, had a statistically significant (p<.001) negative association. i.e., the more RN and CNA hours per resident, the lower the number of COVID-19 cases. In NHs with less than 10 COVID-19 cases, the staffing hours per resident was on average .96 RN hours and 1.69 CNA hours where it was only .61 RN hours and 1.46 CNA hours in NHs with more than 30 COVID-19 cases (see Table 4). However, in the case of LPN hours, there was positive association with COVID-19 cases, i.e., as the number of LPN hours increased, so did the incidence of COVID-19 cases. In NHs that had less than 10 COVID-19 cases, LPN hours per resident was on average .72 hours, but in NHs that had more than 30 cases, there were .77 LPN hours on average. The difference is small, but it was statistically significant with p<.001. On further analysis, we also found that while there is a positive correlation for RN and CNA hours with star rating (RN .432** & CNA .307** p<.01), there was a statistically significant negative correlation between LPN hours and star rating (LPN -.073** p<.01). In addition, RN and CNA hours were negatively correlated with number of beds (RN -206**, CNA -.118**, p<.01), LPN hours were positively correlated with number of beds (LPN .116**, p<.01).

Table 5
Association between Ownership and COVID-19 cases after controlling for number of beds

**p < 0.01



The distribution of NH COVID-19 cases among the Midwestern states seems to be highly correlated with size and population density of these states. However, Illinois was leading in the number of COVID-19 cases until October 2020 (21). The metropolitan city of Chicago (in Illinois) with high population density could have been the reason for Illinois to be leading in COVID-19 cases until Oct 2020. Chicago and Illinois were also one of the first cities and states to experience more COVID-19 cases early on in the pandemic (22). When data from Nov and Dec 2020 were included in the analysis, Ohio led in number of cases. In all Midwestern states, COVID-19 cases doubled when the Nov and Dec 2020 data were added to the data from Jan-Oct 2020 (21).
From National Organization of State Offices of Rural Health (NOSORH) data, Ohio is the only Midwestern state with no frontier population, while S. Dakota and N. Dakota had more than 30% frontier population (23). Frontier areas have very low population density. State-by-state differences in NH COVID-19 rates could also be due to differences in state-level policies on social distancing, mask wearing, level of community spread, and variation in testing and reporting. Variations in reporting format, case definitions and update frequency were also indicated as barrier in another study (11).
The number of beds was positively associated with higher COVID-19 cases, consistent with prior studies (in other States) (11, 13, 18). There have been some studies that have found that smaller NHs, especially greenhouse NHs fared better in the COVID-19 pandemic (13). The stated reasons were that smaller NHs’ residents have better psychosocial well-being, such NHs are usually not-for-profit, and that the resident case mix usually have less minority population (that are often at higher mortality risk) (13). It could also be that larger nursing homes have higher number of staff; spread of COVID-19 through staff is another aspect that some studies have indicated (24), where surges where highly correlated with increase in staff and resident cases. Staff testing was also not fully implemented in around 12% of facilities according to another study (25). This finding is consistent with other studies that indicate smaller sized nursing homes are associated with better quality care (5, 26). Since, COVID-19 is highly contagious in crowded areas, the analysis checked for associations with overcrowding i.e. occupancy in these NHs. However, our findings show that NH COVID-19 cases are negatively correlated with occupancy rate. One possible explanation for this negative relationship is larger NHs tend to have lower occupancy rates.
This study also found a correlation between NH ownership status and COVID-19 cases. From our analysis, for-profit NHs were more likely to have higher rates of COVID-19 cases. Other studies have reported similar findings (14, 18) and a news report (27) also noted that for-profit nursing homes are not faring well in controlling COVID-19. While other studies report a correlation between NH ownership and COVID-19, our analysis included multiple tests to confirm the statistically significant relationship between ownership and COVID-19. Potential explanations for this finding include the tendency for there to be more beds in for-profit facilities, the facilities being larger in general and also usually located in urban areas that has larger proportion of minority population (28). Our study further indicated that for-profit NHs had more cases even after controlling for NH size. In this study, there was a negative correlation between for-profit ownership and 5-star rating and with RN and CNA staffing hours. Poor star rating is associated with lower RN staffing hours and high staff turnover rates (29). Also, for-profit status is associated with higher LPN staffing hours, which could indicate that for-profits are utilizing LPNs (to reduce costs), instead of RNs.
A limitation of the current study is that other factors such as health and functional status of the resident at admission, rate of resident admissions from the community or from the hospital and the population density of the city or town in which the NH is located, could also affect the COVID-19 cases in NHs. However, these factors could not be part of the analysis as CMS database does not have these measures.
Across the 12 Midwestern states, high-performing NHs, especially in terms of health inspection ratings and nurse staffing, had fewer COVID-19 cases than low-performing NHs. This is consistent with prior studies that have focused on other states (19). These findings do indicate that such performance measures are important and they do indicate poor staffing and poor health standards needs to be addressed (10). Poor health standards and nurse staffing shortages can make an NH more vulnerable to future pandemics.
Our study findings also reveal another nursing staff -related insight; specifically, higher RN and CNA hours correlated with lower COVID-19 cases, whereas LPN staff hours lead to higher COVID-19 cases. These findings are consistent with other nursing home studies that link quality care with higher and more qualified staffing (30). However, more research is needed that examines whether it is the reduction of RNs or something specific to LPN training that impacted the COVID-19 cases. We also found from further analysis that LPN hours were negatively correlated with star ratings, indicating a link to quality care. LPN hours was also positively correlated with number of beds, indicating that larger NHs tend to hire more LPNs and from this study and others, we know that the size of the NH is positively associated with higher COVID-19 cases.


Conclusion and Implications

While vaccination campaigns are well underway and will limit the spread of COVID-19, nursing homes are still vulnerable to mutations of the virus and other endemics. The frailty, age and multiple chronic conditions of this population make them especially vulnerable and the safety of older adults in NHs should remain top priority. This study of NHs in Midwestern states indicate that the NH factors that are most associated with a higher prevalence of COVID-19 cases are size of the nursing home/number of beds, for-profit ownership, star ratings, and RN and CNA hours per resident per day. We depart from prior studies on this topic by examining self-reported NH data for the entire year of 2020 (Jan 1 2020 – Dec 27 2020) and by specifically focusing on all the Midwestern states. Our analysis findings imply the potential to use a minimal set of indicators to predict the future incidence of COVID-19 pandemic (and other endemics) among NH residents and inform on appropriate policy considerations to reduce NH vulnerabilities in this context. Future studies could consider state-wide policies to limit community spread and impact on COVID-19 cases in NHs. In addition, studies could also evaluate the impact of the adoption of COVID-19 related policies within NHs such as visitation and staff testing on the incidence of COVID-19 cases and evaluate the impact of providing more resources in terms of qualified staffing and care practices that promote strong infection control on the spread of diseases such as COVID-19. Future studies could consider integrating external data, such as government policy changes, magnitude of the COVID-19 outbreak and attitudes of the population in that region towards the pandemic and the restrictions imposed, with the CMS data to understand how that impacted COVID-19 cases in NHs in that region.


Conflict of Interest: Priya Nambisan: No conflict of Interest to report. Mohammed Abahussain: No conflict of Interest to report. Colleen Galambos: No conflict of Interest to report. Bo Zhang: No conflict of Interest to report. Elizabeth Bukowy: No conflict of Interest to report; Edmund Duthie: . No conflict of Interest to report.

Funding sources: This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors. All authors meet criteria for authorship as stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. All authors contributed to the analysis of the data, interpretation of the results and writing of the paper.



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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
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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.
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19. Centers for Medicare & Medicaid Services. (2015). Nursing home data compendium 2015 edition. Retrieved from https://www.cms.gov




L. Pickenhan1, C. Rungg1, N. Schiefermeier-Mach1


1. FH Gesundheit, Department of Healthcare and Nursing, Innsbruck, Austria. Corresponding author: Dr. Natalia Schiefermeier-Mach, Deputy Scientific Director, PI, FH Gesundheit, Innrain 98, A-6020 Innsbruck, Austria, Tel. +43 512 5322 75482, Fax +43 512 5322 75200, natalia.schiefermeier-mach@fhg-tirol.ac.at

Jour Nursing Home Res 2020;6:14-19
Published online May 13, 2020, http://dx.doi.org/10.14283/jnhrs.2020.3



Background: Electrolyte imbalances strongly impact on morbidity and mortality rate in elderly adults. In particular, residents of long-term care facilities may develop life-threatening conditions as a result of altered serum electrolyte concentration. European nursing homes have restricted availability of general practitioner, therefore the role of nurses in medical care, prevention practices, early symptoms identification and communication with physicians is indispensable. Many of the risk factors associated with electrolyte imbalances are modifiable or preventable and have to be adequately recognized and managed by health professionals in nursing home settings. Objective: The aim of this review is to discuss prevalence and management of electrolyte imbalances in long-term care facilities with focus on nursing homes. Design: Narrative literature review. Methods: Search was performed in MEDLINE/PubMed and CINAHL databases. Key search terms associated with electrolyte imbalances including hyper- and hypo-states of sodium, potassium and magnesium were utilized in the subject search in combination with nursing homes, long-term care and older adults. Results and Conclusions: Published research studies reported higher prevalence of electrolyte imbalances and related mortality rate in nursing home residents when compared to older community adults. Serum sodium imbalances, hyponatremia and hypernatremia, were the most commonly identified. High incidence was also documented for hypomagnesemia and associated hypokalemia. Risk factors strongly associated with electrolyte imbalances included nursing home resident’s dietary/ hydration status, presence of comorbidities and type of prescribed medications. In this review we also summarise early signs of electrolyte imbalances and assessments that can be performed locally by nursing personnel. Strengthening awareness for electrolyte imbalances is an important quality-improvement effort from the perspective of nursing home residents and their families that might lower unnecessary hospital transfers, EI complication rates and residents’ mortality.

Key words: Nursing homes, fluid and electrolyte balance, long-term care.



The European population aged 65 years and older has grown from 10% in 1960 to 19% in 2015 and is expected to further increase (1). This remarkable rise is predicted to be a significant driver for the expansion for long-term care (LTC) and care in nursing homes (NHs). According to European Health Information Gateway, numbers of nursing and elderly home beds in EU account for more than 3 million with the highest numbers in Germany (902.882 beds) and in France (642.168 beds) (2). NH residents are often in a weak health condition, have multiple co-morbidities and strong cognitive impairments and therefore are repeatedly admitted into the hospital (3). Higher incidence of acute hospital admissions among NH residents versus community dwellers has been reported (4). However, a systematic review by Arendts and Howard (5) showed that 40% of NH residents after being transferred to an emergency department were sent back to the NH without admission to hospital. Other published data on avoidable hospital admissions varies from 1.6% to 77% in different countries and settings (6), an Austrian study performed in 2015, reported a 22% rate of avoidable NH-to-hospital transfers (7, 8). Fluid and electrolyte imbalances (EI) are among health conditions that can be often prevented and to some extend managed locally at the NH. It has been previously acknowledged that prevention of electrolyte disorders in LTC facilities decreases unnecessary rehospitalisation rates (9–11).
In NHs, prevention of electrolyte imbalances goes hand in hand with prevention of other nonspecific complications such as malnutrition, dehydration, depression, cognitive decline or falls. However, there exist important nursing considerations that are explicit to the EI management. The aim of this review is to discuss the EI specificities, prevention, monitoring and perspectives in long-term care facilities with focus on NHs.


Specificities of Electrolyte Imbalances in Nursing Home Residents


Fluid and electrolyte imbalances have strong impact on morbidity and mortality rates in older adults. Hypo- as well as hyper states of sodium and potassium are often forms of EI, whereas other electrolyte disorders are less abundant (12, 13). Older people with diagnosed EI repeatedly attend the emergency department, exhibit increased hospitalization and a higher admission rate to NHs (14–17).
Decreased serum sodium, hyponatremia, is the most common EI in hospitalized patients (18) that is associated with high morbidity and mortality (19) and is particularly frequent in the institutionalized older adults (15). Choudhury and co-authors examined NH and older community residents with diagnosed hyponatremia during hospitalization and analyzed risk factors for adverse outcome of this EI. It was found that NH residents were 43-fold more likely to be hospitalized with hyponatremia (Na <135mmol/L) and 16-fold more likely to be admitted with serum Na <125mmol/L than older community patients (14). Miller et al. reported 18% prevalence of hyponatremia among NH residents, whereas solely a prevalence of 8% was recorded in the age-matched ambulant population. The incidence in this study for hyponatremia in NH residents was detected with 53% (20).
Hypernatremia (Na>145mmol/L) is another common EI associated with a high mortality rate (21, 22). In most cases increased serum sodium reflects total body water loss (23–25). In NH residents, hypernatremia is considered avoidable as it goes hand in hand with the prevention of dehydration. Despite this, dehydration was shown as a common reason of admission to hospital in NH residents (26, 27). Wolff et al. collected data from 21.610 emergency patients older than 65 years and determined a 10-fold higher prevalence of hypernatremia (Na>145mmol/L) in patients admitted from NHs compared to those living at their private homes. These NH patients were dehydrated at admission to the hospital and, as a result, appear to be at a significantly greater risk of in-hospital mortality (28).
High serum potassium, hyperkalemia (K>5.0 mmol/L), is a life-threatening electrolyte disorder that can lead to arrhythmias and sudden cardiopulmonary arrest (29). Previous studies in older adults with chronic kidney disease showed up to 50% incidence of hyperkalemia (30). However, no prevalence of hyperkalemia was directly acquired in NH residents so far and this disorder is mainly discussed in association with chronic kidney impairment and RAAS-targeting medications (renin-angiotensin-aldesterone system) (31). Hypokalemia (K<3.5 mmol/L) is occasionally seen in elderly patients and is often attributed to decreased potassium intake, loss through the gastrointestinal tract or urinary loss as a side effect of diuretic medication (21, 32, 33).
Hypokalemia is often associated with hypomagnesemia and hypocalcemia (34). Hypomagnesemia (Mg< 0.66 mmol/L) does not lead to clinically important symptoms until serum levels fall below 0.5 mmol/L. Life-threatening complications of hypomagnesemia arise when associated with hypostates of other electrolytes, such as calcium, phosphorus and potassium (35). The hypomagnesemia was found in 36% of the LTC patients; and amongst them 18% had severe hypomagnesemia (36). The same study found strong association between hypomagnesemia, hypokalemia, hypophosphatemia and hypokalemia and also increased mortality rates in EI-affected residents (36).

Dietary and hydration status

Dehydration and malnutrition were often reported in older adults (24, 37). Thirst response, taste sensation, appetite and food consumption decline with increasing age. Older people are less hungry, consume a smaller amount of meals, eat more slowly, have fewer snacks between meals and become satiated more rapidly after meals. NH residents may not like the offered food due to visual appearance, lack of variety or the inability to address individual food preferences (13). It was suggested that also social factors and psychological stress contribute to malnutrition and decreased fluid intake (38).
Dehydration is acknowledged as a frequently occurring issue among NH residents (39). Dehydration was also reported as one of the most common reasons for emergency hospitalization of NH residents (40). Impairments of mental health, such as dementia, can also affect the sense of thirst resulting in an insufficient liquid supply. A further contributing factor is the immobility to independently gain access to drinks (24). Even with adequate drinking, fluid volume deficits may result from polyuria related to chronical diseases like kidney failure or diabetes (41). Additionally to the abovementioned factors, NH residents may fail to obtain enough liquids as they are depended on water supply and the support in drinking by nursing personnel (28, 42). Contributing psychological factors like a new living situation or shame and fear to express intimate needs may lead to dehydration (40). Several excellent reviews describe the essential importance of drinking and eating especially for older adults and NH residents and thus addressing the complex and challenging matter for nurses to ensure the aforementioned (38, 43).


The prevalence of multimorbidity in NH residents was shown to reach up to 82% (44). The presence of multimorbidity strongly increases the risk to develop EI (45, 46). Clearly, acute and chronic kidney diseases lead to imbalances of all body electrolytes (24, 47). Diabetes mellitus was shown to be associated with hyponatremia and hypomagnesemia (48). Both hypertension and hypotension are strong risk factors for development of EIs. Chronic hypertension was identified as a significant risk factor for hypokalemia and hyponatremia (47, 48). Hypertension itself may also be not a cause, albeit a consequence of hypernatremia, hypercalcemia and hypomagnesaemia (49).The syndrome of inadequate antidiuretic hormone secretion is strongly associated with hyponatremia in the older population (24). Serious hypernatremia and hypomagnesemia may also be a result of an increased loss of water in course of acute infections, emesis or diarrhea (50). Among other important factors, swallowing difficulty (dysphagia), dental problems, alcohol abuse, impaired mental cognition (for example dementia), should alert nurses as these conditions are associated with an increased risk of developing EIs and dehydration (51). Another recurrent problem, urine and bowel incontinence, is a common condition in NH residents and a significant health problem. The prevalence of incontinence worldwide is ranging from 3% to 17% with a high rate of unrecorded cases (52). Frequently going to the toilet, particularly at night, can result in a heavy burden for older NH residents. Feelings of shame or anxiety can lead, consciously or unconsciously, to little or no drinking in order to reduce incontinence and toilet use. As a consequence this may lead to dehydration and sodium imbalance (16, 38).


