The relationship between nurse staffing and quality of care in nursing homes: a systematic review.

BACKGROUND Nursing homes have an important role in the provision of care for dependent older people. Ensuring quality of care for residents in these settings is the subject of ongoing international debates. Poor quality care has been associated with inadequate nurse staffing and poor skills mix. OBJECTIVES To review the evidence-base for the relationship between nursing home nurse staffing (proportion of RNs and support workers) and how this affects quality of care for nursing home residents and to explore methodological lessons for future international studies. DESIGN A systematic mapping review of the literature. DATA SOURCES Published reports of studies of nurse staffing and quality in care homes. REVIEW METHODS Systematic search of OVID databases. A total of 13,411 references were identified. References were screened to meet inclusion criteria. 80 papers were subjected to full scrutiny and checked for additional references (n=3). Of the 83 papers, 50 were included. Paper selection and data extraction completed by one reviewer and checked by another. Content analysis was used to synthesise the findings to provide a systematic technique for categorising data and summarising findings. RESULTS A growing body of literature is examining the relationships between nurse staffing levels in nursing homes and quality of care provided to residents, but predominantly focuses on US nursing facilities. The studies present a wide range and varied mass of findings that use disparate methods for defining and measuring quality (42 measures of quality identified) and nurse staffing (52 ways of measuring staffing identified). CONCLUSIONS A focus on numbers of nurses fails to address the influence of other staffing factors (e.g., turnover, agency staff use), training and experience of staff, and care organisation and management. 'Quality' is a difficult concept to capture directly and the measures used focus mainly on 'clinical' outcomes for residents. This systematic mapping review highlights important methodological lessons for future international studies and makes an important contribution to the evidence-base of a relationship between the nursing workforce and quality of care and resident outcomes in nursing home settings.