State-level minimum nurse staffing requirements for nursing homes

Minimum nurse staffing requirements are a suggested strategy to improve quality of care for nursing home patients¹. Additional evidence is needed to confirm effects.

Overall, minimum nurse staffing requirements increase staffing levels at nursing homes. A nationwide study of minimum direct care staffing requirements from 1999 to 2004 indicates that mandated staffing levels increase staffing, particularly at homes reliant on Medicaid². A study of states that implemented new standards between 1998 and 2000 indicates that such mandates only affect facilities that have low staffing levels when standards are introduced³. Studies of individual states yield similar results: Ohio and California’s requirements appear to have increased the amount of direct care provided to patients in homes with low staffing, mainly through hiring a greater number of CNAs^{4, 5} and LPNs, though some homes with high levels of staff decreased staffing levels⁴.

Research examining nursing home staffing levels and quality measures indicates a small positive association⁶ or no association between staffing levels and performance⁷. This may be due to research designs that do not account for other important factors that can affect quality of care, such as the training and experience of staff, turnover, and use of contracted, temporary (agency) staff⁶. Effects on quality may also vary by case and skill mix⁸. For example, one study suggests that increasing the number of RNs can increase quality of care but increasing nurse aides does not⁹; another study suggests increasing CNAs can benefit quality¹⁰. Some studies indicate that increasing state minimum staffing standards may be associated with improvements in some quality indicators, such as regulatory deficiencies in annual inspections, but not improvements in other measures^{2, 3, 4}, and another study found no quality improvements⁵.

Increases in minimum nurse staffing may lead to decreases in profitability for nursing homes dependent on Medicaid¹¹, and may lead to reductions in other, non-nursing services such as housekeeping, food service, and activities^{4, 12}.

Federal standards require certified nursing homes that provide Medicare and Medicaid services to have a full-time director of nursing (DON), an RN on duty for 8 consecutive hours 7 days a week (this may be the DON), and one RN and licensed nurse (either an RN or LVN/LPN) for the two remaining shifts. While other numbers are not specified, standards require adequate staffing levels to meet the needs of the residents to attain or maintain the highest practicable levels of physical, mental, and psychosocial well-being¹³. For example, when homes are rated using CMS’s Five-Star Quality Rating System, nursing homes with residents with more severe needs are expected to have higher staffing levels than facilities with less severe resident needs¹⁴.

In 2014, there were approximately 15,600 nursing homes in the U.S. serving 1.4 million residents, with an average total of 3.88 nursing hours per resident day: 1.41 nursing hours per resident day by licensed nurses (RNs, LPNs/LVNs) and 2.47 nursing hours per resident day by nurse’s aides¹⁵.