Editor’s Note: A recent publication in the American Journal of Nursing is discussed below by Dr. Susan Horn. The complete reference is: Horn, S.D., Buerhaus, P., Bergstrom, N. & Smout, R.J. (November, 2005). RN staffing time and outcomes of long-stay nursing home residents. American Journal of Nursing, 105:11:58-70. This work has been highlighted in a video that can be accessed online: Kany, K., Horn, S.D., Bergstrom, N., Harrington, C., Deitrich, C., Stotts, N., Westfall, P., Bernet, B. (2006) Staffing Matters: Liability, Research, and Patient Outcomes. www.NursingCenter.com / AJNolderadults

Concern about quality of care provided in hospitals and nursing homes has stimulated research and policy debate.^{1, 2, 3} In hospitals, lower staffing levels have been associated with increased risk of adverse outcomes, ^4-6 including mortality.⁷ However, in nursing homes, where pain, pressure ulcers, malnutrition, and urinary incontinence are

serious problems, evidence linking nurse staffing and adverse outcomes is mixed.¹ Some studies report lower rates of adverse outcomes (for example, falls, pressure sores, and medication errors) associated with a higher percentage of RNs on staff and higher ratios of total nursing staff to residents.^{1, 3, 8-11} Others report that the ratio of RNs to residents is not associated with adverse outcomes or mortality.^{12, 13} Our research examined staffing levels and resident outcomes in sufficient detail to determine how much RN direct care time is needed to obtain better outcomes.

Our findings provide a comprehensive assessment of associations of average nurse staff time with five adverse clinical outcomes (development of pressure ulcers and urinary tract infections (UTIs), deterioration of ability to perform activities of daily living (ADLs), weight loss, and hospitalization) and two care processes (catheterization and administration of nutritional supplements), after controlling for physical limitations, medical diagnosis, severity of illness, and other resident, treatment, and facility factors for long-stay, at-risk nursing home residents. In each analysis, RN staffing of 30 to 40 minutes per resident per day of direct care time was strongly associated with better outcomes and that association was much stronger than those for Licensed Practical Nurse (LPN) and Certified Nurse Assistant (CNA) times.

Severity of illness was strongly associated with all outcomes: sicker residents were more likely to develop pressure ulcers, experience decline in ability to perform ADLs, be hospitalized, have weight loss, and die. Although severity of illness is not directly controllable by nursing home management, nurse staffing is directly controllable by management. After taking severity of illness, study duration, and many other patient, facility, and treatment variables into account, we found strong and consistent associations between the average time RNs provided direct nursing care and pressure ulcer development, weight loss, deterioration in ability to perform ADLs, and hospitalization, and weaker association with development of UTIs. More RN time was associated also with reduced use of catheters and increased resident use of standard medical nutritional supplements, which we’ve found in prior analyses to be associated with less likelihood of developing pressure ulcers.¹⁴ The greatest reductions in adverse outcomes resulted when RNs spent 30 to 40 minutes per resident per day on direct resident care.

The lack of strong, consistent relationships between direct care time provided by LPNs and CNAs and adverse outcomes highlights the critical role of RNs in quality of care in nursing home settings. A recent study of more than 5 million discharge abstracts of hospitalized patients also found that relationships between nurse staffing and adverse patient outcomes are much stronger for RNs than for other nursing personnel.⁴ We hypothesize that nurses influence quality in a facility by providing expertise in direct care and evaluation. Convergence of results of hospital studies and ours is further evidence that workforce policy should focus on increasing the proportion of RNs giving direct resident care in nursing homes.

Considering the large number of residents affected by these outcomes, estimates of decreased rates of adverse outcomes associated with more RN minutes are clinically important. During the three months that they were being studied, one out of three residents experienced deterioration in ability to perform ADLs; more than one-quarter developed a pressure ulcer or experienced weight loss. Between 10% and 20% were hospitalized, developed a UTI, were catheterized, or had some combination of these outcomes; 5% died. These outcomes increase facility expenditures, resource use, and spending on liability-related matters, and these outcomes cause residents to experience pain and suffering and loved ones to bear emotional distress. Our findings suggest a potentially greater risk of nursing home residents suffering avoidable adverse outcomes if nothing is done to improve RN staffing levels, and nursing homes and society incurring greater costs associated with these outcomes. Dorr and colleagues found that there would be a savings to society of almost $3,200 per at-risk resident per year if RN direct care time were increased from less than 10 minutes per resident per day to 30 to 40 minutes per resident per day.¹⁵ We need to increase RN staffing now.

