Nurse Staffing and Quality of Care of Nursing Home

Nurse Staffing and Quality of Care of Nursing Home Residents in Korea Juh Hyun Shin, PhD, RN1 & Ta Kyung Hyun, MSW2 1 Assistant Professor, Ewha Womans University, College of Health Sciences, Division of Nursing Science, Seoul, Korea 2 Doctoral Student, Kyonggi University, Social Work, Kyonggido, Korea

Key words Nursing home, nursing staffing, quality of care Correspondence Juh Hyun Shin, Assistant Professor, 120–750, Ewha Womans University, College of Health Sciences, Division of Nursing Science, Daehyundong, Seodaemoongu, Seoul, Korea. E-mail: [email protected] Accepted: July 27, 2015 doi: 10.1111/jnu.12166

Abstract Purpose: To investigate the relationship between nurse staffing and quality of care in nursing homes in Korea. Methods: This study used a cross-sectional design to describe the relationship between nurse staffing and 15 quality-of-care outcomes. Independent variables were hours per resident day (HPRD), skill mix, and turnover of each nursing staff, developed with the definitions of the Centers for Medicare & Medicaid Services and the American Health Care Association. Dependent variables were prevalence of residents who experienced more than one fall in the recent 3 months, aggressive behaviors, depression, cognitive decline, pressure sores, incontinence, prescribed antibiotics because of urinary tract infection, weight loss, dehydration, tube feeding, bed rest, increased activities of daily living, decreased range of motion, use of antidepressants, and use of restraints. Outcome variables were quality indicators from the U.S. Centers for Medicare & Medicaid and 2013 nursing home evaluation manual by the Korean National Health Insurance Service. Findings: The effects of registered nurse (RN) HPRD was supported in fall prevention, decreased tube feeding, decreased numbers of residents with deteriorated range of motion, and decreased aggressive behavior. Higher turnover of RNs related to more residents with dehydration, bed rest, and use of antipsychotic medication. Conclusions: Study results supported RNs’ unique contribution to resident outcomes in comparison to alternative nurse staffing in fall prevention, decreased use of tube feeding, better range of motion for residents, and decreased aggressive behaviors in nursing homes in Korea. More research is required to confirm the effects of nurse staffing on residents’ outcomes in Korea. Clinical Relevance: We found consistency in the effects of RN staffing on resident outcomes acceptable. By assessing nurse staffing levels and compositions of nursing staffs, this study contributes to more effective long-term care insurance by reflecting on appropriate policies, and ultimately contributes to the stable settlement of the long-term care insurance system for elders.

In 2008, the Korean National Health Insurance Corporation introduced long-term care insurance as a form of social insurance for Korean elders to socialize caregiving for elders who cannot live independently and to relieve the burden of family members who were accountable, conventionally, for the care of older adults at home (Kim, Journal of Nursing Scholarship, 2015; 47:6, 1–10. C 2015 Sigma Theta Tau International

Kwon, Yoon, & Hyun, 2013). Korea is a national healthcare insurance country and all Koreans are required to pay monthly 6.55% of their income in healthcare premiums (Kim et al., 2013). Beneficiaries of long-term care insurance for elders is limited to those who are over 65 years of age and disabled who have passed a national 1

