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Int J Nurs Stud. 2014 Mar;51(3):409-17. doi: 10.1016/j.ijnurstu.2013.10.007. Epub 2013 Oct 14.

The effects of RN staffing hours on nursing home quality: a two-stage model.

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College of Nursing, Eulji University, 771-77 Gyeryong-ro, Jung-gu, Daejeon, South Korea. Electronic address:
Department of Community Health Systems, University of California, San Francisco, 2 Koret Way, San Francisco, CA 94143-0608, United States. Electronic address:
Department of Social and Behavioral Sciences, University of California, San Francisco, 3333 California Street, Suite 455, San Francisco, CA 94118-0612, United States. Electronic address:



Based on structure-process-outcome approach, this study examined the association of registered nurse (RN) staffing hours and five quality indicators, including two process measures (catheter use and antipsychotic drug use) and three outcome measures (pressure ulcers, urinary tract infections, and weight loss).


We used data on resident assessments, RN staffing, organizational characteristics, and market factors to examine the quality of 195 nursing homes operating in a rural state of United States - Colorado.


Two-stage least squares regression models were performed to address the endogenous relationships between RN staffing and the outcome-related quality indicators, and ordinary least squares regression was used for the process-related ones. This analysis focused on the relationship of RN staffing to nursing home quality indicators, controlling for organizational characteristics, resources, resident casemix, and market factors with clustering to control for geographical differences.


Higher RN hours were associated with fewer pressure ulcers, but RN hours were not related to the other quality indicators.


The study finding shows the importance of understanding the role of 'nurse staffing' under nursing home care, as well as the significance of associated/contextual factors with nursing home quality even in a small rural state.


Nurse staffing; Nursing home quality; Nursing home staffing; Nursing homes; Quality indicators; Quality of care

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