nurse staffing in nursing homes. Updated minimum standards should:

  • Require the presence of at least one RN within the facility at all times.

  • Specify staffing levels that increase as the number of patients increase, and that are based on the findings and recommendations of the DHHS report to Congress, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes—Phase II Final Report.

  • Address staffing levels for nurse assistants, who provide the majority of patient care.

Recommendation 5-2. Hospitals and nursing homes should employ nurse staffing practices that identify needed nurse staffing for each patient care unit per shift. These practices should:

  • Incorporate estimates of patient volume that count admissions, discharges, and “less than full-day” patients in addition to a census of patients at a point in time.

  • Involve direct-care nursing staff in determining and evaluating the approaches used to determine appropriate unit staffing levels for each shift.

  • Provide for staffing “elasticity” or “slack” within each shift’s scheduling to accommodate unpredicted variations in patient volume and acuity and resulting workload. Methods used to provide slack should give preference to scheduling excess staff and creating cross-trained float pools within the HCO. Use of nurses from external agencies should be avoided.

  • Empower nursing unit staff to regulate unit work flow and set criteria for unit closures to new admissions and transfers as nursing workload and staffing necessitate.

  • Involve direct-care nursing staff in identifying the causes of nursing staff turnover and in developing methods to improve nursing staff retention.

Recommendation 5-3. Hospitals and nursing homes should perform ongoing evaluation of the effectiveness of their nurse staffing practices with respect to patient safety, and increase internal oversight of their staffing methods, levels, and effects on patient safety whenever staffing falls below the following levels for a 24-hour day:

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