The Relationship between Nurse Staffing and Nurse Outcomes in Nursing Homes: An Integrative Review

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J Korean Gerontol Nurs. 2020;22(2):117-125

Publication date (electronic) : 2020 May 31

doi : https://doi.org/10.17079/jkgn.2020.22.2.117

Jiyeon Lee

Graduate Student, College of Nursing, Ewha Womans University Seoul, Korea

Corresponding author: Lee, Jiyeon College of Nursing, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea. Tel: +82-2-3277-2873, Fax: +82-2-3277-2850, E-mail: dlwldusking@hanmail.net

Received 2019 December 10; Revised 2020 January 29; Accepted 2020 March 27.

Abstract

INTRODUCTION

South Korea has seen a rapid increase in the proportion of the older adult population in the world, with about 15.7% of the population in 2018 were elders, and is expected that by 2050, 38.1% will be older adults. To solve the health problems of older adults and lack of family support for older adults, Korea initiated a universal long-term care social insurance system in 2008. With this change, the number of nursing homes (NHs) increased rapidly from 1,332 in 2008 to 3,389 in 2018; during the same period, the number of older adults in NHs increased more than 2.5 times from 66,715 to 163,484, and this increase is expected to continue [1].

Nurse staffing in the NH setting is significant because the long-term care industry is labor-intensive [2]. In NHs, nurses are core staff, affecting the quality of care of residents [A8]. NH nurses provide clinical care, care management, and planning for evidence-based practice, based on timely assessments of residents’ health status [2]. Nurse staffing in NHs is proportionally different from those in acute-care settings. In general, NHs have fewer registered nurses (RNs) and more assistive nursing staff, such as licensed practical nurses (LPNs) and certified nurse aides (CNAs) [3]. For this reason, most research about nurse staffing in NHs includes LPNs, CNAs, and RNs. Suboptimal nurse staffing in NHs has been found to be associated with a lower quality of care and negative health outcomes in nursing staff [3,4].

In the United States, the NH Reform Act of 1987 requires NHs to assign one RN on duty for 8 hours a day, 7 days a week, and a LPN in the evening and night shifts [5]. The guidance from the Centers for Medicare & Medicaid Services (CMS, 2001) provided minimum nurse staffing standards to implement the following federal guidelines: RNs: 0.75 hours per resident day (HPRD), LPNs: 0.55 HPRD, and CNAs: 2.8~3.0 HPRD [6]. These nurse-staffing policies aim to improve the quality of care and provide a positive practice environment in NHs through proper placement of nursing staff.

Several nurse staffing-related variables are used in the field of NHs, such as HPRD [2,4,7,8], skill mix (the proportion of professionals) [7,8], and turnover and retention (as a measure of the stability of the workforce) [2,4,7,8]. Researchers have conducted a great number of studies about nurse-staffing levels and resident outcomes in NHs [4,7]. Researchers found that lower nurse-staffing levels relate to lower quality of care. Through systematic reviews, researchers found that increased nurse-staffing levels align with better health outcomes, such as use of fewer antipsychotic drugs, reduced use of physical restraints, lower occurrence of fractures, lower incidence of infection, and lower probability of death in NHs [4,7]. Although more research is needed continuously, the relationship between nurse-staffing levels and resident outcomes has been clearly identified.

Researchers and stakeholders should also consider nursing outcomes when deciding which nursing staff provides health care to residents in NHs. With respect to NH nurse outcomes, lower nurse staffing relates to lower job satisfaction, lower retention rates, and higher turnover [A1,A3-A5,A7,A8]. In contrast, some researchers showed that nurse staffing does not align with nurse outcomes such as tenure, job satisfaction, and burnout [A2,A6,A9]. However, no integrative review emerged that investigated the relationship between the level of nurse staffing and nurse outcomes in the NH setting. Because studies focused on different aspects of nurse staffing and nurse outcomes, findings from these studies need to be reviewed. Through an integrative review of the literature, it is possible to draw conclusions on the relationship between NH nurse staffing and nurse outcomes.