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care need assessment screening test conducted by Korean National Health Insurance Corporation experts (Kim et al., 2013). The long-term care insurance is graded from 1 to 5, based on physical function, cognitive function, behavior changes, necessary nursing tasks, and rehabilitation (Korean National Health Insurance Service, 2015a). As of late June 2014, the accumulated number of applicants for long-term care insurance was approximately 709,300. Approximately 11.2% of the total aging population of Korea have applied, and approximately 393,930 people have been rated for long-term care insurance (Korean National Health Insurance Service, 2014). Demands for elderly care facilities for an aging population will increase rapidly, challenging those who provide optimal care for elders in elderly care facilities currently (Korean National Health Insurance Service, 2014; Korean Statistics, 2013). After implementation, the increased rate of long-term care facilities grew about 95.94% quite rapidly, from 1,132 (81,512 residents) in 2008 to 2,610 (about 118,631 residents) in 2012 (Korean National Health Insurance Service, 2013). Stakeholders anticipate increasingly rapid growth in the future in Korea (Choi, Lee, & Lee, 2010). As healthcare professionals expect rapidly increasing numbers of elders in the long-term care population, they place greater emphasis on the quality of nursing home (NH) care in Korea. Benefactors of long-term care insurance among NH users have characteristics that require extensive care, such as being of an old age (80.46%), being female (72.27%), living alone (23.74%), and having an associated disease such as cerebral infarctions and dementia (Kim et al., 2013). Most residents in Korean NHs have high demands for medical care. Approximately 69.7% in 2011 were chronically ill (35% had mental or behavioral disturbances, 29.3% had high blood pressure, 19.2% had cerebral disease), and 72.9% had used medical care, whereas 32.2% had been hospitalized (59 annual average days of hospitalization; Korean Health Insurance Policy Institute [KHIPI], 2012). Of respondents to a survey of employees at elderly care facilities, 63% answered that appropriate care for elders in facilities is not performed when elders go through changes in their health condition or when they require treatment (No et al., 2010). Thus, residents in NHs do not receive intensive hospital care but are chronically ill and require constant medical and care services (Park, Lim, Kim, Lee, & Song, 2011). Moreover, 20.3% (88,083 people) suffered from dementia and senile psychosis. Those with dementia require care distinct from that for other illnesses (Korean National Health Insurance Corporation, 2013). Thus, demands for elderly care facilities for an aging population will increase rapidly, challenging those who provide optimal care for elders currently in 2

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elderly care facilities (Korean National Health Insurance Service, 2013; Korean Statistics, 2013). Several systematically reviewed articles have emphasized the importance of nurse staffing to improve resident outcomes (Bostick, Rantz, Flesner, & Riggs, 2006; Castle, 2008; Kim & Lee, 2013; Spilsbury, Hewitt, Stirk, & Bowman, 2011). The U.S. Centers for Medicare & Medicaid Services (CMS, 2001) revealed that NHs below the standard level of staffing are more likely to have deteriorating resident outcomes. High staff turnover, staff shortages, and the way problems of NH staff and residents are addressed are major concerns in managing the complex needs of the NH population (Krichbaum, Pearson, Savik, & Mueller, 2005; Winzelberg, 2003). A systematic review of 87 research articles supported the concept that higher numbers of RNs on staff align with better resident outcomes (Bostick et al., 2006). Staffing in Korean NHs includes registered nurses (RNs), certified nursing aides (CNAs), and qualified care workers. Nurse staffing consists of those who provide care or medical assistance for patients or pregnant women, have nursing licenses, and perform direct nursing tasks in elderly care (Korean Ministry of Government Legislation, 2013a). CNAs (who perform work analogous to U.S. licensed practical nurses [LPNs]; You, 2013) in Korean NHs help RNs, offer basic wound treatments, and bathe, feed, or transfer residents under the direction of RNs in emergency situations (Korean Ministry of Government Legislation, 2013b). Care workers (analogous to U.S. certified nursing assistants; You, 2013) provide physical or domestic assistance for elders who have difficulty performing daily activities due to senile illnesses, including dementia and stroke, at elder care or rehabilitation facilities. Activities include toileting, bathing, feeding, cleaning, and reporting major problems to RNs (Korean Ministry of Health and Welfare, 2013). Currently, regulation criteria for distribution of nursing staff at NHs have been eased to allow alternative nurse staffing; that is, CNAs have replaced some RNs to reduce costs. CNAs are distinguished by license rather than certificate, and by qualifications, educational or legal roles, and responsibilities (KHIPI, 2012). Thus, most NHs in Korea with too few nurses have hired nurse assistants to reduce costs (KHIPI, 2012). Currently, NHs have more CNAs than RNs, and CNAs play more important roles in smaller facilities than they do in larger facilities. (In NHs with more than 30 beds the required legal RN:CNA ratio is 1:2.6 people; with fewer than 30 beds, 1:4.5 people; KHIPI, 2012). In Korea, the proportion of nurses employed at elderly care facilities is 0.1%, noticeably low compared to other Organization for Economic Co-operation and Development (2011) countries (United States = 53.6%, The Netherlands = 27.1%, Germany = 26.3%, and Japan = 15.3%). Journal of Nursing Scholarship, 2015; 47:6, 1–10. C 2015 Sigma Theta Tau International


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Consequently, NHs do not provide elders with highquality long-term care services (No et al., 2010). Elders in elderly care facilities, as benefactors of long-term care insurance, need medium to highly intensive long-term convalescence for physical or cognitive ills, and nursing staff provide direct long-term care services. Because of alternative nurse staffing like CNAs instead of RNs, NHs have difficultly responding to demands for long-term care services for residents, and require systemic improvements (KHIPI, 2012).

