Review
The relationship between nurse staffing and quality of care in nursing homes: A systematic review

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Abstract

Background

Nursing homes have an important role in the provision of care for dependent older people. Ensuring quality of care for residents in these settings is the subject of ongoing international debates. Poor quality care has been associated with inadequate nurse staffing and poor skills mix.

Objectives

To review the evidence-base for the relationship between nursing home nurse staffing (proportion of RNs and support workers) and how this affects quality of care for nursing home residents and to explore methodological lessons for future international studies.

Design

A systematic mapping review of the literature.

Data sources

Published reports of studies of nurse staffing and quality in care homes.

Review methods

Systematic search of OVID databases. A total of 13,411 references were identified. References were screened to meet inclusion criteria. 80 papers were subjected to full scrutiny and checked for additional references (n = 3). Of the 83 papers, 50 were included. Paper selection and data extraction completed by one reviewer and checked by another. Content analysis was used to synthesise the findings to provide a systematic technique for categorising data and summarising findings.

Results

A growing body of literature is examining the relationships between nurse staffing levels in nursing homes and quality of care provided to residents, but predominantly focuses on US nursing facilities. The studies present a wide range and varied mass of findings that use disparate methods for defining and measuring quality (42 measures of quality identified) and nurse staffing (52 ways of measuring staffing identified).

Conclusions

A focus on numbers of nurses fails to address the influence of other staffing factors (e.g. turnover, agency staff use), training and experience of staff, and care organisation and management. ‘Quality’ is a difficult concept to capture directly and the measures used focus mainly on ‘clinical’ outcomes for residents. This systematic mapping review highlights important methodological lessons for future international studies and makes an important contribution to the evidence-base of a relationship between the nursing workforce and quality of care and resident outcomes in nursing home settings.

Section snippets

Background

Nursing homes – also called long-term, aged or skilled care facilities – have an important role in the provision of care for dependent older people. As the population ages, the need for nursing home care will increase (European Commission, 2008). Ensuring quality of care for residents in these settings is the subject of ongoing international debates (Kovner et al., 2000, Harrington, 2001). Poor quality care has been associated with inadequate nurse staffing and poor skills mix (Harrington, 2001

Objectives

The primary objective of this review is to describe the evidence-base for a relationship between nurse staffing and quality of care and resident outcomes (as described above) in nursing home settings. The review adheres closely to methods aimed at identifying, appraising and synthesizing all relevant studies to provide a summary of the evidence and its implications for practice and policy (CRD, 2001).

Search strategy

Searches were developed (KS & LS) to include terms relating to nursing homes linked with nurse staffing terms. The search required the term ‘quality’ to be adjacent to the terms ‘care’ or ‘nurs$’ in the title or abstract. However, the search was not restricted by quality indicators or outcomes; this was to ensure the search strategy was broad enough to capture all studies potentially relevant for the review. At this stage we did not want to impose any predetermined quality categories. This

Description of studies

Fifty papers are included in the review; 33 excluded, including 4 reviews of studies of nurse staffing and quality in nursing and residential care homes that are used to discuss the findings of this review (Davis, 1991, Dellefield, 2000, Bostick et al., 2006, Murphy, 2006) (Fig. 1). The majority of included studies are US-based (n = 47; 94%), with three studies identified from Australia (n = 1), Netherlands (n = 1) and Hong Kong (n = 1). No UK studies were identified which examine the relationship

Discussion

The existing evidence base does not enable any firm conclusions to be drawn when considering the relationship between nurse staffing and quality of care for residents in nursing homes. The main reasons for this are that the literature presents (i) a wide range and varied mass of findings that (ii) use disparate methods for defining and measuring quality and nurse staffing. When summarising all quality indicators and their relationship to nurse staffing, there is tentative evidence that total

Conclusions

A growing body of literature is examining the relationships between nurse staffing levels in nursing homes and quality of care provided to residents. The research evidence to date has focused predominantly on US nursing facilities. It is difficult to offer conclusions and recommendations about nurse staffing based on the existing research evidence: research has produced inconsistent and contradictory results about the link between nurse staffing and quality in nursing homes. Research in this

Acknowledgements

We would like to thank Professor Nicky Cullum for discussions and insightful comments on this review and Sandi Newby for providing administrative support.

Contributors: KS: preparation of review protocol, literature search and study selection, lead reviewer, analysis and interpretation of data, preparation of manuscript. CH: checking of study selection, co-reviewer, analysis and interpretation, comment on manuscript. LS: preparation of search strategy, updating searches and comment on

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