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Building a High-Quality Long-term Care Paraprofessional Workforce

Quality & Safety


Christine Kovner, Ph.D., Associate Professor, Division of Nursing, New York University, New York, NY.

Marvin Feuerberg, Ph.D., Analyst, Center for Medicaid and State Operations, Health Care Financing Administration (HCFA), Baltimore, MD.

Susan C. Eaton, Ph.D., Assistant Professor of Public Policy, Wiener Center for Social Policy, John F. Kennedy School of Government, Harvard University, Cambridge, MA.

Research findings show that inadequate staffing in long-term care (LTC) facilities can compromise quality of care as well as the safety of both workers and patients, and LTC has the highest injury rates among workers of any service industry. Low staffing can contribute to injury rates, low morale, and high turnover rates.

In addition, research demonstrates a relationship between staffing and patient outcomes. Almost 60 percent of nursing homes with low staffing levels have a large number of deficiencies that vary widely among institutions but include:

  • Inappropriate restraints.
  • Pressure sores.
  • Accidents.
  • Insufficient care plans.
  • Poor quality of care.
  • Insufficient food sanitation.
  • Medication problems.

Between 1993 and 1999, the 2.1 nursing assistant staffing hours per resident remained steady. Although there is a wide variation of staffing levels across facilities, on average, 1999 reported staffing ratios were:

  • One registered nurse to 32 residents.
  • One licensed practical nurse to 34 residents.
  • One nursing assistant to 11.8 residents.

The appropriate level of staffing is unknown, but many feel these ratios are too low.

According to Dr. Kovner, increasing staffing in nursing homes has the potential to:

  • Reduce mortality.
  • Improve functional ability.
  • Improve nutritional status.
  • Reduce behavioral problems.
  • Improve quality of life.
  • Reduce restraint use.
  • Reduce deficiencies.

State policy options for staffing requirements include:

  • Enforcing current regulations.
  • Leaving staffing levels to the market.
  • Adding or augmenting quality regulations.

The arguments for regulation include the belief that nursing homes are unlikely to improve staffing unless States regulate. Each State has the responsibility to assure quality in nursing homes for its citizens and spends substantial amounts of money on nursing homes through Medicaid programs that fund the majority of residents' care.

Arguments for leaving staffing to the marketplace include the beliefs that:

  • The research on staffing and patient outcomes is not convincing.
  • Management is best able to decide the appropriate staffing level in each facility.
  • Ultimately, patients will choose facilities with the best care.

Given these arguments, many States have taken action to establish standards for staffing levels in LTC facilities.

Example: California increased minimum staffing for nursing homes from 3.0 to 3.2 hours per resident day in the 1999 California Budget Act.

This act also added:

  • $72 million for increased staff.
  • Wages and benefits for 2000.
  • Another $133 million for wages and benefits in 2001.

In the summer of 2000, the HCFA released Phase One of a congressionally mandated study to examine the "appropriateness" of establishing minimum nurse staffing ratios in nursing homes. The call for the study stemmed from a 1998 HCFA report that identified a range of quality problems that may be related to inadequate staffing, raising concern about the relationship between low staffing and quality problems.

According to Marvin Feuerberg, Ph.D., there is no Federal requirement of minimum nurse-to-resident staffing ratios. HCFA, however, has a general requirement that staffing be sufficient to meet resident needs. Dr. Feuerberg explained that a new mandatory staffing protocol was implemented in July 1999 and outlined key policy issues related to the development of regulation in this area, including how to:

  • Increase availability of staff to fill the need.
  • Increase payment of nursing facilities and assure money goes to staffing.
  • Group facilities in terms of case mix and adjust minimum levels accordingly.
  • Enforce minimum levels.

Tentative conclusions of the Phase One study found that:

  • There are staffing levels below which facilities are at greater risk for quality problems.
  • The benchmark is 2.9 hours per resident day.
  • These thresholds may vary with the resident case mix in the facility.
  • Staffing levels will need to be increased in the majority of facilities to improve quality.

Phase Two of the study is expected to identify:

  • National optimal staffing ratios.
  • Associated costs.
  • Feasibility of implementing a minimum ratio requirement.

Phase Two also may include case studies of selected facilities that focus on more than staff ratios, such as:

  • Staff turnover.
  • Training.
  • Career paths for nursing assistants.
  • Management practices.

The report is planned for completion in September 2001.

According to Susan C. Eaton, Ph.D., front-line worker satisfaction and retention are at an all-time low, while injuries and accidents are unacceptably high. She has conducted research looking at paraprofessional work organization and management as crucial factors in quality care. Her research found that the following key elements vary systematically:

  • Ownership.
  • Management philosophy.
  • Work organization.
  • Human resource practices.
  • Patient base.
  • Quality outcomes for residents.

Dr. Eaton has developed a typology for clarifying types of nursing homes according to their managerial practices and work cultures, which can have a dramatic impact on the nature of the care provided:

  • Basic custodial care.
  • Higher quality medical and nursing care.
  • Regenerative care, which includes quality of life and quality of care.

Regenerative care views aging as another stage of life and respects individual needs. A regenerative nursing home allows residents more control over their lives.

Example: Regenerative nursing homes allow residents to eat when they want to and not according to a facility schedule.

The management philosophy of care involves:

  • Continued growth.
  • Learning with aging.
  • Community focus.

Work organization in a regenerative nursing home involves cross-training certified nursing assistants as "resident aides" and considers residents as community members. These homes have:

  • Good staffing ratios.
  • Better wages and benefits.
  • A diverse patient base.

Front-line caregivers are the key to quality and must be afforded the dignity and respect they are expected to show residents. Study findings show that:

  • Organizational factors are highly influential in creating and maintaining a high-quality facility.
  • Human resource practices have a direct relationship with quality outcomes.
  • The best quality of care costs no more than the least quality of care.

According to Dr. Eaton, State and local governments have critical roles to play in:

  • Supporting task forces.
  • Research.
  • Best practice models.
  • Teaching.
  • Regional conferences.
  • Interdisciplinary councils.

Dr. Eaton adds that combining financial and regulatory tools with managerial and organizational improvements is essential to achieving good outcomes.


Eaton SC. Beyond "unloving care": Linking human resource management and patient care quality in nursing homes. International Journal of Human Resource Management 2000 Jun;11(3):591-616.

Feuerberg M. Report to Congress: Appropriateness of minimum nurse staffing ratios in nursing homes. Baltimore (MD): Health Care Financing Administration; July 20, 2000.

Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000 Aug 1;109(2):87-94.

Harrington C, Kovner C, Mezey M, et al. Experts recommend minimum nurse staffing standards for nursing facilities in the U.S. Gerontologist 2000;40:5-16.

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