Conceptual Framework Castle and Engberg’s (2005) framework underlays this examination of nurse staffing and quality of care (QOC). The concept of consistency includes consistency of nursing tasks, nursing job staffing levels, staff stability, professional staff mix, and use of agency staff. Coordination is the degree to which different subsystems of an organization interact, based on the necessities and requests of each subsystem or the total system (Georgopoulos & Mann, 1962): staffing levels, staff stability, professional staff mix, use of agency staff, and attaining optimal coordination (Castle, 2008). Care practices are the degree of organization rules (Price & Mueller, 1986). QOC is the amount of direct care to NH residents (Castle, 2008).

Quantity of Care A higher quantity of RNs providing care aligned with less aggression, less use of restraints, less dehydration, fewer fractures (Anderson, Hsieh, & Su, 1998), fewer pressure ulcers (Anderson, Hsieh, & Su, 1998; Bostick, 2004; Castle, 2011; Horn, Buerhaus, Bergstrom, & Smout, 2005; Konetzka, Stearns, & Park, 2008; Lee, Blegen, & Harrington, 2013; Weech-Maldonado, MeretHanke, Neff, & Mor, 2004), better eating patterns (Kayser-Jones & Schell, 1997), more feeding assistance, more incontinence care, more exercise and repositioning (Schnelle et al., 2004), fewer urinary tract infections (Anderson et al., 1998; Horn et al., 2005; Konetzka et al., 2008), less weight loss, fewer catheterizations, less hospitalization (Horn et al., 2005), more out-of-bed activity (Bates-Jensen, Schnelle, Alessi, Al-Samarrai, & Levy-Storms, 2004; Schnelle et al., 2004), more discharge to home, less death (Bliesmer, Smayling, Kane, & Shannon, 1998), more improved functional ability (Bliesmer et al., 1998; Horn et al., 2005), fewer QOC deficiencies (Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000), and fewer administrative deficiencies (Harrington et al., 2000). The number of LPNs did not contribute to fewer pressure ulcers (Hickey et al., 2005), but contributed to more Journal of Nursing Scholarship, 2015; 47:6, 1–10. C 2015 Sigma Theta Tau International

out-of-bed engagement, feeding assistance, incontinence care, exercise and repositioning (Schnelle et al., 2004), and better eating patterns (Kayser-Jones & Schell, 1997). The quantity of CNAs contributed to fewer pressure ulcers (Hickey et al., 2005; Horn et al., 2005), more out-ofbed engagement, feeding assistance, incontinence care, exercise and repositioning (Schnelle et al., 2004), more food/fluid intake during mealtimes (Simmons, Osterweil, & Schnelle, 2001), better eating patterns (Kayser-Jones & Schell, 1997), and weight loss (Dyck, 2007). The quantity of total nursing staff hours contributed to fewer pressure ulcers (Hickey et al., 2005), lower scores on the Health Care Financing Administration deficiencies index (Johnson-Pawlson & Infeld, 1996), and more fluid intake (Kayser-Jones & Schell, 1997). In contrast, other researchers reported the quantity of nurse staffing was not statistically significant or did not contribute to resident outcomes (Johnson-Pawlson & Infeld, 1996; Moseley & Jones, 2003; Rantz et al., 2004; Wan, 2003). Recent studies used quality of life (QOL) as the outcome variable with nursing staff, but the results varied and more research is needed (Shin, 2013; Shin, Park, & Huh, 2014).

