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 Dutch Researchers Question Notion that More Nurses Mean Better Care

Dutch researchers are questioning the notion that more nurses equal better quality of care for long term and post-acute care residents.
Reviewing more than a decade’s worth of longitudinal studies on the correlation between nurse staffing and care quality, Maastricht University professor Romona Backhaus and her colleagues say they’ve found “no consistent evidence for a positive relationship between nurse staffing and QofC,” or quality of care.
“Our less-positive and unexpected result can partly be explained by the fact that we included only longitudinal studies,” Backhaus says. “In general, cross-sectional study designs, as included in the previous reviews, lead to more positive findings.”

Cross-sectional studies often offer just a snapshot, Backhaus argues, whereas longitudinal studies offer a deeper look of what’s happening long term. 
The inconsistencies were across the board, Backhaus and her colleagues found. For instance, one study in their review found that higher nurse staffing levels decreased hospitalizations, while three others found that higher staffing levels had no impact on hospitalizations. Previous researchers have also been split on whether more nurses mean fewer instances of the use of restraints, or more; four studies found that having more nurses meant fewer pressure ulcers, while another found that more nurses meant more pressure ulcers; other studies have shown that having more nurses either doesn’t change the level of help they provide with activities of daily living or that they actually provide less, Backhaus says in the latest issue of the Journal of the American Medical Directors Association.
Backhaus and her colleagues don’t say that more nurses are bad. But they do say that the research on the relationship between nurse staffing and quality has been wanting. Part of the problem, they say, is that researchers don’t understand the complex interplay involved in quality care, and instead assume that inputs have a direct line to outcomes.
“First, most studies hypothesized a linear relationship between nurse staffing and QofC outcomes, assuming that more staff would lead to better QofC outcomes,” Backhaus says. “As the relationship is probably nonlinear… this could be an explanation for the lack of effect.”
Further, researchers will have to be more careful in how they select quality measures because each category “only serves as a proxy for overall” quality, Backhaus says. 
“Further research is needed before firm conclusions can be drawn,” Backhaus writes. “To deepen our insight into the impact of nurse staffing on QofC in nursing homes, future studies should consider characteristics beyond those of quanty of care provided.”
In the same issue of the journal where Backhaus publishes her team’s findings, Indiana University Professor Greg Arling and University of Minnesota Professor Christine Mueller wonder whether the profession is “posing the wrong question.”
“Further research focused narrowly on the relationship between staffing and quality, with all its conceptual dimensions, is unlikely to give us a definitive answer,” they say. “Shouldn’t we be asking: How can we achieve better-quality nursing home care? And, how does the construct of staffing contribute to this goal?”
Bill Myers is Provider’s senior editor. E-mail him at Follow him on Twitter, @ProviderMyers.

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