NH residents with chronical diseases receive multiple medications. It was shown that more than 70% of NH residents from eight European countries obtain five or more medications regularly (53). Many medications commonly used in NHs may cause strong EIs: diuretic drugs, medicaments against cardiovascular diseases, analgesics, non-steroidal anti-inflammatory drugs, laxatives and antidepressants were shown to cause EIs (48, 54). It was revealed that administration of psychotropic drugs (phenothiazines, butyrophenones, benzodiazepines, tricyclics, serotonin-reuptake inhibitors), anti-epileptic drugs (carbamazepine, oxcarbazepine), anti-cancer drugs (prostaglandin-synthesis inhibitors, cyclophosphamide), opiate derivatives, thiazide diuretics and desmopressin are associated with hyponatremia, whereas lithium, vasopressin V2 receptor antagonists, loop diuretics and mannitol may induce hypernatremia (55). Thiazide and loop diuretics were also linked to hypokalemia as well as hypomagnesemia (48). Medications to treat hypertension (angiotensin converting enzyme inhibitors, renin inhibitors, angiotensin receptor blockers), heparin and nonsteroidal anti-inflammatory drugs were shown to interfere with urinary excretion of potassium (55).

Management of Electrolyte Imbalances in Nursing Homes

In many European countries, NHs are not required to employ GP and are not equipped with diagnostic and therapeutic resources (7, 8, 56). In Norway for instance, roles or duties of physician in NH are not specified in legal protocols and they are not obliged to provide medical service at all times (57). In Germany and Austria, NH residents can choose their physician freely but the availability of GP is often limited (8, 57, 58). Only 25% of German NHs were reported to have a contract with GP and accessibility of physician outside working hours is not organized (57). Thus, nursing personnel is solely responsible for residents’ care, prevention practices, early symptoms identification and communication with physician. Current EI management and perspectives in the NH setting are summarized in Figure 1 and discussed below.

Figure 1
Prevention and early detection of electrolyte imbalances. Risk assessment categories, additional tests currently available at NH, perspectives and outcome of EI management are illustrated

EI – electrolyte imbalance, NH – nursing home, BIA – bioelectrical impedance analysis, DRAC – Dehydration Risk Appraisal Checklist, MNA – Mini Nutritional Assessment, RAI-MDB – Resident Assessment Instrument RAI-MDB


Initial Management

A new admission into a NH is the essential moment to review and document resident’s medical history. In case of unclear documentation and/or cognitive impairment of residents, it is important to contact the family and GP. Medical history records have to include questions about chronic diseases, injuries, use and dosage of specific medication received up to the day of NH admission. In some cases existing prescription of medication might be reconsidered to decrease strong side effects and optimize the NH resident’s quality of life (59). Thorough analysis of NH resident medical history and protocol of current health status will not only support the estimation of a given risk for EI, but also in many cases help nurses to prevent potential future problems.
In clinical practice, it is recommended to regularly monitor serum electrolytes in diseased and older adults. Laboratory tests are performed in hospital settings or are prescribed by GP. However, diagnostic options, medical care and availability of GP at NHs vary among different countries and even within one county. Therefore, it should be recommended to perform blood/urine biochemical testing short after NH admission and also plan future monitoring schedules.

Monitoring and Prevention Practices

Regular practices should be applied locally in the NH settings in order to avoid unnecessary stress of hospital transfer. Moreover, NH nurses cannot rely on one-time procedure/test, but instead they should have the possibility to perform electrolyte EI checks at a regular basis in order to monitor changes. Thus, compared to hospital settings, the system of EI management in NHs may be absent or not clearly stated.
Nursing considerations in EI management include recognition of multiple factors, in case of noticed abnormalities interaction with/report to GP is obligatory:
• Assessment of hydration and nutrition status
dehydration and malnutrition can be prevented and to some extend improved by nursing stuff, assessment and monitoring can be performed in NH
assessment includes monitoring of food and fluid intake/output, body weight measurements, checking vital signs as well as skin, mouth and eye assessments, blood pressure and pulse rate, capillary and foot vein refill, and analysis of urine colour and volume (43);
hydration status can be also assessed by bioelectrical impedance analysis (BIA) and checklists /assessment tools such as Dehydration Risk Appraisal Checklist (DRAC) (60), The Mini Nutritional Assessment (MNA) (61) or as a part of more general assessment tools, for instance Resident Assessment Instrument RAI-MDB (62)
assessment can be performed monthly/weekly or more often according to the GP prescription for the high risk residents;

• Clinical signs and symptoms of dehydration
checking of dehydration clinical signs and symptoms can be performed in NH (see above); clinical signs include dryness of tongue, oral mucosa and/or lips, decreased saliva, dryness of skin and loss of elasticity, hypotonia of ocular globes, changes in urine including low volume, dark colour, increased pulse rate, low blood pressure, increasing confusion, lethargy, agitation or headache.

• Monitoring of kidney function
additional to weight/fluid monitoring, renal function laboratory values should be checked annually, interaction with GP is required for monitoring schedules and prescription

• Cardiovascular symptoms
blood pressure, pulse and heart rhythm measurements can be performed in NH

• Vital signs and neurological assessment
regular monitoring of vital signs can be performed in NH, nurses should be educated also about neurological signs of EIs and encouraged to check recurrently for warning signs

Education and Training

Since the capacity of NHs to manage EIs can be limited due to the absence of diagnostic equipment and lack of GP professional input, the role of nurses becomes indispensable (7,8,56). Nurses are often responsible for the decision-making of resident transfer to hospital. Previous studies showed that registered nurses (RNs) and to some extend assistant nurses (ANs) possess a high degree of self-responsibility in ensuring NH medical care and hospital transfer (63).
Insufficient geriatric knowledge of nurses results in difficulties in early sign interpretation and delays in symptom recognition. A critical review of nursing staff education showed a strong need to improve training in NH settings (64, 65). It has been documented that the professional knowledge of fluid and electrolyte balance amongst nurses is insufficient (66, 67). There is a major gap in the way EIs are managed (68) and nursing staff fail to appreciate the susceptibility of NH residents with electrolyte abnormalities to poor health outcomes (69). Our preliminary data from a survey performed among Austrian NH staff (RNs and ANs) revealed that 86% of nurses described their knowledge about body electrolytes as “insufficient” and 93% of participants have high interest in further professional training to this topic (our unpublished data).
Under these circumstances, prevention and early detection become crucial. As long as there is no legal obligation to organize regular presence of physician, more emphasis should be given on educational initiatives for NH nurses. Training courses should include information and advice relating the risk factors for EIs, drinking and dietary principles as well as possible complications. Nurses also need decision-support tools, strong interprofessional communication skills and possibility to contact GP at any time. Residents with re-occurring EI or recognized high risk to develop the latter should undergo regular assessments, which are preferably performed within the NH. Availability of point-of-care testing could provide a good opportunity for consistent electrolyte monitoring. Consequently, revision of the dietary plan and drinking protocols should be addressed. It is important not only to monitor for symptomatic improvement or signs of deterioration but also to track the rate of correction. It may also be suggested to establish robust outcome measures to assess the EI management within NH including hospital transfer rates, complication rates, residents’ mortality and costs calculation.


Conclusions and Perspectives

Older residents of NH are at high risk to develop EIs. Compared to hospital settings, EI prevention and management in NH is the responsibility of nursing personal. Regular assessments performed locally in NH, additional educational and training initiatives for nursing personnel and improved interprofessional communication are strongly suggested to ensure good quality of long-term care in NH settings.


Methods, Data Sources: Search was performed in MEDLINE/PubMed and CINAHL databases. Key search terms associated with electrolyte imbalances including hyper- and hypo-states of sodium, potassium and magnesium were utilized in the subject search in combination with nursing homes, long-term care and older adults. The full texts of research papers were reviewed prior to their inclusion according to the Strobe guidelines.

Conflict of Interest Disclosure: All participating authors declare no conflict of interest

Acknowledgment: We want to thank Dr. Sandra Schaffenrath for writing assistance, language editing, and proofreading of the manuscript.



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A.M. Foiles Sifuentes, K.L. Lapane

Department of Population and Quantitative Health Sciences University of Massachusetts Medical School, Worcester, USA; Both authors contributed to the manuscript equally.

Corresponding author: Kate L. Lapane, PhD, MS, Associate Dean, Clinical and Population Health Research,Division Chief and Professor of Epidemiology– Department of Population and Quantitative Health Sciences University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA  01655, USA, Phone:  508-856-8965, Fax: (508) 856-8993, email:  Kate.Lapane@umassmed.edu

Jour Nursing Home Res 2020;6:1-5
Published online February 28, 2019, http://dx.doi.org/10.14283/jnhrs.2020.1



A “silent epidemic» of oral diseases is afflicting older adults. Older adults develop coronal caries at “approximately one new cavity per year”. Despite the rapidly growing older adult population, no recent data exist for adults aged ≥ 75 years. Oral disease impacts physical, psychological, and social well-being through pain, diminished function, and reduced quality of life. People of color disproportionately experience oral disease, yet little is known about racial/ethnic disparities in older adults. In the United States, the Health and Human Services Oral Health Strategic Framework proposed concrete steps to eliminate oral health disparities. Notably absent from this strategic plan is explicit consideration of nursing home residents. In the United States, federal regulations require nursing homes to evaluate oral health needs and facilitate access to dental care. Compliance to the regulations is unknown. Data are urgently required to provide essential information for program planning and evaluation on “racial and ethnic minorities, rural populations, and the frail elderly”.

Key words: Nursing homes, oral health, dental, dental caries, edentulism.



Across the globe, the age distribution of the general population has changed dramatically over the past century. For example, in the United States, 14% of the population is aged ≥ 65 years (1).  By 2030, this proportion is expected to increase to 20%, with 5% over age 80 years (2).  By 2050, one in four Americans will be aged ≥65 years (3) with those over ≥85 years reaching 17.9 million (4, 5). Communities of color are expected to grow over the coming decades (6).
A “silent epidemic» of oral diseases is looming and our most vulnerable segments of society, older adults, are at greatest risk (7). In the United States, older adults develop coronal caries at a rate of “~one new cavity per year” (8, 9). Despite the rapidly growing older adult population, data for adults aged ≥ 75 years are lacking. For example, in the United States, the most recent national estimate is decades old and indicates that 37.9% of adults aged ≥ 75 years have untreated coronal caries. Further, people of color disproportionately experience oral disease, yet little is known about racial/ethnic disparities in older adults (10).  Oral health is an often forgotten, modifiable risk factor that could reduce pervasive and persistent racial/ethnic health disparities.
This article reviews information regarding oral health in nursing home settings. The purpose of the paper is to shed light on a serious, yet understudied issue afflicting nursing home residents. We review the link between oral health and overall health, describe the changing oral health needs of older adults, review the importance of nursing homes as a health care setting, review information regarding oral health care needs in nursing homes, summarize the challenges facing nursing home staff to provide dental hygiene, and discuss regulations relating to oral health of nursing home residents. We conclude with a call for more information regarding oral health in nursing homes.

Oral health is important to overall health

Oral disease impacts physical, psychological, and social well-being through pain, diminished function, and reduced quality of life (11). Robust evidence supports the notion that there is an increased risk of atherosclerotic vascular disease among people with chronic periodontitis (12), and that dental disease affects pulmonary health (specifically COPD and pneumonia) (13). Indeed, orofacial pain may be the sole symptom of stroke in some patients (14). A systematic review also supports the link that periodontal disease, tooth loss, and oral cancer are associated with diabetes (15). Further, the review noted that periodontal care appears to have a short-term, but not a long term beneficial effect on metabolic outcomes (16). Lastly, a systematic review demonstrated that dental hygiene is associated with dementia and that gingivitis, dental caries, tooth loss, edentulousness may be linked increased risk of developing cognitive impairment and dementia (17).

Oral health needs changing

With the aging of the “baby boomers”, shifts in oral health needs are expected. Although the rate of edentulism is falling, there now exists a higher risk for root caries with increasing age (18).  More complex dental care may be needed by the aging “baby boomers” (19).  For example, in the United States, Medicare beneficiaries have coverage for 22 preventive screenings, but Medicare Parts A and B do not cover dental care (e.g., dental procedures, cleanings, fillings, tooth extractions, dentures, dental plates). Among adults ≥ 65 years of age, 21.8% of non-Hispanic Whites, 40.7% of Black/African Americans, and 34.4% of Latinos had untreated dental caries, nearly half did not have a dental visit in the past year (range: 43% Whites to 71% Blacks) (20, 21). In 2016 among a non-institutional population, 7.9% of adults aged 65-74 years, and 5.7% of those ≥ 75 years old were unable to receive needed dental care because of cost (22), estimates that doubled in recent years with racial/ethnic minorities at greater risk (23).  Oral health is an often forgotten, modifiable risk factor that could reduce pervasive and persistent racial/ethnic health disparities. Older adults have medical conditions (e.g., diabetes, cardiovascular disease), that worsen oral health, and vice versa (24). Poor oral health is the most prevalent risk factor for malnutrition (25). Oral health care reduces the risk of aspiration pneumonia (26).

Nursing homes are an important health care setting

With the aging of the population (27), nursing homes are an increasingly important site of care. There are ~16,000 regulated nursing homes in the United States, with ~1.67 million certified beds (28). Multiple comorbidities often necessitate long term care and currently, about 1.4 million people reside in nursing homes (29). The average length of stay for long-stay nursing home residents is 2.3 years and for the ~3 million short-stay post-acute care residents, the average length of stay is ~28 days (30). While the national health insurance program for older adults in the United States – Medicare – is the primary payor for post-acute care, state-level Medicaid programs predominantly pay for nursing home care (31). The number of nursing home residents are anticipated to increase (32).  Informed by the Institute of Medicine reports, Advancing Oral Health in America (33) and Improving Access to Oral Health Care for Vulnerable and Underserved Populations (34),  the Health and Human Services Oral Health Strategic Framework proposed concrete steps to eliminate oral health disparities (35). Notably absent is explicit consideration of nursing home residents, despite the need for oral health research in this vulnerable population.

Oral health and nursing home residents

Of those 1.4 million living in nursing homes, only 16% receive oral care with 15% being reported as having very good or better oral hygiene (36). The oral care received by residents consisted primarily of tooth brushing that lasted approximately 1.25 minutes. Sloane, Zimmerman, Chen, et al (2013) conducted a patient-centered of oral health care program in nursing homes (n=3) and found that adequate oral care required 6 minutes to brush, floss, clean, etcetera, in order to maintain oral health (37). A random sample of nursing home residents with dementia or in hospice (n=506) over 14 nursing homes in North Carolina found that plaque covered more than 1/3 of tooth surface and 50% or more of denture surfaces (15). A 2018 study of nursing home care providers (n=195) in Japan suggested that caregivers in tested facilities (n=8) learned dental knowledge on a case-by-case basis while working with residents. The study found that professional training was required to prepare caregivers to adequate address the oral health needs of residents (25).

Nursing home staffing may not be prepared to provide oral health care

Oral health is “disturbingly… misunderstood or neglected” in general and more so in elderly adults with dementia and institutionalized individuals (38). A federal report noted that nursing homes have limited capacity to deliver needed oral health services and most nursing home residents are at an increased risk for oral diseases (39). Direct care staff members in nursing facilities include registered nurses (RNs), licensed practical nurses (LPNs), licensed vocational nurses (LVNs), certified nursing assistants (CNAs), and nurses aides-in-training (40). Nursing homes are an important employer for nurses. For example, in the United States, ~8% of RNs and one-third of LPN and LVNs are employed by nursing facilities (41).  In nursing homes, it has been estimated that more than half of nursing staff are CNAs (42). CNAs are the direct care staff responsible for helping residents (most of whom are frail) carry out basic activities of daily living. The extent to which dental hygiene training is widespread among nursing home staff is unknown. Furthermore, staff turnover can be quite high in this setting. For example, within the United States, 38% of nursing home staff expect to leave their position within 2 years (43).  Turnover likely contributes to insufficient training of direct care staff (44, 45). Additional staff dedicated to dental hygiene may be prudent. In a study comparing in-person assessments of nursing home residents to MDS, under-reporting was noted with the gingivitis assessment and with tooth fragments and edentulism (46).  The MDS underwent an oral health revision from the MDS 2.0 to the MDS 3.0 and the American Dental Association made guidelines recommendations for training and assessment. A recent study provided evidence that regular professional brushing every 2 weeks by a dental nurse improves oral health in nursing home residents and can reduce the development of root caries incidence (47).