Coordination Researchers studied coordination in many ways: skill mix, ways of interacting, and supervision. Skill mix studies that examined higher numbers of RNs and fewer LPNs and CNAs reported that more RNs contributed to fewer physical restraints, antipsychotic drugs, pressure ulcers, mood decline, and cognitive decline (Weech-Maldonado et al., 2004). The skill mix studies that examined more licensed nursing hours (RN or LPN hours) versus unlicensed nursing hours (CNA hours) reported that more licensed hours positively influenced pressure ulcers, discharge to home, death, and functional ability (BatesJensen et al., 2004; Bliesmer et al., 1998). A higher ratio of RNs to LPNs and CNAs had a statistically significant negative influence on some domains of QOL: meaningful activity, food enjoyment, and security (Shin et al., 2014). CNAs exhibited a better relationship with residents, yielding better resident outcomes (Bowers, Esmond, & Jacobson, 2000), whereas poor relationships between RNs and CNAs negatively related to food intake (Crogan & Shultz, 2000). Greater supervision constraints negatively related to food intake of residents (Crogan & Shultz, 2000). Changes in staffing patterns positively influenced the frequency of pressure ulcers (Hickey et al., 2005). Organization-level interventions by gerontological advanced practice nurses related positively to health function (Krichbaum et al., 2005). 3


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Consistency Researchers studied the consistency of staffing related to turnover, stability (long-tenured nursing staff), and use of agency staff. Major research studies examined the influence of nurse staffing turnover on QOC and consistency of staffing. Some studies reported that increased turnover of RNs and CNAs related to worse outcomes (Castle & Anderson, 2011), whereas the turnover of LPNs and CNAs was not statistically significant (Castle & Anderson, 2011; Castle & Engberg, 2007). The increased

Turnover rate =

of residents (CMS, 2014). RN HPRD was classified as director of nursing, RNs who directly cared for residents, RNs who were responsible only for training qualified care workers, and RNs only with administrative work, if the job description of RNs was divided. The operational definition of the skill mix was the ratio of RNs to CNAs, and the CNAs or care-worker ratio measured skill mix. Turnover was calculated using the Nursing Facility Staff Survey in the following formula, developed by the American Health Care Association (2011):

The number of terminations × in a calendar year (12 months) ×100 The total number of current employees at the end of the calendar year

QOC Measures turnover rate of RNs aligned with better outcomes (Castle & Engberg, 2007). In the same vein, long-tenured nursing staff aligned with improved resident outcomes (Castle & Engberg, 2007). The use of agency staff due to the nurse staffing shortage showed mixed results: the use of agency RNs and CNAs did not contribute to better resident outcomes, whereas use of LPNs was not statistically significant (Castle & Anderson, 2011; Castle & Engberg, 2007). In sum, researchers conducted very few studies on NHs, and most were conducted before Korea introduced national long-term care insurance (Kim, Nam, Chae, & Lee, 2008; Kim et al., 2013; M. A. Lee, 2005; Y. K. Lee, 2009; Lim, 2008).

Methods Design of the Study This study used a cross-sectional design to describe the relationship between nurse staffing and 15 QOC outcomes. We sampled 150 NHs from six provinces in Korea, including all NHs under operation in 2014, excluding those with fewer than 30 beds because of a low signalto-noise ratio (Castle & Engberg, 2007). Nineteen NHs agreed to participate in this study.

Instruments We collected the bed size, number of beds, operation period, ownership status, member of a chain, religion of establishment, referral hospitals, location, and the percentage of long-term care beneficiaries. Administrators and nursing staff from each participating NH provided all staff measure data. Independent variables were hours per resident day (HPRD), skill-mix HPRD, and staff turnover. We defined HPRD as the mean hours worked by licensed nurses or nursing assistants divided by the total number 4

We refer to quality indicators from CMS (2014) and 98 quality indicators in the 2013 NH evaluation manual by the Korean National Health Insurance Service (2013). The Korean Ministry of Health and Welfare (public insurer) should inspect every NH every 3 years, based on the NH evaluation manual (Korean National Health Insurance Service, 2015a). Following are the 15 QOC measures; the prevalence of cases at admissions was not included: • prevalence of residents experiencing more than one fall or slip in the past 3 months • prevalence of residents with pressure sores • prevalence of residents with aggressive behaviors • percentage of residents with depression • percentage of residents with cognitive decline • percentage of residents with incontinence or fecal incontinence • percentage of residents with prescribed antibiotics because of urinary tract infection • percentage of residents with weight loss more than 5% within 1 month or 10% within the past 6 months • percentage of residents who experienced dehydration • percentage of residents who had tube feeding • percentage of residents who had bed rest • percentage of residents whose need for help with activities of daily living increased • percentage of residents whose need for help with range of motion decreased • percentage of residents who have been prescribed antidepressant or sleeping pills • percentage of residents who were physically restrained

