Experts recommend minimum nurse staffing standards for nursing facilities in the United States
Charlene Harrington; Christine Kovner; Mathy Mezey; Jeanie Kayser; Et al

02/01/2000
Gerontologist
5-16
Copyright (c) 2000 Bell & Howell Information and Learning Company. All rights reserved. Copyright Gerontological
Society of America, Incorporated Feb 2000

Registered nurses (RNs), licensed vocational nurses/ licensed practical nurses (LVN/LPNs), and nursing assistants
(NAs) make up about 60% of total nursing home personnel (Harrington, Carillo, Thollaug, & Summers, 1999).
Nursing care is central to the process and the outcomes of nursing home care (Aaronson, Zinn, & Rosko, 1994;
Cohen & Spector, 1996; Spector & Takada, 1991 ). The positive relationship between nurse staffing and quality of
nursing home care was recognized by an Institute of Medicine (1996) committee that recommended adding more
RNs to the staff in nursing homes. 

Recently, the U.S. General Accounting Office (1998) found poor quality in many nursing homes; one third of
California's nursing homes had seriously jeopardized the health and safety of residents over a 2-year period, and
most other California nursing facilities had a range of serious problems identified. Another U.S. General Accounting
Office (1999) study of four states found that many nursing homes had caused actual or potential death or serious
injury or other actual harm to residents, and about 77% of those facilities had the same or more serious problems in
subsequent surveys conducted by state licensing and certification agencies. The U.S. Office of the Inspector
General (1999) confirmed the many chronic and recurring quality problems in nursing homes; state surveyors
reported that nursing home staffing shortages and inadequate staff expertise were major factors in poor quality.

To address the issue of staffing and quality of care in nursing facilities, a 1-day conference of experts was convened
at the John A. Hartford Institute for Geriatric Nursing, Division of Nursing, at New York University in April 1998.
National experts attending the conference consisted of leading nurse researchers, educators and administrators in
long-term care, consumer advocates, health economists, and health services researchers knowledgeable about
nursing homes. 

To consider nurse staffing, the expert panel re viewed four sources of information. First, the panel reviewed previous
studies on staffing and quality of care. Second, the panel examined current nurse staffing levels for all nursing
homes in the United States using data from the federal On-Line Survey Certification and Reporting System
(OSCAR). Third, the panel examined the Health Care Financing Administration (HCFA) staff time management
studies on nursing care in nursing homes in 1995-1997. Fourth, the panel reviewed the minimum standard for nurse
staffing adopted by the National Citizens' Coalition for Nursing Home Reform (NCCNHR) in 1995. In this article we
present the literature review and the time study data available from OSCAR and the HCFA time studies. The panel
was asked to consider the following questions: (1 ) Should nurse staffing levels be increased? and (2) What should
be the minimum standards for nurse staffing levels in nursing homes for different types of staff (RNs, LVN/LPNs, and
NAs)? After the conference, drafts of the recommendations were developed and circulated to the conference
attendees for comments. Revisions were made and the majority (17 individuals) of the conference participants
endorsed the final recommendations presented in this article (see Appendix 1). Three groups did not endorse the
recommendations. One group (8 individuals) composed of government officials, government contractors, or
individuals on commissions were unable to take official positions, although most of these individuals supported the
recommendations. One group (3 individuals) did not respond, and 1 participant did not believe he had the expertise
to make a judgment. Three did not support the proposal; 2 were nursing home administrators who were concerned
about the government funding for the proposal and labor shortages, and 1 was an economist concerned about cost
effectiveness. 

In this article we present the final recommendations on staffing from the majority of the expert panel. The
recommendations focus on the amount and type of nursing staff considered essential to meet minimum standards,
as well as education and training requirements. The proposed standards can be used as guidelines by providers,
accrediting organizations, states, Congress, and HCFA in setting minimum standards. 

Federal Certification Standards 

To participate in the Medicare or Medicaid programs, long-term care facilities are required to meet federal
certification requirements established by HCFA (Medicare and Medicaid Programs, 1994). Congress passed the
Nursing Home Reform Act in the Omnibus Budget Reconciliation Act of 1987, which was implemented by HCFA in
a series of regulations and transmittal letters (HCFA, 1995a, 1995b, 1995c; Medicare and Medicaid programs,
1994). Among the many changes made in the Nursing Home Reform Act was a requirement for increased nurse
staffing. Current minimum federal standards require that all certified nursing homes have an RN director of nursing;
an RN on duty for 8 hr/day, 7 days/week; and a licensed nurse (either an RN or an LPN/LVN) on duty on evening
and nights. In addition, the law requires sufficient nursing staff to provide nursing and related services to attain or
maintain the highest practicable level of physical, mental and psychosocial well being of each resident. The
Omnibus Budget Reconciliation Act of 1987 also allowed nursing facilities to request waivers from the staffing
requirements in areas where shortages of nurses exist. 

