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The Influence of Nurse Staffing Levels on Quality of Care in Nursing Homes


In this Commonwealth Fund–supported study, researchers found that an increase in nurse staffing hours was associated with lower deficiency scores — and thus improved quality of care — in Florida nursing homes. Such findings, when reported on public Web sites, can help families make informed decisions when shopping for long-term care.

The Issue

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Families wrestling with the complex and often emotionally daunting task of finding long-term care for their elderly relatives often turn to the Nursing Home Compare Web site. The site, which is operated by the Centers for Medicare and Medicaid Services (CMS), provides information on the quality of care in U.S. nursing homes, including average number of nurse staffing hours per resident per day and "deficiency scores," which are based on violations of federal safety regulations found during annual inspections. Deficiencies fall within categories that include quality of care, resident rights, and physical environment. But researchers have found that the Web site’s data on day-to-day staffing levels are inconsistent and not reflective of new state staffing regulations. Until recently CMS posted the number of deficiencies, which obscured how serious the deficiency was and how many residents were affected by the deficient practice. CMS now reports deficiency scores that assign values to scope and severity of deficiencies and help consumers gain insight into the quality of care and quality of life at nursing facilities. In this study, the authors examined the relationship between nurse staffing levels and deficiency scores in Florida nursing homes.

Key Findings

  • The researchers found a relationship between high nurse staffing levels and low deficiency scores. Every additional hour of certified nursing assistant care per resident day is associated with a 10 percent decrease in the total deficiency score.
  • Facilities that staff one hour fewer certified nursing assistants per resident day have a 33 percent increase in quality-of-care deficiencies.
  • Every six-minute increase in certified nursing assistant time reduces the quality-of-care deficiency score by 3 percent.

Addressing the Problem

By hiring more nursing staff, nursing home providers can lower their deficiency scores and improve quality. In doing so, they can improve their ability to attract consumers who are exploring long-term care options on the Nursing Home Compare Web site. Likewise, providers participating in certain pay-for-performance demonstrations can benefit financially by increasing nurse staffing and thus reducing deficiencies.

About the Study

The researchers used data from CMS’s Online Survey Certification and Reporting database and from the Florida Nursing Home Staffing Reports, which every facility in the state must self-report to the Florida Agency for Health Care Administration. All freestanding licensed nursing homes in Florida were included in the analysis. The final sample included 663 nursing homes. The study period was 2002 to 2005.

The Bottom Line

By increasing nurse staffing hours, nursing homes may be able to lower their deficiency scores, raise their quality of care, and improve their marketability.

Publication Details



K. Hyer, K. S. Thomas, L. G. Branch et al., "The Influence of Nurse Staffing Levels on Quality of Care in Nursing Homes," The Gerontologist, published online May 20, 2011.