Data Collection and Analysis In Korea, 2,160 NHs exist (Korean Statistics, 2013). We included those with more than 30 beds (operating Journal of Nursing Scholarship, 2015; 47:6, 1–10. C 2015 Sigma Theta Tau International


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in 2014) in this study. The project investigator visited the 19 NHs that agreed to participate, introducing this study to administrators and obtaining consent forms. Administrators, directors of nursing, or executive secretaries in 19 NHs who had experienced overall management of NHs filled out the survey on a quarterly basis by reviewing residents’ charts, nurses’ notes, and accident reports at the organizational level. When collecting data, we did not obtain individual residents’ information. We obtained approval from the Institutional Review Board of Ewha Womans University. We used a multilevel linear model to analyze the data. Because NH effect may exist, we needed to appropriately handle heterogeneity in subjects between NHs. Thus, we treated NH effect as a random effect. We performed power analysis using a simple mixed-effects model with only one fixed effect of interest; a sample size of 19 was large enough to provide 80% power for seven of the 10 fixed effects (variables) of interest. We investigated the relationship between six variables of interest on staffing and 15 QOC measures. Geographic location, profit market share, and bed size were controlling variables. The five-grade system of long-term care insurance was used to control residents’ different functional status. We used the mixed procedure of SAS 9.3 (SAS Institute, Cary, NC, USA), finding variables with coefficients that satisfy p values below .05 and .1.

Results Characteristics of Facilities, Nurse Staffing, and Participants Descriptive statistics of participating facilities are summarized in Table S1 (available with online version of this article). The average number of beds in participating organizations was 75.56, ranging from 49 to 296. Most facilities (89.5%) were not for profit. More than half were located in a small city. Most (89.5%) did not have formal referral hospitals, and 47.4% were established based on religion. Average occupancy was high (90.92%), and the average duration was about 7 years and 6 months (SD = 3.52). Of residents, 44.2% were third grade longterm care beneficiaries (elders who are partially dependent for activities of daily living).

Nursing Staff Hours Per Resident Day As direct-care RN HPRD increased by 1 HPRD, 6.8% of the incidence of falls decreased (ß = −.46, p = .04), and the prevalence of residents with L-tubes decreased about 6.5% in 3 months (ß = −0.45, p = .022; Table S2, available with online version of this article). Journal of Nursing Scholarship, 2015; 47:6, 1–10. C 2015 Sigma Theta Tau International

Furthermore, the prevalence of residents who experienced deteriorated range of motion decreased by 5% (ß = 0.34, p = .002). As the administrative RN HPRD increased by 1 HPRD, about 12% of aggressive behaviors decreased (ß = −12.85, p < .001), and the prevalence of cognitively impaired residents decreased by 324% (ß = −324.14, p = .003).

Certified Nurse Aids HPRD. As CNA HPRD increased by 1 HPRD, 5.3% of residents with L-tubes increased (ß = 0.543, p = .027).

Qualified Care Workers HPRD. As administrative CNA HPRD increased by 1 HPRD, 4.1% of residents with aggressive behaviors increased (ß = 0.053, p = .001), and about 5.2% of residents with L-tubes increased (ß = 0.066, p = 0).

Skill Mix We examined skill mix to see if it predicted QOC for NH residents. As more RNs and fewer CNAs worked, a statistically significant negative influence emerged for fall prevalence (ß = −1.19, p = .02) and deteriorated range of motion (ß = −1.18, p = 0) increased; as the ratio of RNs to CNAs increased by 0.0514, fall prevalence decreased by 6% and residents with deteriorated range of motion decreased by 6%. However, the ratio of CNAs and qualified care workers was not statistically significant on any QOC outcomes (Table S3, available with the online version of this article).