Beyond the one RN and the licensed nurse requirement, the HCFA regulations provide no guidance for facilities on
the minimum or appropriate numbers of staff (HCFA, 1995a, 1995b, 1995c; Medicare and Medicaid Programs,
1994). Although state survey agencies are charged with determining compliance with the federal Medicare and
Medicaid certification standards, the lack of specificity in the regulations makes it difficult for the state surveyors to
determine whether facilities are providing adequate staffing levels for different types of residents. In addition, the
federal statutes do not require licensed staff levels to be proportionate to the size of nursing facilities. Finally, the
HCFA survey and certification program that regulates nursing facilities does not have procedures for auditing staffing
levels or for monitoring the accuracy of staffing data. 

Review of Nurse Staffing and Quality of Care Literature 

Many studies consistently show the positive relationship between higher nurse staffing levels, especially RN staff,
and the outcomes of nursing home care (Aaronson et al., 1994; Bliesmer et al., 1998; Cherry, 1991; Cohen &
Spector, 1996; Linn et al., 1977; Munroe, 1990; Nyman, 1988; Spector & Takada, 1991 ). Nyman and colleagues
(Nyman, 1988; Nyman, Breaker, & Link, 1990) found that nurse hours per patient day were positively related to
three quality measures. Munroe (1990) found a positive significant relationship between the quality (measured by
deficiencies) and higher ratios of RN and LPN hours per resident day and concluded that the higher ratios of
licensed nurses may be more important than total nursing hours. 

Spector and Takada (1991 ) reported that higher staff levels and lower RN turnover rates were related to
improvements in resident functioning. Lower staffing was associated with high urinary catheter use, low rates of skin
care, and low resident participation in activities. Cherry (1991 ) also found that increased RN hours were positively
associated with a composite of good outcome measures (fewer decubitus ulcers, catheterized residents, and
urinary tract infections and less antibiotic use). Cohen and Spector (1996) found that higher ratios of RNs to
residents, adjusted for resident case-mix, reduced the likelihood of death and that higher ratios of LPNs to residents
significantly improved resident functional outcomes. 

A recent study of Minnesota nursing homes found that in the 1 st year after admission to a nursing home, the
licensed nursing hours (but not nonlicensed) were significantly related to residents' improved functional ability,
increased probability of discharge home, and decreased probability of death (Bliesmer et al., 1998). Although the
role of professional nursing staff disappeared when examining chronic care residents, the findings supported greater
use of licensed nurses in nursing homes (Bliesmer et al., 1998). Nursing staff and other direct care staffing levels
had a consistent, significant negative relationship with deficiencies, although overall staffing levels did not explain as
much of the variation in deficiencies as did facility characteristics (Harrington, Zimmerman, Karon, Robinson. &r
Beutel,. 1999). 

Inadequate food intake is a major determinant of mortality in the frail elderly in nursing homes (Blaum et al., 1995;
Frisoni et al., 1995). Other studies have reported that inadequate staffing and inadequately trained staff are major
contributors to poor feeding of residents, inadequate nutritional intake, undiagnosed dysphagia, poor oral health,
resident deterioration, hospitalization, malnutrition, dehydration, and starvation (Amella, 1999; Kayser-Jones, 1996,
1997; Kayser-Jones & Schell, 1997; Kayser-Jones, Schell, Porter, & Paul, 1997; Kayser-Jones, Schell, Porter, et
al., 1998; Kayser-Jones, Wiener, & Barbaccia, 1989). 

Other studies (Bowers & Becker, 1992; Foner, 1994) reported that NAs cut corners to manage workloads and lack
time to provide high quality, individualized care given the requirements for institutional efficiency and the high work
volume. Two studies reported that psychological and physical abuse of residents by NAs was related to stressful
working conditions in nursing homes (Foner, 1994; Pillemer & Moore. 1989). 

High turnover rates have been associated with lower quality of care in nursing homes (Munroe, 1990; Spector &
Takada, 1991 ). The American Health Care Association (1997) reported that the turnover rate for NAs was 97%, for
RNs was 52.5%, and for total staff was 68.8% in 1996. Some of the high staff turnover rates can be directly related
to poor wages and limited or no health benefits (Institute of Medicine, 1996). Other turnover rates may be
associated with the heavy workloads that NAs are given. 