The purpose of this review was to determine the current state of knowledge about the relationship between nurse staffing and nurse outcomes in NHs. Specifically, 1) identify nurse staffing measures and nurse outcome measures used in the literature (2009~2019), 2) summarize the effects of the appropriate level of nursing staff on nursing outcomes, and 3) suggest future research directions to improve nurse outcomes in the NH setting.

METHODS

3. Search Outcome

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines directed the systematic review process [9]. In this review, the author identified and screened a total of 500 titles from the search of electronic bibliographic databases. After deleting duplicates, the initial search yielded 91 publications. After screening titles and abstracts, the number of remaining articles were 19. Of the remaining 19 articles, three articles did not use objective indicators in measuring nurse-staffing levels (instead, they used a subjective indicator of the adequacy of nurse-staffing levels), six articles did not measure nurse outcomes, and one article’s setting was NHs and sheltered housing. Through this step, nine articles remained. Therefore, nine articles related to nurse staffing and nurse outcomes were reviewed and synthesized (Figure 1). In this review, a PRISMA diagram explains how sources were identified and selected.

Figure 1.

Flow diagram for study selection (PRISMA).

4. Data Extraction/Synthesis and Analysis

Findings from the included studies were summarized. The following data fields were extracted from the included studies: author, year, country, sample, setting, design, nurse staffing variables, nurse outcomes variables, and study findings (Table 1).

Table 1.

Summary of the Relationships between Nurse Staffing and Nurse Outcomes

RESULTS

DISCUSSION

In a review of the last ten years of research in nurse staffing and nurse outcomes in NHs, it was found that better nurse outcomes aligned with higher levels of nurse staffing. Of the nine studies, six studies reported that an increased number of nursing staff and stable nurse staffing with more tenure and less turnover related to positive nurse outcomes in NHs [A1,A3-A5,A7,A8]. In contrast, three studies reported no relationship between nurse staffing and nurse outcomes [A2,A6,A9]. More stable nurse staffing included more DON tenure and lower nursing staff (RN, LPN, and CNA) turnover. However, some studies showed no relationship between nurse staffing and nurse outcomes [A2,A6,A9].

With respect to nurse staffing, lack of nursing staff resulted in an insufficient HPRD that prevents nurses from providing high quality of care. The American Health Care Association RN Manpower Survey found that 82% of NHs needed more CNAs, 76% were short of LPNs, and 71% were short of RNs [14]. Accordingly, in 2015, the U.S. government proposed new regulations about nurse staffing [15]. However, the proposed regulations do not require a change in the federal staffing standard. Considering that nurse-staffing levels relate not only to resident outcomes but also to nurse outcomes, appropriate nursestaffing levels should be identified for NHs.

None of the studies in this review considered ratios of RNs to all staffing levels. In addition to providing direct care to residents, RNs in NHs are responsible for multiple tasks, such as leadership and assistance to residents, staff supervision, recognizing significant changes in residents, and educating LPNs and CNAs [16]. However, most NHs hire CNAs rather than RNs due to financial pressures [17]. Because the responsibilities and roles of each nursing staff level are different, the roles distributed to each nursing staff member and the consequences (nurse outcomes) may vary, depending on the proportion of each nursing profession. Therefore, in future studies, skill mix as a factor related to nurse outcomes should be considered.

A high RN turnover rate is a major concern for NH nurses and residents because many studies and government reports have addressed the issue of adverse outcomes resulting from higher RN turnover rates [18,19]. Researchers reported that nursing turnover links to other staff turnover and poor quality of care in NHs [A4,18]. Also, the turnover of nursing staff leads to increased costs for facilities in recruitment, training, selection, and supervision of new nursing staff [20]. Adequate nurse-staffing levels should be addressed to improve resident outcome and RN retention.

