1. 1 Is there Evidence for Mandated Nurse Staffing Standards for Nursing Homes? Christine Mueller, PhD, RN, C, CNAA Associate Professor Center for Gerontological Nursing University of Minnesota, School of Nursing

2. Research Collaborators Robert Kane, MD, Professor and Minnesota Chair in Long-term Care and Aging Greg Arling, PhD, Associate Professor, Cookingham Institute, University of Missouri-Kansas City Research Assistants Julie Bershadsky Theresa Lewis Diane Holland, MS, RN

3. Nurse Staffing/Nursing Time and Quality

4. Four research activities related to staffing and quality in long-term care facilities: Critical review of literature Analysis of States’ staffing standards Interviews of Minnesota stakeholders Analysis of Minnesota nurse staffing time and risk- adjusted process and outcome quality measures

5. Critical literature review—Scope Relationship between nurse staffing and quality as primary focus of the study 1977-2005 30 quantitative studies –Adequacy of staffing data source and measures –Adequacy of care quality data sources and measures –Generalizability of study findings –Presence and strength of relationships 6 qualitative studies –How staffing relates to processes of care and how the processes affect the health status of residents

6. Critical literature review—Main Findings Data sources for staffing OSCAR (46% of studies) –Accuracy issues Other state level databases, interviews One study observed time spent Staffing measures RN, LPN, NA, Total HPRD or ratio

7. Critical literature review—Main Findings Data sources for Quality 11 different data sources Quality measures Risk adjustment

8. Summary of findings from studies Quality MeasureHigh staffing/ better outcomes High staffing/ worse outcomes No significance Totals/ percent Resident status11 (38%)1 (3%)17 (59%)29 (100%) Health and Functioning 32 (44%)4 (5%)36 (51%)72 (100%) Care Processes18 (53%)5 (15%)11 (32%)34 (100%) Deficiencies12 (40%)0 (0%)18 (60%)30 (100%) Composite measure3 (50%)1 (17%)2 (33%)6 (100%) Other4 (24%)0 (0%)13 (76%)17 (100%) Totals/percent80 (43%)11 (6%)97 (51%)188 (100%)

9. Stakeholder perceptions regarding staffing and quality in long-term care facilities Group Interviews 13 group interviews 212 persons Key organizations helped facilitate interviews Surveys 114 respondents Family councils (4) Resident councils (4) RNs LPNs NAs Directors of Nursing Ombudsmen Administrators Union representatives Nurse practitioners

10. Two Primary Questions What are the greatest concerns you have with staffing in nursing homes? What is your advice to the State about what should be included in a staffing standard for MN nursing facilities?

11. Concerns of Stakeholders Lack of continuity of care for residents Quality of staff Communication/English fluency Lack of compassion; negative attitudes Not enough nursing staff Lack of knowledge/training needs of staff Management/supervision Turnover/retention Acuity needs of residents changing Quality of care is associated with staffing Examples after examples

12. Recommendations of Stakeholders More staff but no specific recommendations for ratios or HPRD Link staffing to acuity Associated with quality Training/education Management, leadership, and supervision Positive work environment that fosters staff involvement in decision making about the residents’ care and their work Major Caveat: Support increased staffing standards as long as their was the assurance of financial support to meet the standards.

13. State Staffing Standards—Scope of work Research questions: 1) What are the characteristics of state staffing standards in the U.S.? 2) Are state staffing standards associated with nursing staff hours per resident day (HPRD), licensed HPRD and unlicensed HPRD? Obtaining staffing standard data 50 states plus District of Columbia (2004) Abstracting variables Obtaining actual staffing OSCAR (2004) 14,147 facilities in 50 states plus D.C. Creation of a data file for analysis Published in The Gerontologist

14. State staffing standards--Findings 40 States have staffing standards over and above the federal requirement 33 specify HPRD or ratio –Median 2.35 HPRD (highest 3.6 HPRD) 33 specify additional licensed nurse staffing requirements 7 require 24 hour RN staffing Actual Staffing (for each state) Licensed: 1.26 HPRD NA: 2.31 HPRD Total: 3.57 HPRD

15. Variables for analysis Categorical staffing variables: No HPRD,  2.5 HRPD, >2.5 HPRD Presence or absence of 24 RN staffing Presence or absence of additional licensed staffing Covariates Size of nursing home Type of Medicare/Medicaid certification Percent of private pay residents Hospital affiliation Chain affiliation Percent occupancy Ownership Resident acuity

16. State staffing standards—Findings (cont). Facility HPRD staffing varied a great deal more within than between states. Staffing standards per se accounted for only a small proportion of between-state variance in facility staffing levels (11% of total HPRD). Medicaid payment rate and facility-level covariates did a much better job of accounting for between-state variance (70% of total HPRD) Facilities in states with low HPRD standards had the lowest average total, licensed, and aide HPRD Facilities in states with high HPRD standards had highest total, licensed and aide HPRD; Facilities in states with no standards were in between.

