UC Irvine-led study reveals relationship between nursing home staffing types and quality of care

Irvine, Calif., July 17, 2024 — As nursing homes constantly strive to balance staffing decisions and optimal health outcomes for residents, a new study led by the University of California, Irvine reveals the complex relationship between different staff disciplines and quality of care.

Recently published online in the Journal of the American Medical Directors Association, the study found opposite effects between registered nurses, licensed practical nurses and certified nursing assistants on various quality measures, ranging from antipsychotic medication usage to treating pressure sores.

“These novel results provide a more complex picture of the influence of staffing types on quality measures,” said first author Dana Mukamel, Distinguished Professor of medicine. “The intricate relationship between nursing disciplines and resident care requires a nuanced approach to policies that go beyond simple headcounts. Hiring decisions, including ones about staffing mix, should be tailored to meet the needs of individual residents.”

The team constructed separate models for six distinct quality measures associated with quality, using RNs, LPNs and CNAs as key independent variables. Previously unavailable payroll information from nursing homes across the country was leveraged to provide a comprehensive view of staffing patterns, including weekends and holidays. The study’s novel insights are credited to the use of the well-established economics technique, Two Stage Least Squares, which has not been used in most previous nursing home staffing studies in this field.

Key findings indicate that higher numbers of RNs led to more frequent use of antipsychotic drugs and fewer hospitalizations and emergency room visits and better care for pressure sores. Increased levels of CNAs however, resulted in a decrease in antipsychotic drug use and improvements in long-stay activities of daily living and short-stay functioning, but increased hospitalizations. The team also found that RN and CNA staffing levels were associated with better quality much more often than LPNs.

“These outcomes suggest that RNs and CNAs have a different focus in their roles. CNAs are often closer to residents. This enables them to develop insights into residents’ routines and offer behavioral modifications to mitigate symptoms, while RNs might focus on communicating behavioral issues to prescribing providers and developing overall care plans. The difference in pressure sore improvement reflects the complexity of treatment, which requires close guidance and supervision from RNs,” Mukamel said. “Understanding the interdependence between disciplines is crucial for developing effective staffing regulations and ultimately improving the quality of care in nursing homes.”

Other team members included Dr. Debra Saliba, UCLA Anna & Harry Borun Professor of medicine; R. Tamara Konetzka, Louis Block Professor of Public Health Sciences and professor of medicine at the University of Chicago; and Heather Ladd, a senior statistician in the UC Irvine Department of Medicine.

This work was supported by the National Institute on Aging of the National Institutes of Health under award number R01AG066742.

About the University of California, Irvine: Founded in 1965, UC Irvine is a member of the prestigious Association of American Universities and is ranked among the nation’s top 10 public universities by U.S. News & World Report. The campus has produced five Nobel laureates and is known for its academic achievement, premier research, innovation and anteater mascot. Led by Chancellor Howard Gillman, UC Irvine has more than 36,000 students and offers 224 degree programs. It’s located in one of the world’s safest and most economically vibrant communities and is Orange County’s second-largest employer, contributing $7 billion annually to the local economy and $8 billion statewide. For more on UCI, visit www.uci.edu.

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