Statistical measures in nearly half of the nursing QMs evaluated in this study revealed significant differences between the mean percentages of residents, with a quality concern in facilities with contrasting staffing levels. Specifically, QMs most sensitive to staffing measures in this study include long-stay, low-risk residents who had become incontinent, residents whose need for help with activities of daily living has increased, short-stay residents who are having moderate to severe pain, and short-stay residents with pressure ulcers. For each of these QMs, plots shown in reveal differences in the means of CNA and RN/LPN groups, respectively. For example, the plots for low-risk residents who were incontinent indicate that as the level of RN staffing is held constant and the number of CNA staff increases, the percentage of residents who were incontinent also increases (~5%). The same phenomenon persists when the number of LPN hours per resident per day is held constant as the number of CNA staff increases.
More residents were noted who had increased need for help with activities of daily living when licensed nurses were available to assess their status. The plots of significant findings in indicate that as RN levels rose enabling licensed staff members to spend at least 15 more minutes per day with residents, they were able to detect more resident needs that needed to be met; in addition, as LPN levels rose, they were also able to assess more needs, although it appears to take less time for a more highly trained person to evaluate needs than other kinds of staff.
Likewise, the percentage of short-stay residents who have moderate to severe pain appears to increase dramatically (~10%) in facilities that have constantly lower levels of RN staffing (<0.30 hours per resident per day). In these same facilities, the percentage of short-stay residents with pain continues to rise, despite even higher levels of LPN staffing. In facilities that are mostly staffed by LPNs and CNAs, fewer short-stay residents with pain issues are found when both of these disciplines are understaffed; when LPNs and CNAs consume most of the hours per resident per day, there is a substantial increase in the number of short-stay residents experiencing pain.
Facilities reporting having 45 minutes or less of RN time per resident appear to have fewer pressure ulcers than facilities reporting higher RN staffing levels. Extreme levels of LPN staffing from low to high appear to also adversely affect the occurrence of pressure ulcers in short-stay residents (). When comparing the occurrence of pressure ulcers in short-stay residents, as LPN time is held constantly at the lower end (<0.53) and CNAs hours per resident per day increase, the frequency of pressure ulcers in short-stay residents increases by more than 6%. In contrast, as licensed LPNs are consistently employed more often at rates greater than 0.73 hours per resident per day and the number of CNAs is also increased, the outcome is reversed, resulting in 3% less short-stay residents experiencing pressure ulcers.
These findings would be consistent with the level of care that is required of staff to care for persons are incontinent, residents who have increased support needs, persons experiencing increased pain, and persons developing pressure ulcers. Specifically, toileting activities and assistance with activities of daily living (ie, bathing, eating, etc), while evaluated by RNs, are mostly carried out by CNAs. Therefore, lower staffing levels in this category of staff would adversely affect the scores. This may also be evident in the interaction between the different staffing levels of RNs and LPNs, as shown in , where the scores appear to increase significantly with higher staffing levels of LPNs rather than the more highly trained RNs. Furthermore, persons who are experiencing pain typically require the assistance of professional nursing personnel to assist in pain relief measures (ie, medication administration). Lower levels of staffing hours per resident would adversely affect the scores associated with this parameter because if there is no staff to provide pain relief measures, patients will experience more pain.