In summary, the evidence shows that RN staffing and total nurse (RN, LVN/LPN, and NA) staffing levels are
important factors in ensuring high quality of care in nursing homes. These findings, along with the evidence for poor
quality of care in many nursing homes, support the need for increased minimum nurse staffing levels to improve
quality of care. On-Line Survey, Certification, and Reporting System 

One important source of data on staffing in U.S. nursing homes is from the federal OSCAR system. This data
system is a uniform database on all nursing facilities federally certified for Medicare (skilled nursing care) and
Medicaid (nursing facilities) that includes facility characteristics and staffing data reported by facilities themselves.
OSCAR data are collected during the regular certification surveys by state agencies that verify compliance with all
federal regulatory requirements conducted about every 12 months. 

Table 1 shows the OSCAR staffing data for 14,140 facilities in the United States for calendar year 1997. The
average ratio of RN (including nurse administrators) hours was 0.72 hr (43.2 min) per resident day (Harrington,
Carrillo, et al., 1999). LPN/LVN hours were 0.69 hr (41.4 min) per resident day, and NA hours were 2.10 hr (126
min) in 1997. The total nurse staffing hours per resident day was 3.51 hr (210 min). When the total hours are divided
by three (8-hr) shifts in a day, residents averaged about 14 min of RN time per shift, about 14 min of LPN/LVN time,
and 42 min of NA time per shift. The proportion of RN time to total nursing hours is also an important measure. On
average, RNs provided 20.6% of total nursing hours (including administrative nurses), LPN/LVNs provided 19.7% of
total hours, and NAs provided 59.7% of total hours in 1997 (Harrington, Carrillo, et al., 1999). 

Wide variations in nurse staffing levels are found for different types of facilities (Harrington, Carrillo, Mullan, & Swan,
1998). Table 1 shows that hospital-based facilities had 5.88 total hr of nursing care per resident day, compared with
3.18 hr for nonhospital facilities. Skilled nursing facilities (SNFs) for Medicare-only residents had 7.09 hr per
resident day, compared with only 2.93 hr for nursing facilities with Medicaid-only residents. Smaller facilities,
nonprofit and government facilities, nonchains, and facilities in the West had higher staffing than their comparison
groups (Harrington, Carrillo, et al., 1999; Harrington, Swan, Mullan, & Carrillo, 1999). 

HCFA Time Studies 

The most important factor in determining staffing levels should be the resident case-mix within facilities. Previous
studies have shown a strong positive relationship between resident characteristics (casemix) and nurse staffing time
needed to provide care (Arling, Nordquist, Brant, & Capitman, 1987; Cohen & Dubay, 1990; Fries et al., 1994; Zinn,
1993a, 1993b). Congress passed legislation requiring HCFA to develop a Nursing Home Case-Mix and Quality
Demonstration program (Omnibus Budget Reconciliation Act of 1990). This project developed a method for
classifying nursing home residents into 44 different resource utilization groups (RUG-III; Fries et al., 1994) on the
basis of resident characteristics in relation to the facility staff time expended to provide nursing care. and therapy
services. These RUG groups and time studies were used to develop a Medicaid payment system for use by the four
states participating in the demonstration in 1995 and for the development of the new Medicare prospective payment
system (PPS) implemented by HCFA in July 1998. 

Prior to the implementation of Medicare PPS payments, HCFA commissioned three major staff time measurement
studies to define the relationship between resident resource utilization and nursing and therapy staff time. The
facilities selected for these time studies met screening criteria for high-quality care and had substantial numbers of
Medicare beneficiaries (Burke & Cornelius, 1998; Reilly, 1998). The major concern about these studies has been
that they reflect current staffing practices and not necessarily appropriate staffing levels as judged by clinicians. 

Table 2 shows the average minutes per resident day for different types of nursing staff from the HCFA staff time
management studies in 1995 and 1997 (averaged together), including direct and indirect care time as well as
administrative nursing time. The average minutes for all RNs was 69 min (1.15 hr) per resident day, the LVN/LPN
time was 42 min (.7 hr) per resident day, and the NA time was 139 min (2.32 hr) per resident day. This resulted in a
total of 250 min (4.17 hr) per resident day on average across all RUG classification groups of residents (Burke &
Cornelius, 1998). 

The data show a wide range of nursing time for residents in different resource groups. Residents classified in the
highest RUG category for extensive nursing care received an average of 433.5 min (7.2 hr) of nursing time per
resident day in the 19951997 time studies (32% was RN time, 23% was LVN/ LPN time, and the remainder was NA
time; Burke & Cornelius, 1998). (No table shown.) The lowest RUG category received 130.8 min (2.18 hr) of care
(21.6% was RN time, 22.8% was LVN/LPN time, and the remainder was NA time). The highest rehabilitation RUG
category received 347 min (5.8 hr) per resident day (32.5% was RN time, 15.5% was LVN/LPN time, and the
remainder was NA time). Thus, residents in the highest RUG category received more than three times as many
nursing hours as residents in the lowest category, and the education levels of staff varied by the case-mix of
residents (Burke & Cornelius. 1998). 

