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Management Brief No. 198

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Management eBriefs
Issue 198 May 2022

The report is a product of the VA/HSR Evidence Synthesis Program.

Effects of Nurse Staffing on Processes of Care and Nursing Home Outcomes: A Systematic Review

Nursing homes are complex environments serving a variety of resident needs, including rehabilitative post-acute, end-of-life, or custodial long-term care. VA operates 134 nursing homes, called Community Living Centers (CLCs), that provide a total of 8,480 beds. CLCs are often attached to VA medical centers or hospitals but may also be stand-alone facilities. Due to VA nurse staffing requirements, CLCs have higher levels of nurse staffing than non-VA community nursing homes. There also is a set of State Veterans Homes that are independently run by state governments. These Homes do not follow the same VA nurse staffing requirements as CLCs; however, VA must certify that they meet certain standards.

Within nursing homes, direct care nursing staff generally includes registered nurses (RN), licensed vocational or practical nurses (LPN), and nursing assistants (NA).

The VA Office of Nursing Services (ONS), in collaboration with Geriatrics and Extended Care (GEC), requested an evidence review on the effects of nurse staffing and skill mix on process of care and outcomes for Veterans in nursing homes. In order to assist these VA partners with recommendations for nurse staffing at VA CLCs and State Veterans Homes, VA’s Evidence Synthesis Program (ESP) Center in Minneapolis, MN conducted a systematic review to summarize evidence on the effects of nurse staffing levels and skill mix on a variety of resident and process of care outcomes. Investigators searched MEDLINE, Embase, CINAHL, and the Cochrane Database of Systematic Reviews from January 2000 to May 2021 for peer-reviewed, English language articles.  For three high-priority resident outcomes (pressure ulcers, nursing home-associated infections, and pain outcomes), the certainty of evidence was determined using GRADE.

GRADE (Grading of Recommendations, Assessment, Development and Evaluations) is a framework for developing and presenting summaries of evidence. GRADE has four levels to describe the confidence in the available evidence: very low, low, moderate, and high.

Summary of Findings

Of the 44 eligible studies in this systematic review, the most frequently addressed outcomes were pressure ulcers and nursing home-associated infections, with one-third of the latter group evaluating COVID-19. Only one study focused on nurse staffing and resident outcomes in VA CLCs. Most studies were cross-sectional and used Centers for Medicare & Medicaid Services (CMS) data, which were reported by nursing home staff to meet federal requirements. Key findings include:

  • Higher RN staffing is probably associated with fewer pressure ulcers among residents of nursing homes (moderate confidence in the evidence); LPN and NA staffing also may be associated with fewer pressure ulcers (low confidence).
  • Total nurse staffing is probably not associated with pressure ulcers in residents (moderate confidence), but higher skill mix might be associated with fewer pressure ulcers (low confidence).
  • Higher RN and NA staffing, and higher skill mix, may be associated with lower resident COVID-19 infection and mortality in nursing homes, while LPN staffing might not be associated with COVID-19 outcomes (low confidence for all findings).
  • Higher RN staffing and skill mix may be associated with fewer UTI’s among nursing home residents, while LPN, NA, and total staffing might not be associated with rates of UTI (low confidence for all findings).
  • Higher RN staffing and skill mix may be associated with lower rates of moderate-severe pain among nursing home residents (low confidence), but it is unclear if LPN, NA, and total staffing are associated with pain outcomes (very low confidence).

Results for other resident outcomes and processes of care were largely inconsistent across studies, and sometimes within the same study.

Implications for VA

Although higher nurse staffing was associated with better outcomes in some cases, these effects were often quite small. Findings also may not generalize to VA CLCs, which have different resident characteristics and higher staffing levels than non-VA community nursing homes. VA CLCs may wish to consider changes beyond nurse staffing to improve specific resident outcomes. Options may include modifications to the nursing home environment and processes, as well as greater resources for other allied health professionals (i.e., social workers and mental health staff). Some of these measures have been implemented by certain VA CLCs, including specialized teams to address behavioral symptoms among residents with dementia.  

Future Research

Due to concerns noted above regarding the applicability of results from non-VA community nursing homes, the investigators recommend conducting future studies that directly examine other high-priority outcomes among Veterans residing in VA Community Living Centers. Additionally, dedicated assessments of nurse staffing and resident outcomes in observational studies may provide more accurate evaluations of the effects of nurse staffing. It also would be valuable to include data on organizational culture and other structural characteristics of nursing homes that are not usually reflected in CMS datasets.

Further, the complex relationships between nurse staffing, nursing home facility characteristics, and resident factors make it very difficult to understand causal effects of nurse staffing from observational studies alone. One possible avenue to address these concerns is to consider an implementation science approach and study designs that incorporate randomization in real-world setting (i.e., stepped wedge).

Jutkowitz E, Landsteiner A, Ratner E, Shippee T, Madrigal C, Ullman K, Linskens E, Wilt TJ, and Duan-Porter W. Effects of Nurse Staffing on Processes of Care and Resident Outcomes in Nursing Homes: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2022.

To view the full report, go to (Intranet only)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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