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Mandating specific levels of direct care nursing staff would seem to be a straightforward method to improve staffing in nursing facilities.  If more nursing staff are needed, why not simply require facilities to employ more nurses?  The strategy is far more complex, however, than it at first appears.  This paper reviews which states have tried this approach, what they have done, how they did it, and whether it worked.  It also considers unintended consequences of mandating staffing levels and continuing calls for use of this approach to improve nurse staffing levels.

Background/Early Research

In 2003, a report written for the Office of Disability, Aging and Long-Term Care Policy reported that 36 states had established minimum nurse staffing ratios.[1]  The descriptive, comparative report primarily focused on case studies of eight states – Arkansas, California, Delaware, Minnesota, Missouri, Ohio, Vermont, and Wisconsin – that had implemented or revised their rules or policies establishing minimum nurse staffing ratios since 1997.  The researchers identified “considerable variation across the study states in the type of ratio, measurement of the ratio, adjustment for case mix, monitoring and enforcement of the ratio, and payment for ratios.”[2] 

            Ratios’ structure

The 2003 report describes how states varied in their definition of staffing ratios

Three of the eight states set requirements using hours per resident day (HPRD); two states used a staff-to-resident ratio; and three states used both.[3] The nursing home industry typically supports ratios based on HPRD because they give facilities more flexibility and can more easily accommodate a facility’s physical structure “and local labor market conditions.”[4]  In contrast, advocates for residents and ombudsmen favor staff-to-resident ratios because they believe these ratios are easier to understand and monitor.

Two of the eight states – Arkansas and Delaware – had standards that varied with the time of day, responding to consumer concerns that nights and evenings are particularly short-staffed.

Two states – Minnesota and Wisconsin – adjusted their HPRD standards based on the resident case mix.

A second structural issue is “the time period over which ratios are calculated.”[5]  Vermont calculated ratios over a week’s time; other states used 24-hour periods in order “to ensure adequate staffing on all days, particularly weekends.”[6]

Whether states enacted separate ratios by nursing category (licensed [registered nurses and licensed practical nurses]) or by direct vs. indirect care workers was another difference among the eight states.  Only California treated temporary staff differently from permanent staff, requiring that temporary workers receive eight hours of orientation “before their hours can be counted toward the hprd.”[7]

            Monitoring and enforcing ratios

Most of the states monitored compliance with their staffing ratio requirements as part of annual licensing and certification surveys.  Surveyors reviewed “a sample of staff schedules, time sheets, or payroll records to determine facility compliance,” choosing either a random time period or the time immediately before the survey.[8]  Arkansas and Vermont reviewed monthly staffing data, which both states required facilities to submit outside the state survey process.  Vermont audited the monthly reports, comparing the reports with payroll records.[9]

The researchers had little information about the actual imposition of remedies at facilities that failed to meet their state’s ratio.[10]

State Data Collection

States collected data on staffing, but there was little consistency among states.

Although, most frequently, states’ data came from Medicaid cost reports, Wisconsin and Delaware used staffing data from annual surveys and Arkansas and Vermont used data from monthly staffing reports submitted by facilities.  California’s data, the most extensive in the eight states studied, merged “Medicaid cost reporting with a state public disclosure report.”[11]

California posted its staffing data, but provided no analysis.  Wisconsin produced an annual report “on staff levels, turnover, and retention [and deficiencies] and provide[d] average data for similarly sized facilities so that consumers can make relevant comparisons.”[12]  Vermont made data on wages and benefits available to the nursing home association.  The University of Missouri analyzed data from Medicaid cost reports and reported nursing staff hours per patient day.[13]

Outcomes Associated with Ratios

Although “[m]ost states have done little analysis to determine the outcome of their ratios, either with regard to the level of staffing or the effects on quality,” most staff officials believed that staffing levels increased as a result of their ratios.[14]  Data from California and Wisconsin supported the belief.  In 1999, 25% of California nursing facilities were staffed at or above 3.2 hprd; by 2001, the California Department of Health’s Licensing and Certification Program, reviewing a sample of 111 facilities, estimated that 67% staffed at or above 3.2 hprd.[15]  The Wisconsin Department of Health found that “the average hprd increased from 3.2 in 1998/1999 to 3.4 in 2002.”[16]  Staffing deficiencies also increased in Wisconsin during the same time period.