Federal mandates regarding oral health in nursing homes in the United States

Federal regulations require nursing homes to evaluate oral health needs and facilitate access to dental care (48).  Compliance to federal code is unlikely; nursing homes have limited capacity to do so (49). The seminal Surgeon General’s Report on Oral Health in America acknowledged nursing homes role as the primary source of oral health care for its residents and highlighted nursing homes as a target for implementing programs to improve oral health. In the nearly twenty years since the Surgeon General’s Report (50), no national data in the United States on oral health of nursing home residents exist. The US Code of Federal Regulations (CFR) requires that all nursing home facilities: 1) conduct an oral health assessment (on admission and periodically thereafter); 2) meet residents routine and emergency dental service needs (using outside resources); 3) facilitate residents requesting dental appointments to make appointments, arrange for transportation, and apply for dental service reimbursement; and 4) refer residents with lost or damaged dentures within three days (51). Nursing homes are not required to provide routine dental services for all residents. Regulatory guidance states that nursing homes must provide routine dental services to the extent that they are covered under the State Medicaid plan.

Coverage of dental services

In the United States, Medicare is the national health insurance program for older adults and those with disabilities. Routine dental care is not covered by Medicare. As a result, the majority of older adults lack dental insurance which reduces access to dental care or leaves people to endure high expenses for dental care. For those who are covered by Medicaid (~70% of long stay nursing home residents), depending on which state they live in, they may have dental insurance coverage (52). Each state decides whether their Medicaid plans cover routine dental services. In 2016, about one third of the United States provided extensive dental benefits defined as a comprehensive mix of services, including more than 100 American Dental Association approved diagnostic, preventive, and minor and major restorative procedures with per-person annual expenditure caps ≥$1,000 (53). Approximately another third provided limited benefits, with only a handful of states provided no dental benefits at all (54). The remainder of states provided emergency dental benefits.

Compliance to nursing home regulations

State surveyors conduct annual nursing home inspections that are guided by the F-Tags (55). Only two F-Tags exist for oral health and these relate to Routine/Emergency Dental Services (skilled nursing facilities Medicare F-Tag 790; Medicaid F-Tag 791). The Interpretive Guidance states that blanket facility policies of non-responsibility do not meet the federal requirement, nor do policies claiming the facility is only responsible when the dentures are in actual physical possession of facility staff (56).  Surveyors may visually observe the lack of or poorly fitting dentures or broken/decaying teeth. Facilities are encouraged to have “a sound system” for annual dental exams and routine monitoring to identify changes in a resident’s dental care needs (57). For some areas of care quality, facilities are motivated to change practices because the inspections are available to consumers on the Nursing Home Compare website (58).  Not so for oral health measures.
Research on whether or not nursing homes across the nation adhere to federal regulations is scant. On a national level, studies on the extent to which nursing homes are being cited for deficiencies based on F-Tag 790 and/or 791 and facility factors associated with deficiencies have not been conducted. In one state, half of nursing homes had written care plans for resident dental needs and dental professionals reviewed written policies in only 13% of homes. Twenty-eight percent of nursing homes do not conduct oral assessments at admission, and when dental assessments were done, 90% were completed by a charge nurse (42%) or other registered nurse (15%) (59).  Federal regulations fall short of naming which provider type should conduct oral health assessments. Typically, certified nursing assistants with little or no training in oral health assessment conduct oral health assessments in nursing homes (60). A national template for nursing home administrators and dental professionals for standardized dental screenings completed by dental professionals at nursing home admission has been proposed (61).
A single state, observational study found that only 16% of residents (N=67) received mouth care (62), in part because many residents resist oral health care (e.g., residents with Alzheimer’s disease and other related dementias). In a study conducted in 14 nursing homes in North Carolina, on average, plaque covered more than 1/3rd of the tooth surface and plaque covered >50% of denture surfaces (63). Mild gingival irritation was often present (64). High risk subgroups of poor oral health included those in hospice, with Alzheimer’s and other related dementias, and long stay residents (65). Despite oral health being a modifiable risk factor for many adverse health outcomes in older adults, nursing home staff lack awareness of the health benefits of good oral hygiene (66). The lack of dentist availability and cost are barriers to dental care in community dwelling older adults is unknown. The geographic distribution of dentists varies substantially and the variation in dental visits across the rural-urban continuum are shocking. The number of dentists per 10,000 population ranged from 4.2 (Alabama) to 10.8 (District of Columbia) (67). Dental fees can vary widely, even in the same community (68). In 2011, the Institute of Medicine noted that dental coverage is positively tied to access to and use of oral health care, but the extent to which applies to nursing home residents has not been studied.



Contemporary data to describe oral health among long stay nursing home residents is urgently needed. In addition, research to estimate the association between organizational characteristics (e.g., staffing, presence of a full-time medical director, cited deficiencies in delivery of oral health care) and area-based factors (e.g., market-level racial segregation of nursing homes, Medicaid generosity of dental benefits, availability of dentists) on oral health decline experienced by nursing home residents could inform interventions to improve oral health in nursing home residents. Research is needed to characterize the barriers and facilitators of oral health care for nursing home staff regarding employer-based oral health care training and daily oral health care practices of nursing home residents. Exploratory work is also needed to inform the development of interventions aimed at improving oral health care among older adults residing in nursing homes. In the United States, we believe such foundational knowledge will be essential to design strategies to reduce racial disparities in oral health in nursing homes.


Funding Sources and related paper presentations: This work was funded by a grant to Dr. Lapane from the National Council on Advancing Translational Science (NCATS) (TL1TR001454). There are no related paper presentations to report.

Conflict of interest: The authors have no conflicts of interest to disclose.

Ethical standard: This paper is a narrative review and as such did not require review by an Institutional Review Board.



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C.M. Ulbricht1 , J.N. Hunnicutt2 , A.L. Hume3, K.L. Lapane1,2


1. Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA; 2. Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA USA; 3. Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI,  USA. Corresponding author: Kate L. Lapane, PhD, 368 Plantation Street, AS6th floor, Worcester, MA 01605 USA, Email: kate.lapane@umassmed.edu, Phone: 508-856-8965, Fax: 508-856-8993

Jour Nursing Home Res 2019;5:40-48
Published online July 1, 2019, http://dx.doi.org/10.14283/jnhrs.2019.8



Background: Depression, anxiety, and pain are commonly experienced by older adults living in nursing homes. Objectives: To describe the prevalence of depression, anxiety disorders, and pain among newly admitted nursing home residents in the United States and to describe the treatment of these disorders. Design: Cross-sectional study of newly admitted residents. Setting: Residents able to complete a pain assessment (n=783,826) living in Medicare- and Medicaid-certified nursing homes in the United States in 2011-2012. Measures: Measures of sociodemographic, mood and behavior, pain, diagnoses, and functioning items from the Minimum Data Set (MDS) version 3.0. Results: Approximately 36% of residents had a diagnosis of depression (other than bipolar disorder) and/or an anxiety disorder (n = 272,311). Of these residents, 25.2% had both depression and an anxiety disorder (95% CI = 25.0-25.4%), 54.3% (95% CI = 54.1-54.5%) had depression without an anxiety disorder, and 20.5% had an anxiety disorder without depression (95% CI = 20.3-20.6%). Fifteen percent had the triad of depression, anxiety, and pain at admission (95% CI = 9.3-23.3%). Depressive symptoms were more commonly reported by residents with pain than by those without pain. Receipt of psychological therapy (range: 0.9%-2.0%) or any psychiatric medication was lacking (range: 35.3%-48.5%), regardless of pain status. Participants reporting pain received a combination of scheduled, pro re nata (PRN)/as-needed, and non-medication pain interventions (range: 59.8% depression without anxiety to 62.9% depression and anxiety disorder). Conclusion: Residents often suffer from combinations of depression, anxiety, and pain at admission to nursing home. While treatment of pain is more common than treatment of psychiatric treatments, both psychiatric treatment and pain management may be suboptimal in nursing homes..

Key words: Nursing homes, major depressive disorder, anxiety, pain.



Depression (1), anxiety (2), and pain (3) are commonly experienced by older adults living in nursing homes. It has been estimated that 11.0% of older adults admitted to nursing homes had depression in 1999 whereas the prevalence of depression had been estimated to be as high as 51.8% for older nursing home residents in 2007 (1, 4). Estimates of the prevalence of anxiety in nursing home residents has varied from 3.2% to 20% (2). Up to 80% of nursing home residents experience pain (3). The wide variation in these estimates is likely due to differences in study sample selection and how each condition or disorder is defined and measured (2, 5, 6). Depression, anxiety and pain are each independently associated with distress, impaired functioning, worse outcomes for additional multimorbid conditions, increased health services use, higher total healthcare costs, and mortality (7). These conditions, either individually or together, often remain undiagnosed and unsuccessfully treated (8). Furthermore, while these disorders have been observed to co-occur frequently in community-dwelling adults (9), few studies have examined multimorbid depression, pain, and anxiety among older nursing home residents and thus the extent to which nursing home residents experience all three conditions simultaneously is unclear (10).
While the appropriate assessment and management of depression, anxiety, and pain are widely recognized goals in nursing homes (11), successful management of these conditions is hampered by the general complexity inherent in treating multimorbidity; a lack of research focusing on simultaneously occurring depression, anxiety, and pain (10); and an insufficient knowledge about effective interventions in this population of older adults (12). Addressing multimorbidity is necessary to improve overall psychiatric and physical health. Comorbid anxiety with depression might hinder symptom remission as antidepressant treatment response appears to differ by the presence of anxiety and those with anxious depression are more likely than those with depression without anxiety to discontinue treatment (13). Additionally, undertreatment of pain in the nursing home setting persists (14) and lack of receipt of analgesics has been associated with depressed mood and anxiety (15).
Despite the recognition of the importance of addressing these conditions in older adults, little is known about the current prevalence and treatment of depression, anxiety, and pain in nursing homes. Nursing home residents are routinely excluded from US population-based surveys and the clinical trials that form the basis of treatment guidelines. Previous observational studies have differed in years of data collection; depression, anxiety, and pain assessment.
Using the national Minimum Data Set 3.0 (MDS 3.0), the objectives of this descriptive study were to: 1) estimate the prevalence of multimorbid depression, anxiety disorders, and pain in newly admitted nursing home residents; 2) describe the sociodemographic and clinical characteristics of residents by psychiatric disorder and pain status; 3) examine receipt of psychiatric treatment by psychiatric disorder and pain status; and 4) describe characteristics of pain by psychiatric disorder. We hypothesized that depression, anxiety, and pain would frequently co-occur and that residents experiencing this triad would be less likely than those not experiencing all three conditions to receive relevant psychiatric treatment and pain management.



Data source

We used data from MDS 3.0 from 2011-2012. The MDS is a comprehensive clinical assessment that is federally mandated to be completed for all residents of Medicare- and Medicaid-certified nursing facilities in the United States. MDS 3.0 contains more than 450 items pertaining to disease diagnoses, health conditions, treatments, and functional and cognitive status. Assessments are conducted on admission, quarterly, and annually thereafter and if there are substantial changes in a resident’s health status. The assessments are conducted by registered nurses and other facility staff, who review residents’ medical records and use a validated instrument to evaluate their health (16). The MDS is intended to be used by stakeholders not only as an assessment tool but also for care planning. The Institutional Review Board at the University of Massachusetts Medical School approved this study.


We identified residents with MDS assessments performed at admission between 2011-2012 who were 65 years of age or older; were non-comatose; were not admitted to a swing bed provider; did not have intellectual or developmental disabilities; and were able to self-report pain presence. Of the 759,055 residents who met these criteria, 35.9% (n = 272,311) had a documented active diagnosis of depression (other than bipolar disorder), anxiety disorder, or both upon admission and were included in this study.


Depression and anxiety disorders

Depression (other than bipolar disorder) and anxiety disorder diagnoses were ascertained from the Active Diagnoses section of the MDS 3.0. A diagnosis is considered active if 1) it has been documented by a physician in the last 60 days; and 2) has a “direct relationship to the resident’s current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.” In addition to depression being documented as an active diagnosis, depressive symptoms and severity within the previous two weeks were assessed with the Patient Health Questionnaire-9 (PHQ)-9 (17). Symptoms were considered present for the purposes of this study if they bothered the resident for any amount of time within the two weeks prior to the interview.

Psychiatric treatment

Treatment with antidepressant, antianxiety, hypnotic and antipsychotic medication is assessed in a checklist in the Medications section of the MDS. Use refers to medications received by the resident at any time during the previous seven days or since admission if admission was less than seven days before the MDS assessment was conducted. The resident’s medical record and documentation from other health care settings that may have provided medication to the resident during the look-back period are reviewed to complete this section. Receiving any pharmacological psychiatric treatment was defined in this study as treatment with any antidepressant, antianxiety, hypnotic, and/or antipsychotic medication.
The receipt of psychological therapy by any licensed mental health professional is documented in a checklist in the Therapies subsection of the Special Treatments, Procedures, and Programs section. To be included in the MDS, therapy must be medically necessary, occur after admission, and documented in the resident’s medical records. Therapy could have been provided inside or outside the nursing home.


The pain assessment interview portion of the MDS 3.0 evaluates pain presence (yes/no). Pain frequency (almost constantly, frequently, occasionally, or rarely), difficulty sleeping due to pain (yes/no), limitation of daily activities because of pain (yes/no), and pain intensity is noted for all residents who endorse having pain or hurting. Pain intensity refers to the worst pain over the previous five days and is measured either with a numeric rating scale that is scored 1-10 with 10 being the worst pain or a verbal descriptor scale (mild, moderate, severe, and very severe/horrible). Both instruments can be summarized as a four-point ordinal scale where a score of one = mild and a score of four = very severe pain. Pain management is also recorded, based on review of medical records. It is noted if a resident has been on a scheduled pain medication regimen, received pro re nata or as- needed (PRN) pain medications, and received non-medication intervention for pain. This is done for all residents, regardless of level of pain. All items for pain have a five-day look back period. The accuracy of subjective measures such as pain has been improved in the MDS 3.0 (17).

Additional sociodemographic and clinical characteristics

Sociodemographic characteristics of interest include gender, age group, race/ethnicity, and marital status (married, other). Clinical characteristics include functional impairment, cognitive impairment, and active diagnoses of comorbid conditions commonly associated with pain and/or depression and anxiety. Functional impairment in activities of daily living was measured with the MDS-ADL Self-Performance Hierarchy. The MDS-ADL Self-Performance Hierarchy assesses the resident’s need for assistance with four activities of daily living (ADLs): personal hygiene, toileting, locomotion, and eating. Dependence required with ADLs indicates that full staff assistance was required for “one or both of eating and locomotion” every time the activity occurred during the 7-day lookback period. Total dependence means that full staff assistance with hygiene, toileting, locomotion, and eating was required every time each activity was occurred during the lookback period. The Cognitive Function Scale (CFS) was used to evaluate cognitive impairment. The CFS relies on the Brief Interview for Mental Status (BIMS) for residents who were able to self-report and the Cognitive Performance Scale (CPS) for those who were not able to complete the BIMS and received a staff assessment. Comorbid conditions were assessed similarly to depression and anxiety diagnoses, as described above.


The overall goal of this study was to provide descriptive information relating to depression, anxiety, and pain. As such, we estimated descriptive statistics pertaining to the demographic and clinical characteristics of newly admitted nursing home residents with depression, anxiety, or both. Ninety-five percent confidence intervals (CI) for the prevalence of depression and anxiety disorders were estimated using standard formulas. Analyses were stratified by psychiatric disorder and presence of pain as appropriate. Differences in psychiatric symptoms, receipt of psychiatric treatment, pain characteristics, and pain treatment between those experiencing the triad and those who were not were evaluated with χ2 tests. Because even minor differences can achieve statistical significance in studies with very large sizes, we considered an absolute difference of at least 5 percentage points to indicate clinically notable differences across the groups.



Prevalence of concurrent depression and anxiety disorders

Of the 272,311 nursing home residents with a diagnosis of depression or an anxiety disorder eligible for this study, 25.2% (95% CI = 25.0-25.4%) had an active diagnosis of both depression and an anxiety disorder, 54.3% (95% CI = 54.1-54.5%) had an active diagnosis of depression without anxiety disorder, and 20.5% (95% CI = 20.3-20.6%) had an anxiety disorder without depression.
Characterization of depression/anxiety groups
Table 1 shows the descriptive statistics for the nursing home residents stratified by the groups of depression and anxiety diagnoses (both, depression but no anxiety, anxiety but no depression). Across all groups of depression and anxiety, the average age was 81.2 years (standard deviation (SD): 8.2 years), which ranged from 80.8 years (SD: 8.2) for residents with both depression and an anxiety disorder to 82.1 years (SD: 8.3) for those with an anxiety disorder but not depression. Regardless of the depression/anxiety group, most residents were women (range: 66.6-76.6%), nearly one third were married (29.7-32.1%), and few were African American (3.5-6.6%). Most residents were admitted from an acute hospital (57.3%-63.1%).

