The relationship between different nursing home staffing types and health outcomes is incredibly nuanced, and as operators grapple with optimizing the clinical workforce in the aftermath of the staffing mandate, researchers in the space say more study is needed to really understand the correlation between roles and quality measures.
According to a July study published in JAMDA, the effect of overall staffing levels on care quality can’t be casually interpreted because it might include omitted causes, leading to biased and inconsistent estimates.
“In an era when new staffing regulations are under consideration and specific levels are being debated, it is important to have accurate estimates of the relationship between staffing levels and quality,” researchers said.
Researchers studied the relationship between staffing hours per resident day (HPRD) and six quality measures.
“The intricate relationship between nursing disciplines and resident care requires a nuanced approach to policies that go beyond simple headcounts. Hiring decisions, including ones about staffing mix, should be tailored to meet the needs of individual residents,” said lead author Dana Mukamel.
Key findings of the study point to higher numbers of RNs as leading to more frequent use of antipsychotic drugs and fewer hospitalizations and emergency room visits and better care for pressure sores.
Meanwhile, increased levels of CNAs resulted in a decrease in antipsychotic drug use and improvements in long-stay activities of daily living and short-stay functioning, but increased hospitalizations. Researchers also found that RN and CNA staffing levels were linked to better quality of care much more often than LPNs.
“The relationship between more CNA HPRDs and lower antipsychotic use is not surprising given the role of CNAs in providing most of the daily care and ADL support that often triggers resident behavioral symptoms,” researchers said.
CNAs develop insights into person-centered care routines and other behavioral and environmental modifications that might mitigate symptoms, according to the study. Allocating more hours per resident day to the CNA allows that staff member to provide care that’s less rushed, and helps the CNA anticipate resident needs, in so doing relieving agitation and poor behavioral responses.
The relationship between more RNs and more antipsychotic medications is less expected, researchers said.
“We speculate that the explanation might relate to RNs’ role directly communicating behavioral concerns to the prescribing provider and that RNs may initiate the request for antipsychotic orders,” they said in the study.
Non-leadership RN hours per resident day may not capture this role’s involvement in developing overall care plans, or other policies that support person-centered care, they said.
Studies that delve into the causes for different care approaches based on role might offer more insight here.
An increase of CNAs “at the margin” while keeping the number of RNs and licensed practical nurses (LPNs) the same might give CNAs more time to observe residents and detect and report changes from baseline.
If RNs aren’t able to follow up and perform full assessments, more residents may be sent to the ER, the study found.
CNAs were also found to have less of an impact on improving pressure injuries, since these types of injuries require assessment and identification of risks, along with the development of an appropriate care plan.
“For higher-risk residents, this can be complex and require more than one intervention,” researchers said. “Thus, CNAs’ effectiveness might depend on more complex performance than in other care areas and may require closer supervision by RNs to ensure that the necessary care is provided.”
In this case, increasing CNA hours while keeping RN hours the same can be harmful, since RN ability to supervise CNAs is diminished, and leads to decreased effectiveness of more complex care.
Mandated staffing ratios face many obstacles and challenges, but finding a way to achieve higher staffing ratios would be worth it in terms of resident outcomes, the study found.
“There are important nuances and interplays between staffing types,” researchers concluded. “Although they suggest in some of the cases that increasing staff HPRDs improves outcomes, they also indicate that considering how the scope of practice among RNs, LPNs, and CNAs plays out in practice, and how they interact and support each other is an important consideration in optimizing the quality of care they provide.”
The study involved 11,261 nursing homes nationally and statistical analysis of 2017-2019 Payroll-Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term Data Focus. Pandemic data was avoided because it wouldn’t be reflective of normal operations.
Dana Mukamel, PhD.; Debra Saliba, Dr. Health Ladd; and R. Tamara Konetzka, PhD., authored the study.