1. Mueller, Christine PhD, RN

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Older Adults in Nursing Homes

This issue of Nursing Counts takes a critical look at the quality of care older adults receive in nursing homes and the factors that affect it: staffing standards, staff training, and the competence of clinicians, now and in the future.


It has been assumed that statemandated staffing standards increase the number of staff in nursing homes and ultimately lead to better care. To test that assumption, my colleagues and I examined whether staffing standards influence actual staffing levels in nursing homes.1


We collected data on staffing standards and staff levels from nursing homes in 50 states and the District of Columbia. Thirty-three states have state-mandated staffing standards, measured as staff-resident or resident-bed ratios or nursing hours per resident day (HPRD); the latter is the total number of hours of direct care provided by a facility's nursing staff RNs, LPNs, LVNs, or certified nursing assistants) divided by the number of residents. In states that mandated HPRD, the range was from 1.76 to 3.6 hours. Eleven states had no staffing standards; facilities in those states adhered to the federal guidelines for nurse staffing, which do not prescribe HPRD but rather require facilities to employ enough staff to "attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care."2, 3


Facilities in states without staffing standards had higher total staffing levels than did facilities in states where the staffing standard was 2.5 HPRD or less, but differences in licensed staffing and unlicensed staffing were not significant. Facilities in states with a staffing standard higher than 2.5 HPRD had the highest actual staffing levels, although in those states actual staffing levels averaged only 0.22 HPRD more than in states with no staffing standards. Actual staffing varied more within states than between states. Medicaid payment rates and other factors, such as facility occupancy rate, ownership, and resident acuity, contributed more to variations in staffing than staffing standards did.


Our findings suggest that if a nursing home staffing standard is too low, it might have a dampening effect or even no effect on staffing. There is also the risk that a facility will hire staff according to a mandated standard-and no more. Some states are exploring how nursing home reimbursement systems could provide incentives for facilities to improve the quality of care.


Christine Mueller, PhD, RN




1. Mueller C, et al. Nursing home staffing standards: their relationship to nurse staffing levels. Gerontologist 2006;46(1):74-80. [Context Link]


2. Requirements for nursing facilities. 42USC1396r [S]1919. [Context Link]


3. Requirements for, and assuring the quality care of in, skilled nursing facilities. 42USC1395i-3 [S]1819. [Context Link]

Section Description


Nursing Counts, highlighting data that illustrate the value of nursing, appears in AJN as a periodic column and is provided by the John A. Hartford Foundation Institute for Geriatric Nursing, College of Nursing, New York University,;