Nurse Staffing Standards and Quality of Care Outcomes in For-Profit and Not-For-Profit Religious-Based Nursing Homes Omotayo O. Omotowa, PhD Idaho State University College of Nursing

Introduction: Overview & Background of Topic Nurse staffing levels in nursing homes (NHs)-a concern The 1987 Nursing Home Reform Act (NHRA) Lack of adherence to nurse staffing standards Insufficient nurse staffing levels Poor NHs health care outcomes Poorer outcomes in for-profit NHs Source: Rankasky Law Firm. (n.d)

Problem Statement Lack of adherence to staffing standards results in occurrences of staffing related health deficiencies. Quality of care for more than 1.4 million older adult nursing homes residents continues to lag behind the expected quality care indicators (Castle & Fergusson, 2010; CMS, 2016; Shin, 2013). Optimal or poor care outcomes and safety in nursing homes were related to adequate nursing staffing hours or its lack thereof (Lee, Blegen, & Harrington, 2014; Lin, 2014). Poor care outcomes included pressure ulcers and falls.

Purpose of the Study Determine and compare the relationship between adherence to government staffing standards and care outcomes in for-profit and not-for-profit religious-based NHs. Examine the impact of profit maximization on adherence to staffing standards. Examine the impact of profit maximization on pressure ulcers and falls.

Research Question & Hypothesis What is the relationship of profit maximization between adherence to nurse minimum staffing standards and quality of care outcomes in for-profit and not-for-profit religious-based nursing homes? H1: There is a relationship between adherence to nurse minimum staffing standards and quality of care outcomes in for-profit and not-for-profit religious-based nursing homes and profit maximization. H0: There is no relationship between adherence to nurse minimum staffing standards and quality of care outcomes in for-profit and not-for-profit religious-based and profit maximization.

Theoretical framework Profit maximization theory/model (PMT). Marginal cost of production/improvement equals the marginal gain (Aaronson et al., 1994; Alhabeeb & Moffitti, 2013; O’Boyle, 2012).  A decision making tool in normative microeconomics (Alhabeeb & Moffitti, 2013; Simon, 1959). Focuses on economic behavior of maximizing economic utility and profits while minimizing costs (Alhabeeb & Moffitti, 2013; Simon, 1959). Firms exist to make and maximize profits for the owners and shareholders.

Illustration of PMT and Study Variables + - Profit Maximization - LN and RN Nursing Hours Pressure Ulcer Falls - + Adherence to Staffing Standards

Research Method/Design Correlational, cross-sectional quantitative method Archival public data Descriptive and inferential statistics Setting and Sample Target population-older adults ages 65 and above Unit of analysis-Nursing homes (NHs) Sampling frame: 15,662 (total NHs), 10,895 (69.6%) for-profit NHs; 561 (3.6%) not-for-profit religious-based NHs (CMS, 2017). 10,525 (96%) FP and 497 (89%) NFPRB NHs.

Frequency Table: Nursing Homes NH types Frequency Percent Valid percent Cum. Percent Not-for-profit religious –based nursing homes   497 4.5 For-profit nursing homes 10525 95.5 100.0 Total 11022 NH types Frequency Percent Valid percent Cum. Percent Not-for-profit religious –based nursing homes   497 4.5 For-profit nursing homes 10525 95.5 100.0 Total 11022

Research Method/Design Data Collection: Secondary Sources Nursing Home Compare (NHC) datasets. Certification and Survey Provider Enhanced Reporting (CASPER)-staffing, providers, and health surveys outcomes Minimum Data Set (MDS) 3.0-quality measures Medicare Cost Report (MCR)-profit measures Data Analysis Statistical Package for the Social Sciences (SPSS) Descriptive and inferential statistics Nonparametric test

Definition of Key Terms Staffing Standards NHRA (1987)-0.08 RN and 0.30 LN Hours Per Resident Day Hour Per Resident Day-0.75 RN and 1.30 LN (CMS) Profit maximization Patient profit margins Total operating profit margins

Definition of Key Terms cont’d Pressure ulcers/injuries (PUs) Total average percentage of long-stay high-risk residents with stages II-IV PUs Falls Total average percentage of long-stay residents with one/more falls Major injuries

