2 February 2000
Panel Says Low
Staffing Puts Nursing Home Patients at Risk
Nurse staff levels in the nation's nursing homes are, on average, too low to assure
quality care, according to a report co-authored by UCSF researchers. Moreover, the authors
report that residents of nursing homes with limited nursing staff have a greater incidence
of health problems.
The report, published in the February issue of The Gerontologist,
stems from an expert panel on nursing home care convened by the John A. Hartford Institute
for Geriatric Nursing, Division of Nursing at New York University.
"One of the major reasons that some nursing homes are still providing inadequate
quality of care is that they provide inadequate levels of nursing staff," said
Charlene Harrington, RN, PhD, UCSF professor of social and behavioral sciences in the
School of Nursing and lead author of the study. "Caregiving is the central feature of
a nursing home and needs to be improved in order to ensure high quality of care to
The findings are particularly relevant in light of a 1999 report from the US General
Accounting Office (GAO) which found that one-third of California's nursing homes had
seriously jeopardized the health and safety of its residents. Another 1999 GAO study of
nursing homes in four states found that many institutions had caused actual or potential
death or serious injury to residents.
Based on a review of research studies, the panel reaffirmed the positive relationship
between higher nurse staffing, particularly registered nurse staff, and resident health.
The experts also found that in nursing homes where nurse staffing was low, resident
problems such as high urinary catheter use, low rates of skin care, poor feeding of
residents, malnutrition, dehydration, starvation and low participation in activities were
more frequent, said Harrington.
Added to the problem of limited staff is the problem that registered nurses in nursing
homes have substantially lower levels of education compared to nurses in hospitals.
"Nursing management, leadership and education are central to quality care,"
said Harrington. "Many nurses in nursing homes have no training in gerontology or
chronic disease management, so nursing management and leadership are central to providing
high quality of care in nursing facilities given the complex needs of residents."
The experts recommended 24-hour RN supervision, additional education and training, and
minimum staffing standards for nursing administration. They also recommended specific
ratios of caregivers and licensed nurses to patients, depending on the time of day and the
needs of patients. For example, they suggested a minimum ratio of one caregiver to five
residents during the day, one caregiver to 10 in the evenings, and one to 15 residents at
night. The experts recommended residents receive at least 4 ½ hours per day of direct
care, with increases in staff for residents that require additional care. According to
current federal information, residents currently receive 3 ½ hours of direct care.
"These minimum staffing standards will help state legislators, the US Congress,
and the Health Care Financing Administration develop new legislation aimed at insuring
quality care in our nation's nursing homes," said Harrington. "It's important to
remember that staffing must be adjusted upward for residents with higher nursing care