Health of elderly patients in nursing homes at risk due to understaffing, according to expert panel

March 06, 2000

According to an article published in the February issue of The Gerontologist, nurse staff levels in the nation's nursing homes are, on average, too low to assure quality care. Moreover, the authors report that residents of nursing homes with limited nursing staff have a greater incidence of health problems.

The article stems from an expert panel on nursing home care convened by the John A. Hartford Institute for Geriatric Nursing, Division of Nursing at New York University.

"One of the major reasons that some nursing homes are still providing inadequate quality of care is that they provide inadequate levels of nursing staff," said Charlene Harrington, RN, PhD, UCSF professor of social and behavioral sciences in the School of Nursing and lead author of the study. "Caregiving is the central feature of a nursing home and needs to be improved in order to ensure high quality of care to residents."

The findings are particularly relevant in light of a 1999 report from the U.S. General Accounting Office (GAO) which found that one third of California's nursing homes had seriously jeopardized the health and safety of its residents. Another 1999 GAO study of nursing homes in four states found that many institutions had caused actual or potential death or serious injury to residents.

Based on a review of research studies, the panel reaffirmed the positive relationship between higher nurse staffing, particularly registered nurse staff, and resident health. The experts also found that in nursing homes where nurse staffing was low, resident problems such as high urinary catheter use, low rates of skin care, poor feeding of residents, malnutrition, dehydration, starvation and low participation in activities were more frequent, said Harrington.

Added to the problem of limited staff is the problem that registered nurses in nursing homes have substantially lower levels of education compared to nurses in hospitals.

"Nursing management, leadership and education are central to quality care," said Harrington. "Many nurses in nursing homes have no training in gerontology or chronic disease management, so nursing management and leadership are central to providing high quality of care in nursing facilities given the complex needs of residents."

The experts recommended 24-hour RN supervision, additional education and training, and minimum staffing standards for nursing administration. They also recommended specific ratios of caregivers and licensed nurses to patients, depending on the time of day and the needs of patients. For example, they suggested a minimum ratio of one caregiver to five residents during the day, one caregiver to ten in the evenings, and one to fifteen residents at night. The experts recommended residents receive at least 273 minutes (4 1/2 hours) per day of direct care, with increases in staff for residents that require additional care. According to the federal On-Line Survey, Certification, and Reporting System, a database on all nursing facilities federally certified for Medicare and Medicaid, residents currently receive 210 minutes (3 1/2 hours) of direct care.

"These minimum staffing standards will help state legislators, the U.S. Congress, and the Health Care Financing Administration develop new legislation aimed at insuring quality care in our nation's nursing homes," said Harrington. "It's important to remember that staffing must be adjusted upward for residents with higher nursing care needs."

A key barrier to adding more nursing personnel is cost, said Harrington. The panel found that increased staffing could affect cost savings by improving staff morale and productivity and by reducing the amount of on-the-job injuries. Additionally, the costs of supplies and drugs may be reduced as residents have more active and satisfying lives and have fewer complications and loss of functioning, she said. Higher staffing levels may also lower personnel turnover thus lowering costs associated with hiring and training.
In addition to Harrington, co-authors of the paper include Christine Kovner, PhD, RN, FAAN, and Mathy Mezey, PhD, RN, FAAN, professors of nursing, John A. Hartford Institute for Geriatric Nursing, New York University; Jeanie Kayser-Jones, PhD, RN, FAAN, UCSF professor of physiological nursing and medical anthropology; Sarah Burger, RN, MPH, National Citizens' Coalition for Nursing Home Reform; Martha Mohler, RN, MN, MHSA, National Committee to Preserve Social Security and Medicare; Robert Burke, PhD, Muse & Associates; and David Zimmerman, PhD, Center for Health Systems Research and Analysis, University of Wisconsin, Madison.

University of California - San Francisco

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