17. Staffing Standards analysis--Implications Introducing a high HPRD staffing standard may increase facility staffing; But, how high? A low standard may have no affect or even a dampening effect. Some facilities may treat staffing standard minimums as if they were maximums, and lower their staffing accordingly Other facility characteristics, such as management style or labor market conditions, not measured in our study may explain some of the variation that was not accounted for in this study.

18. Nursing Time and Quality Limitation of other studies Staffing and quality assessed at the facility level Our study addressed this limitation Data included nursing time that could be associated with – specific residents –specific nursing units Resident and unit risk adjusted quality measures/ indicators at the resident level Accounted for resident acuity and staffing at the unit level

19. Research Questions Is there a positive relationship between nursing time (nursing resource used) and quality related outcomes/ measures? Is more staff time associated with better quality indicators? Is the association causal? If quality related resident outcomes are positively associated with more nursing resources, what is the nursing resource/quality threshold, that is, what amount of nursing resource use will provide no further improvement in quality outcomes?

20. Care Outcomes Care Processes Resident Resource Use Resident acuity/risk Unit Unit Quality Unit Unit Staffing Unit Unit Acuity Nursing Resource Use & Care Quality Model

21. Staff Time Study 43 Minnesota LTC facilities 68 nursing units 2,506 residents 40 conventional units 18 special care (dementia) units Staff time data collected over 48 hour period Resident specific time Non-resident specific time MDS assessments for each resident

22. Variables Staff time (RST and NRST) RN LPN NA Therapy Social services Activities Quality indicators/measures 5 Process measures 7 Outcome measures Risk adjusted Control variables Resident acuity Unit acuity Unit type

23. Resident-Level Direct Care Times as Predictors of Process and Outcome Measures Quality Indicator/MeasureDirect Care Minutes/Day RNLPNNA Restraints (P)ns*ns1.25** Psychotropic medications (P)ns Range of motion training (P)ns 1.14 Toileting training (P)ns 1.16 ADL Skill training (P)ns Loss of function in basic daily activities (O)ns1.130.93 Incidence of decline in range of motion (O)ns Worsening of bowel or bladder incontinence (O)ns 1.06 Worsening behavior (O)ns Worsening depression or anxiety (O)ns Weight loss (O)ns Worsening pain (O) ns1.22ns Non-significant result; only results significant p>.05 are shown as actual odds ratios ** odds ratio associated with a 15 minute/day increase in care time

24. Unit-Level Direct Care Times as Predictors of Process and Outcome Measures Quality Indicator/MeasureDirect Care Minutes/Day RNLPNNA Restraints (P)ns*ns Psychotropic medications (P)ns Range of motion training (P)ns2.15**ns Toileting training (P)ns ADL Skill training (P)ns Loss of function in basic daily activities (O)ns Incidence of decline in range of motion (O)ns Worsening of bowel or bladder incontinence (O)ns1.520.81 Worsening behavior (O)ns Worsening depression or anxiety (O)1.54ns Weight loss (O)ns Worsening pain (O)ns Non-significant result; only results significant p>.05 are shown as actual odds ratios ** odds ratio associated with a 15 minute/day increase in care time

25. Strength of the Evidence? Support from literature is marginal Use of staffing standards requires caution No support for the relationship between nurse staffing time and quality measures While stakeholders believe staffing and quality are related, they are unable to identify staffing ratios or HPRD that would result in desired quality.

26. What are the questions we should be asking? Quality may be more of a function of the way nursing care is organized and delivered— –Continuity of care provider fostering the nurse-resident relationship Expertise of direct care staff Staff morale and teamwork Facility or unit management practices Leadership and supervision Care related technology Availability of support staff

27. Our Recommendations Premature to propose specific staffing standards Rather, establish incentives to allow facilities to be more creative and apply cost-effective solutions to address staffing factors Quality based Medicaid payment system Reward higher quality of care Give facilities flexibility for channeling resources Need research to see if this approach improves quality Focus research on other factors that might influence quality

28. Thank you! Questions?