Table 1
Sociodemographic and Clinical Characteristics of Newly Admitted Nursing Home Residents
by Psychiatric Disorder (n = 272,311)

*Depression other than bipolar disorder; †MDS-ADL Self-Performance Hierarchy (Morris et al., 1999); The categories “extensive 1” and “extensive 2” were combined to form this category; ‡ Categories provided by CMS derived from the Cognitive Performance Scale (CFS) or Brief Interview for Mental Status (BIMS): none or mild = BIMS 13-15 or CPS 0-2; moderate = BIMS 8-12 or CPS 3-4; severe = BIMS 0-7 or CPS 5-6 (CMS: Centers for Medicare and Medicaid Services, 2015, Nursing Home Data Compendium, 2015 Edition; BIMS; Saliba, Buchanan et al., 2012; CPS: Morris et al., 1994); Missing: gender: n = 53; marital status: n = 5,141; race/ethnicity:  n = 5,696; ADL: n = 23.


Comorbidities were common across all groups. Dementia was the most frequent neurological condition, regardless of depression/anxiety group (26.3-31.2%). Hypertension affected the majority of these residents (75.3-78.0%). Arthritis was the most common musculoskeletal condition (30.3-35.3%) and was most commonly documented for residents with both depression and anxiety disorder. The prevalence of diabetes was highest for residents with depression but not an anxiety disorder, 34.1% of whom had a documented diabetes diagnosis (26.0-34.1%). Slightly more than a fifth of all residents had severe limitations with activities of daily living, with 20.3-21.9% of residents being dependent or totally dependent on assistance. Almost half of all residents had intact cognition or mild cognitive impairment upon admission (44.9-46.8%). Pain was common within each group, with more than half of residents having documented pain (range: 53.0-59.6%). Fifteen percent of all residents who were eligible for this study had the triad of depression, anxiety, and pain at admission (95% CI: 9.3-23.3%).

Depression characteristics

Individual depressive mood symptoms and depression severity from the self-reported PHQ-9 are presented in Table 2. Across the depression and anxiety groups, those in pain were more likely than those not in pain to report insomnia/hypersonmnia (15.7-18.9% vs 9.5-11.6%), fatigue (27.3-31.7% vs 18.8-21.5%), and eating too much or too little (13.3-15.3% vs 8.4-9.4%). The majority of all residents had minimal depression (62.4-77.4%) although residents in pain reported more severe depression than residents without pain.

Table 2
Depressive Mood Symptoms and Severity by Psychiatric Disorder and Pain Status

Missing individual PHQ-9 items: depression & anxiety disorder, n = 3,750; depression without anxiety disorder: n = 8.189; anxiety disorder without depression, n = 3,594; Missing PHQ-9 depression severity: depression & anxiety disorder, n = 3,930; depression without anxiety disorder, n = 3,853; anxiety disorder without depression: n = 1,876.


Treatment of depression and anxiety

As displayed in Table 3, lack of psychological treatment was common for these residents despite all having documented active diagnoses of depression and/or anxiety. This did not differ by pain status. Psychological therapy was rare, with only 0.9-2.0% of residents receiving any number of minutes of therapy. More than a third of the residents did not receive any psychiatric medication (range: 35.3-48.5%), with residents with anxiety disorders only being the least likely to receive treatment (45.5% of residents with pain, 48.5% of residents without). Approximately one quarter of residents with both depression and an anxiety disorder received both antidepressant and antianxiety medications (25.8% of residents with pain, 22.7% of residents without pain). Of the residents with depression only, 40.8% with pain and 41.7% without pain received an antidepressant alone. The psychiatric treatment most commonly received by residents with a diagnosis of an anxiety disorder without depression was antianxiety medication alone (27.7% of residents with pain, 23.9% of residents without pain).

Table 3
Psychiatric Treatment Received by Psychiatric Disorder and Pain Status


Pain characteristics

Table 4 shows that pain occurred almost constantly for 12.8-15.4% of the residents reporting any pain within the five days prior to the assessment. Slightly more than one-quarter of the residents reporting said that pain had made it difficult to sleep (range: 25.2-29.8%). Daily activities were also reported to be limited by pain for more than a third of residents (range: 37.3-40.2%). The worst pain over the previous five days was reported to be of moderate to severe intensity for the majority of residents. More than half of residents reporting pain (range: 59.8-62.9%) received a combination of scheduled and PRN pharmacological pain management and non-medication intervention. Few residents in pain did not receive any pain management (range: 4.8-6.0%).

Table 4
Characteristics of Pain for Residents Reporting Pain Stratified by Depression/Anxiety Disorder (N = 151,283)

Missing: frequency: n = 2,391; affects sleep: n = 2,528; affects daily activities: n = 2,996; intensity: n = 3,694; management: n = 633.



This study identified depression and anxiety as being prevalent and commonly co-occurring disorders among older adults newly admitted to nursing homes. Approximately half of all of these residents also reported being in pain. Psychiatric treatment was lacking for these vulnerable older adults with 40% were not receiving any psychiatric medication or psychological therapy. Those with anxiety disorders without depression were the least likely to receive such treatment. The triad of depression, anxiety disorders, and pain was particularly prevalent among these older adults. Most reported that the worst pain over the previous five days ranged from moderate to severe intensity. Analgesic agents were employed for the majority of these residents who reported pain, with a combination of pharmacological treatment being the most commonly utilized strategy.
That almost 36% of older adults had an active diagnosis of depression and/or an anxiety disorder upon admission to a nursing home is in accordance with previous studies in nursing homes (18). The substantial multimorbidity between depression, anxiety, and pain in our study is also consistent with the growing body of research examining the increasing multiplicity of chronic diseases experienced by an aging population, especially those residing in nursing homes (19).While depression appears in 40% of patterns of chronic co-morbid medical conditions observed in older adults in U.S. nursing homes (20), less is known about the simultaneous occurrence of anxiety and pain, the directionality of this multimorbidity that was documented for 14% of residents with an active diagnosis or depression and/or anxiety disorder included in this study, and how best to treat these residents.
Disentangling the commingled effects of pain, depression, and anxiety is difficult. Pain is a risk factor for developing both depression and anxiety and can exacerbate psychiatric symptoms (21). Moreover, depression and anxiety increase the risk of experiencing pain and can also adversely affect pain outcomes such as intensity (22). As such, the complex interplay of these conditions likely needs to be addressed in a comprehensive fashion to improve residents’ quality of life. Treatments which incorporate strategies for addressing all of the components of this triad might be most effective than approaches that address depression, anxiety, and pain separately.
Although providing successful treatment in this population is a complicated issue, it was somewhat surprising to see that 35.3-48.5% of residents in this study did not receive psychiatric treatment, especially given the morbidity and mortality associated with inadequate treatment of psychiatric disorders and the emphasis on depression as a measure of nursing home quality. Although pharmacologic management of depression in nursing homes is common in some states, evidence from clinical trials in this population is limited and the effectiveness of antidepressants may be modest (23). Poor antidepressant treatment response is associated with a more severe and chronic course of depression and with comorbid psychiatric disorders, particularly anxiety. Treating depression by itself may improve quality of life and functional impairment, anxiety, pain, functional impairment, and diabetes for community-dwelling older adults and nursing home residents.
While these residents all had an active diagnosis of depression and/or an anxiety disorder, it is unknown how or when the diagnosis was originally made and thus the residents’ need for active treatment remains unclear. Somatic mood symptoms such as sleep problems, lack of energy, and appetite issues were reported by more residents with pain than without pain, regardless of psychiatric disorder, in this study. Many of the new residents were admitted from a hospitalization and we were unable to determine if pharmacological treatment for depression and anxiety was discontinued during the hospital stay. While the PHQ-9 has been validated for use in a variety of populations (24), including being preliminarily validated in for nursing home populations (17), there are concerns that it may not accurately identify depression in older nursing home residents. Not only are older adults with depression more likely than younger adults to present with somatic symptoms not included in the PHQ-9 and other depression instruments (25)but pain can also impact item response in geriatric depression assessments (26). Research on how best to assess depression and anxiety in older adults with multiple intersecting comorbidities, as are typically seen in nursing homes, would be valuable for informing treatment efforts.
Despite almost all residents reporting pain in the prior five days received some form of pain management, approximately half of all the included residents said that they had experienced pain almost constantly or frequently over the previous five days. Furthermore, 25.2-29.8% of residents in pain reported sleep difficulties due to pain and 37.3-40.2% of residents reported functional limitations because of pain. While the cross-sectional nature of the data in this study limit our ability to determine temporality between the occurrence of pain and receipt of management, this may indicate potential undertreatment of pain. This would be consistent with previous research of pain management in the nursing home setting. Such pain management issues may be in part due to uncertainty about the long-term safety and efficacy of common analgesics and a lack of knowledge about both the course of common pain syndromes and the effectiveness of interventions to improve pain management (27). In nursing homes, systematic approaches to pain management are needed to understand how different types of treatment can improve pain management for residents (28). These approaches might include care pathway algorithms with dose, duration, and schedule of pain treatments.
Our work has several strengths and limitations that must be considered. This study is a national study on a topic which to our knowledge has not been explored. We relied on documented active diagnoses of depression and anxiety, which could have led to underestimating the prevalence of these disorders. The MDS 3.0 does not contain a screening instrument for anxiety disorders. Because of this, we did not examine the PHQ-9 as a screener for probable major or minor depression. Psychiatric disorders are routinely underdiagnosed in general and older adults may be less likely to be properly diagnosed given that they tend to present with somatic symptoms that are sometimes misattributed to normal aging (25). It is also possible that pain is underestimated in nursing home residents, especially for those with psychiatric disorders (10), although pain measurement has been improved in MDS 3.0 relative to MDS 2.0.
Although this study attempted to capture depressive symptoms that did not occur frequently enough to formally qualify as significant enough to warrant a depression diagnosis by examining PHQ-9 items that were endorsed as present with any frequency, MDS 3.0 does not uniformly capture symptoms of depression and anxiety that do not meet formal diagnostic criteria but may still be clinically significant. The MDS 3.0 now includes the PHQ-9, which is an advantage of this study. A systematic review of 18 studies also concluded that clinically significant anxiety symptoms among older adults living in residential aged care facilities were more frequent than threshold anxiety disorders (2). Estimates of subsyndromal depression among older adults in long-term care settings range from 4.0-30.5%, depending on diagnostic criteria (29).It is necessary to address these symptoms as subsyndromal depression is associated with comorbid anxiety disorders, impaired functioning, increased medical service utilization, and suicidal ideation (30).
Because we focused on the period closest to admission to the nursing home, we cannot establish temporality between our measures, nor can we comment on the prevalence of these conditions beyond the admission period. Examining these conditions throughout the nursing home stay could provide valuable information about the course of symptoms and could inform improvements in processes of care. Furthermore, we restricted our sample to those residents able to answer questions about their pain and thus our results may not be generalizable to residents incapable of self-reporting. Despite this exclusion, our sample is drawn from two years of admissions to all Medicaid- and Medicare-certified nursing home facilities in the United States whereas other recent studies have been limited to community-dwelling older adults, used older datasets that did not have detailed pain and depression measures, or focused on a subset of nursing homes (2).



Many older adults in the U.S. are experiencing some combination of depression, anxiety, and pain when they are admitted to a nursing home. With the aging of the population and the need for long-term care persisting, it is important to improve our understanding of the multimorbidities faced by many of the older adults residing in nursing homes. Advancing knowledge of the complicated relationships between depression, anxiety, and pain is necessary for adequate treatment of these sources of considerable negative health outcomes and diminished quality of life. This is particularly true for nursing home residents as they are often excluded from the clinical trials that provide the evidence base for treatment decisions, despite being at high risk for adverse events associated with pharmacotherapy.


Funding: The work was supported by the National Center for Advancing Translational Sciences, National Institutes of Health under Grant TL1 TR001454; by the National Cancer Institute, National Institutes of Health under Grant R21CA198172; by the National Institute on Aging, National Institutes of Health by Grants R21AG046839 and R21AG056965; and by the National Institute of Nursing Research, National Institutes of Health by Grant R56NR015498 and R01NR0116977.

Conflict of interest: The authors  have no conflicts of interest to declare. Dr Hunnicutt now works for a pharmaceutical company but this work was conducted when he was student.

Ethical standard: This study was approved by the University of Massachusetts Medical School Institutional Review Board.



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L.J.M Hoek, J.C.M. van Haastregt, E. de Vries, R. Backhaus, J.P.H. Hamers, H. Verbeek


Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands. Corresponding author:
Linda Hoek, Maastricht University Faculty of Health, Medicine and Life Sciences CAPHRI Care and Public Health Research Institute, Department of Health Services Research P.O. Box 616, 6200 MD Maastricht, The Netherlands, Telephone: 0031 43 3882193, Fax: 0031 43 38 84162, Email: l.hoek@maastrichtuniversity.nl

Jour Nursing Home Res 2019;5:33-39
Published online June 27, 2019, http://dx.doi.org/10.14283/jnhrs.2019.7



Background: Being able to live the life you want to live within a nursing home might be challenging for residents with dementia, as they become dependent on others in achieving autonomy. However, little is known about which factors support or impede resident autonomy within nursing homes. Objectives: The purpose of this study was to gain insight into factors that support or impede autonomy for nursing home residents with dementia, from the perspective of their family caregivers. Design: A qualitative study was conducted. Setting: Five psychogeriatric nursing home wards within three care organizations in the Netherlands. Participants: 30 family caregivers. Measurements: Semi-structured interviews were held and a qualitative thematic approach was used. Findings: This study identified several factors that seemed to influence resident autonomy within six themes: activities; personal approach; visits from family and friends; being part of a group; physical environment; and organization of care. Within these themes, factors were mentioned that could either support or impede resident autonomy. For example, being socially engaged with family and fellow residents and participation in meaningful activities were supporting factors. The inability to go outside when wished or having inadequate private space were impeding factors. Overall, daily life was mostly organized from a communal and task-centered perspective instead of adaptation to individual preferences. Conclusions: The current study suggests that in order to improve the support of resident autonomy, nursing homes should focus on flexibility in providing care, finding ways to offer meaningful activities, and stimulating resident’s social environment to continue social traditions.

Key words: Autonomy, nursing homes, dementia, family caregivers.


Background and objective

There has been an ongoing culture change within nursing homes towards providing person-centered care that supports resident autonomy. This care philosophy emphasizes care provision that is tailored to residents’ needs and wishes (1). Understanding the person, empowerment in decision-making and relationships in care are important concepts within person centered-care (2). Nonetheless, providing person-centered care might be challenging, especially when providing care to nursing home residents with dementia, as these residents often encounter difficulties expressing their needs and wishes and, therefore, are dependent on others (3). The nursing home sector recognizes the importance of making a shift towards person-centered care that supports autonomy as much as possible, yet, there seems to be a gap between recognizing the value of providing person-centered care, and clinical practice (4-5).
Nursing home residents with dementia are often highly dependent on their environment in achieving as much autonomy as possible. Nursing staff has an important role in supporting residents’ choices over daily life (6). For instance, residents need other people to support them to make decisions regarding daily routines and care preferences. A general belief is that people’s autonomy is restricted if they become dependent on others (7). This view, however, does not consider the fact that all humans are interdependent, and devalues people with disabilities who rely on the help of others. In light of a person-centered point of view, relational autonomy is presently considered as a more appropriate approach of conceptualizing autonomy for residents within long-term care settings (7). This approach draws on the ideas of person-centered care, in which people’s identities are developed and maintained within social relations, and a person can still be a free, autonomous individual within personal relations and mutual dependencies (8). Therefore, it is important that the environment addresses the need for autonomy for residents, regardless of living in a nursing home and needing help from others.
Together with staff, family caregivers can support resident autonomy. Feeling at home and being able to live the life you want might be challenging to individuals after moving into a nursing home (9). Limitations in privacy, the balance between feeling independent while being dependent on others due to the consequences of having dementia, and sharing a living space with other residents, challenge the sense of autonomy in daily life and feeling at home (10). Therefore, family involvement is of major importance, as family can contribute to care by sharing biographical knowledge of the resident with staff as well as residents’ preferences in everyday life (11). Moreover, they can provide instrumental and emotional support, advocate for their relatives and indicate what might be valuable things in (daily) life and meaningful activities for the resident (12). Therefore, the family caregiver’s role, requires to be better integrated in the current life of nursing home residents in order to be able to help them to live the life they want to live within the nursing home.
In many nursing homes, however, it is difficult for family caregivers to support resident autonomy and stay actively involved. Although there is growing attention for providing person-centered care, nursing homes often still have an institutional character and focus on the provision of task-centered care, in which residents’ daily lives are often highly determined by organizational rules and routines (13). Moreover, supporting resident autonomy has not always been prioritized within long-term care (6). Efforts to provide better person-centered care were made when developing small-scale living facilities that focus on normalization of daily life and meaningful activities within a joint small household. Previous research regarding these small-scale living facilities, indicates that individual needs and wishes were better met when nurses actively sought residents’ strengths and capacities (14). In addition, residents’ interest was stimulated when engaged in daily household activities, which increases the sense of home and the ability to live the life you want within a nursing home (15).
Little is known about which factors support or impede autonomy of nursing home residents with dementia. Therefore, this study explores factors that influence resident autonomy, which is operationalized as the ability to live the life you want to live, as experienced by family caregivers.



