As nursing home staffing policies remain stuck in a national spotlight thanks to controversy surrounding the new federal staffing mandate, new study results indicate that improving quality of care is more complicated than simply adding more staff.
Care being provided by registered nurses, licensed practical nurses or certified nursing assistants may yield not only different, but opposite results, according to the recent JAMDA study, which considered a variety of care quality measures.
Higher numbers of RNs in a nursing home, for example, was linked to fewer hospitalizations, emergency room visits and complications from pressure sores — but it also marked increased use of heavily scrutinized antipsychotic drugs.
Greater numbers of CNAs, meanwhile, were linked to more hospitalizations but produced better results when measuring activities of daily life and antipsychotic drug use.
Staffing levels have long been linked to quality of care — a fact that has contributed to policymakers at the state and federal levels mandating minimum levels of staffing in nursing homes. This study’s results indicate there is another dimension to that relationship.
“These findings suggest that there are important nuances and interplays between staffing types,” the researchers wrote. “Although they suggest in some of the cases that increasing staff HPRDs [hours of care per resident day] improves outcomes, they also indicate that considering how the scope of practice among RNs, LPNs and CNAs plays out in practice, and how they interact and support each other is an important consideration in optimizing the quality of care they provide.”
The study’s results quantify the complementary skill sets of nursing home workers, according to lead author Dana Mukamel, PhD, professor of medicine, public health and nursing at the University of California, Irvine.
“These outcomes suggest that RNs and CNAs have a different focus in their roles,” Mukamel explained in a report on the study Wednesday. “CNAs are often closer to residents. This enables them to develop insights into residents’ routines and offer behavioral modifications to mitigate symptoms, while RNs might focus on communicating behavioral issues to prescribing providers and developing overall care plans.”
Notably, the researchers found that 55% of quality indicators were not significantly linked to staffing levels. Higher levels of LPNs were also less likely to be associated with quality indicator increases.
“The intricate relationship between nursing disciplines and resident care requires a nuanced approach to policies that go beyond simple headcounts,” Mukamel said. “Hiring decisions, including ones about staffing mix, should be tailored to meet the needs of individual residents.”
The study sample included more than 15,000 nursing homes, using data submitted to the Payroll Based Journal. Researchers looked at data from 2017-19 to avoid any warping effects of the COVID-19 pandemic.
