The Effects of Staffing on In-Bed Times of Nursing Home Residents
Bates-Jensen BM, Schnelle JF, Alessi CA, Al-Samarrai NR and Levy-Storms L;
Commented by , 28 Jul 2004
Objectives
To examine the effect of staffing levels on time spent in bed during the daytime in nursing home residents.
Objectives/Background Information
Some nursing home residents spend excessive time in bed; this is known to be associated with increased morbidity (pressure ulcers, pneumonia, under-nutrition, incontinence, depression) and mortality. There has been little research or practice guidelines on how much time nursing home residents should spend out of bed, though nursing interventions such as feeding, toileting and exercise are known to be easier if the resident is out of bed. This study sought to collect cross-sectional data on residents’ activity, and correlate it with staffing levels in a large number of nursing homes in California.
Method
88 nursing homes in California were contacted, 34 agreed to participate. All 2,651 residents in these 34 homes were approached, 973 (or their representative) provided written informed consent. 91 did not complete because of death, transfer or hospitalisation.
Cross-sectional data was obtained on demographics, hourly observation (in or out of bed; asleep or awake), meal time observation, resident interview (including assessment of depression and chronic pain), medical record review, and physical performance tests for about 800 residents. The primary outcome measure was percentage of hourly observations in bed.
All participating nursing homes were divided into two groups based on staffing (licensed and non-licensed nurses) levels according to cost reports and direct interviews with nursing staff. One group had an average of 10 residents/nurse/shift, the other an average of 7.6 residents/nurse/shift.
The data was analysed by multivariate analysis using logistic regression.
Results
71 % of participants were female, with a mean age of 81 years. There were few differences between high and low staffed homes in terms of residents’ physical disability, though residents in the high staffing group were more likely to be female, Caucasian, older, and more cognitively impaired.
The main finding was that participants with more than 50 % observations in bed consumed less food and fluids, experienced less social engagement, and were asleep in the daytime more often than participants spending less time in bed. Staffing level was the strongest predictor of time observed in bed after controlling for resident functional measures.
Discussion
The authors produced data that suggests participating homes were no, or little, different from none-participating homes, and conclude that the results are generalisable.
The authors are mainly academic nurses, but include one doctor. Their group has previously reported that having high nursing staff levels correlates with spending less time in bed; conversely they now report lower staffing levels correlates with spending more time in bed. Residents in lower-staffed homes were nearly six times more likely to have more than 50 % observations in bed than residents in high-staffed homes.
Decisions about the amount of time residents spend in bed must take into account medical conditions and resident preferences. However, most individuals would find it unacceptable if residents are being kept in bed for long periods as it is easier for over-stretched nursing staff to keep them there, which is my interpretation of this study.
Caring well for multiply disabled individuals in the latter stages of their lives is a great challenge for nursing and other disciplines. This study lends support to the self evident notion that to deliver care well requires enough staff, both trained and untrained. Time spent out of bed may be a good indicator of quality of care for licensing authorities.