Table 2 compares the average nursing hours per resident day from OSCAR data and the HCFA time studies. The
OSCAR data showed 210 min per resident day, compared with 250 min per resident day reported for selected
facilities from the HCFA time studies. The RN time was 43 min on OSCAR, compared with 69 min on the HCFA
time studies, but the LNV/LPN time was similar. The NA time on OSCAR was 126 min, compared with 139 min for
the HCFA time studies. We expected that the HCFA time studies would show higher average hours because the
sample was of facilities with reputations for higher quality and had Medicare residents. The OSCAR staffing data
and the HCFA time studies are somewhat similar in nurse staffing Levels, but the HCFA time studies show higher
hours per resident. 

Consumers' Minimum Standard for Nurse Staffing 

NCCNHR has long advocated for improved staffing levels in nursing homes and has reported that many facilities are
not providing adequate levels of staff and poor quality of care. NCCNHR, a nonprofit organization formed in 1975,
studied nursing home residents and developed three primary areas of concern about quality: "treatment with dignity
and respect; self determination and the opportunity to make choices about their daily lives; and kind, caring staff
who regarded them as individuals" (NCCNHR, 1985; see also Burger, Frazer, Hunt, & Frank, 1996; Nursing Staff in
Nursing Homes, 1991). NCCNHR (1995) adopted a statement of guidance for consumers on minimum standards for
nurse staffing developed by nurses experienced in nursing home care. These recommendations were endorsed by
other organizations such as the National Committee to Preserve Social Security and Medicare and the National
Association of Directors of Nursing Administration-Long Term Care and were used as a guide by the expert panel
(NCCNHR, 1998). 

Expert Panel Recommendations 

After considering the previously discussed find ings, the expert panel generally concluded that many nursing
facilities are operating with inadequate staffing levels and that staffing levels need to be improved substantially (see
Table 3). 

Administrative Staff 

On the basis of the information presented, the expert panel agreed with the NCCNHR recommendation for minimum
administrative staffing in nursing homes. The standards recommended were for one full-time RN director of nursing
in every nursing home and a full-time assistant director of nursing for facilities with 100 beds or more
(proportionately adjusted for smaller facilities) to provide leadership and administration for complex nursing services
(see Table 3). In addition, at least one RN nursing supervisor should be on duty at all times (24 hr/day, 7
days/week) in each nursing home facility because of the complex care requirements of nursing facility residents. A
full-time RN director of in-service education in facilities of 100 beds or more (proportionately adjusted for smaller
facilities) was recommended to be responsible for administration and supervision of an ongoing training program for
staff at all levels. Because of the high staff turnover rates, nursing homes need to have a continuous training effort to
oversee training and testing of new NAs, administration of a competency exam, regular inservice education
programs, and new staff orientation programs. 

Overall, for a 100-bed facility, the administrative nursing staff would be a minimum of three RNs (representing 10 min
per resident day) and a 24-hr RN nursing supervisor (15 min per resident day) for a total of 25 administrative nursing
min (0.42 hr) per resident day. 

Licensed Nursing Staff 

In addition to the administrative staff, licensed RNs and LVN/LPNs are needed to provide direct care of residents on
nursing units, including conducting assessments, giving treatments and medications, delivering hands-on care, and
supervising NAs. Minimum ratios recommended are 1 licensed nurse to every 15 residents during the day shift, 1:20
in the evenings, and 1:30 at night (see Table 3). The licensed staff provide the ongoing care and leadership at the
unit level. A total of 72 min (1.2 hr) is needed for the licensed staff supervision to further improve care. At the same
time, nursing homes should increase the ratio of RNs to LVN/LPNs, because RNs have more professional training
ands.expertise in assessment and clinical care than LVN/LPNs (Kayserjones & Schell, 1997; Smith, 1996)., 

Direct Care Nurse Staff 

For direct nursing caregivers (including RNs, LPN/ LVNs, and NAs), the experts recommended a ratio of 1 direct
caregiver to 5 residents on the day shift, 1:10 for evenings, and 1:15 for nights (see Table 3). Although most nursing
homes currently use primarily NAs for direct caregivers, a shift from NAs to RNs and LVN/LPNs was recommended
for direct caregivers. Of the total of 2.93 hr of direct resident care per day, at least 14 min was recommended for
direct care time by RNs or LPN/LVNs. Administrative staff is excluded from the direct care standard except in
facilities with 30 residents or less. No waivers of these standards should be allowed, and these requirements should
be in place for all residents, regardless of payer source, type of a facility, or ownership of a facility. 

