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Caregiver Staffing in Nursing Homes and Their Influence on Quality of Care: Using Dynamic Panel Estimation Methods

The Issue

Many nursing homes operate with suboptimal staffing, including insufficient numbers of caregivers, the use of agency (temporary) workers, and an inadequate mix of professional staff, such as registered nurses, licensed practical nurses, and nurse aides. Higher staffing levels and a richer mix of professional staff are believed to positively influence quality of care, while high staff turnover—a problem common in many nursing homes—is associated with poor quality. The evidence, however, is inconclusive. In this study researchers used more definitive methods than previously employed to explore the links between staffing and quality of care in nursing homes.

What the Study Found

Results verified hypotheses that better staffing characteristics for registered nurses (RNs) and nurse aides positively affect quality, with findings most significant for RN staffing levels. Increasing RN staffing levels in all cases resulted in better quality scores on pain management and pressure sores, among other indicators. Staffing levels for nurse aides, who provide the most direct care to residents, also significantly influenced quality. In addition, the authors noted that staff composition—reflected in professional mix, turnover, and use of agency personnel—also affected quality meaningfully.

For their Commonwealth Fund–supported study, the researchers used longitudinal and quarterly staffing data from a survey of nursing home administrators and from the Centers for Medicare and Medicaid Services' Nursing Home Compare and Online Survey Certification and Reporting databases.


The study findings lend credence to efforts to establish standards for nursing home staffing. They also indicate that policymakers may have more options than simply setting minimum staffing levels, given the importance of the mix of professionals employed at nursing homes. Among the possible measures policymakers might consider are caps on the number of agency personnel and support for programs targeting reduction of staff turnover. Future studies, the authors write, should determine minimum staffing characteristics that can be used to improve quality of care in U.S. nursing homes.

Publication Details



N. G. Castle and R. A. Anderson, "Caregiver Staffing in Nursing Homes and Their Influence on Quality of Care: Using Dynamic Panel Estimation Methods," Medical Care, June 2011 49(6):545–52.