Residents’ advocates thought staffing ratios had not made a difference or that it was too soon to determine the impact of ratios, while facilities contended that most facilities already met the ratios.  Both advocates and facilities agreed that states’ ratios “serve as a minimum bar for facilities, not a standard that most need to strive to reach.”[17]  This fact was illustrated by Ohio.  The state set aside $13 million for fiscal year 2002 for facilities’ compliance, but only 19 facilities applied for the additional funding and only $1 million was spent.[18]

Staffing levels did not decline and quality of care did not change in Missouri nursing facilities when the state eliminated its staffing ratio.  Some suggested that staffing deficiencies were easier to cite in Missouri after the ratio was repealed “because it was easier to cite staffing problems under the federal standard of having ‘sufficient staff’ than under the old staff-to-resident ratio.”[19]  A contrary view is that specific numerical standards are easier to enforce.[20]

States that required staffing ratios by shift saw some change in how facilities were staffed, with staff moved from days to nights and weekends.[21]

Implementation Issues

Not surprisingly, implementation was more difficult in states that made more significant changes.  An example was Vermont, which began to require the monthly submission of uniform staffing data by facilities and periodic auditing.[22]

Implementation of staffing ratios was often accompanied by increases in Medicaid reimbursement to nursing facilities, with state budgetary problems leading to delays or indefinite postponements of implementation.[23]

The researchers were surprised by their finding that labor shortages for certified nurse assistants were not seen as a critical issue, but reported that the economic downturn in 2002 and 2003 “led to a larger labor supply for such entry-level positions.”[24]

Related Staffing Initiatives

States increased Medicaid reimbursement to facilities, often through a bed tax or quality improvement fee paid by, and then returned to, facilities.  Some states implemented wage pass-through legislation at the same time, but did not necessarily measure whether the funding was spent by facilities as intended.  States also implemented complementary programs to address staffing shortages.[25]

More Recent Studies

Two recent studies evaluate in additional depth the effects of various approaches to state requirements for staffing ratios.

Bowblis Analysis

An analysis by John R. Bowblis, published in 2011, looks at the impact of minimum direct care staffing (MDCS) requirements on (1) nurse staffing levels, (2) nurse skill mix (i.e., proportion of registered nurses [RNs], licensed practical nurses [LPNs], and certified nurse assistants [CNAs]), and (3) quality (i.e., care practice measures, outcome quality measures, and regulatory deficiencies) in nursing facilities nationwide between 1999 and 2004.[26]  The findings are complex, nuanced, and inconsistent.

            Nurse staffing levels

Bowblis reports, “As expected, higher MDCS requirements increase the total amount of staff in a nursing home.”[27]  In particular, nursing facilities that rely heavily on Medicaid “have larger increases in their staffing.”[28] 

            Nurse skill mix

“MDCS requirements are associated with using more RNS but fewer licensed staff, although the result for licensed staff is not statistically significant.”[29]  However, the impact of MDCS on skill mix depends on how much a nursing facility relied on Medicaid.  Facilities that rely heavily on Medicaid increase their RN staffing levels as a result of MDCS requirements.  Facilities relying less heavily on Medicaid reduce their licensed staff, but keep the same proportion of RNs.[30] 

Bowblis offers a possible explanation for these findings:

[N]ursing homes that are less reliant on Medicaid are required to increase staffing but cannot increase non-Medicaid reimbursement to offset the cost of this staff.  It may be more cost-effective for the low Medicaid reliant nursing homes to meet staffing requirements by hiring CNAs compared with licensed nurses.[31]


With respect to care practices, the results are mixed.

  • Physical restraints: “Higher MDCS requirements are associated with fewer residents being physically restrained, but more residents acquiring the physical restraints at the facility.”[32]  The extent of a facility’s reliance on Medicaid does not affect the use of physical restraints.
  • Catheters: “MDCS requirements [are] associated with more catheter use but . . . [there was] no statistically significant effect on facility-acquired catheters.”[33]  Facilities that rely more heavily on Medicaid use catheters less often.
  • Antipsychotic medications: “Antipsychotic medication use is higher in facilities with higher MDCS requirements.”[34]  Facilities that rely more heavily on Medicaid use antipsychotic drugs more often.

With respect to quality measures, the effects of MDCS are also mixed (and in surprising ways).

  • Facility-acquired pressure ulcers and rashes: “Higher MDCS requirements are associated with fewer facility-acquired pressure ulcers and rashes.”[35]
  • Bowel incontinence: Higher MDCS requirements are associated with higher rates of bowel incontinence.[36]
  • “For four of the six quality measures, nursing homes with more reliance on Medicaid show improvements in quality relative to those less reliant on Medicaid.”[37]

With respect to deficiencies:

  • “Higher MDCS requirements are associated with fewer deficiencies and a lower probability of receiving a specific deficiency.”[38]  Nursing facilities relying more heavily on Medicaid have more total deficiencies.

Bowblis concludes, “MDCS requirements improve quality in terms of resident health outcomes and meeting federal standards for all nursing homes regardless of reliance on Medicaid.[39]

Chen and Grabowski analysis

Min M. Chen and David C. Grabowski conducted an in-depth analysis of the impact of minimum staffing standards that in California and Ohio, which changed their requirements for staffing in 2000 and 2002, respectively.[40]

In 2000, California amended its law both to raise the minimum nursing staff requirement from 3.0 to 3.2 hours of direct resident care per day and to eliminate the prior policy of allowing RN or LPN hours to be counted double toward meeting the staffing standard.  In 2002, Ohio increased its minimum total direct care hours from 1.6 to 2.75.  The researchers describe as “remarkable” the fact that both states’ laws gave “the same weight to RN, LPN, and CNA hours.”[41]