For this study, a qualitative research design was chosen (16). Semi-structured interviews were held to assess family caregivers’ opinions on the extent to which they perceive that their loved ones can live the life they want within the nursing home, and which factors support or impede this.

Setting and Participants

Participants were recruited from three different care organizations in the Netherlands, including three small-scale and two large-scale psychogeriatric nursing home wards. In the Netherlands, traditional, large-scale nursing home wards are characterized by providing care for a large group of residents per ward, where daily life is mostly determined by organizational rules and routines. In small-scale wards, residents live within a joint household with, generally, six to eight residents. Here, care aims to be provided within a fixed team and a homelike environment, and activities are integrated in daily life. The selected wards provided care for residents with moderate to severe cognitive impairment. Family caregivers were eligible for this study if they were involved in the care for a resident with dementia living at the included wards. Family caregivers who functioned as the main contact person, and were responsible for making decisions on behalf of the resident, were invited to participate in the study (N=58).


All participants were informed about the study in writing and received a consent form. Family caregivers who were willing to participate returned the consent form directly to the researchers and were called and asked when the interview could take place. Participants were interviewed individually; however, if the participant preferred that a second family caregiver was present, this person was allowed to join. Interviews were held at a location of the participant’s choice. Participants were interviewed by a member of the research team between February and October 2017. Before starting the interview, participants were verbally debriefed about the study, informed about how the data would be processed, and reassured that any data would be treated confidentially.

Data collection

Data were collected by semi-structured interviews (16). In addition, the following background characteristics of participants were collected: age; gender; relationship to the resident (spouse, child, other); and how frequent they visited the nursing home. An interview guide, including a topic list, was developed to standardize the interview procedure. Participants were asked about the extent to which their relative is able to live his or her life within the nursing home. Table 1 presents an overview of the topic list and examples of questions. When needed, the interviewer prompted participants to elaborate on factors that support having choice in valuable moments in the resident’s daily life and things the resident appreciates and enjoys while living in a nursing home. Three researchers collected data (LH, EdV & RB). Interviews were audio-recorded and transcribed verbatim.

Table 1
Topics and example questions of the interview


Data analysis

A qualitative thematic approach was used to analyze the data (16). Analyst triangulation was used in order to increase reliability of the data analyses (17). First, to acquire an overall sense of the data and become familiar with the text, researcher LH read all transcripts. Initially, three transcripts were coded (LH) and the coding was discussed in detail with a second researcher (LH & HV). Relevant text fragments were identified, which were meaningful parts of the text, containing words and phrases. Fragments were compared among each other to find similarities and differences, assigned to a similar category and given a code that corresponds to and contains the meaning of the fragment. After that, all remaining transcripts were analyzed independently by two researchers (LH & EdV), using qualitative data analysis software MAXQDA (18), and interpretations were compared as a form of cross-checking. In the case of disagreement, the most suitable interpretation was chosen, e.g. the interpretation which best signifies the meaning of what was expressed. A code scheme was developed, in which connections between categories were made, and codes were integrated and refined. Relationships and connections between codes were made in order to develop central themes that derived from the qualitative data. All codes were grouped and collectively categorized and main themes were identified. Weekly meetings were held between the researchers (LH, EdV & HV) during the analysis to discuss coding of the transcripts and interpretation of the data. After coding all transcripts, codes and themes were discussed within the whole research team for general interpretation of the data.

Ethical procedure

This study had been approved by the Ethics Committee of Zuyderland-Zuyd (No. 16-N-233). Participants submitted informed consent after receiving information about the purpose and procedure of the study. Participants could withdraw their voluntary participation at any moment during the study. Confidentiality of the interviews was guaranteed.


In total, 30 out of 58 family caregivers agreed to be interviewed. Seventeen caregivers did not return the consent form and 11 refused to participate. Participant characteristics are described in Table 2. Of the participants, the majority were daughters who visited their relatives at least once a week.

Table 2
Participant characteristics


Most participants found it difficult to reflect on to what extent their relative is able to live the life he or she wants to live. They expressed difficulties determining whether their relative with dementia had the potential to carry out autonomy: most relatives were not able to express actively and verbally their wishes and needs. Participants stated that the cognitive decline caused loss of previous interests and the cognitive and/or verbal inability to express interests. Consequently, participants were asked to elaborate on specific situations that used to be important and meaningful for their relative at home, and whether these are still important and possible while living at the nursing home. Based on this, information on resident autonomy was deduced and reflected within six themes (Table 3) which are described in more detail below.

Table 3
Main themes



The theme ‘activities’ concerns resident engagement in meaningful activities and stimulating their interest in activities. Participants indicated that autonomy was supported when residents were engaged in (meaningful) activities that suited their interest and when care professionals stimulated the interest of residents in participating in certain activities. The majority of participants indicated that care professionals could better address needs and adjust activities to residents’ cognitive abilities when they organized activities at an individual level, or in a small group of residents with similar interests. In addition, most participants mentioned that activities were not tailored to residents’ individual preferences. Activities were mainly organized by staff from a logistic point of view, instead of these being adapted to residents’ personal preferences. Furthermore, for those residents whose interests matched the organized group activities, family caregivers felt that autonomy was supported, whereas activities adjusted to residents’ personal preferences were rarely centrally organized.
“Nothing happens at the ward. There are no activities for my father. He will not join activities such as arranging flowers, and he doesn’t need his nails done. There is nothing to do for the gentlemen, I don’t see it” [Daughter,56]
Moreover, some participants mentioned that participation in activities in a familiar environment, such as the ward’s living room, better supported autonomy, compared to organized activities in a communal room outside of the ward.

Personal approach

The theme “personal approach” pertains to staff providing care that suited residents’ preferences and giving personal attention to the residents throughout the day. Correspondingly, a personal approach was the ability to choose a specific ward before admission, maintaining residents’ daily routines, being offered preferred food and taking care of the physical appearance as residents would have wished. Participants indicated that an important factor in achieving resident autonomy was the nursing staff making an effort to get to know the resident, by asking both resident and their family caregiver about preferences regarding activities and life history. These aspects were mainly discussed during the intake at admission but rarely at another point in time. Some participants were asked about how they felt about an update conversation during the year and responded positively. According to them, this would contribute to support resident autonomy. One participant responded:
“At a certain point in time she started singing and they asked me ‘do you think it’s ok if she joined the singing group?’ That’s something I’ve noticed, they try things like ‘wouldn’t this or that be nice for your mother to do?’” [daughter,63]
Only a few participants spontaneously indicated that their relative had a close relationship with (a member of) the nursing staff. These participants were more satisfied with the support of the autonomy of their relative whenever their relative received care from these nursing staff members.

Visits from family and friends

Continuation of family traditions and meaningful social encounters were considered important by the family caregivers in supporting autonomy. All participants reported that residents were able to continue social activities they used to do when living at home, when they were be able to welcome family and friends at any time. One contributing factor that was mentioned was nursing staff making participants feel welcome whenever they visited, as well as the presence of nursing staff on the ward during visits.
“You really feel at ease, you feel like you’re being invited. As if you could come over whenever you want” [Daughter,56]
Nonetheless, most of the participants were not able to visit their relative as much as they wished, due to work or travel distance. Keeping in contact by phone was mentioned as helpful for the resident to stay in touch with relatives. Residents, however, did not receive sufficient help with using the phone or with having a private area where they could make a call, according to some participants.
“For me, I call a lot less now, otherwise I would have called on a daily basis, I called her every day. […] And when I call now, it is more complicated because they have to transfer your call and then something goes wrong. Also, she sits in the living room, where the TV is turned on and people are chatting” [Daugther,58]

Being part of a group

Participants’ opinions differed as to whether living in a nursing home, and being a part of a group of residents or joint household, either supported or impeded the autonomy. Some participants felt that living in a group could positively support their relative’s interest in socially connecting to others, e.g., other residents and their family members.
“‘Your mother is always cheery and peppy, she talks to everybody’, staff say. We had a family with five children and other people also came over a lot, a ‘Leave it to Beaver’ household. So, she’s always used to having people around. The only concern would be that my mother could get lonely, but I don’t feel like that’s the case. She sits and talks with everybody” [Daughter,57]
On the other hand, a small number of participants viewed that living in a group was sometimes too busy for their relatives and that they preferred spending more time on their own during the day. Therefore, it was considered important for these residents to have a place where they could seclude themselves from the group when they wished.
“It is hard for people to adjust to five other people you don’t even know. And they all have a completely different background, they didn’t choose them themselves. They are not friends or acquaintances or whatever” [Daughter,59]
Tailoring daily routines to residents’ preferences played a major role in achieving autonomy; for example, getting up when they wanted to or having meals at a preferred time. Some participants mentioned that autonomy was currently restricted, as residents’ daily life was oriented toward what fits the group instead of the individual.
“My mother doesn’t like the music that’s mostly played on the ward. She likes music we played at home back in the day. Now, she sings along with the music on the ward, only because she knows all the songs now by repeating and repeating” [Daughter,56]

Physical environment

Being able to adjust the environment into a place that feels like home and experience the freedom to move within and outside the ward as much as residents wish, contributed to resident autonomy. In all cases, participants mentioned that being able to bring personal belongings and valuable belongings, such as furniture, carpets, photographs, clothes and toiletries, contributed to living in a familiar and homely environment.
“We asked her before: ‘by the time you would have to live in a smaller place, what would you bring?’ […]. Her bedclothes, she even took her own mattress and bedclothes, all those kinds of things. The most important thing, she took my father with her, the urn in her room, she brought things that were extremely important to her” [Daughter,53]
It was suggested by participants that the ability to walk around the ward freely, without restrictions, addressed the need for physical movement and freedom within the ward. This contributed to autonomy as residents can freely choose to go wherever they want and residents do not feel restricted within their living environment. This was also the case when nursing staff accompanied residents for a walk within or outside the nursing home. In particular, for those residents who are wheelchair-dependent, some participants viewed that regular walks would help them be exposed to a different environment during the day. In addition, for the majority of participants, help from nursing staff and family caregivers, and a freely, easily and safely accessible garden or outside space contributed to the feeling of having autonomy.
Some participants indicated that sufficient access to private areas, belonging to the resident, improved resident autonomy. For example, if residents had access to their wardrobe they would experience more freedom, according to participants, even though this might cause inconvenience for nursing staff. The ability to have a private space to be alone outside of the bedroom, as well as a private space for residents to welcome family, are also factors that contributed to autonomy, indicated by the participants:
“He needs his own space, right. And of course he has his own room but he is not capable of finding his own room and turning the key to open the door. So that is not an option” [Son,58]
A small number of participants mentioned that their relative considered the nursing home as their home. They pointed out that their relative felt satisfied and at ease, and visibly enjoyed daily life at the nursing home. For a few other residents, for example, the ward was a familiar and safe environment and felt like their own home.

Organization of care

Within the organization of nursing home care, several factors concerning nursing staff and working routines promoted resident autonomy according to the participants. Participants were unanimous in the view that deploying a fixed team on a ward enabled nurses and residents to know each other better. This would allow staff to develop a personal relationship with residents, and therefore enable them to approach residents in a more personal way, better addressing individual needs and preferences.
“Well, what I think is really important and keep on seeing, is of course linked to staff changes. My mom, she wouldn’t accept the way she’s being taken care of. She can’t express it anymore, but it’s not the way she would want it. She would get angry, so to speak. Right from the beginning, I took a picture of her and I put that photograph over there, just to give an example of ‘this is my mom, this is how she felt human’. And some of the staff pay attention to this and others completely don’t […]. And if I see her and how her hair is done, it’s greasy and she’s not wearing any make-up. My mom wouldn’t open the door to anyone like this back home” [Daughter,53]
“Well, a fixed team. Yes, it would be nice for mom if she had a steady, identifiable person instead of all these new faces. […] Yes, someone who knows what she likes and prefers” [Daughter,53]
Moreover, participants indicated that when staff had more freedom to work without a predetermined list of care tasks, resident autonomy could be better supported. For example, they would be able to effectively address residents’ daily needs, such as timely toilet use, preferred physical appearance and meaningful activities. Furthermore, if nurses had more time for tasks other than physical care, residents could better live the life they want − for example, going outside with residents when residents wanted to, being able to support residents with keeping their pet and participate in daily activities.
“Someone takes care of the medicine, the other one starts with porridge […]. It’s such a routine, right? Someone does this, the other one does that […]. It’s ‘go, go, go, feeding, and done’ and then they clean up, it’s all that routine, it’s like ‘I have to be ready in time because my shift ends at 7 o’clock’. I think that’s what it is” [Daughter,59]
Furthermore, in order to increase resident autonomy, some participants indicated that changing staff working hours could contribute to addressing residents’ needs regarding daily routines and habits. For example, residents should be able to go to bed when they want and stay up late when visiting their children’s home without being dependent on staff working hours during the evening.
“For example, sometime last week, a staff member was in one of the living rooms and took all the residents to the other living room. Like she (staff member) said, she’d previously already done something with games: ‘for me to do that again, I feel like I’m not doing anything usefull’. She was really thinking about helping her colleagues with all those residents who had to be put to bed. That’s a typical example of nurses who might think ‘oh, I have to put ten people to bed’ or ‘I have to reach my quota for today’’ [Daughter,60]



The current study identified six themes that influenced autonomy of nursing home residents with dementia: 1) activities; 2) personal approach; 3) visits from family and friends; 4) being part of a group; 5) physical environment; and 6) organization of care. Within these themes, factors were mentioned that could either support or impede resident autonomy. The most important factors that were considered by family caregivers to influence resident autonomy were: 1) residents being involved in individual activities that suited their interest, while activities that were organized from a communal and logistic perspective impeded autonomy; 2) providing a personal approach by getting to know the resident positively influenced resident autonomy; 3) autonomy was supported when family and friends were be able to visit, though private spaces for family to continue family traditions were absent; 4) being able to socially engage with fellow residents had a positive influence, whereas, on the other hand, daily life with fellow residents was mostly determined by what fits the group instead of the individual; 5) creating a homely environment supported resident autonomy, while limited freedom of movement was considered impeding; 6) having a fixed team supported autonomy while, nursing staff having fixed routines regarding moments of care, impeded resident autonomy.
Some methodological limitations need to be considered. All first-contact persons of the residents from the selected wards were approached, which led to an inclusion of a high number of daughters. Consequently, experiences from spouses have been underrepresented in this study. This could have led to somewhat other findings as spouses may have a different, closer relationship with a resident (19). Adult children might grow into a different relationship, as they distance themselves from the parent when taking on a caring role (20). Accordingly, they may take over the decision process as the hierarchy within the child-adult relationship changes (21). Nonetheless, the sample is likely to be representative regarding gender, as women often take on the role of family caregiver (22). We used a descriptive generic research design, and our sampling procedure did not primarily focus on attaining data saturation when recruiting participants. Instead, we mainly focused on recruiting participants to capture a variety of experiences with resident autonomy from different wards, as previous studies suggested that the nursing home environment influenced family caregivers’ perception on the care process (23), and autonomy in daily life in these homes may differ. Furthermore, participants had difficulties in determining whether their relative was able to live the life he or she wants. Other research methods, for example photo elicitation (24), which is an interview method that uses visual images to elicit comments, may have been able to stimulate more response.
Our findings suggest that when residents are being cared for according to the nursing staff’s fixed routines regarding moments of care, and staff’s working shifts, this impedes resident autonomy. This is an impeding factor to resident autonomy as this task-centered focus gives staff little opportunity to recognize and respond to the daily needs and wishes of the resident. These findings are in accordance with recent studies indicating that nursing staff are often too much involved in taking over caring tasks, and therefore residents are poorly stimulated to make their own choices (25). In order to provide care that incorporates residents’ needs and wishes, care flexibility is essential (26). More research is needed to explore the relationship between the identified factors and cognitive status, duration of stay, and other background characteristics. Participants acknowledge that autonomy could be better supported when staff have more freedom to work without a predetermined list of care tasks. Therefore, it is important for staff to view the nursing home as a place to live in rather than a place to be cared for, in order to address residents’ needs and wishes (27).
Another finding was that family caregivers perceived that resident autonomy was impeded when activities were mainly organized from a logistic and communal principle. Therefore, it was perceived as important that the staff are able to spontaneously organize meaningful activities, in an individual or small setting. This would support resident autonomy as staff would be able to directly address residents’ needs and wishes and activities, and could therefore be more meaningful to the resident. Our findings suggest that going outside is, amongst others, a meaningful activity for many residents. When staff are able to spontaneously arrange this activity, this would contribute to activities that are more meaningful and therefore, residents are better supported in living the life they want. This also accords with earlier observations, which showed that being able to go outside was mentioned as a meaningful activity and, therefore, is related to a higher quality of life for nursing home residents with dementia (28). In addition, our findings indicate that in order to enhance the feeling of having the choice to go wherever you want, the physical environment should be developed to facilitate the possibility for residents to independently go outside into a safe environment.
As is well known, it is exceedingly important for nursing home residents with dementia to keep a social connection to their family and friends. The current study found that while all participants were able to visit their loved one anytime during the day, there was a need to have a private space or suitable area to continue social traditions, such as celebrating birthdays together with family, or just being together amongst family, away from the communal group. In addition, besides being socially involved in the residents’ life, it is also important for family to be involved in the care of their relative to support resident autonomy (29). In order to do so, they have to feel at home and welcome, and be able to take part in decision-making about the resident’s care equally, instead of solely being a visitor (30). Nonetheless, communication between family and staff appears to remain challenging, causing shortcomings in discussing roles (31). This can hinder the support of resident autonomy. Moreover, as participants repeatedly mentioned frequent changes in care staff, family caregivers, nursing staff and residents might face difficulties in developing a strong relationship, which is needed to support resident autonomy. Therefore, this study indicates that low staff turnover is important for residents and family caregivers to allow them to adjust to the nursing home and develop a personal connection with nursing staff. In that way, knowledge of residents’ life preferences can mutually be transferred, as a basis to create a solid partnership in supporting resident autonomy (28, 32).
Findings of this study indicate that several factors might improve the support of resident autonomy. Improvements should focus on good implementation of person-centered care by creating possibilities to better tailor care to residents’ preferences regarding daily routines, social and meaningful activities. Realizing improvements regarding supporting resident autonomy might be a challenge, as providing an opportunity to make own choices and, consequently, being able to live the life residents want, has not been a priority in current nursing home care (6). Nonetheless, the most important improvements that can be made concern the care professionals. They need to be given the opportunity to know and understand the residents in order to provide care and activities that suit the residents’ interests. Care professionals should be able to provide care that is based on residents’ personal preferences and support the life residents want to live. In addition, creating a familiar, homely environment and enabling residents to go outside whenever they want should be facilitated to better support autonomy. Lastly, the physical environment should encourage residents and family caregivers to continue social activities in private.
In conclusion, the current study suggests that there are still numerous possibilities to improve the support of resident autonomy. Enabling flexibility in providing care, finding ways to offer activities that are meaningful to residents, and stimulating resident’s social environment to continue social traditions are of major importance in supporting resident autonomy. Based on the findings of this study, efforts should be made to improve the support of resident autonomy within nursing home care.


