Nurse staffing and quality of care in nursing homes

Almost all studies, including those cited by the Centers for Medicare and Medicaid Services, conclude that increased nurse presence in nursing homes lead to fewer negative outcomes. But why is that? This week on the podcast, we welcome Dr. Haizhen Lin to bridge the link between nursing care and quality of care in nursing homes.

Schenk: Hey out there. Welcome back to the podcast. My name is Rob. I’m going to be your host for this particular episode. We’ve been talking all about nursing services, the type of care that nurses provide, all the levels of nurses that there are, whether they be LPNs, RNs, CNAs, and then how their work, their provision of care to nursing home residents is directly related to the quality of care received at nursing homes.

But before we do that, I would super like it if you guys could like and subscribe wherever you get your podcasts from. If you are so inclined, leave a review, let us know how we’re doing. If there’s a particular topic you’d like us to talk about, please let us know. We’ll be happy to get into it in a future episode. Also while you’re at it, please check out our YouTube channel over at Nursing Home Abuse Podcast. There are plenty of videos for you to look at. We’re almost hitting 200 episodes of this podcast. Again, it’s a lot of data out there. It’s a lot of videos. Anyways, check that out.

And with that being said, let’s get into the content of the episode. Nursing care, I mean it’s highly critical to the quality of life, to the quality of care received in nursing homes. And I wanted to have an episode directly dedicated to that idea. We’ve talked about nursing care in the past, the different roles, the different people in nursing homes. We’ve done that in previous episodes, but I wanted to have an episode directly related to this subject.

But we’re not doing it alone. We’re going to have Dr. Haizhen Lin on the podcast today to walk us through this topic. Dr. Lin is an associate professor of economics in the Business, Economics and Public Policy Department in the Kelley School of Business in Indiana University. She is also a Weimer Faculty Fellow. Her primary area of research concerns the U.S. healthcare market and covers topics related to market competition, pricing, quality provision, government intervention and health information technology. Dr. Lin’s work has appeared in top economic journals such as the International Economic Review, Journal of Public Economics, Journal of Health Economics, Journal of Industrial Economics and Economics Letters. That is a heck of lot of economic publications. This kind of reminds me of in “30 Rock” where Jack Donaghy, which is Alec Baldwin’s character, would always talk about how important his meetings are, and in fact they had been rated by several different meeting magazines. So there’s a magazine, there is a journal for everything out there, and she has been apparently published in a ton of them, a ton of economic journals.

Anyways, she is also a faculty research fellow at the National Bureau of Economic Research and she serves on the editorial board for the American Journal of Health Economics, and we are so excited to have her on this show today. Dr. Lin, welcome to the show.

Lin: Thank you. It’s great to be here.

Schenk: Fantastic. We on this program have talked in several episodes about the importance of nursing and nursing care in nursing homes. And “nursing” is in the name of “nursing homes” so of course it’s important, but we’ve never really gotten into the nitty gritty, the minutiae of what exactly it means to provide nursing care and why at all nursing care is linked to quality of care and positive outcomes in nursing homes. So that’s why we wanted to have you on for this particular topic because you’re an expert in this.

So I guess from the opening here, from your perspective, in your experience, what technically is nursing services in nursing homes? What is the role of the nurse?

What are nursing services in a nursing home?

Lin: Sure. I’m happy to talk about that. So as you mentioned, nursing home is about nursing service. So generally speaking, there are three different types of nurses offering nursing services in a nursing home. Let me try to explain them and talk about what they do.

So first we have registered nurses, RNs. They mainly play supervisory roles. They supervise other nurses, assess residents’ health conditions, develop treatment plans and administer medications. So RNs are also responsible for assigning nurses’ work schedules. Their clinical knowledge, the care coordination and professional oversight make them likely to be crucial inputs in determining the care offered in a nursing home.

And then we also have licensed practical nurses or LPNs. They primarily carry out medication management and tasks such as taking patients’ vital signs. LPNs might have a lesser influence on quality of care given the narrow range of duties that they do as compared to RNs and nurse aides.

So this is the last kind of category or type of nurse that works in a nursing home. So nurse aides, or NAs, include certified nursing assistants and nursing assistants. They provide a direct nursing care to help residents with daily living activities such as dressing, using the toilet, taking medication. NAs also appear essential because they deliver the majority of the care to patients like 80 to even 90 percent of all the care to the patients. So they also play a very important role in delivering care to residents in a nursing home.

Schenk: Thank you for that. So I guess a question that I have off of that is we’re using the term “care,” and you mentioned that CNAs, certified nursing aides or certified nursing assistants depending on I guess what state you’re in, but they provide a majority of the “care.” But care itself has different categories, as you mentioned. So the nurse, the care that they provide is coordination of care. They provide assessments. They provide the training, essentially. The LPN, the care they provide is they’re the ones that may or may not administer the medications or observe vital signs. And then the CNA, the care they provide is kind of assistance with daily living, activities of daily living, that kind of thing. So I guess, if I understand it correctly, help with physical health with activities of daily living, that’s predominantly the care that’s provided at a nursing home because the CNA, that’s their job, they’re doing the majority of work. Right?

