1. 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

2. 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)

3. 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.

4. 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.

5. 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.

6. 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.

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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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
-1.724
.085
Total percentage of PUs
258.21
236.67
-1.642
.101 FP
6172
4234
10406
-7.479
.000
6171
10405
-7.533

16. 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

17. 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
-2.172
.030
Total percentage of PUs
258.09
242.55
-.886
.376 FP
2454
7952
10406
-6.154
.000
7951
10405
-.998
.318

18. 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.

19. 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

20. 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.

21. 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

22. 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

23. 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).

24. 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.

25. The Ultimate Goal

26. QUESTIONS