Definition of Key Terms cont’d For-profit nursing homes Publicly-owned by investors/shareholders Operated to make and maximize profits (Grabowski et al., 2013; Harrington et al., 2014, 2015). Not-for-profit religious-based nursing homes Non-profit, non-governmentally owned by religious, community groups, or agencies (Ronald, McGregor, Harrington, Pollock, & Lexchin, 2016). No defined shareholders, exist to provide value based services (Harrington et al., 2012, 2014; Paul III et al., 2016)

Results Staffing Standards and Profits/Falls/Pressure Ulcers For-profit nursing homes Increased falls with RN/LN standards violation; pressure ulcers with RN standards violation Increased pressure ulcers with LN standard compliance Statistical significance differences in outcomes. Non-statistical significance between LN standard and pressure ulcers Increased patient and total profit margins with standards violation

RN Staffing Standards and Care Outcomes NH Types D. Variables RN staffing standard N Mean Rank Mann-Whitney U Z Asymp. Sig (2-sided) NFPRB Total percentage of falls Not met standard 189 258.87   Yes met standard 300 236.26 Total 489 Test statistics 25728.00 -1.724 .085 Total percentage of PUs 258.21 236.67 25852.50 -1.642 .101 FP 6172 5385.88 4234 4937.65 10406 11940495.50 -7.479 .000 6171 5386.75 4935.19 10405 11930094.00 -7.533

Results Cont’d Staffing Standards and Profits/Falls/Pressure Ulcers Not-for-profit religious-based nursing homes Increased falls and pressure ulcers with standards violation Non-statistical significance differences in outcomes; except for LN and falls Increased patient profit margin with standards violation Decreased total profit margin with standards violation

LN Staffing Standards and Care Outcomes NH Types D. Variables LN Staffing Standard N Mean Rank Mann-Whitney U Z Asymp. Sig (2-sided) NFPRB Total percentage of falls Not met standard 77 277.10   Yes met standard 412 239.00 Total 489 Test statistics 13390.50 -2.172 .030 Total percentage of PUs 258.09 242.55 14854.00 -.886 .376 FP 2454 5529.68 7952 5102.84 10406 8956652.50 -6.154 .000 5150.12 7951 5219.32 10405 9626103.50 -.998 .318

Results Cont’d Profits and Care Outcomes Among the NFPRB nursing homes: Negative statistically significant relationships between profits and pressure ulcers. Non-statistically significant relationship between profits and falls. Among the FP nursing homes: Negative statistically significant relationship between profits and pressure ulcers/falls.

Spearman’s Correlation: Patient and Total Profit Margins, PUs, and Falls   Variables PUs Falls NFPRB NHs PPM Correlation coefficient -.119 .074 sig. (2-tailed) .040 .203 N 299 TPM -.138 .027 .017 .640 FP NHs -.040 -.050 .000 8498 8500 -.047 -.062

Results Cont’d Profits and Staffing Standards Among the NFPRB nursing homes: Non-significant relationships between profit measures and staffing standards. Among the FP nursing homes: Significant relationship between the patient profit margin and RN/LN staffing standards. Significant relationship between total profit margin and LN staffing standard. Non-significant relationships between the total profit margin and RN standard.

Binary Logistic Regression for Profits and Staffing Standards by NH Types D. Variables Regression Coefficients   B df Sig Exp(B) NFPRB NHs LN Standard PPM .000 1 .250 1.000 TPM .420 RN Standard .648 .234 FP NHs .001 .054

Significance of the Study Uniqueness to the study of nurse staffing standards/levels Rarity of focus Rarity of theoretical foundation Contribution to knowledge in geriatric nursing Practice/curriculum policy change Moral basis for adequate NHs staffing Contributions to positive social change advocacy instrument for the vulnerable Morally appropriate Evidence base for public policy making Reduced health care cost

Significance of the Study Better care experience Improved quality of life Decreased adverse events Reduced death rates Improved management quality scores Nursing homes marketability Positive public perception Source: Mira Dental Services. (2015).

Conclusion Older adult residents in all Medicare and Medicaid NHs deserve optimal quality of care. Pressure ulcers and falls are staffing related, costly, potentially deadly, but avoidable. Adequate staffing standards/levels must be ensured to safeguard the wellbeing of this frail and vulnerable population. Quality of care and maximization of profits. Nursing homes older adults must not be treated like economic commodities. Strict enforcement of nurse staffing adherence.

The Ultimate Goal

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