Lin: Yes.

Schenk: Did I hear that properly?

Lin: Yes.

Schenk: Okay. So I guess what’s the – I guess is that the primary difference between a CNA and say, a registered nurse? The care that they are technically allowed to provide?

How does nursing quality of care differ from nursing aide care?

Lin: Yes. Yes. And you do see some substitution going on, and the RNs, although they are like – how should I put it? – like supervisors or managers, they plan, they work out the schedules for NAs, but sometimes you do see some substitution going on. For example, the RNs might offer some direct care if there is some shortage of the nurse aides. But typically speaking, the nurse aides, they are the nurses who take care of the residents in nursing homes directly.

Schenk: I see. So there might be – the RN might roll up his or her sleeves and do maybe some of the ADL work, but it’s not appropriate, if I understand you correctly, for a CNA, for example, to do an assessment.

Lin: That’s correct.

Schenk: Yeah. And can you tell me what’s – and you don’t have to go into depth for this, but why is that important? What level of training would a nurse have versus a CNA, I guess to understand why the difference is critical?

Lin: Well I actually – well maybe you should not quote me because I am not an expert on this particular area, but this is what I know. Basically those RNs, they require say four years training, so basically they know a lot about how to assess a health condition for the patient. They can develop treatment plans. So it’s just like you go to a clinic basically. Those registered nurses, sometimes depending on the regulation or the state, they can even prescribe medications for the patients. So you should think about those registered nurses – they really know a lot about how to take care of the patients in terms of their medical needs. Put it this way, the nurse aides, they are more like taking care of the daily living activities for the residents. So it’s not so much about the medical conditions of the resident.

Schenk: I see. That makes sense. And actually that’s a great segue into my next question, which we’re talking about nursing care. Why is nursing care important in the sense of why is nursing care linked to quality of care?

Why is nursing care important?

Lin: So now you can think, because we already gone over the three different types of nurses in nursing homes and we all know that this industry, the nursing home industry is very labor intensive. This is, I would say, kind of different from other settings. For example, if you compare to manufacturing, of course, it won’t be as labor intensive, and even if you compare nursing homes to hospital settings, hospitals, if you want to compare hospitals to hospitals, you might consider a lot of other things, not just to look at nurses, right? You have to look at physicians, technology adoption, these types of things, capitals.

But in the nursing home setting, I think one kind of important feature about this setting is that it is very labor intensive. That speaks a lot. That’s why it is very important to talk about or to link the staffing to patient outcomes, because those are the nurses who take care of the residents, right? So if you care about the quality of care, if you care about patient health condition, you have to look at what’s happening in a nursing home. And what’s happening in a nursing home is that those nurses, they play different roles. They take care of the patients. So that’s why there is a direct and very obvious link between nurse staffing and quality of care.

And another reason that a lot of research has been done trying to establish this relationship between nurse staffing and quality of care is because we do have very good data measuring nurse staffing. It’s a relatively objective measure, right? You can call up a nursing home and ask them about their staffing, the nurse to resident ratio. That also offers a very objective way to compare different nursing homes. And a lot of research has been done and we do have some very solid and rigorous findings about the relationship between nurse staffing and quality of care.

Schenk: And what are those – what does that tell you? What does the data tell you about nurse staffing and how it relates to the quality of care? Like the number of staff?

What does data say about nurse staffing as it relates to quality of care?

Lin: So there’s a lot of research. We can maybe first talk about how the government thinks about that. Back in 2000, 2001, CMS, Centers for Medicare and Medicaid Services, they offered a report and they argued that it is really important to have, say, a minimum 0.75 RN hours per resident day and 0.55 hours per resident day for licensed practical nurses and 2.8 to 3.0 hours per resident day for certified nurse aide. So if you add up all those numbers together, that would be a total of 4.1 nursing hours per resident day. Basically that’s a recommendation that the government kind of came up with back in 2000. But we know that the reality, most of the nursing homes and I would say maybe more than half of the nursing homes in the U.S. fell short of this recommendation. And if you look at some academic research papers, because I mentioned earlier that it’s good that we do have very objective measures of nurse staffing and a lot of research has been done, try to build a relationship between nurse staffing and quality of care.

And I myself have done research on that area. I would say the good thing is we have a lot of research that has been done, so you can basically compare different methodologies using different papers, trying to see whether using different data sources, using data coming from different areas or different time periods, whether we can generate very robust results among all those different types of research designs, things like that. So I would say although we have seen some inconsistency about research findings, I believe that overall we do support these results findings, that is a higher level of registered nurse staffing is associated or will lead to better quality of care in the nursing home setting.

Schenk: I see. And if I’m understanding correctly that you provided certain amounts of time in increments of an hour for each of those categories based on a study that was done in the early 2000s by CMS. Those, as your contention, based on your research, are those still holding up? Or are your studies saying it should be higher? Is that a minimum threshold? I mean obviously the more you can have, the better, but in terms of that being the minimum threshold, what is your research showing?