Turnover As expected, we found a statistically significant positive relationship between the turnover of RNs and prevalence of residents with dehydration (ß = 0.0012, p = .05), bed rest (ß = 0.008, p = .001), and antipsychotic drug use (ß = 0.029, p = .053; Table S4, available with the online version of this article). As RN turnover increased by 12.44%, prevalence of residents with dehydration increased by 1.2%, with bed rest increased by 9.9%, and with antipsychotic medication increased by 36%. A statistically significant negative relationship emerged between turnover of qualified care workers and prevalence of residents with dehydration (ß = −0.001, p = .03) and bed rest (ß = −0.008, p = .002). As the turnover of qualified care workers increased by 119.24%, the prevalence of residents with dehydration decreased by 11.9% and residents with bed rest decreased by 95%. 5


Discussion This groundbreaking study examined the relationship between nurse staffing and QOC in Korean NHs. We found consistency in the effects of RN staffing on resident outcomes acceptable. Effects of RN HPRD was supported in fall prevention, decreased tube feeding, decreased residents with deteriorated range of motion, and decreased aggressive behavior. Greater RN HPRD aligned with a 6.8% decrease in the incidence of falls on the most recent 3-month assessment, consistent with previous studies that showed fewer fractures (Anderson et al., 1998) and more exercise and repositioning with increased RN hours (Schnelle et al., 2004). This outcome may imply that RNs, compared to other staff in NHs, acknowledge the serious outcomes of falls for NH residents. More RN hours contributed to a decrease in falls—aligned with previous research in Korea—showing RNs have more serious attitudes about safety issues than other NH staff, and undertake an important administrative role to improve overall safety issues in NHs (Castle, 2006; Yoon, Kim, & Wu, 2014). Furthermore, more RN HPRD related statistically to a 6.5% decline in the number of residents with feeding tubes, consistent with previous studies (Kayser-Jones & Schell, 1997; Schnelle et al., 2004). RNs are more concerned about the importance of nutrition and eating and may consider the insertion of L-tubes as the final way to provide more feeding assistance. Another contribution of RNs was that the proportion of residents who experienced deteriorated range of motion decreased by 5% with more RN HPRD, consistent with research that RN hours aligned with improved functional ability (Bliesmer et al., 1998; Horn et al., 2005). Increased administrative RN staffing hours aligned with a decline in aggressive behaviors and higher RN staffing hours related to less aggression in a recent study (Anderson et al., 1998). However, inconsistent with previous research, use of restraints, a decline in dehydration (Anderson et al., 1998), fewer pressure ulcers (Anderson et al., 1998; Bostick, 2004; Castle, 2011; Horn et al., 2005; Konetzka et al., 2008; Lee et al., 2013; Weech-Maldonado et al., 2004), more out-of-bed activities (Bates-Jensen et al., 2004; Schnelle et al., 2004), incontinence care (Schnelle et al., 2004), fewer urinary tract infections (Anderson et al., 1998; Horn et al., 2005; Konetzka et al., 2008), less weight loss, and fewer catheterizations (Horn et al., 2005) were not statistically significant for RN HPRD in this study. As NHs provided more CNA hours in Korea (You, 2013), the prevalence of residents with tube feeding increased. With the significant findings from this study, increased RN HPRD and diminished CNA hours aligned 6

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with a decline in tube feeding. Although previous research reported that more CNA HPRD aligned with fewer pressure ulcers, more out-of-bed engagement, feeding assistance, incontinence care, exercise and repositioning, more food and fluid intake during mealtime, better eating patterns, and weight loss, these QOC measures did not emerge in this study. RNs may consider the insertion of L-tubes as the final care to enhance feeding assistance, whereas Korean CNAs may require more education on the use of L-tubes. Many researchers reported that turnover of nursing staff negatively impacted the QOC of residents, the demanding workload for colleagues, and the cost for recruitment and training for newly hired nurses (Castle & Anderson, 2011; Castle & Engberg, 2005). However, in some studies, no statistically significant connections arose between turnover rate of LPNs and results for elders in care facilities (Castle & Anderson, 2011; Castle & Engberg, 2007) or between the turnover rate of CNAs and results for elders in care facilities (Castle & Engberg, 2007). Results about turnover were inconsistent across nursing staff types. Higher turnover of RNs related to more residents with dehydration, bed rest, and use of antipsychotic medication. The higher turnover rate of care workers related to a decreased prevalence of residents with dehydration and bed rest. Clearly, stable nurse staffing of RNs contributed to better hydration management and out-of-bed activities, and decreased antipsychotic medication. Turnover information about nurse staffing in long-term care settings has not been reported. It has been 5 years since Korea implemented long-term care insurance, which was late compared to other advanced countries. However, issues arise consistently about the quality of long-term care insurance for residents; levels of care and maintenance of physical and mental health must improve. This study examined the effects of nursing staff on resident outcomes under long-term care insurance services to suggest optimal nurse staffing criteria. NHs in Korea have failed to reflect the differences in roles and functions of RNs and CNAs, and greatly lack services of professional nurses. Emergency treatments, based on quick and professional judgments of professional RNs, are an absolute requirement because RNs provide residents limited and temporal treatments until rare visits from doctors occur, when residents need medical care. Annual medical treatment costs per elder are about $4,000. Furthermore, long-term, effective, efficient control of residents in NHs with senile illnesses, physical malfunctions, reduced daily life activity performance, and difficulties in independent activities are impossible at this point (KHIPI, 2012). Most NH residents have dementia with reduced cognitive function or difficulty Journal of Nursing Scholarship, 2015; 47:6, 1–10. C 2015 Sigma Theta Tau International


