More nursing home staffing leads to fewer hospitalizations and deaths, with the greatest impact seen from the workers providing day-to-day care, according to research presented during a UW-Madison seminar.
David Grabowski, a professor in the Department of Health Care Policy at Harvard Medical School, spoke yesterday during an event organized by the UW School of Medicine and Public Health.
He discussed a study that explored the effects of short-term staffing reductions on patients, looking at three types of workers: registered nurses, or RNs; licensed practical nurses, LPNs; and certified nurse aids, or CNAs. While prior research has found RNs and LPNs contributed more to improvements in quality, this study found the lower-ranked CNAs are playing an important role, Grabowski said.
“Staff hours have the impact we would expect, more staff lead to fewer hospitalizations, less mortality, fewer hospital days and less hospital spending … this is largely being driven by CNAs,” he said.
Specifically, an extra nursing staff hour per resident day was linked to a 15% lower chance of hospitalization, a 15% lower chance of death, an 11% reduction in hospital days and 14% reduction in hospital standing.
“These are huge effects,” he said, adding the outsized role of CNAs shown by the data can be explained in part by the study model. Researchers were looking at short-term and sometimes unexpected staffing losses, rather than long-term shortages, he noted.
“CNAs are really the ones doing the assistance with the activities of daily living. They’re doing most of that hands-on care, LPNs and RNs are sort of working at a different level,” he said. “We would argue CNA losses are particularly harmful to the residents when you have these unexpected losses.”
He explained RNs are typically tasked with developing and overseeing implementation of plans for patient care, meaning their brief absences would have a relatively smaller impact compared to the CNAs. Grabowski said consistently higher staffing for administrative-focused RNs “might improve care over the longer term” but he emphasized the short-term impacts of CNA absences.
While LPNs are doing much of the medication work in most U.S. states and providing nursing care with residents, the CNAs are providing up to 90% of the direct care to residents, Grabowski said. He said CNAs are largely women, and many are recent immigrants or minorities.
“They’re paid very close to minimum wage, and less than half have health insurance through the nursing home,” he said. “This is a very fluid workforce.”
Researchers used data from various sources to conduct this analysis, including information on staff vacation time. By focusing on vacation time, rather than a more simple “outcomes versus hours worked” assessment, the team was able to explore variations in staffing that weren’t linked to patient characteristics.
That’s important because looking only at the number of hours worked could lead to “paradoxical” results, he said. As an example, facilities may “staff up” in order to provide adequate care for particularly sick patients, who will likely have worse health outcomes, leading researchers to the incorrect conclusion that more staff hours worsen health outcomes.
The study comes as the national nursing home workforce has “finally returned” to pre-pandemic levels nearly five years later, after it initially lost more than 400,000 workers, Grabowski noted.
“RNs, LPNs and CNAs all have different training and certification requirements, obviously the RNs and LPNs have their degrees, CNAs go through 100 hours of certification, but they have very different roles in the nursing home,” he said. “And you might imagine that all are important, but they might be important in different ways.”
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