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State-level minimum nurse staffing requirements for nursing homes

Health Factors: Quality of Care
Decision Makers: Local Government State Government Federal Government Healthcare Professionals & Advocates Public Health Professionals & Advocates
Evidence Rating: Expert Opinion
Population Reach: 1-9% of WI's population
Impact on Disparities: No impact on disparities likely

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Minimum staffing requirements for nursing homes are state level regulations that require nursing homes to employ at least a set number of licensed and non-licensed nursing staff. Often set in terms of staff hours per resident day, requirements may be influenced by patient mix and acuity and may apply to registered nurses (RNs), licensed practical/vocational nurses (LPN/LVNs), or certified nursing assistants (CNAs) and other nurse’s aides (NAs). Federal law provides baseline requirements; many states have higher standards.

Expected Beneficial Outcomes

Improved quality of care
Increased staffing levels in nursing homes

Evidence of Effectiveness

Minimum nurse staffing requirements are a suggested strategy to improve quality of care for nursing home patients (IOM-Page 2003). Additional evidence is needed to confirm effects.

Overall, minimum nurse staffing requirements increase staffing levels at nursing homes. A nationwide study of minimum direct care staffing requirements from 1999 to 2004 indicates that mandated staffing levels increase staffing, particularly at homes reliant on Medicaid (Bowblis 2011). A study of states that implemented new standards between 1998 and 2000 indicates that such mandates only affect facilities that have low staffing levels when standards are introduced (Park 2009). Studies of individual states yield similar results: Ohio and California’s requirements appear to have increased the amount of direct care provided to patients in homes with low staffing, mainly through hiring a greater number of CNAs (Chen 2015, Matsudaira 2014) and LPNs, though some homes with high levels of staff decreased staffing levels (Chen 2015).

Research examining nursing home staffing levels and quality measures indicates a small positive association (Spilsbury 2011) or no association between staffing levels and performance (Backhaus 2014). This may be due to research designs that do not account for other important factors that can affect quality of care, such as the training and experience of staff, turnover, and use of contracted, temporary (agency) staff (Spilsbury 2011). Effects on quality may also vary by case and skill mix (Cohen 1996). For example, one study suggests that increasing the number of RNs can increase quality of care but increasing nurse aides does not (Lin 2014); another study suggests increasing CNAs can benefit quality (Tong 2011). Some studies indicate that increasing state minimum staffing standards may be associated with improvements in some quality indicators, such as regulatory deficiencies in annual inspections, but not improvements in other measures (Chen 2015, Bowblis 2011, Park 2009), and another study found no quality improvements (Matsudaira 2014).

Increases in minimum nurse staffing may lead to decreases in profitability for nursing homes dependent on Medicaid (Bowblis 2015), and may lead to reductions in other, non-nursing services such as housekeeping, food service, and activities (Chen 2015, Bowblis 2013).


United States

Federal standards require certified nursing homes that provide Medicare and Medicaid services to have a full-time director of nursing (DON), an RN on duty for 8 consecutive hours 7 days a week (this may be the DON), and one RN and licensed nurse (either an RN or LVN/LPN) for the two remaining shifts. While other numbers are not specified, standards require adequate staffing levels to meet the needs of the residents to attain or maintain the highest practicable levels of physical, mental, and psychosocial well-being (CMS 2015). For example, when homes are rated using CMS’s Five-Star Quality Rating System, nursing homes with residents with more severe needs are expected to have higher staffing levels than facilities with less severe resident needs (CMS-5 star).

In 2014, there were approximately 15,600 nursing homes in the US serving 1.4 million residents, with an average total of 3.88 nursing hours per resident day: 1.41 nursing hours per resident day by licensed nurses (RNs, LPNs/LVNs) and 2.47 nursing hours per resident day by nurse’s aides (CDC-NCHS-Harris-Kojetin 2016).


Wisconsin statute requires minimum staffing levels based on resident needs. For each resident in need of intermediate or limited nursing care, 2.0 hours per day are required, with a minimum of 0.4 hour provided by an RN or LPN. For each resident in need of skilled nursing care, 2.5 hours per day are required, with a minimum of 0.5 hour provided by an RN or LPN. For each resident in need of intensive skilled nursing care, 3.25 hours per day are required, with a minimum of 0.65 hour provided by an RN or LPN (WI Statute 50.04).

Citations - Evidence

Backhaus 2014* - Backhaus R, Verbeek H, van Rossum E, Capezuti E, Hamers JPH. Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies. Journal of the American Medical Directors Association. 2014;15(6):383-93. Accessed on January 26, 2016
Bowblis 2011 - Bowblis JR. Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Services Research. 2011;46(5):1495-516. Accessed on January 26, 2016
Bowblis 2013 - Bowblis JR, Hyer K. Nursing home staffing requirements and input substitution: Effects on housekeeping, food service, and activities staff. Health Services Research. 2013;48(4):1539-1550. Accessed on April 28, 2016
Bowblis 2015* - Bowblis JR. The cost of regulation: More stringent staff regulations and nursing home financial performance. Journal of Regulatory Economics. 2015;47(3):325–338. Accessed on April 28, 2016
Chen 2015* - Chen MM, Grabowski DC. Intended and unintended consequences of minimum staffing standards for nursing homes. Health Economics. 2015;24(7):822–839. Accessed on April 28, 2016
Cohen 1996* - Cohen JW, Spector WD. The effect of Medicaid reimbursement on quality of care in nursing homes. Journal of Health Economics. 1996;15(1):23–48. Accessed on April 28, 2016
IOM-Page 2003 - Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Keeping patients safe: Transforming the work environment of nurses. Page A, ed. Washington DC: Institute of Medicine (IOM) of the National Academies. 2003. Accessed on February 23, 2018
Lin 2014* - Lin H. Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach. Journal of Health Economics. 2014;37(1):13-24. Accessed on April 28, 2016
Matsudaira 2014* - Matsudaira JD. Government regulation and the quality of healthcare: Evidence from minimum staffing legislation for nursing homes. The Journal of Human Resources. 2014;49(1):32–72. Accessed on April 28, 2016
Park 2009 - Park J, Stearns SC. Effects of state minimum staffing standards on nursing home staffing and quality of care. Health Services Research. 2009;44(1):56-78. Accessed on January 26, 2016
Spilsbury 2011* - Spilsbury K, Hewitt C, Stirk L, Bowman C. The relationship between nurse staffing and quality of care in nursing homes: A systematic review. International Journal of Nursing Studies. 2011;48(6):732-50. Accessed on January 26, 2016
Tong 2011* - Tong PK. The effects of California minimum nurse staffing laws on nurse labor and patient mortality in skilled nursing facilities. Health Economics. 2011;20(7):802–816. Accessed on April 28, 2016

Citations - Implementation

CDC-NCHS-Harris-Kojetin 2016 - Harris-Kojetin L, Sengupta M, Park-Lee E, et al. Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 2013–2014. National Center for Health Statistics (NCHS). Vital Health Statistics. 2016;3(38). Accessed on April 28, 2016
CMS 2015 - Centers for Medicare and Medicaid Services. State operations manual: Appendix PP - Guidance to surveyors for long term care facilities. 2015;10(c):10-14. Accessed on April 28, 2016
CMS-5 star - Centers for Medicare & Medicaid Services (CMS). Five-star quality rating system. Accessed on January 26, 2016
WI Statute 50.04 - Wisconsin State Legislature. WI Statute 50.04: Special provisions applying to licensing and regulation of nursing homes. Accessed on January 26, 2016

Page Last Updated

April 29, 2016

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