Systematic Review of Studies of Staffing and Quality in Nursing Homes Jane E. Bostick, PhD, APRN, BC, Marilyn J. Rantz, PhD, RN, FAAN, Marcia K. Flesner, PhD, RN and C. Jo Riggs, PhD, RN, BC Purpose: To evaluate a range of staffing measures and data sources for long-term use in public reporting of staffing as a quality measure in nursing homes. Method: Eighty-seven research articles and government documents published from 1975 to 2003 were reviewed and summarized. Relevant content was extracted and organized around 3 themes: staffing measures, quality measures, and risk adjustment variables. Data sources for staffing information were also identified. Results: There is a proven association between higher total staffing levels (especially licensed staff) and im- proved quality of care. Studies also indicate a signifi- cant relationship between high turnover and poor res- ident outcomes. Functional ability, pressure ulcers, and weight loss are the most sensitive quality indica- tors linked to staffing. The best national data sources for staffing and quality include the Minimum Data Set (MDS) and On-line Survey and Certification Auto- mated Records (OSCAR). However, the accuracy of this self-reported information requires further reliability and validity testing. Conclusions: A nationwide instrument needs to be de- veloped to accurately measure staff turnover. Large- scale studies using payroll data to measure staff reten- tion and its impact on resident outcomes are recommended. Future research should use the most nurse-sensitive quality indicators such as pressure ul- cers, functional status, and weight loss. (J Am Med Dir Assoc 2006; 7: 366 –376) Keywords: Nursing homes; staffing; quality; review Numerous studies in the past 3 decades have explored the relationships between staffing levels in nursing homes and quality of care measures. However, the wide array of studies researching staffing and quality of care, many with conflicting results, make it increasingly difficult to interpret and use the findings. The demand for evidence to establish staffing levels based on quality of care is growing, but finding the best evidence to support these decisions has become more and more complex. A systematic review of staffing and quality of care is critical to synthesize relevant research and assist the long-term care community to understand the “state of the art” in the measurement of staffing and quality of care. Systematic reviews are considered the “gold standard” for reviewing a body of research, whereby the results of many independent studies can be synthesized to offer valid evidence on a particular topic of interest. 1 Systematic reviews usually focus on the rigor of randomized controlled trials to assess the effectiveness of a particular intervention. But, many nursing studies seek to answer different questions such as the impact of nursing care on certain conditions that do not easily lend themselves to experimental designs. Many nursing studies that are descriptive, observational, correlational, or quasi- experimental have not been included in systematic reviews because when judged against randomized controlled trials they have been classified as “lower level” evidence. Evans and Pearson 1 suggest that systematic reviews bring together all valid and relevant evidence to determine the “effectiveness, appropriateness, and feasibility of an intervention. This ap- proach would provide a more useful basis for health care decisions, because it better reflects the complex nature of these decisions” (p. 596). Staffing is not an intervention, but it is a critical factor in carrying out interventions to improve the quality of care in nursing homes. Therefore, the tradi- tional approach to reviewing literature must be adapted to address questions regarding the impact of staffing on specific quality measures; the appropriate staff-mix conducive to qual- ity; and the feasibility of staffing recommendations. FOCUS OF THE REVIEW Under a consulting agreement with the Colorado Founda- tion for Medical Care, the authors conducted a systematic literature review of staffing measures linked to quality out- comes in nursing homes. The purpose of this literature review University of Missouri-Columbia, Columbia, MO (J.E.B., M.J.R., M.K.F.); Central Missouri State University, Warrensburg, MO (C.J.R.). The analyses upon which this publication is based were performed under Contract Number 500-02-CO01, funded by the Centers for Medicare & Med- icaid Services, an agency of the U.S. Department of Health and Human Ser- vices. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. Address correspondence to Jane E. Bostick, PhD, APRN, BC, University of Mis- souri-Columbia, S407 Sinclair School of Nursing, Columbia, MO 65211. E-mail: bostickj@missouri.edu Copyright ©2006 American Medical Directors Association DOI: 10.1016/j.jamda.2006.01.024 366 Bostick et al. JAMDA – July 2006