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
“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
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
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
“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
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
“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.