Table 2 shows the summary of the total nursing time proposed by the experts compared with the time reported on
the OSCAR data and the HCFA time studies in 1995-1997. The proposed time for RNs and LVN/LPNs would be the
same as in the HCFA time studies. The proposed time for the NAs would be 162 min, compared with 126 min on
the OSCAR data and 139 min on the HCFA time studies. The experts recommended a minimum of 273 min (4.55
hr) per resident day of total nursing time (RNs, LVN/LPNs, and NAs), compared with 210 min (3.51 hr) reported on
the OSCAR data and 250 min (4.17 hr) for the average time in HCFA time studies. 

Adjusting for Resident Case-Mix 

Nurse staffing levels should be adjusted upward for residents with higher nursing care needs. The time adjustment
for case-mix should be proportional to the RUG staff time for the relative amount of time needed for the different
resident categories beyond the basic minimum requirement. For example, residents requiring extensive nursing
care are expected to need three times the level of care that residents at lower levels require (Burke & Cornelius,
1998). The overall effect of the proposed new staffing levels would be to bring the nursing time for the lowest RUG
category up from 130 min to a proposed minimum of 273 min. The nursing time for the highest RUG group would
continue to be at least the 433 min of nursing time per resident day observed in the HCFA time studies (Burke &
Cornelius, 1998), but this group could require more. 

Staff at Mealtime 

Another major concern addressed by the expert panel was the issue of staffing levels during mealtimes.
Kayser-Jones (1996, 1997; Kayser-Jones et al., 1997; Kayser-Jones & Schell, 1997) showed that the amount of
time to assist one dependent resident in eating ranges from 30 to 60 min. On the basis of these findings,
Kayser-Jones and the experts recommended that a least 1 nursing full-time equivalent (FTE) is needed to assist
every 2-3 residents who are entirely dependent in eating. (See Table 3.) For those that are partially dependent in
eating, 1 nursing staff member is needed for each 2-4 residents. Nursing staff should encourage residents to remain
as independent as possible in feeding themselves, and this may actually require more staff time than would be
required if residents were fed entirely by a nurse. 

Moreover, adequate RN supervision and appropriate training of staff at mealtime are needed to prevent staff from
mixing food together, setting up trays improperly, discontinuing feeding before the food is eaten, and providing
insufficient assistance to residents. All nursing staff need to be taught to recognize and manage dysphagia, so they
will not force residents to eat quickly and cause them to aspirate or choke on food. Moreover, nursing staff who
assist with feeding should be at least certified NAs who are adequately trained in mealtime procedures, and NAs
should be supervised by licensed nurses. 

Education and Training 

Simply adding more nursing personnel may not improve the quality of care unless nursing personnel in facilities are
carefully managed and care is organized and provided efficiently. Nursing management and leadership are central to
providing high quality of care in nursing facilities, especially given the complex needs of residents. Ballard (1995)
described the complexity of the roles of directors of nursing in nursing homes and the expertise required in clinical
nursing, management, organizational theory, finance, marketing and planning, personnel administration,
supervision, and government regulations. RNs in nursing homes have substantially lower levels of education (74%
with associate or diploma degrees) compared with nurses in hospitals (59% with associate or diploma degrees)
(Maas, Buckwalter, & Specht, 1996; Moses, 1997). Many nurses in nursing homes have had no training in
gerontology or chronic disease management (Bahr, 1991; Maas et al.. 19961. 

Because of the importance of education for training effective leaders, the expert panel recommended that the
director of nursing in nursing facilities should have a minimum of a bachelors' degree. Because most directors of
nursing in nursing facilities currently do not have that level of education (Moses, 1997), provisions should be made
for grandfathering current directors of nursing to practice over a specified time period. Several studies have shown
the importance of nursing management by professional nursing staff and gerontology specialists in making
improvements in quality of care (Hawkins, Burgio, Langford, & Engel, 1992; Schnelle, 1990; Schnelle, Newman, &
Fogarty, 1990). The knowledge, handson care, and leadership of RNs were found to be essential to sustained
quality improvement interventions (Schnelle, 1990). 

