January 10th, 2018
State Minimum Staffing Standards – Literature Review
To answer the PICO question, I searched electronic databases availed through the university library for studies on the subject. Firstly, I concentrated my search on CINAHL and OVID, two databases presenting articles on nursing perspectives, then conducted additional search in Academic Search Premier. I used keywords such as ‘nurse’, ‘staffing’, ‘nursing’, ‘nursing home’, ‘state’, ‘minimum’, ‘standards’, ‘optimal’, and ‘staffing levels’. With Boolean operators (e.g. AND, OR), I combined the keywords to refine the search results to those relevant to the subject (effectiveness of state minimum staffing standards) and care setting (nursing home) and limited the search to publications from the year 2000. The refined search narrowed down the initial results to a sum of 20 studies for all the databases. Out of these 20 results, one study was replicated in the three databases while another was replicated in two databases. In Ovid, results generated also had five duplicated studies. Eliminating these duplicates, the studies left for consideration for review were 13, five of which I review below.
A study that had evaluated the PICO question in detail replicated in searches in the three databases. In this study, Park and Stearns (2009) investigated “the impact of state minimum staffing standards on the level of staffing and quality of nursing home care” (p. 56). The study used a non-experimental, quantitative study design with data being drawn from Online Survey and Certification Reporting System – OSCAR (p. 65). OSCAR surveys cover approximately 96 percent of nursing homes in the US and aim at identifying nursing homes’ compliance with federal regulations (Park and Stearns, 2009, p. 65). A limitation of the data from such surveys is that they involve self-reporting, a factor that elicits concerns about their accuracy (Zhang & Grabowski, 2004). The authors linked the OSCAR-drawn data with state minimum staffing standards. After eliminating facilities that did not meet any of the aspects of the inclusion criteria (e.g. those that reported more residents than beds or reported no registered-nurse hours despite having 60 or more beds), 15,217 freestanding facilities were included from an initial 18,275 facilities identified (pp. 65-66). From the included facilities, 55,248 facility-year observations (the sample size) were used to assess the objective of the study (p. 66).
The study used two dependent variables – staffing and quality of care – to assess the effect of minimum standards. Staffing was a construct of nursing hours per resident day (HPRD) with respect to the type of licensed practitioner (e.g. RN and LVN) and total staff (Park and Stearns, 2009, p. 66). Six quality measures were used and included percentages of pressure sores, contractures, incontinence, catheter use and restraint use (p. 70). The sixth quality measure was total deficiencies observed in the nursing homes. Independent variables were categorized into “transition effects” and “steady-state effects”, which indicated presence or absence of any changes in the state standards within the year (p. 67). Various covariates such as bed size, percent on residents on Medicare and facility ownership were included.
On staffing, the study found out that such standards were particularly relevant to nursing homes staffed below or close to the standards, but not to those staffed in excess of the standards. This was significant because many nursing homes reported staffing levels above the defined minimum standards through the OSCAR system, during the period of the study. With respect to quality outcomes, the study noted that such standards led to decreases in total deficiencies and restraint use across the nursing homes evaluated (p. 73). The negative findings on staffing could arise out of lack of incentives for facilities that have staffing levels above the stipulated minimum level, to alter their staffing or performance initiatives, even when they face low-staffing challenges (Park and Stearns, 2009).