The committee believes that, based on currently available evidence, the use of minimum personnel standards is presently and generally more appropriate for nursing homes than for hospitals, for two reasons. First, we find that in general, the evidence for specific numerical staffing standards is stronger for nursing homes (although evidence of the effect of specific ICU staffing levels on patient safety is also strong). The CMS (2001) study on the appropriateness of minimum nurse staffing ratios in nursing homes greatly advanced the knowledge base on the effect of different nursing staff-to-patient ratios on patient outcomes. It identified staffing levels (2.4–2.8 hprd for NAs, 1.1–1.3 hprd for licensed nursing staff, and 0.55–0.75 hprd for RNs) above which no further improvements in patient outcomes were observed, and below which improvements in quality occurred with each incremental increase in staffing.
The purpose of minimum standards for staffing in nursing homes would be to ensure that at least the minimum resources are in place to preserve the safety of nursing home residents. Current requirements for 8 hours of RN and 24 hours of licensed nurse coverage per day are, in fact, minimum standards. Although these minimum standards ensure that long-term care facilities can administer medications 24 hours a day and have an RN available to supervise NAs and respond to issues during 8 hours per day, this minimum is not based on the premise of patient safety. Patient safety requires staff resources that are sufficient to prevent an inappropriately high rate of untoward events that could be avoided with adequate staffing levels. For such a standard to be reasonable, it must at least be based on the number of residents in the nursing home and address NAs, who provide most of the care to nursing home residents. Such minimum staffing standards are not a precise statement of how many staff are required to fully meet the needs of each specific group of residents on each unit, nor are they a quality improvement tool to optimize quality in each nursing home. Rather, a minimum staffing level is one that avoids placing individual residents unnecessarily at risk because of insufficient numbers of staff to provide even the most basic care.
In contrast, with the exception of studies of ICU staffing, the committee identified only one hospital staffing study that measured the effects of different staffing levels within a specific type of hospital patient care unit (i.e., medical–surgical unit [Sochalski, 2001]). In this study, the frequency of adverse events was subjectively reported by nursing staff using a Likert scale, rather than being counted using clinical data sets. The need for hospital unit–specific information is important because, as pointed out previously, the hospital patient population and the nursing units in which they receive care are more heterogeneous than is the case in nursing homes, making hospital-level data more difficult to interpret.