In the long term, most nursing homes should have directors of nursing with a clinical nurse specialist (CNS) degree
or a nurse practitioner (NP) degree, with a specialty in the care of the chronically ill and disabled and/or the elderly.
A number of studies have demonstrated the important role that gerontological nurse specialists and geriatric nurse
practitioners play in improving quality (Evans & Strumpf, 1989; R. A. Kane, R. L. Kane, Arnold, et al., 1988; R. L.
Kane, Garrard, Skay, et al., 1989; Mezey & Lynaugh, 1989, 1991 ). Improved outcomes of care and fewer
hospitalizations have been documented with the use of gerontological nurses (Buchanan et al., 1990; Mezey &
Lynaugh, 1989, 1991; Mor, 1999). Nursing homes are also urged to hire a fulltime CNS or NP on staff for facilities
with 100 beds or more (proportionate to the facility size). 

The issues of ongoing training are important to quality of care in nursing facilities (Maas et al., 1996). One of the
problems with establishing training standards is that little research has been conducted to determine desirable
standards for training. Thus, the alternative is either to make a recommendation on the basis of professional
expertise or to recommend more research. On the basis of experience, the experts recommended that all licensed
nurses in nursing homes should have continuing education in care of the chronically ill and disabled and/or
gerontological nursing as well as training in resident assessment and care planning. The expert panel
recommended that each licensed nurse have at least 30 hr of training every 2 years. (This is the current standard
required in some states.) Because no federal requirements for continuing education training of licensed nurses in
nursing homes have been established, minimum training requirements should be specified in the federal regulations.

Training for NAs 

The Omnibus Budget Reconciliation Act of 1987 required that NAs have a minimum of 75 hr of training and that they
pass a competency test within 4 months of employment. They must also have 12 hr of inservice education training
per year. The quality of training varies substantially across facilities and states because nursing homes are allowed
to conduct their own on-the-job training. Although states set some standards for training and competency exams,
these are minimal and not closely enforced. Many argue that training should be significantly increased, especially
on the job because of the complexity of nursing tasks (Burgio & Burgio, 1990). NAs themselves are reported to say
they need more training, particularly in managing residents with dementia, depression, and aggression and
communicating more effectively (Mercer, Heacock & Beck, 1993). 

Unfortunately, little research has been conducted on the impacts of different levels and types of training. Despite the
lack of research on training standards, the experts concurred that clinical experience suggests that a relationship
exists between the level and type of training and the quality of care NAs provide. The experts, therefore,
recommended doubling the training required for NAs in nursing homes to 150 hr. The training of NAs can be
provided by the facility in-service education RN director. Because much of the training actually takes place in
facilities in the process of performing NA activities, the increase in training would not take the trainees away from
productive activities. Increasing 24-hr RN supervision in facilities would also allow for improved on-the-job training
and supervision. Eventually, it would be desirable to have NA training conducted by educational institutions rather
than by nursing home providers. Increased levels of training are expected to increase the quality of care in nursing
facilities. As NAs have more training, they will be better prepared to manage the complex problems of residents,
and this may lead to reductions in staff turnover. 

Costs of the Proposed Increases in Staffing 

The key barrier to adding more nursing personnel is the costs of such increases, especially to government, which
pays a majority of the total nursing home expenditures in the United States (Levit, Lazenby, Braden, et al., 1997). In
1996, Medicaid paid an estimated 47.7% of the nation's nursing home expenditures, Medicare paid 11.3%, and
other government sources paid 2.3%. The remainder was paid directly out of pocket by consumers (31.5%), private
insurance (5.1 %), and other private sources (1.9%; Levit et al., 1997). 

Since July 1998, the new Medicare PPS system has paid each facility on the basis of the average staffing time
measurement for each resident in each RUG group within the facility times the average salaries (Medicare Program,
1998). Although Medicare is now paying facilities on the basis of expected resource use, Medicare-certified facilities
are not required to actually provide the amount and type of staff for which they are being paid. Requiring nursing
facilities to provide staffing at the levels paid for under Medicare PPS should not require additional funds. At the
same time that nursing home PPS was adopted, however, the Balanced Budget Act of 1997 made major cuts in
Medicare nursing home reimbursement rates (estimated to be as much as $10 billion). Thus, the overall rates paid
under Medicare may not currently be adequate to sustain the current staffing levels for Medicare residents. Private
pay residents generally pay higher rates than Medicaid and should expect to receive staffing at the level provided for
Medicare residents. 

Twenty-six states are also reimbursing facilities for Medicaid residents on the basis of case-mix reimbursement
formulas (Swan, Harrington, de Wit, & Zhong, 1997). Some states have established minimum staffing levels for their
facilities, but these are not always tied to the state case-mix reimbursement system (Mohler, 1993; Swan,
Clemena, Harrington, & Walker, 1998). States have considerable discretion in developing Medicaid reimbursement
methods and rates, and many state Medicaid programs have attempted to control the growth in nursing home
reimbursement rates (Buchanan, Madel, & Persons, 1991; Holahan & Cohen, 1987; Holahan, Rowland, Feder, &
Heslam, 1993; Nyman, 1988; Swan et al., 1997). Some Medicaid programs may not be providing adequate payment
levels to ensure appropriate staffing. 

