1. Bates-Jensen, Barbara M. PhD, RN, CWOCN

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This issue of AJN presents a study by Horn and colleagues ("Original Research: RN Staffing Time and Outcomes of Long-Stay Nursing Home Residents,"A New Look at the Old, page 58) that adds to the growing body of evidence supporting a relationship between nurse staffing and quality of care in nursing homes. The researchers report a decrease in unfavorable resident outcomes (such as pressure ulcer development, weight loss, and hospitalization) with each 10-minute increase in RN direct care time, pointing to the important role of the RN in nursing homes. But is increasing the amount of RN time per resident going to dramatically improve nursing home care?


Adding more RNs or increasing RN hours is only part of the solution. We must also do more to determine how best to measure quality of care, increase the ability of RNs to act as managers and leaders in this care environment, and use technology more effectively.


Quality indicators derived from the federally mandated Resident Assessment Instrument and the Minimum Data Set (MDS) assessment items are currently used in nursing homes as measures of quality. The MDS is used to assess all nursing home residents on admission, quarterly, and whenever there is a change in condition. Data from the MDS are electronically submitted to the Centers for Medicare and Medicaid Services (CMS) by individual nursing homes, and CMS uses items from the MDS to calculate quality ratings for all certified nursing homes; these are available to nursing home staff, state and federal surveyors, and consumers.


But reports issued by the U.S. General Accounting Office in 1998 and 2002 suggested that there may be accuracy problems with MDS ratings, exacerbated in most states by a lack of auditing systems. In addition, my colleagues and I have shown (in studies published in the Journal of the American Geriatrics Society and the Gerontologist) that medical records in some nursing homes inaccurately document care that has not in fact been delivered. These findings reflect the need to develop better measures of quality of care. And they highlight possible shortcomings of chart-based reviews of quality, such as that conducted in the Horn study.

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Because many long-term nursing home residents will decline in function over time, using decline in function as a measure of quality may be misleading. Direct measurement of the process of care delivery-for example, by observing feeding assistance during mealtimes-may be a more accurate measure of quality and provide a better understanding of how to improve the delivery of care.


To ensure consistent, ongoing implementation of quality improvement that focuses on the processes of care, RNs would have to use quality improvement principles routinely. Unfortunately, RNs in nursing homes typically have limited education in management principles, leadership skills, quality improvement, and even gerontology. Nurses with more education in management and leadership have been exposed to alternative organizational systems and management models that might positively influence nursing home care. Thus, the staff mix or educational level of nurses may be as important as the number of nurses on staff.


The nursing home environment is also significantly behind other health care settings and other businesses in adopting new technology. Yet this is the care setting most desperately in need of electronic medical records and other software that provides more timely and informative reporting functions.


Quality improvement efforts should focus on direct measures of quality of care, routine quality monitoring of care processes, improved educational preparation of RNs, and technological systems appropriate for the nursing home environment.


Until we can address education and technology issues as well as staffing levels, the quality of care in nursing homes will remain in need of improvement.