Workforce issues and staffing are on all of our minds as we all feel the impact of shortages in nursing homes as well as other sites of care. Further, there are concerns among nursing home owners related to pending regulations around staffing and the consequences of those regulations.
It is important to focus, however, on what difference staffing makes in terms of the quality of care for residents. This is not a new issue or concern. An article published in the August issue of the Journal of the American Medical Directors Association focused on just that.
“The Relationship Between Nursing Home Staffing and Health Outcomes Revisited” by Dana B Mukamel, PhD, and team, reminds us that the actual level of needed staffing is subject to debate.
This was demonstrated by the discussion surrounding the Biden-Harris administration’s proposed minimum registered nurse and certified nursing assistant staffing levels. High minimum standards have cost implications but low minimum standards may have quality implications.
Mukamel and her team did a retrospective data analysis including data from the 2017-2019 Payroll Based Journal, the Minimum Data Set, Nursing Home Care Compare, and Long-Term Care Focus, and included 11, 261 nursing homes. There were some interesting findings.
The first was that increasing CNA staffing lowered the use of antipsychotic medications, while increasing RN staffing increased it.
The CNAs often know the resident best and how to manage or prevent behavioral symptoms, particularly during care interactions. Conversely, the RNs may be more focused on medication management as a way to resolve symptoms and are the ones to call the prescribing provider to make medication changes.
The RN and licensed practical nursing staffing levels were noted to be particularly important with respect to decreasing hospitalization and emergency room visits while increasing CNA staffing was associated with an increase in both hospitalization and emergency room visits.
Lastly, CNAs had an important beneficial impact on improving activities of daily living, particularly preventing a decline in function among long- and short-stay residents, but not on prevention of pressure injuries.
Overall, the findings remind us we need to learn more about staffing and the interplay between staffing levels across RNs, LPNs and CNAs. We may need to explore more about scope of practice and make sure the scope of practice and knowledge and ability of the individual match what they are able to perform.
Although the idea of staffing requirements for nursing homes is of great concern, maybe it will help us to finally learn more about the impact of staffing on the needs of residents and the best way to optimize the quality of care.
Please note that in 2025 JAMDA will be publishing a special virtual issue on workforce issues in the post-acute and long-term care environment. The call for papers is open and we encourage submissions as we learn more about this topic.
Barbara Resnick, PhD, CRNP is a Professor at the University of Maryland School of Nursing, the Associate Dean of Research and the Sonya Ziporkin Gershowitz Chair in Gerontology. She is currently the co-editor of the Journal of the American Medical Directors Association.
Paul Katz, MD, CMD is a Professor of Medicine at McMaster and Florida State University.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
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