Medicaid reimbursement rates have important im pacts on staffing levels. Zinn (1993a, 1993b) found that increased
Medicaid reimbursement rates had positive effects on the number of RNs and LVNs in nursing homes, whereas
Cohen and Spector (1996) found a positive relationship for LVNs only. Aaronson et al. (1994) found a positive
relationship between quality and all care staff. Thus, limited Medicaid payment rates may be considered de facto
staffing limits, depending how staffing levels are built into the rates. 

Although it is difficult to assess the costs of increased staffing, some cost increases would be required to meet the
minimum staffing recommendations. Facilities already meeting the proposed staffing standards would have no new
costs, but other facilities operating below the proposed minimum would be required to increase their expenditures
for wages and benefits. 

Table 4 compares the differences between the average nursing time on the OSCAR data and the HCFA weighted
staff time studies with the new proposed staffing time. The difference between the OSCAR time and the proposed
staffing time is .43 hr of RN time, .01 hr of LVN/LPN time, and .60 hr of NA time per resident day. A total increase
of 1.04 hr of nursing staff time would increase costs by about $10.93 per resident day, on the basis of American
Health Care Association (1997) cost data. The difference in time between the HCFA time and the proposed time is
0.38 hr of NA time per resident day, for an additional cost of $2.64 per resident day. Multiplying the cost increases
by approximately 1.5 million residents by 365 days/year, the overall cost increases could range between
approximately $1.4 billion and $6 billion dollars (in 1996 dollars). Of this total, Medicaid would be responsible for
67% of total residents ($938 million-$4 billion) with approximately half of those costs assigned to each of the federal
and state governments. Although these numbers are sizable, they represent a 2-7% increase in total nursing home
expenditures over the $87.5 billion spent on U.S. nursing homes in 1996 (Levit et al., 1997). 

Although difficult to estimate, some savings may occur with an increase in staffing levels in those facilities now
below the proposed minimum standard. The costs of hospitalization may be reduced, which could reduce the costs
of Medicare (Kayser-Jones et al., 1989; Kayser-Jones & Schell, 1997). Better staffing may improve staff morale and
productivity and reduce the amount of on-the-job injuries that result in the higher worker compensation costs
common in nursing homes (Institute of Medicine, 1996). 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 (including
incontinence supplies and nutritional supplements) (Kayser-Jones & Schell, 1997). For example, Phillips, Hawes,
and Fries (1993) estimated that a reduction in the use of restraints actually saves facilities money by improving
resident outcomes. Other studies have shown that high quality of care can reduce facility costs (Ouslander & Kane,
1984; Ouslander, Kane, & Abrass, 1982; Ribeiro & Smith, 1985). Thus, higher staffing levels may improve overall
resident outcomes and may reduce facilities' costs. Higher staffing levels may also lower personnel turnover, so that
costs of hiring and training may decline. Replacement costs of staff are estimated at four times the employee's
monthly salary when the costs of recruiting and training are included (Pillemer, 1996). 

In the United States, only 36% of total nursing home expenditures was for direct care (nursing staff and other direct
care staff), 15.7% for indirect care (food, housekeeping, and other such activities), and 3.1 % for ancillary services
in 1996 (HCIA & Arthur Anderson, 1998). Administrative costs were reported at 27.2% of operating expenses,
depreciation and interest expenses were 8.1 %, and the remaining 9.9% was for other costs (HCIA & Arthur
Anderson, 1998). Profits were 3.18% (net patient revenues minus expenses). Perhaps some of the costs of
increasing staffing as well as wages and benefits can be offset by creative approaches to controlling or reducing
administrative costs, capital, and profits (Swan et al.. 1997). 

On the other hand, the reallocation of resources to staffing is difficult because 66% of the nursing home facilities in
the United States are for-profit (Harrington, Carrillo, et al., 1999) and many of those are publicly traded corporations.
Many facility resource allocation decisions are in the hands of corporate owners and investors who seek to
maximize profits, and these companies are subject to the vagaries of the stock market (Aaronson et al., 1994;
Rudder, 1994; Ullmann, 1987). Government, which currently pays 61 % of nursing home costs, must be willing to
pay for adequate staffing levels and adequate overall funding for nursing homes, while ensuring accountability for
public dollars. In the long run, new approaches are needed to finance long-term care to ensure that adequate
resources are available to meet the needs of residents. 