Analyzing data from 1996 to 2006, the researchers found

  • Total nursing hours per resident (HPRD) increased by about 5%.[42]
  • The impact of state staffing standards on direct care staffing continued even after the standards had been in place for three or more years.[43]
  • Individual facilities’ response to new staffing standards depended on “their initial staffing level and the market competitiveness.”[44]  Facilities in the bottom quartile of staffing increased their staffing at all levels (RN, LPN, CNA), while facilities in the top quartile of staffing saw no change in RN or LPN staffing and a decrease in CNA staffing.  Facilities in the bottom quartile of staffing in the most competitive markets increased their LPN and NA staffing “significantly” while facilities in the least competitive markets “saw no impact on all three types of nursing staff.”[45]
  • With respect to skill mix, however, RN HPRD decreased, while LPN and CNA HPRD increased.[46]
  • With respect to deficiencies, the number of cited deficiencies increased from 7.9 to 8.6 after staffing standards were implemented, although “the percentage of nursing homes with a severe deficiency decreased by 60%.”[47]
  • Increasing nurse staffing requirements resulted in a decrease in HPRD for indirect staff (housekeeping, food service, activities).[48]
  • “Nursing homes that initially ranked in the top quartile of total staffing had the largest decrease in support staff HPRD.  Moreover, nursing homes with greater market power on average reduced their support staff HPRD more.”[49]
  • Increasing nurse staffing requirements was correlated with fewer resident contractures, “but other quality measures (physical restraints, antipsychotic medications, pressure ulcers, and catheters) remained unchanged.”[50]

The researchers describe the “multitasking problem” – that is, regulators have “multidimensional” goals “and not all dimensions are regulated.”[51]  Application of that economics term here means that nurse staffing laws address nurse staffing, but also have an effect on the non-regulated area of indirect staff.  (The decrease in indirect staff could affects residents’ quality of life.)[52]  The researchers suggest that wage pass-through legislation attempts to avoid the multitasking problem, but such legislation has its own implementation problems.[53]

Continued Call for Increasing Minimum Staffing Standards

A 2016 Commentary by Charlene Harrington, John F. Schnelle, Margaret McGregor, and Sandra F. Simmons calls for higher minimum staffing standards.[54]  Citing such factors as the correlation of high nurse staffing levels and high quality of care, experts’ recommendations, the fact that staffing levels are too low in nursing facilities, and barriers to reform (interest in controlling health care spending, insufficient enforcement of regulatory standards, and political influences), they recommend “the need for higher U.S. minimum nurse staffing standards, adjusted for resident acuity, to ensure adequate quality of nursing home care as a necessary precondition for making other quality improvements such as in leadership, management, and training.”[55]


Minimum staffing laws and regulations are complex and their implementation may have serious unintended consequences, such as the substitution of less skilled nurses for RNs and the reduction of indirect care staff.  Two obvious modifications of these laws to correct for these concerns are specifying staff by skill mix and enacting standards for indirect care staff.


Toby S. Edelman
March 14, 2017







[1] Jane Tilly, Kirstein Black, Barbara Ormond, The Urban Institute, State Experiences with Minimum Nursing Staff Ratios for Nursing Facilities: Findings from Case Studies of Eight States (Nov. 2003),
[2] Id. v.
[3] Id. 9.
[4] Id. 10.
[5] Id. 10. 
[6] Id. 10.
[7] Id. 11.
[8] Id. 11.
[9] Id. 11.
[10] Id. 12.
[11] Id. 12.
[12] Id. 12.
[13] Id. 12-13.
[14] Id. 13.
[15] Id.
[16] Id.
[17] Id.
[18] Id. 17.
[19] Id. 13.
[20] Id. 16.
[21] Id. 14.
[22] Id.
[23] Id.
[24] Id.
[25] Id. 15.
[26] John Bowblis, “Staffing Ratios and Quality: An Analysis of Minimum Direct Care Staffing Requirements for Nursing Homes,” Health Services Research 2011 Oct.; 46(5): 1495-1516,
[27] Id. 1507.
[28] Id.
[29] Id.
[30] Id. 1507.
[31] Id. 1513.
[32] Id. 1512.
[33] Id.
[34] Id.
[35] Id.
[36] Id.
[37] Id.
[38] Id. 1512.
[39] Id. 1514.
[40] Min M. Chen, David C. Grabowski, “Intended and Unintended Consequences of Minimum Staffing Standards for Nursing Homes,” Health Economics, Vol. 24, No. 7, pages 822-839 (July 2015),;jsessionid=D1C94F93FE069B7A5AAC7C44F6C202D6.f02t01 (abstract).
[41] Id. 824.
[42] Id. 823.
[43] Id. 832.
[44] Id. 833.
[45] Id.
[46] Id. 832.
[47] Id. 832.
[48] Id. 834 and 834 Table IV.
[49] Id. 834.
[50] Id. 835.
[51] Id. 836.
[52] Id. 836.
[53] Id. 837.
[54] Charlene Harrington, John F. Schnelle, Margaret McGregor, Sandra F. Simmons, “The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes,” Health Services Insights 2016:9 13-19,
[55] Id. 17.

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