Acknowledgements: The care organizations that participated in this study were part of the Living Living Lab in Ageing and Long-Term Care. This is a formal multidisciplinary network consisting of Maastricht University, seven large long-term care organizations, Gilde Intermediate Vocational Training Institute and Zuyd University of Applied Sciences, all located in the southern part of the Netherlands. The authors would like to thank all participating family caregivers and care organizations for their valuable contributions to this study.

Funding: This work was supported by the Living Lab in Ageing and Long-Term Care. They had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Conflict of interest: The authors declare no conflict of interest.

Ethical standard: This study had been approved by the Ethics Committee of Zuyderland-Zuyd (No. 16-N-233).



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F. Bortolazzi1,2, A. Calabrò2, M. Pesce2, U. Tortorolo1, T.F. Piccinno3, M. Masini3, C. Chiorri3,4


1. Korian srl, Italy; 2. Gruppo Insieme srl, Italy; 3. VIE srl, spin off of the Università degli Studi di Genova, Italy; 4. Università degli Studi di Genova, Italy. Corresponding author: T.F. Piccinno, VIE srl, spin off of the Università degli Studi di Genova, Italy, piccinno@vie-srl.com

Jour Nursing Home Res 2019;5:27-32
Published online June 12, 2019, http://dx.doi.org/10.14283/jnhrs.2019.6



Objectives: Dysphagia in elderly patients can cause serious health problems. The aim of this study was to investigate the effects of a new method for the identification of the elderly dysphagic patient. We hypothesized that a simple identification device could reduce errors in providing food and therefore reduce negative outcomes. Design: Two group of participants were enrolled (experimental and control). Each patient received a diagnosis of the severity of his/her own dysphagia disorder on a scale ranging from 1 (no swallowing problem) to 5 (unable to swallow). Inpatients of the experimental group only worn a bracelet with a specific color code for each level of the dysphagia disorder. Operators were trained to check the bracelet color and provide the corresponding diet to the patients. Participants were tested three times over a two months period. Setting: The participants were hospitalized in three nursing homes of the same institute. The colored bracelet method was adopted in two of these nursing homes. Participants: Fifty-five participants were enrolled for the study (44 in the experimental group, 78% female, mean age = 88.9±6.6 years). Forty-two operators (86% female, 64% of age between 36 and 55)) filled in an evaluation questionnaire. Measurements: Several measures of nutrition, hydration, and clinical condition were collected. Results: The method significantly improved hydration (p = .002) and BMI (p = .010) and reduced the risk of bedsore (p < .001) of the patients. Conclusion: The colored bracelet method is an effective instrument for managing the diet of elderly dysphagic inpatients.

Key words: Dysphagia, malnutrition, nutritional intervention, aged, nursing homes.



Background and objective

Dysphagia is an alteration in the swallowing process due to degeneration and ageing of involved organs.
The number of dysphagic inpatients in rehabilitation centres and residential structures is going to increase with the extension of life expectancy. Dysphagia occurs in 15% to 23% of older persons living in the general non-patient population and it is prevalent in hospitalized patients (1).
Dysphagia may lead to serious health and life-threatening complications such as malnutrition and aspiration pneumonia (2). Malnutrition from dysphagia is considered a risk factor for pressure ulcers in elderly people (3). Errors in providing the correct type of nutrition to the patients could have serious consequences such as suffocation, aspiration pneumonia, denutrition, dehydration and, eventually, death. A recent study (4) showed that patients who suffered from dysphagia or malnutrition had poor outcome with regard to mortality, and that patients suffering from both dysphagia and malnutrition had the poorest outcome.
Guidelines of the International Dysphagia Diet Standardisation Initiative (IDDSI) and of the Italian Society of Artificial Nutrition and Metabolism (SINPE) for the management of dysphagic patients recommended that all patients with dysphagia should be assessed by a specialist (speech therapist) and should be referred to a dietitian to develop individual nutrition care plans.
Functional severity of dysphagia makes recommendations for nutritional therapy. The primary aim of nutritional therapy is to meet nutritional requirements of individuals and prevent adverse events such as aspiration pneumonia.
A simple and fast method to identify the severity of dysphagia in elderly patients could reduce the probability of feeding errors and, consequently, increase the health quality of patients.

Aim of the study

In this study, we aimed at investigating the effects on patients and operators of a device for the identification of severity of inpatients’ dysphagia using colored bracelets.
We hypothesized that the introduction of this method could improve the health of the inpatients, and could reduce the number of adverse events, such as feeding errors and consequently aspiration pneumonia. Specifically, we are interested in measuring the effects of the colored bracelets method on:
a)    nutrition of the inpatients
b)    hydration of the inpatients
c)    risk of bedsore of the patients

Furthermore, we were interested in evaluating the operators’ perception of the usefulness and ease of use of the device.



Design of the study

At the beginning of the study each patient received an evaluation of the severity his/her own dysphagia disorder by a speech therapist using Bedside Swallowing Assessment and the Smithard’s Three-oz Water Swallow Test (5). Patients with the most severe clinical conditions took also an instrumental phoniatric examination with Fiberoptic Endoscopic Examination of Swallowing (FEES). The evaluation of the severity of the dysphagia disorder ranged from 1 (no swallowing problem) to 5 (unable to swallow),  it  was identified by a different color-code (1 = green, 2 = blue, 3 = yellow, 4 = orange, 5 = red) and was associated to a specific diet. Three nursing homes were involved in the study: the participants of the experimental group were enrolled from two of them, while the control group was sampled from the third nursing home. The three clinics had similar procedures, patients had similar health and personal characteristics, and staff were equally trained and experienced. A colored bracelet indicating the severity of dysphagia was always worn by the patient of the experimental group. A speech therapist trained the operators every six month in the physiopathology of the dysphagia disorder and in the management of the diet of dysphagic inpatients. During this course, the operators of the experimental group were also trained to check the bracelet color and provide the corresponding diet to the patients. Participants of both groups were tested at the beginning of the study, i.e., before the introduction of the bracelet method (T0), after one month from the beginning of the study (T1), and after two months (T2).


Fifty-five participants were enrolled in the study (78% female, mean age = 88.9±6.6 years). Three participants died before the end of the study, therefore there were only 52 observations in T2. The experimental group included 44 inpatients, while the control group comprised 11 inpatients. Furthermore, 42 operators (86% female, 64% of age between 36 and 55, 71% with secondary school degree or higher) working in the nursing homes of the experimental group were asked to fill in a questionnaire to evaluate their perception of the of the usefulness and ease of use of the device for the identification of the dysphagia severity.


Several measures were collected to evaluate the nutritional status of the patients: Body Mass Index (BMI), Mini Nutritional Assessment (MNA) (6), and calorie intake through food.
BMI was calculated with the classical formula W/H2 (W = weight [kilograms]; H = height [metres]).
The MNA test comprises simple measurements and brief questions that can be completed in about 10’-15’. The full MNA includes 18 items grouped in 4 rubrics: a) anthropometric assessment; b) general assessment; c) short dietary assessment; and d) subjective assessment. It provides a single, rapid assessment of nutritional status in elderly patients. The MNA score distinguishes between elderly patients with adequate nutritional status (MNA ≥ 24 up to 30), patients at risk of malnutrition (MNA between 17 and 23.5) and patients with protein-calorie malnutrition (MNA < 17).
Calorie intake was estimated from the patient’s diet. The diet was prescribed according to the nutritional needs of elderly population indicated by the Italian Human Nutrition Society (SINU) (7). Each diet of the inpatients was determined accordingly considering age, sex and clinical status. Therefore, the calorie intake is an esteem of the nutritional needs.
Hydration was evaluated using three measures collected by a physician: blood pressure, tongue moisture, and skin turgor (the degree of elasticity of skin). Furthermore, a subjective hydration score (ranging from 0 = very low hydration to 5 = good hydration) was provided by the physician after a physical examination of the patient. Given the high correlation of these indices, a general hydration index (GHI) was calculated performing a principal component analysis (PCA) on these measures.
The risk of bedsore of the patient was measured with the Braden Scale for Predicting Pressure Sore Risk (BS) (8). It comprises six subscales representing the most common risk factors for pressure ulcers. It ranges from 6 to 23, with higher scores indicating lower risk of developing sores. A cutoff score of 18 is generally used to designate increased risk of pressure ulcer development. It has been shown that this measure has adequate levels of validity and reliability (9, 10).
Several other variables were collected from the medical records to obtain a more detailed assessment of the health of the patients and to be used as control variables in the statistical analyses. Alzheimer dementia, Parkinson’s disease, and stroke data were collected. Furthermore, comorbidity was measured with the Cumulative Illness Rating Scale (CIRS) (11). CIRS provides two scores (a) severity of the illness; and (b) comorbidity.
Two items were administered to the operators to investigate their perception of the usefulness and ease of use of the bracelet method. Both item responses were collected on a Likert scale ranging from 1 = “not at all” to 5 = “a lot”. We considered mean ratings of no less than 4 on either characteristic as a satisfactory result (12).



Linear mixed models (LMMs) (13) were used to assess the effect of the use of bracelet on the measures of nutrition (BMI and MNA), hydration, and risk of bedsore while controlling for background and clinical characteristics.
Four LMMs were specified, one for each dependent variable (i.e., BMI, MNA score, GHI score, BS score). Predictors of the model were a) treatment (experimental or control), b) time of the observation (T0, T1, T2), c) daily calorie intake, d) severity of dysphagia, e) Alzheimer dementia diagnosis, f) Parkinson’s disease diagnosis, g) past stroke diagnosis, h) diabetes diagnosis, i) comorbidity (CIRS S and CIRS C scores), j) artificial nutrition with nasogastric intubation, k) sex, and l) age.. While the focus variables were treatment, and time, the rest of the predictors were included in order to reduce the bias in the estimate of the effect of the treatment due to the impossibility to randomly assign patients to treatment levels.
Results are reported in Figure 1 and in Tables 1. As for BMI, participants in the experimental group had a higher  BMI than controls (p = .035) and  an overall decrease of BMI over time (p = .031) was observed; also the group-by-time interaction was statistically significant (p = .014), due to  a decrease of BMI in the control group and a lack of substantial change  in the experimental group (Table 1 and Figure 1a).

Table 1
Results of the four linear mixed models performed (only fixed effects are shown)

Significance Codes: < 0.001 ‘***’; < 0.01 ‘**’; < 0.05 ‘*’; < 0.1 ‘.’

Figure 1
Group-time interaction effects for each dependent variable. Each dashed line represents a participant. Thick solid lines represent group means. Error bars represent 95% confidence intervals of the mean scores.


The LMM for MNA revealed a significant fixed-effect of diabetes on MNA (p = .018, inpatients with diabetes diagnosis had higher scores), but the group-by-time interaction was only marginally significant (p = .081). However, the mean score of the experimental group tended to increase from T0 to T2, while the mean score of the control group remained substantially stable (Table 1 and Figure 1b).

A significant fixed-effect of the amount of daily calorie intake (p < .001) on the GHI score was found, where higher amounts of daily calorie intake was associated to higher hydration scores. The group-by-time interaction was statistically significant (p = .002), showing an increase of the hydration level in the experimental group and a decrease in the control group form T0 to T2 (Table 1 and Figure 1c).
Finally, a significant fixed-effect of the group (p = .004) was found on the BS score: inpatients of the experimental group had lower scores on the BS and therefore higher risk of pressure sores; also the group-by-time interaction was statistically significant  (p < .001) due to a reduction of the sore risk in the experimental group from T0 to T2, while no change was observed in the control group (Table 1 and Figure 1d).
One-sample t-tests were used to test whether the operators’ ratings of usefulness and ease of the use of the device differed from the expected result (score 4). Both t-test revealed that the target rating was achieved since there were not a statically significant differences (Usefulness: M = 3.80±1.27; t(39) = -0.98, p = .331, d = 0.16; Ease of use: M = 3.75±1.31; t(39) = -1.19, , p = .241, d  = 0.19).



The aim of this study was to test the efficacy of a new method for the identification of elderly dysphagic patients in improving their health outcomes. The method uses a color code on a bracelet worn by the inpatients that indicates to the operator the severity of the dysphagia. Results supported the efficacy of the method as they showed an overall improvement of the health condition of the inpatients of the experimental group with respect to those of the control group. The average BMI of the patients in the experimental group was stable across time, while it decreased in the control group. Hydration level significantly increased in patients identified with bracelets, while it decreased in the other patients. Finally, participants of the experimental group had lower pressure sore risk over time. The method was also considered adequately useful and easy to use by operators. Taken together, these findings suggest that the colored bracelet method is an effective method to manage the diet of elderly inpatients and it has a positive impact on their nutritional status and health condition.
Some limitations of this study have to be acknowledged. It was not possible to randomly assign the participants in the experimental and control group. Then the sample resulted unbalanced, although its size is not small. In this study differences of the two groups were statistically controlled, but a different sampling with more participants could solve this issue in the future. Furthermore, the study last for only two months. Next studies should enrol a higher number of and they should be conducted for longer period. These changes in the design of the study should allow to evaluate the impact of the colored bracelet method on aspiration pneumonia and related death incidence in elderly dysphagic inpatients.


Conflict of interest: Dr. Bortolazzi (francesca.bortolazzi@email.it) reports personal fees from NOEMA CONGRESSI during the conduct of the study; to have other relationships with nursing homes in Genoa; and to be consultant of KORIAN group and GRUPPO INSIEME. Dr. Calabrò (alessiocalabro83@gmail.com) reports personal fees from NOEMA CONGRESSI during the conduct of the study; and to have other relationships with nursing homes in Genoa; and to be manager of GRUPPO INSIEME. Dr. Pesce (pesce.matteo1@gmail.com) reports to be consulent for SERENITA S.R.L. and CITTADELLA S.R.L. (GRUPPO INSIEME); Dr. Tortorolo (umberto.tortorolo@pcdo.it) reports to have other relationships with nursing homes in Genoa and to be health director in KORIAN group. Dr. Piccinno (piccinno@vie-srl.com) reports grants from Noema S.r.L. Unipersonale during the conduct of the study. Dr. Masini (masini@vie-srl.com) has nothing to disclose. Dr. Chiorri (carlo.chiorri@unige.it) has nothing to disclose.»

Ethical standard: All procedures performed in the study were in accordance with the ethical standards of the institutional and/or national research committee, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.



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7.    Società Italiana di Nutrizione Umana SINU. LARN Livelli di Assunzione di Riferimento di Nutrienti ed Energia per la Popolazione Italiana–IV Revisione. SIdN Umana, Rome, 2014.
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10.    Braden BJ, Bergstrom N. Predictive validity of the Braden Scale for pressure sore risk in a nursing home population. Res Nurs Health, 1994;17(6), 459-470
11.    Linn BS, Linn, MW, & Gurel LEE. Cumulative illness rating scale. Jour Americ Geriat Soc, 1968;16(5), 622-626.
12.    Rosson MB, Carroll JM. Usability engineering. Scenario-based development of human-computer interaction. Morgan Kaufmann Publishers, San Francisco, 2001.
13.    Henderson CR. Applications of linear models in animal breeding (Vol. 462). University of Guelph, Guelph 1984.