NHs have remarkably low RN-retention rates. Although recent data is lacking, in 2004, the retention rate of RNs at NHs in the United States was reported to be 67.3% [A8]. The tenure of RNs in Korea’s NHs in 2016 was reported to be 2.2 years [21]. The difference in the retention rates and tenure of RNs between the United States and Korea is due to the difference in the work environment. In the United States, an elder-care expert panel in Hartford in 2000 required at least one RN for every 15 residents on the day shift, one for every 20 residents on the evening shift, and one RN for every 30 residents on the night shift. Also, the median RN HPRD in the United States is 4 hours 25 minutes [5]. Korea’s nurse-staffing standards are significantly lower than those of the United States. The legal requirement for nurse staffing in Korea is that each NH should deploy one RN (or CNA) for every 25 residents, regardless of shift. This is 18 minutes, when converted into HPRD. Also, only 1,472 RNs are deployed in NHs, whereas 7,806 CNAs and 64,179 care workers are deployed in NHs in Korea [1].

To increase the retention rate and tenure among RNs, a positive work environment should be created through adequate nurse staffing (higher staffing and higher RN skill mix). Studies are needed on RNs’ working environments in NHs to improve resident health outcomes because high tenure affects other nursing-staff retention [A8] and will ultimately result in seamless, high-quality care. Organizational efforts are needed to create a positive work environment.

A gap exists in the current state of NH literature. The parameters measured as outcomes of nurses are limited. In a study of hospital nurse staffing and nurse outcomes, researchers measured parameters such as emotional exhaustion, stress, and needlestick injuries as nurse outcomes [22]. More diverse outcome variables should be identified and measured in studies of nurses working in NHs. Additionally, all nine studies used a cross-sectional design. As a result, it is not possible to establish causality between nurse staffing and nurse outcomes. Research design may be why studies did not find significant relationships between nurse staffing and nurse outcomes. Future studies should be conducted using longitudinal designs to explain causality. Finally, in this review, most (88.9%) studies were conducted in the United States, thereby limiting generalizability.

This review has several limitations. First, although a comprehensive search strategy was used in this study, the search terms used for nurse staffing and nurse outcomes may not capture all possible terms indicating nurse staffing and nurse outcomes in publications in this area. Therefore, future studies involving all studies related to this area are needed. Second, the measurement of nurse staffing, nurse outcomes, and study samples varied dramatically. This wide variety made it impossible to compare the rate of change in nurse outcomes across studies. Third, the limited number of included studies may limit the ability to explain variation in the relationship between nurse staffing and nurse-outcome measures.

Despite these limitations, this review provides important evidence that nurse staffing relates to nursing outcomes such as turnover rate, retention rate, intent to leave, and job satisfaction. Results from this review provide preliminary information to identify appropriate nurse-staffing levels to improve positive nurse outcomes and residents’ health and wellness. A need persists for continued research to examine the effects of increased nurse staffing on short-term and long-term NH resident health outcomes to provide guidance on nurse-staffing policy for NHs.

CONCLUSION

Data from this review provide preliminary evidence that nurse staffing (number and stability) in NHs is associated with nursing outcomes such as turnover rate, retention rate, intent to leave, and job satisfaction. Future research needs to be conducted that includes more diverse variables than nursing staff and nursing outcomes such as nursing error, emotional exhaustion, burnout, and stress. Through this review of studies related to NH nurse staffing and nurse outcomes, study results can help health care professionals, researchers in practice, administrative staff, researchers, and politicians establish strategies for nurse staffing to prevent adverse nurse outcomes. These results can also provide evidence of the importance of nurse staffing in NHs and lead to more effective deployment of nursing staff and help for NHs’ nurse-staffing policies.

Future research is necessary to derive more causative research results through intervention studies or longitudinal studies on nurse outcomes, based on nurse staffing. Based on these findings, research should be conducted to estimate the appropriate level of nursing staff to improve nurse outcomes.

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