Summary 

The experts concluded that current data show that the average nurse staffing levels (for RNs, LVN/LPNs, and NAs)
in nursing homes are too low in some facilities to provide high quality of care. Caregiving, the central feature of a
nursing home, needs to be improved to ensure high quality of care to residents. Because detailed time studies have
not been conducted on the amount of time that is required to provide high quality of care to residents, expert opinion
is currently the best approach to addressing the problem of inadequate staffing. Increases in the education level and
training of nursing staff are also strongly recommended as a step to improving quality of care and reducing turnover
rates in nursing homes. 

These recommendations are designed for consideration by Congress, HCFA regulators, policymakers, nursing
home administrators, and nurses. Ideally, Congress would pass legislation establishing these recommendations as
minimum standards for all nursing homes or direct HCFA to establish detailed minimum nurse staffing standards to
ensure that staffing levels take into account the number and the case-mix of the residents. Alternatively, HCFA
could introduce minimum staffing standards through the regulatory process. 

In 1999 there were a number of efforts at the state level to increase minimum staffing levels. Mohler (1999) surveyed
selected states and found that 21 states had either proposed new legislation or were considering proposals for new
legislation or new regulations. In California, for example, in 1999 the state budget approved $31 million in new state
funds (to be matched with $31 million in federal Medicaid dollars) to increase nursing home staffing minimum
requirements from 2.8 to 3.2 hr per resident day and to increase wage rates. 

Overall, nursing facilities need to be held accountable by HCFA for providing adequate levels and types of staffing to
meet the needs of their residents, especially because government is paying for 61 % of the expenditures. Adopting
these minimum standards will have an important impact on improving the quality of the nation's nursing home care.
Additional research is needed to determine appropriate levels and types of staff to provide high quality of care to
residents. These studies could test the proposed staffing standards against existing staffing levels to examine the
impacts on quality. As new data become available on staffing levels, revisions of staffing standards should be made
if necessary to ensure that high standards are maintained. 

Charlene Harrington, PhD, RN, FAAN,1 Christine Kovner, PhD, RN, FAAN,2 Mathy Mezey, PhD, RN, FAAN,2
Jeanie Kayser-Jones, PhD, RN, FAAN,3 Sarah Burger, RN, MPH,4 Martha Mohler, RN, MN, MHSA,5 Robert
Burke, PhD,6 and David Zimmerman, PhD7 

The conference was funded by the Agency for Health Care Policy & Research. This article reflects the opinions of
the authors and not those of the funding agencies. 

'Address correspondence to Charlene Harrington, PhD, RN, FAAN, Department of Social and Behavioral Sciences,
University of California, San Francisco, CA 94143. E-mail: chas@itsa.ucsf.edu 

2John A. Hartford Institute for Geriatric Nursing, Division of Nursing, New York University. 

'University of California, San Francisco. 

'National Citizens' Coalition for Nursing Home Reform, Washington, DC. 

SNational Committee to Preserve Social Security and Medicare, Washington, DC. 

6Muse & Associates, Washington, DC. 

7Center for Health Systems Research and Analysis, University of Wisconsin, Madison. 

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Received December 29, 1998 Accepted October 26, 1999 

Decision Editor: Vernon L. Greene, PhD 

Appendix: 

Peter Buerhaus, PhD, RN, FAAN Harvard University 

Sarah Greene Burger, RN, MPH National Citizen's Coalition for Nursing Home Reform 

Robert Burke, PhD Muse & Associates 

Joyce Fitzpatrick, PhD, MBA, RN, FAAN Case Western Reserve University 

Terry Fulmer, PhD, RN, FAAN New York University 

Charlene Harrington, PhD, RN, FAAN University of California at San Francisco 

Ann Hurley, RN, DNSc, FAAN Edith Nourse Rogers Memorial Veterans Hospital Geriatric Research Education and
Clinical Center 

Jeanie Kayser-Jones, PhD, RN, FAAN University of California at San Francisco 

Christine Kovner, PhD, RN, FAAN New York University 

Mathy Mezey, PhD, RN, FAAN New York University 

D. Kathy Millholland, RN, PhD Uiversity of South Florida 

Ethel Mitty, EdD, RN New York University 

Martha Mohler, RN, MSN National Commission on Social Securtity and Medicaid 

Peri Rosenfeld, PhD New York University 

Cynthia Rudder, PhD Nursing Home Communtiy Coalition of New York 

May Wykle, PhD, RN, FAAN Case Western Reserve University 

David Zimmerman, PhD University of Wisconsin, Madison




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