State Minimum Staffing Standards – Literature Review(continued)

A second study reviewed was a literature review. In this study, Wells (2004) presents studies that highlight the importance of mandatory staffing standards in nursing home settings, using three core perspectives. Firstly, reviews literature on the link between “identified nursing staff-to-resident ratios and quality of care” (p. 42-45). Secondly, the study argues out the association of prevalence of medical conditions that can otherwise be avoided with the number of hours of direct care availed per resident (pp. 42-45). Thirdly, the study argues out the lack of effect of minimum standards not to arise out of the inadequacy of the standards per se, but out of inadequate enforcement by respective government authorities (p. 41). Out of such premise, the study presents reviews covering areas such as existing staffing needs of nursing homes, actual staffing levels and their adequacy, outcomes of non-optimal staffing levels, and recommendations from various bodies on minimum staffing standards. Subsequently, the study highlights the costs and benefits of implementing higher staffing standards with a discussion of aspects that hinder the increase of such standards.

The two other studies reviewed were by the same author, the second study expounding on findings of the first study. In the first study, Harrington (2005a) embarked on a descriptive study whose aims consisted highlighting the specific nurse-staffing standards for nursing homes that were effective in each of the US states and the District of Columbia from 2000 to 2001, as embodied in the statutes, regulations and administrative policies of respective states (p. 19). Secondly, the study aimed to highlight perceptions of state licensing and certification officials regarding aspects of state staffing standards such as the adequacy of the standards hence the need or lack of such a need to change existing standards (p. 19).

The study methodology involved collection of from state statutes, regulations, and policies availed through the internet for the period from January 1999 to May 2001 (Harrington, 2005a, p.21). Secondly, data was collected through ‘a telephone survey of state licensing and certification program directors or their designees … during the year 2000 to 2001” (p. 21). Such officials are charged with conducting federal surveys and providing certification on behalf of the US Centers for Medicare and Medicaid Services – CMS (cited by Harrington, 2005a, p. 21). A single researcher conducted the surveys, whereas two researchers performed the needed coding independently. Using a model, the researchers calculated HPRD values that enabled inter-state comparisons as well as comparison between different states’ standards and those of the federal government. The results of the study were varying.

According to the results, the general finding was that states had either equal or higher minimum standards compared to federal standards. Almost half (24) had higher standards for Licensed nurses than the calculated minimum HPRD requirement by the federal government, with 17 states having equivalent standards to those specified by federal government (Harrington, 2005a, p.22). However, 10 states had standards with a lower HPRD ratio than federal requirement. Secondly, the study noted that most states had changed their standards over time, mainly in the 1990s with 18 states changing their standards during the period between 1999 and May 2001, a period when advocacy for better staffing in nursing homes was prevalent (p.22). Thirdly, state officials exhibited a general perspective of the need to increase standards with officials in more than half of the states (31) supporting such increase (p. 22). Although officials from 13 states perceived existing standards to be adequate thus not requiring any change, 10 states from this population had increased their standards in the period preceding the survey (p. 22). Officials from the remainder of the states did not express their opinion on the necessity of changing the standards.

Harrington’s second study provides a comparative study of minimum nurse staffing levels of nursing homes envisaged in state regulations, actual staffing in respective states, and staffing standards recommended by experts and CMS (2005b). Primary data collection was synonymous with that of the first study (already explained in the review), whereas secondary data was obtained from OSCAR system, whose limitations were discussed earlier. The study’s findings generally had a negative implication to the use of state minimum staffing standards to guide safe staffing practices in nursing. This was the case since the study indicated that actual staffing levels are higher than the minimum standards required by the state, for most nursing homes. Such a case, as noted by Park and Stearns (2009), may reduce the incentive of nursing homes to enhance their staffing levels even when they face staffing-related challenges. However, both the actual and standard-advised staffing levels were below those recommended by experts and CMS (Harrington, 2005b).

The final study reviewed was on recommendations for optimal staffing of nursing homes with healthcare professionals. In the study, Maas, Specht, Buckwalter, Gilttler and Bechen (2008) offer recommendations on optimal nurse staffing in nursing homes following a review of existing literature on the subject. Firstly, the authors review literature on aspects such as how implementation of standards have had contrasting effects on staffing levels in different states, staffing thresholds, and implications of staff turnover rate on quality of care. Following such a basis, the study highlights approaches such as RN leadership of nursing homes and implementation of evidence –based practices, which have the potential to alleviate staffing challenges in nursing homes, and those that constrain increase in staffing standards. Some of the constraining factors highlighted are the OSCAR system that could motivate inaccurate reporting and federal government conflict of interest since increasing staffing standards would increase the amounts it pays out in Medicaid and Medicare reimbursements. Following the comprehensive review, the authors recommend increasing RN staffing of nursing homes to 1.13 HPRD and the total nurse staffing to a range between 5.16 to 6.68 HPRD (p.144).

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