M. Fetterolf1, P. Kao2, N. Castle1


1. University of Pittsburgh, USA; 2. Department of Anthropology, Harvard University, USA. Corresponding author: Philip Kao, Harvard University, USA, philip_kao@fas.harvard.edu

Jour Nursing Home Res 2019;5:24-26
Published online June 5, 2019, http://dx.doi.org/10.14283/jnhrs.2019.5



Across the United States, 60% of Assisted Living administrators noticed an increase in legal claims; meanwhile nearly 75% noticed an increase in lawsuits and 71% noticed an increase in settlements. This article asks whether or not the rise in legal pressure may be attributed to a higher proportion of residents with moderate to severe cognitive impairment in Assisted Living.  More broadly, the findings indicate that there is a lack of consumer choice and solutions for the elderly in need of long-term services. As a short-term option to mitigate the rise in legal pressure, long-term facilities could explore ways to work with residents in defining various thresholds of care that are safe, sustainable and economically sound whilst preserving certain aspects of residents’ desired lifestyles. Over the long term, the United States needs to develop innovative options for the provision of long-term care services with a focus on redesigning care for older adults with their input. The consequences of such a positive change are examined.

Key words: Assisted Living, Nursing Homes, Consumer-Centered Healthcare, Lawsuits, Dementia.



In the US, some attorneys are finding that after years of targeting Nursing Homes, law firms are shifting their focus toward Assisted Living. Some firms are using a “nursing home lawsuit playbook” to litigate against these expanding facilities (1).  As the number of older adults in Assisted Living with moderate to severe cognitive impairment increases, facility administrators face severe challenges to care for the complex needs of residents while maintaining the values which Assisted Living was founded upon, namely: care, dignity, autonomy, and privacy.
In February 2017, the authors sent out 225 research questionnaires, by postal and electronic mail, to Assisted Living administrators in ten states across the US.  Of the 225 facilities, 85% percent of them listed having “memory care units” on their websites. Our research surveys were structured to capture opinion-based, qualitative data from administrators regarding their perceptions of the number of claims, lawsuits, and settlements trending over the past five years. The methodology for collecting responses from the various facilities across the country was based on geographic spread, and the presence of a “memory care unit” in each respective Assisted Living Facility (ALF). Additionally, the majority of the facilities we targeted were medium-sized. The surveys solicited information about the types of lawsuits, prevalence of dementia in their facility, and the effects that legal pressure might have had on notions of resident choice, dignity, privacy, and safety (2). This study received 58 responses from nine states with a total 25.7% response rate overall (3).



Administrators were asked to appraise the number of claims, lawsuits, and settlements over the last five years. Almost 60% of administrators noticed an increase in claims; nearly 75% of the respondents noticed an increase in lawsuits; and 71% noticed an increase in settlements.

Figure 1


Additionally, when asked to respond to the statement “Litigation is forcing ALFs to become more like nursing homes in terms of regulation”; 68% of administrators responded with somewhat or strong agreement; 22% neither agreed or disagreed; and 10% showed some form of disagreement.


Consumer Driven Assisted Living

The Assisted Living industry has become a target for litigation due to large variation with respect to facility size, admission policies, level of complex care needs (e.g. mobility support, eating/medication assistance) and dementia care capability (4). Growth in the Assisted Living sector across the US has been attributed to its market model of care promoting resident independence, autonomy, privacy, and dignity (5), as well as serving the primary provider for residential care for older adults with dementia (6).
As a point of clarification, ALFs offer residents assistance with the activities of daily living in a residential setting.  In contrast, skilled nursing facilities (SNF) are places that can be temporary or longer term stays for people who need constant care and medical treatment from a registered nurse 24/7. Historically, the process of identifying a suitable home for a loved one has not been a consumer-driven process. Put simply, if an older adult can no longer live independently and does not require the level of support offered in skilled nursing, they are left to choose among the current supply of assisted living (or similar) facilities. In terms of care needs, this cohort accounts for the largest proportion of older adults needing supportive services. A combination of online research and touring of ALFs close to one’s current residence is the basis for a decision.  There is no shortage of checklists and online resources to select a home for an older adult (most sites appeal to the son or daughter of a loved one as opposed to the actual resident). Given that 60% of assisted living residents only relocate within a 10-mile radius from their home, and 80% relocate within a 25-mile radius, this is a very narrow range to find a suitable home (7).  As such, one is likely to be subject to the geographical definitions of quality and amenity; given that although the industry has rapidly expanded since its inception in the late 1970s, there has been no establishment of a threshold at or below which an ALF can provide adequate care without comprising resources and safety.
The establishment of a “threshold of care” should be an agreement between the resident and the facility in question. The facility shouldering responsibility should refer any individuals for whom they can no longer care for adequately and safely to more appropriate care settings such as SNFs. Residents with severe dementia are broadly defined as those who need non-stop assistance with daily activities and personal care. They lose awareness of recent experiences as well as of their surroundings; they also experience changes in basic physical abilities (including the ability to walk, sit, or even swallow sometimes). Furthermore, they have increasing difficulty communicating, and become vulnerable to infections, especially pneumonia (8).   One memory care unit administrator from a Pennsylvania ALF said that “The population that used to be in nursing homes is now in Assisted Living”, which suggests that the industry is reacting to increasing demand, market competition, and a changing population base, instead of responding to the way they can provide services, especially with respect to medium-severe dementia. In fact, the ‘patient’ populations in both ALFs and SNFs have changed because of particular social-economic factors, but the fact remains that ALFs have to figure out how to balance when dementia related deficits have reached a tipping point.
In 2014, seven out of ten residents in ALFs exhibited some form of cognitive impairment. More specifically, 29% of residents had mild impairment; 23% have moderate impairment; and 19% have severe impairment (6). Considering that ALFs are private facilities which need to provide an economically feasible margin through staffing, overhead, and private reimbursement (that is about half of the cost of a skilled nursing home bed) questions arise regarding whether ALFs are appropriately suited to provide care to individuals with moderate to severe cognitive impairment. This is a contentious point in the industry, given that less than half of ALFs have a registered nurse on staff or licensed practical nurse hours (4). Correspondingly, hospitalization rates for moderate to severe dementia residents were 69% and 42% higher respectively in ALFs than for similar residents in nursing homes (9). This also feeds into the issue of a lack in government regulations pertaining to ALFs.  Whether or not a consumer-driven model will provide an economic solution to finding appropriate care is still inconclusive.  After all, ALFs are emergent models that require more research and consumer-led education, lobbying, and outreach. Still today, very little research has shown the outcomes of care for dementia patients in Assisted Living.
The US can no longer assume that an older adult will fit into one of three global/standard care models. We must begin to redesign care for our older adults by meeting older adults where they are in their life course, and with their input, design supportive care solutions that have the inherent ability to change as one’s care needs and preferences change. For example, cutting edge healthcare organizations are beginning to incorporate patient choice in one’s care plan. The creation of a care plan is multifactorial and based on one’s preferences. These preferences take into account treatment options between biomedicine and alternative medicine, one’s inclination towards pain, quality of life, risk and even types of healing that extend beyond the person, incorporating the larger family unit in the decision process. The long term care industry should facilitate autonomy.  Care plans should innovate and possibly draw from artificial intelligence in order to create self-learning models that could update and predict particular changes in care needs and outcomes.  Autonomy is difficult to start initiating when someone already has severe dementia.  A possible solution, however, could be to rescale the ‘resident autonomy’, allowing the resident (and/or his/her family) to customize a set of services and progressive models of care in line with one’s lifestyle and the kind of future life they want to live out.



Assisted Living administrators across the country, are reporting that the number of claims, lawsuits, and settlements are increasing. Most administrators believe that this increased legal pressure is bound to reshape the regulatory framework of the ALF. Although this study doesn’t provide conclusive evidence to state that higher proportions of residents with moderate to severe cognitive impairment in Assisted Living is driving this trend, our results suggest that this phenomenon may be one explanation for the observed rise in litigation and worthy of further research and policy action. A broader explanation for the rise in litigation could be that the Assisted Living industry is experiencing the effects of a non-consumer driven environment exacerbated by an increasingly diverse, wide and complex population of older adults.
The ideal solution to the rising legal scrutiny would be to re-establish assisted living to allow for individualized and dynamic care planning. However, this cultural shift will take time. A short-term necessity will be to clearly define the threshold care needs that Assisted Living can safely and economically provide. According to our research, a threshold of care should be defined through individual agreements between each resident and the facility. Ideally, the facility is obligated to provide the supportive care necessary to allow the individual to preserve the kinds of autonomy they desire. Increased autonomy may result in compromised safety metrics (e.g. an uptick in the number of falls). Therefore, if a facility decides to accommodate the kinds of autonomy a person wishes to have, that facility should be afforded some meaningful legal protection.
Given the well-documented variation across the Assisted Living industry and the lack of federal regulation, Kathryn Hawes states that the effort to define quality in Assisted Living takes on a “Sisyphean cast”. Hawes goes on to say that “[…] there has been substantial progress with nursing home care, at least at a conceptual level, the rock slips and one is then faced with the uphill challenge of considering quality’s meaning in a new and different care modality— [Assisted Living] (10).”  If no threshold of care standard is established and institutionally monitored, lawsuits will continue to increase which may force policy initiatives to be reactive and tip the balance disproportionately toward safety as opposed to autonomy; a criticism common to nursing homes. It is time for ALFs to set reasonable boundaries and reestablish themselves as innovative care providers. ALFs can shield themselves from legal scrutiny and reserve a place for individuals that need person-centered care by shifting the focus from developing a solution for a population to designing a dynamic solution based on the ever-changing needs and input of the consumer.


Conflict of interest: There were no identified conflicts of interest in this article.

Ethical standard: All respondents of the survey were informed how their responses would be used. There were no financial or personal relationships that would bias the findings.



1.    Adelman, R. Esq. (2013). Assisted living lawsuits: An ounce of prevention is worth a pound of cure. Geriatric Nursing, 34(16), 6e169.
2.    The survey was reviewed by two health policy lawyers and a long-term care quality expert at the University of Pittsburgh’s School of Public Health before distribution.
3.    The nine states were broken down into three regions (East, Middle, and West) and included: NY, PA, FL, KY, SD, CO, TX, CA, NV. No Assisted Living facilities in OR provided a response.
4.    Han, K., Trinkoff, A. M., Storr, C. L., Lerner, N., &Yang, B. K. (2016). Variation Across US Assisted Living Facilities: Admissions, Resident Care Needs, and Staffing. Journal of Nursing Scholarship.
5.    Mollica, R. (1998). State regulation update: States are adopting new rules at a brisk pace. Contemporary Long Term Care, 21, 45-49..
6.    Zimmerman, S., Sloane, P. D., & Reed, D. (2014). Dementia prevalence and care in assisted living. Health Affairs, 33(4), 658-666
7.    2009 Overview of Assisted Living – AHCA/NCAL
8.    As defined by the Alzheimer’s Association – https://www.alz.org/alzheimers-dementia/stages
9.    Sloane, P. D., Zimmerman, S., Gruber-Baldini, A. L., Hebel, J. R., Magaziner, J., & Konrad, T. R. (2005). Health and functional outcomes and health care utilization of persons with dementia in residential care and assisted living facilities: comparison with nursing homes. The Gerontologist, 45 (suppl. 1), 124-134.
10.    Hawes, C., & Phillips, C. D. (2007). Defining quality in assisted living: Comparing apples, oranges, and broccoli. The Gerontologist, 47(suppl_1), 40-50.



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.



1.    Harrington C, Stockton J, Hooper S. The effects of regulation and litigation on a large for-profit nursing home chain. Journal of Health Politics, Policy and Law 2014; 39(4): 781-809.
2.    Park J, Stearns SC. Effects of state minimum staffing standards on nursing home staffing and quality of care. Health Services Research 2009; 44(1): 56-78.
3.    Weech-Maldonado R, Laberge A, Pradhan R, et al. Nursing home financial performance: The role of ownership and chain affiliation. Health Care Management Review 2012; 37(3): 235-245.
4.    Alhabeeb MJ, Moffitti LJ. Managerial economics: A mathematical approach, 1st edn. 2013.  John Wiley & Sons, Inc. Retrieved from http://www.ebrary.com
5.    Bowblis JR, Brunt CS. Medicare skilled nursing facility reimbursement and upcoding. Health Economics 2014:23(7): 821-840.
6.    Paul III DP, Godby T, Saldanha S, Valle J, Coutasse A. Quality of care and profitability in not-for-profit versus for-profit nursing homes. In: Sanchez J (ed) Proceedings of the Business and health administration association annual conference 2016, Chicago, IL.
7.    Harrington C, Olney B, Carrillo H, Kang T. Nurse staffing and deficiencies in the largest for-profit nursing home chains owned by private equity companies. Health Services Research 2012; 47(1): 106-128.
8.    Bos A, Boselie P, Trappenburg M. Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review. Health Care Management Review 2016;42(4):352-368.
9.    McDonald SM, Wagner LM, Castle NG. Staffing-related deficiency citations in nursing homes. Journal of Aging & Social Policy 2013;25:83-97.
10.    Gichungeh I, Kim A. The mediating role of staffing on quality of care in nonprofit and for-profit nursing homes in Indiana. Journal of the Indiana Academy of the Social Sciences 2015;18:88-102.
11.    Hsu AT, Berta W, Coyte PC, Laporte A. Staffing in Ontario’s long-term care homes: Differences by profit status and chain ownership. Canadian Journal on Aging 2016;35(2):175-189.
12.    Grabowski DC, Feng Z,  Hirth R, Rahman M, Mor V. Effect of nursing home ownership on the quality of post-acute care: an instrumental variables approach. Journal of Health Economics 2013;32(1):12-21.
13.    Ronald LA, McGregor MJ, Harrington C, Pollock A, Lexchin J. Observational evidence of for-profit delivery and inferior nursing home care: When is there enough evidence for policy change? Plos Medicine 2016;13(4):e1001995.
14.    Harrington C, Armstrong H, Halladay M, et al. Comparison of nursing homes financial transparency and accountability in four locations. Ageing International 2016;41(1):17-39.
15.    Paek SE, Zhang NJ, Wan TTH, Unruh LY, Meemon N. The impact of state nursing staffing standards on nurse staffing levels. Medical Care Research and Review 2016;73(1):41-61.
16.    Jacobs, G. A., & Polito, J. A. How faith-based nonprofit organizations define and measure organizational effectiveness. International Journal of Organization Theory and Behavior 2012;15(1):29-56.



B.M. Jesdale1, S.A. Chrysanthopoulou1,2, C.E. Dubé1, Kate L. Lapane1


1. Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA; 2. Department of Statistics, Center for Statistical Sciences, Brown University, Schoolf of Public Health.  Corresponding author: Kate L. Lapane, Albert Sherman Center 6th floor, Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Road North, Worcester MA 01655, USA, Email: Kate.Lapane@umassmed.edu, Phone: 508-856-8965, Fax: 508-856-8993

Jour Nursing Home Res 2018;4:36-41
Published online November 14, 2018, http://dx.doi.org/10.14283/jnhrs.2018.8



Objectives: We estimated the impact of safe patient handling legislative efforts to reduce nursing home worker injuries, and examined potential impacts among specific nursing home types. Design: Difference-in-difference analysis. Setting: 2,034 nursing homes in 8 states enacting safe patient handling and movement legislation from 2004 to 2007 and 5,901 nursing homes in 36 comparator states. Measures: Reductions in reported work-related injuries and illnesses resulting in Days Away from work, Restricted job activities, or Transfer (DART) rates per 100 full time equivalents (FTE’s). Facility characteristics included size, profit orientation, chain membership, nursing staffing measures, and location (urbanicity). Results: Among nursing homes in 8 states that enacted legislation, there was a 23.5% decrease in mean DART rate from 7.53 per 100 FTE’s in the pre-enactment period (2002-2003) to 5.76 per 100 FTE’s in the post-enactment period (2008-2010) whereas in 36 comparator states, there was a 24.4% decrease in the mean DART rate, from 8.54 to 6.46 per 100 FTE’s. After adjustment for nursing home and aggregated resident characteristics, a difference-in-difference model showed that DART rates were similar in states with and without legislation (adjusted estimate: 1.03; 95% confidence interval: 0.96 to 1.11), with estimates similar across a range of nursing homes characteristics. Conclusions: The promise of enacting safe patient handling and movement legislation to reduce nursing home worker injuries has yet to be realized. In a context of rapidly declining injury rates, substantial financial incentives, other forms of assistance, and/or enforcement activities may be needed to improve the effectiveness of legislative initiatives.