Award Nominations Sought
 

The Isla Carroll Turner Friendship Trust
 

In 1982, The Isla Carroll Turner Friendship Trust (ICTFT) funded The Isla Carroll Turner Chair in Gerontological Nursing, the first Chair at The University of Texas Health Science Center at Houston to be named for a woman. In 1988, it was also the first chair to be awarded in the School of Nursing . Sharon K. Ostwald, PhD, RN, FGSA, currently holds this position.

The ICTFT has generously provided funding for Center on Aging special projects. Funds were used to create the Mediation Pilot program in 2004. Currently, funds are being used by Dr. Sharon Ostwald to produce a stroke survivor video. The ICTFT also funds three newsletters published by the Center on Aging, Elder Advocate, Family Voice, and Recovery Journal.

Isla Carroll Turner was the widow of Frank Prior Sterling, a founder and former president of Humble Oil & Refining Co. (now Exxon Company U.S.A.). After Mr. Sterling’s death, Isla Carroll married Percy E. Turner. She founded the Friendship Trust in 1956 to assist some widowed friends who were in financial distress after the deaths of their husbands and to give care and help to Houston’s aging citizens. Mrs. Turner died in 1979.

The late Carroll Sterling Masterson, Mrs. Turner's daughter, memorialized her mother's interest in care of the aged by establishing, in 1982, the Isla Carroll Turner Professorship in Geriatrics. In 1988, the Professorship evolved into the Chair in Gerontological Nursing. Mrs. Isla Carroll Reckling, Turner's grand-daughter, now directs the ICTFT.

The COA Shares Knowledge
 

Presentations

• Joan Wasserman, DrPH, MBA, RN. February 24, 2006. "An Intervention for Stroke Survivors and Their Spouses: Preliminary Findings." Center for Nursing Research, School of Nursing, Houston, TX.

• Sharon K. Ostwald, PhD, RN, FGSA, Professor, Isla Carroll Turner Chair in Gerontological Nursing and Coordinator of International Activities in the School of Nursing, recently spent three weeks in Thailand. She presented a research paper titled "Spousal Caregivers of Stroke Survivors: Burden, Coping, and Social Support" at the International Nursing Conference on Prevention and Management of Chronic Conditions: International Perspectives 2006 in Bangkok. She represented the School of Nursing at an international conference with nurses from China and Thailand in Chiang Mai, where she presented a paper titled, "Working Collaboratively Among Educational Institutions in Asia and the USA."

• Dr. Ostwald spent two weeks at Chiang Mai University, where we have an agreement to work with doctoral students in their International Doctoral Program. Since 2003, we have worked with 11 doctoral students from that program. While there, she served as an examiner on Totsaporn Khampolsiri’s dissertation committee. Ms. Khampolsiri did an intervention research study with Thai stroke survivors following hospital discharge, based on her work with Dr. Ostwald while in Houston.

• Dr. Ostwald also consulted with faculty and staff in the Chaing Mai University Center on Aging and presented lectures on research and gerontology to master’s and doctoral students there. She had an opportunity to meet with many of our "alums" while there — Pom, Apinya, Choi, Luppana, Jutamus, and Salee. They have spread the word that the University of Texas School of Nursing at Houston is a great place to study!

• Wasserman, J., Godwin, K., & Ostwald, S.K. "Capturing Costs for Outpatient Rehabilitative Stroke Care." Abstract presentation at the International Stroke Conference, Kissimmee, FL. February, 2006.

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Director's Corner
 

In this issue we are pleased to highlight a study on the value of nurses in long-term care. Dr. Susan Horn, a highly respected health services researcher, wrote a brief story about a recent study. There are many reasons to increase the level of RN staffing. Improvement in resident condition, decreased complications, and fewer hospitalizations are outcomes that save money.

There is a conundrum however, money spent by nursing homes to increase the number of nurses results in savings to Medicare/Medicaid, not to the nursing home. Better outcomes do not necessarily result in financial rewards to nursing homes. Something needs to be fixed.

We want to recognize all of the incredible support we’ve received from the Isla Carroll Turner Friendship Trust (page 2). The latest project supported by the Trust is the new video, Living After Stroke: Conversations with Couples (Sharon K. Ostwald, Executive Producer, and Tom Cole, Co-Producer) which premiered at the recent 2006 Stroke Survivor Conference (April 1, 2006). The video shows honest and profound portrayals of the experiences of stroke survivors and their spousal caregivers.

~ Nancy Bergstrom, PhD, RN, FAAN

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