Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach

Abstract

This paper revisits the relationship between nurse staffing and quality of care in nursing homes using an instrumental variables approach. Most prior studies rely on cross-sectional evidence, which renders causal inference problematic and policy recommendations inappropriate. We exploit legislation changes regarding minimum staffing requirements in eight states between 2000 and 2001 as exogenous shocks to nurse staffing levels. We find that registered nurse staffing has a large and significant impact on quality of care, and that there is no evidence of a significant association between nurse aide staffing and quality of care. A comparison of the IV estimation to the OLS estimation of the first-difference model suggests that ignoring endogeneity would lead to an underestimation of how nurse staffing affects quality of care in nursing homes.

Influence of workplace incivility on the quality of nursing care

“…This descriptive and cross‐sectional investigation was designed to examine the influence of WPI on the QNC scale in two hospitals in Saudi Arabia. In this study, nurses perceived their QNC to be moderate, which is lower than the findings of the previous study conducted amongst Mongolian (Gaalan, Kunaviktikul, Akkadechanunt, Wichaikhum, & Turale, ), American (Lin, ) and Belgian (Van Bogaert, Kowalski, Weeks, Van heusden, & Clarke, ) nurses but slightly higher than that of Iranian nurses (Khaki, Esmaeilpourzanjani, & Mashouf, ). Nurses from different countries are likely to have different views on QNC because of differences in cultural backgrounds and perceptions of the characteristics of care.…”

Staffing subsidies and the quality of care in nursing homes

“…State policy and local nursing home market information are then merged into the facility level data. State policy, such as the presence of a wage pass-through policy, minimum nurse staffing requirements, average Medicaid reimbursement rates, and the use of case-mix reimbursement, were collected from surveys of state Medicaid offices conducted by Brown University’s Community Health Department and the literature that examines minimum staffing laws (Bowblis 2011, Lin 2014). Lastly, the Bureau of Health Professions’ county-level Area Resource File provides local nursing home market characteristics.…”

“…Many states enacted or increased minimum nurse staffing requirements during our study period. Bowblis (2011) and Lin (2014) find that CNA hours increase with minimum staffing requirements. Given the similar timing of the two policies, controlling for state minimum staffing requirements will be crucial to correctly identify the wage pass-through effect.…”

The effect of political control on financial performance, structure, and outcomes of US nursing homes

“…Laws on state level (a) may influence financial performance of NHs, for example, through changes in Medicaid reimbursement rates, (b) may affect the resident composition, for example, by changing the Medicaid eligibility criteria, or (c) may have an impact on the outcomes, for example, through public reporting. The literature shows that NHs react to regulatory changes with changes in their resident mix, staff structure, or resident outcomes . While we can observe the political control of the House and the Senate and the effects on NHs, we are often not able to observe and disentangle the multitude of different measures that are enacted simultaneously by the legislature (see Figure ).…”