Nurse Staffing Patterns and Quality of Care in Nursing Homes Robert Weech-Maldonado Louise Meret-Hanke Maria C. Neff Vince Mor Abstract: Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care. N ursing homes are experiencing significant fi- nancial challenges because of constrained reve- nues and rising costs. In response, nursing homes may consider restructuring their staffing patterns in an effort to control costs such as by reducing the number of registered nurses (RNs). 1–3 Nevertheless, it is generally believed that more RNs are necessary to ensure the quality of care received by nursing home patients. 4–7 Furthermore, evidence is increasingly supporting the role of nurse staffing in the quality of care. 8–10 A recent study of nurse staffing in hospitals identified a definitive link between nurse staffing and mortality rates. 11 To date, however, research into the link between nurse staffing structures and quality of care in nursing homes has produced inconsistent and contradictory results. 5,6,12–14 Such results may arise from differences in conceptual frameworks, methods, data, data quality, and adjustments for case-mix intensity. 5,6,15 The Institute of Medicine called for more research into the relationship between staffing structures and outcomes of patient care. 6,7,14 Using Donabedian’s structure-process-outcome (SPO) framework that was developed in the 1960s and the re- source-based view of the firm, 16 this study considers the direct and indirect effects of staffing (RN staffing mix and full-time RN-staffing) on patient outcomes. RN staffing mix is defined as the proportion of RNs relative to other nursing staff. 17 Full-time RN staffing is the proportion of RNs who are full-time, permanent employees of the nursing homes as opposed to part-time RNs or contract RNs supplied by nurse staffing agencies. CONCEPTUAL FRAMEWORK Health services research into the effect of nurse staffing on the quality of patient care outcomes has primarily used Donabedian’s SPO quality framework. 4–6,18 Within this framework, structural indicators of quality include staffing patterns and organizational characteristics that April–June  2004 107 Health Care Manage Rev, 2004, 29(2), 107-116 A 2004 Lippincott Williams & Wilkins, Inc. Robert Weech-Maldonado, MBA, PhD, is Assistant Professor, Department of Health Policy and Administration, Pennsylvania State University, University Park, PA. E-mail: rxw25@psu.edu Louise Meret-Hanke, MA, MOD, is Doctoral Candidate, Depart- ment of Health Policy and Administration, Pennsylvania State Univer- sity, University Park, PA. E-mail: lam330@psu.edu Maria C. Neff, MS, is a Health Insurance Specialist, Centers for Medicare and Medicaid Services, Chicago, IL. E-mail: mneff@cms. hhs.gov Vince Mor, PhD, is Professor and Chair, Department of Commu- nity Health, and Faculty Associate, Center for Gerontology and Health Care Research, Brown University, Providence, RI. E-mail: Vincent_ Mor@brown.edu Key words: nursing homes, nurse staffing, quality of care