Key words: Nursing homes, long-term care, staff injuries, occupational health, regulation.




Worker injury rates in nursing homes are among the highest among occupational sectors in the United States (1). Although worker training alone appears to have little impact (2), comprehensive interventions at the nursing home level to reduce the burden of nurse injuries have reduced not only staff injuries, but also lost workdays, and workers’ compensation costs (3-8). Training and hiring replacement staff has high costs (9) as does losing seasoned staff to preventable injuries (10).
Numerous states have enacted legislation designed to reduce worker injuries in the health care sector, including nursing homes. The content and extent of these legislative efforts varies widely, from the funding of demonstration projects (Ohio, 2004) (11), to aspirational statements (Hawaii, 2005) (12). We have described these legislative efforts in detail elsewhere (13).
Declines in nursing home worker injury rates in selected nursing homes located in Ohio (14, 15) and New York (16) were seen after implementation of Safe Patient Handling and Movement (SPHM) legislation. Statewide, compensable injury rates among workers in hospitals in Washington state declined, but not more so than in Idaho, a neighboring state with no SPHM enactment (17). In a nationwide analysis, injury rates among health care and social assistance workers declined in most, but not all, states enacting SPHM legislation in the year following implementation (18). Aside from the Washington study (17), none of these analyses accounted for rapidly declining trends in injury rates in unaffected states (19).
We sought to estimate the effect of state-level SPHM legislation on nursing home worker injury rates, accounting for declining worker injury rates in the nursing home sector nationwide, and adjusting for potential shifts in resident characteristics over time. Further, we investigated whether the apparent effect of SPHM legislation would differentially affect nursing homes according to pre-specified nursing home characteristics, namely: bed size, profit orientation, chain membership, nurse:bed ratio, staff mix (ratio of registered nurses to other nursing staff), and urbanicity.



This study was approved by the Institutional Review Board at our institution.

Data sources

Appendix 1 reviews the data sources considered for conducting this study. We included private sector nursing homes not affiliated with a hospital and in operation throughout the study period (2002-2010) with identifiable data from three sources: the Centers for Medicare and Medicaid Services Provider of Service (POS) annual files (addresses, hospital affiliation, profit orientation, chain membership, bed size, the number of staff full time equivalents (FTEs), and workforce composition), the Occupational Health and Safety Administration’s OSHA Data Initiative (ODI) (annual nursing home-level injury rates, addresses), and the Minimum Data Set (MDS) (annual distribution of resident-level characteristics). Urbanicity was assigned to nursing homes using a six-level urbanicity code developed by the National Center for Health Statistics (20).
The ODI contains establishment-level, work-related injury and illness rates reported by work establishments, including nursing homes from 1996 to 2011. Government-owned nursing homes were usually exempt from reporting requirements, as were nursing homes with fewer than 10 employees. Seven states were waived from ODI reporting requirements for two or more consecutive years during our study period (Alaska, Arizona, Oregon, South Carolina, Virginia, Washington, Wyoming), and are not included in our analyses.
Collected by federal mandate in all Medicare/Medicaid certified homes, the MDS is a standardized resident assessment instrument completed at admission, quarterly, annually, readmission, and when there is a significant change in clinical status. The MDS collects a wide range of clinical and functional data, including height and weight of residents, mobility status, and functional capacity. We calculated quarterly aggregates of resident characteristics using MDS version 2.0 (1/1/2002 to 9/30/2010), then averaged these quarterly aggregates to obtain annual descriptors of resident characteristics.


We identified 11,491 nursing homes using the POS files. See Supplementary Table 2 and Appendix 2 for details regarding the matching procedures of the data sources. Eligible nursing homes were those that were open throughout 2002-2010, not government-owned, not hospital affiliated, and located in one of the 43 states or the District of Columbia (DC) that collected ODI data. The ODI does not contain a unique identifier for nursing homes, but includes self-reported name, address, and industrial sector codes which were used to match 10,584 (92.6%) of the nursing homes above to ODI data for at least one year. Of all eligible nursing homes collecting ODI data, 11,425 (99.4%) were successfully merged with their resident data in the MDS. To be eligible, information on more than 9 residents for a nursing home was required for each study year. To reduce missing data, we further restricted our sample to 7,935 nursing homes with all of the following:  1) ODI data for at least one year in the period from 2000 to 2004 (before any state enacted SPHM legislation); 2) ODI data for at least one year in the period 2008-2011 (after all states had enacted SPHM legislation); and 3) no more than 5 consecutive years of missing ODI data in 2002-2010. Of otherwise eligible nursing homes 69.5% were excluded (see Supplementary Tables 3 and 4 for a comparison of excluded nursing homes to the otherwise eligible sample).

Exposure periods

Eight states with ODI injury rate reporting enacted SPHM legislation between 2004 and 2007 (Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island, Texas). No states had enacted SPHM legislation before this period, and no others enacted SPHM legislation directed towards nursing homes before 2010. We defined three periods for legislation enactment in the SPHM legislation states: a pre-enactment period from 2002 to 2003, an enactment period from 2004 to 2007, and a post-enactment period from 2008 to 2010.

Outcome assessment

ODI data are reported as the DART rate (reported work-related injuries or illnesses resulting in Days Away from work, Restriction of job activities, or Transfer to another position, per 100 FTE’s). In general, nursing homes were required to report injury and illness rates every three years, with nursing homes reporting a high injury rate usually required to report again the following year. Following previous literature (21-23), we treated DART rates higher than 50 per 100 FTE’s (0.08% of reported values) as likely outliers, and re-set these to missing.

Imputation of missing values

Among the 7,935 nursing homes included in the 9 years of the analysis, 74.4% of nursing home-years were populated with reported ODI data. A relatively low injury and illness rate in the previous year strongly predicted missing data; of those with an observed DART rate under 5.00 per 100 FTE’s, 51.1% had missing data in the following year, compared to only 13.9% of those with an observed DART rate of 5.00 per 100 FTE’s or higher. Missing data increased over time, from 8.9% in 2002 to 50.5% in 2010. State-level missing data varied from 11.8% of nursing home-years in Maine to 47.2% in the District of Columbia. Missing data were modestly associated with some nursing home-level characteristics (see Supplementary Table 5).
We used multiple imputation to estimate the natural logarithm of DART rates from 1996 to 2011, in which injury rates of 0 were replaced with ln(0.5) (post-imputation exponentiated values of 0.5 or lower were set to 0). To restrict DART rate imputations to plausible values, an upper limit of ln(100) (twice the cut-point for re-assigning a reported value to missing) was applied. Details regarding the imputation method are provided in the Supplementary Imputation Appendix 3.
The analysis and imputation unit is the nursing home. For the imputation we used 16 measured variables potentially related to DART rates and missingness, including the region of the country (10 Medicare regions), the urbanicity of the nursing home’s county (6 categories), profit orientation in 2002 and 2010 (2 categories at each time point), and chain membership in 2002 and 2010 (2 categories at each time point). We also included the mean values across the 9 years for the number of beds, staffing levels, and nursing home-level aggregates of resident characteristics, including resident age, weight, and proportions of residents with clinical, demographic, and care-related factors. We also included the mean values across the 9 years for number of beds, staffing levels, and nursing home-level aggregates of resident characteristics including resident age, weight, and proportions of residents with clinical, demographic, and care-related factors. We produced 50 imputed datasets using PROC MI in SAS, version 9.4 (SAS Institute, Inc., Cary, NC), using the fully conditional specification (FCS) method with 100 burn-in imputations.

Analytic strategy

We estimated the impact of SPHM legislation on nursing home-level DART rates using the Generalized Estimating Equations (GEE) method to fit a Poisson model including status (SPHM legislation state or not), the three exposure periods, and an interaction between these terms. The exponentiated coefficient of the interaction term comparing the post-enactment period to the pre-enactment period is interpreted as the difference between the average injury rate (per 100 FTE’s) observed in enactment states relative to what would be expected if the same temporal trend had been held as in comparator states; a ratio greater than 1 indicates a higher injury rate than expected, and a ratio between 0 and 1 indicates a lower injury rate than expected. We weighted observations by the total number of FTE’s among full and part time employees in the nursing home in each year. We also adjusted this analytic model with a subset of the variables included in the imputation model (see footnote in Table 3).
To estimate the effect of SPHM legislation within subgroups of nursing homes, we repeated the analyses above after nesting the main effects within pre-specified nursing home characteristics, namely: bed size (under 100 beds, 100-299 beds, 300+ beds), profit orientation (yes, no), chain membership (yes, no), nurse:bed ratio (0.05 to 0.50, 0.50 to 0.70, 0.70 to 2.51), ratio of registered nurses to other nursing staff (0.01 to 0.15, 0.15 to 0.25, 0.25 to 2.59), and urbanicity (large metropolitan areas of 1 million or higher population, medium or small metropolitan areas of 100,000 to 999,999 population, or micropolitan and rural areas). We compared our findings with a complete-case analysis (no imputed values).


We conducted sub-analyses to further investigate the impact of legislation under alternate specifications: 1) a “high contrast” comparison restricting the SPHM states to the four enacting the most comprehensive forms of legislation (Maryland, Minnesota, New Jersey, Rhode Island), and excluding three states that enacted SPHM legislation after our study period; 2) a comparison of 7 SPHM legislation states (excluding Hawaii) to 18 states neighboring at least one SPHM legislation state; and 3) an analysis using a naïve single imputation method (linear interpolation from 2002-2010, or carry last observation forward after the last observed DART rate).



Nursing homes in the 8 states with safe patient handling and movement (SPHM) legislation differed from those in the 36 comparator states in several respects (Table 1). Nursing homes in the states that enacted SPHM legislation were more frequently large homes (11% vs. 2% with 300 or more beds), for-profit in orientation (66% vs. 73%), part of a chain (43% vs. 58%), or located in a central county, large metropolitan area (33% vs. 20%).

Table 1
Nursing Home Characteristics in 2002, by Safe Patient Handling and Movement (SPHM) Legislation Status

* Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island and Texas; † Percents are weighted by size of nursing home staff.


Table 2 shows that DART rates in SPHM legislation enacting-states declined from an average of 7.53 per 100 FTE’s in the pre-enactment period (2002-2003), to 6.50 per 100 FTE’s in the enactment period (2004-2007), and further to 5.76 per 100 FTE’s in the post-enactment period, an average drop of 1.77 work-related injuries and illnesses per 100 FTE’s. DART rates were, on average, higher in the comparator states, declining from 8.54 per 100 FTE’s in the pre-enactment period to 7.37 per 100 FTE’s in the enactment period to 6.46 per 100 FTE’s in the post-enactment period, an average drop of 2.08 per 100 FTE’s. Wide variation between homes is also apparent.

Table 2
Distribution of Injury and Illness Rates by Enactment Period and Safe Patient Handling and Movement (SPHM) Legislation Status

* DART rate: work-related injuries and illnesses resulting in Days Away from work, Restriction of job activities, or Transfer to another position, per 100 FTE’s per year. † Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island and Texas. ‡ Averages, medians, 25th and 75th percentiles are weighted by the staff size of the nursing homes. § During the pre-enactment period (2002-2003), no states had yet enacted SPHM legislation. All 8 SPHM states enacted  legislation between 2004 and 2007. No states enacted SPHM legislation during the post-enactment period (2008-2010)


Table 3 shows crude and adjusted estimates for the effect of enacting SPHM legislation on DART rates. In the unadjusted analysis, we estimate that DART rates were 6% higher in SPHM legislation-enacting states in the post-enactment period than they would have been had they followed the same secular trend as seen in comparator states [Rate Ratio (RR)=1.06, 95% Confidence Interval (CI): 0.93 to 1.20]. After adjustment for a wide range of static and time-varying nursing home and aggregated resident characteristics, our estimates were similar: DART rates were 3% higher than expected [RR=1.03, 95% CI: 0.96 to 1.11] . Table 3 also shows difference-in-difference estimates for various subsets of nursing homes. These subsets show similar patterns to those in the whole population of nursing homes studied, especially after adjustment.

Table 3
Difference in difference estimates for the impact of safe patient handling and movement (SPHM) legislation

* Ratio of work-related injury and illness rates during the post-enactment period (2008-2010) to the pre-enactment period (2002-2003) among SPHM states relative to the ratio during the post-enactment period to the pre-enactment period in states with no SPHM legislation. Pooled across 50 multiply imputed datasets, weighted by the staff size of the nursing homes, and with a generalized estimating equation specification (m-dependent correlation matrix) to account for repeated measures for each nursing home. 95% confidence intervals generated from model-based standard error estimates; † As above, and adjusted for state, year, urbanicity, calendar year, and the following time-varying covariates: profit orientation, chain membership, nursing home bed size, nurse:bed ratio, ratio of registered nurses to other nursing staff, mean resident weight, mean resident age, percent of residents with: severe activities of daily living limitations, require mechanical lifting, resist care and are not easily modified, have conflicted relationships with staff, restrained, loss of movement in one or both legs, had fallen in the previous 30 days and/or had a hip fracture in the previous 180 days, had dementia and/or Alzheimer’s, had bipolar depression, had a high grade (2-4) pressure ulcer, used antipsychotics in the previous week, and resident proportion Asian, proportion Black, and proportion Hispanic residents.


Complete-case (Supplementary Table 9) and sub-analyses resulted in similar results (see Supplementary Tables 7, 8, and 10); restricting the analysis to a “high contrast” comparison between 4 states that enacted comprehensive SPHM legislation and after excluding three states from the comparator group that enacted SPHM after our observation period (Supplementary Table 7); restricting the comparator group of states to those with at least one SPHM legislation-enacting neighbor (Supplementary Table 8); or using a naïve single imputation model (Supplementary Table 10).



These findings were contrary to our expectation. We hypothesized that injury rates in SPHM legislation-enacting states would have declined more so than comparator states. Several alternate explanations for these findings should be considered. Publicity around the enactment of SPHM legislation may have increased the proportion of worker injuries and illnesses reported to employers, and/or have encouraged employers to more faithfully record reported worker injuries and illnesses. If this were the case, then a lower rate or proportion of serious injuries might be expected in the SPHM legislation-enacting states. Unfortunately, we did not have the data to evaluate this. Likewise, several states required nursing homes to enact written SPHM policies, which may have increased worker knowledge and use of reporting mechanisms increasing reported injuries which may have been previously unreported. We do not have specific evidence to support or refute these possibilities.
Another possibility arises from the nature of the SPHM legislation itself. In most cases, these state-wide enactments included no appropriations to assist nursing homes with enacting SPHM policies, purchasing lift equipment, or even to offset the paperwork burden of compliance with the new regulations. Furthermore, most included no compliance enforcement provisions (13). Although our analysis of states enacting more comprehensive legislation produced similar results to our overall findings, these legislative efforts may have fallen short of providing sufficient incentives or disincentives to motivate lasting, integrated, efforts to reduce worker injuries. Several studies have found that provision of lift equipment alone or provision of worker training alone fail to produce a lasting impact on worker injury rates. A multicomponent approach to reducing worker injuries appears to be required within individual nursing homes or hospitals  (3, 6, 8, 24, 25) and within an entire healthcare delivery system (26).
While convincing evidence of efficacy exists for the impact of legislative actions to generate change in nursing homes in some settings (27, 28) it is not unusual for efforts to assess legislative efficacy to fail to document substantive change (29). For example, state-level restrictions on feeding tube use in severely cognitively impaired residents appear to have a small impact on preventing their use (30, 31) while legislation designed to increase staffing by qualified social workers has largely been circumvented, failing to produce improvements in quality of care (32), and legislation to improve overtime payments for nurses appears to paradoxically have reduced care quality by encouraging nursing homes to substitute contract workers for experienced staff (33). The extent of state efforts to enforce legislation appears to have a sizeable impact on the efficacy of the legislation as well (34), as does the infrastructure capacity of legislative bodies themselves (35). It is also possible that the legislative enactments intended to reduce worker injuries that were included in our analysis were not sufficiently enforced to produce marked reductions.
Finally, these legislative efforts occurred during a period of rapidly declining worker injury rates, both in nursing homes (19), and in the nation’s workplaces as a whole (36). Overlapping legislative efforts, shifts in worker compensation systems, and a growing focus on occupational injuries in general (37, 38) may have affected nursing homes in states that did not enact SPHM legislation during this time period.



The promise of enacting safe patient handling and movement legislation to reduce nursing home worker injuries has yet to be realized. In a context of rapidly declining worker injuries nationwide, 36 states enacting SPHM legislation had somewhat slower declines in reported worker injury rates than comparator states. Furthermore, estimates for a range of nursing home subtypes failed to demonstrate markedly different responses. National or state-level legislation including substantial financial incentives, other forms of assistance, and/or enforcement activities may improve the efficacy of legislative initiatives. Wider enactment of these more comprehensive laws would be required to evaluate the potential for greater efficacy.


Acknowledgements: This study was funded by a grant from the National Institute For Occupational Safety And Health.

Conflict of Interest: None

Ethical Standard: Approval by the University Massachusetts Medicals School Institute at Review Board.





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