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performing daily life activities, and cerebral infarctions that lead to falling or suffocation during eating. For current nurse staffing criteria in Korea, NHs only provide minimal numbers of nursing staff; NHs do not provide optimal numbers of nursing staff for best quality nursing services. The International Council of Nurses, Agency for Healthcare Research Quality in the United States, and the Joint Commission have also emphasized the health and safety of patients through high-quality nursing services. In the same vein, the KHIPI (2012) has suggested strengthening the staffing criteria of professional RNs and expanding their roles and functions in NHs as a countermeasure for medical requirements for elders in care facilities in Korea. This study provides basic data on establishing more efficient and consistent staffing nurse systems in NHs in Korea.

Limitations The present study has some limitations. First, data came from a limited number of facilities in Korea and generalizability should be considered. The threat to internal validity also should be considered, because to recruit participating organizations, more favorable organizations that support use of more RNs in NHs were more likely to agree to participate, compared with NHs with only CNAs. Furthermore, the sample of this study did not reflect the total population of NH residents in Korea. The Korean national data reported the population quality as first grade (15.077%), second grade (24.19%), third grade (44.2%), fourth grade (15.2%), and fifth grade (1.333%) longterm care beneficiaries in 2014, whereas the population for this study was composed of first grade (6.4%), second grade (12.3%), third grade (29.1%), fourth grade (22.9%), and fifth grade (1.8%; Korean National Health Insurance Service, 2014). Consequently, this potential selection bias may have resulted in underrepresentation of NHs in Korea. More research throughout Korea is necessary to confirm the relationship between nurse staffing and QOC. The cross-sectional design is the last limitation of this study. We controlled the extraneous variables by instituting a statistical model to offset this limitation.

Conclusions This study investigated how nurse staffing relates to residents’ QOC in NHs in Korea. Study results supported RNs’ unique contribution to resident outcomes in comparison to CNAs (alternative nurse staffing) in fall prevention, decreased use of tube feeding, better range of motion for residents, and decreased aggressive

Journal of Nursing Scholarship, 2015; 47:6, 1–10. C 2015 Sigma Theta Tau International

behaviors in NHs in Korea. More research is required to confirm the effects of nurse staffing on residents’ outcomes. This study also contributes to the need for change in the quality of long-term care services for elders. By assessing nurse staffing levels and compositions of nursing staffs, this study contributes to more effective long-term care insurance by reflecting on appropriate policies, and ultimately contributes to the stable settlement of the long-term care insurance system for elders. This study improves the QOL for elders in need of government assistance and their family members, and contributes to improvements in the overall happiness level of elderly in NHs.

Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Science, Information Communication Technology & Future Planning (grant # 2-2014-1221-001-2).

Clinical Resources

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Center for Medicare and Medicaid: Find a nursing home: https://www.medicare.gov/nursinghome compare/search.html Korean National Health Insurance Corporation: Long term care insurance: http://longtermcare.or. kr/portal/site/nydev/

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Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web site: Table S1. Organizational Characteristics of 19 NHs. Table S2. Hours per Resident Day and Quality of Care. Table S3. Skill Mix and Quality of Care. Table S4. Turnover and Quality of Care.