Are there minimum thresholds for nursing time and quality of care?

Lin: So let me first talk about the reality. I think I kind of briefly alluded to that. The reality is not looking good. We do see some kind of increase in terms of staffing over time. For example, let’s look at a national sample of data, all the nursing homes about the median. So the median RN hours per resident day were 0.5 in 2009. So the CMS recommendation was you need to have 0.75 RN hours per resident day in 2001. But if you look at the data in 2009, the median is below that 0.75 RN hours, so it’s only 0.5.

We do see some improvement in increase in terms of staffing, if you look at the data from 2014, the RN hours per resident day was to 0.7, if my memory is correct, in 2014. But again, it still fell below the recommendations back in 2001. And I can tell you that based on one of the most recent studies published in a top economics journal, that paper suggests an optimal level of 1.9 hours by skilled nurses. So I should make this clear – the skilled nurses include both RN hours and the LPN hours, licensed practical nurses. And so if you add up those two types of nurses together, that paper suggests an optimal 1.9 hours per resident day for a nursing home.

Schenk: So we’ve come a long way since the 2000 study.

Lin: Yes.

Schenk: Do you know offhand the name of that paper or that study with the 1.9 nursing hours?

Lin: I don’t know the title but it was written by Martin Hackman. He is a Young Scholar. I think he’s in UCLA in UCLA Economics Department.

Schenk: I’ll do some research and I’ll link that in the show notes for audience members that maybe…

Lin: Yeah, that is exciting. The research design is very bigger and I particularly want to mention this because this is one of the most recent studies published in a top economics journal, so I think that’s why it’s kind of important too, because you’re asking me about optimal levels of nursing hours. That offers a benchmark for us to think about, 1.9 hours. Really, it’s far above what we have and even if you look at the data in recent years, it’s far above what we are actually having in nursing homes.

Schenk: I see. How did you get into this field, Dr. Lin?

How did Dr. Lin get into the field of nursing quality of care?

Lin: So I was doing my PhD many years ago back in Boston, and I was just reading newspaper articles and I was shocked to read a newspaper article talking about like abuse in nursing homes and a lot of people do not want to move to nursing homes. Someone said, “I’d rather be killed than move to a nursing home.” And I was just shocked. And that kind of got me starting to think about this very important industry. And given the aging of society, it happens in the U.S. and it also happens in a lot of developed countries and even in developing countries as well. How we can take care of those seniors is a very important question, but it really lacks a lot of rigorous economic research, so that sort of got me started looking into the healthcare industry. Actually working on the nursing home industry sort of got me started to think about other questions in healthcare in the U.S., but it’s actually my starting point, so my dissertation is basically about the nursing home industry.

Schenk: Wow. Well I’m glad that you went down that path because I mean your research is certainly helping out the industry. Is there anything you’re working on now? Is there any research you’re doing now that you can share with us and maybe any information that you’re kind of uncovering?

Lin: So currently I don’t have any ongoing research related to the nursing home industry, but I got started thinking about this industry has gone through dramatic changes over the past one decade or so. You can think about a lot of reimbursement changes that’s happening after the ACA. We’re talking about reform. We’re talking about how can we come up with a new kind of reimbursement system to incentive better quality of care. Disclosing information to the consumers so to help those patients make better decisions about which nursing homes that they want to go to.

What policy proposals are available for increasing nursing quality?

There are a lot of policy proposals under a lot of debate, of course, and there has been some policy proposals that have already been implemented. So another thing that kind of interests me is about home care, sort of like substitution away from nursing home care. Home care, the market is basically growing tremendously. That definitely will affect the business in the nursing home and how do the nursing homes adjust the competition from home care. Home care agency is also very interesting. So I look forward to kind of digging back into this area for the years to come, I guess.

Schenk: Right. Well like you said, home healthcare, nursing home industry, it’s only expanding as the population ages. Your work is going to be extremely critical and even more critical as time goes by. We certainly appreciate you taking a few moments away from your research and your studies to come out of this program and talk about nursing services and how it’s linked to quality of care. This has really flown by for me and we’ve only barely scratched the surface, but we thank you so much, Dr. Lin, for coming on and sharing your expertise.

Lin: Thank you so much. It has been my pleasure talking to you.

Schenk: It can never be said enough that there is a direct correlation between the work and care provided by nurses in a nursing home and quality outcomes at that nursing home, meaning that the more nurse hands, the more nurse time provided to each resident, the less likely it is there’s going to be some problem or degradation of the quality of life of the residents. I think we can put all that to rest. So happy that Dr. Lin could join us for this episode. Like I mentioned, we only scratched the surface, but I think it’s important for our listeners to hear.

New episodes of the Nursing Home Abuse Podcast are out every other week. They publish on Mondays so be on the lookout for the next episode. We thank you so much for watching or listening. And with that, we’ll see you next time.