Introduction

Older adults who reside in our nation's nursing homes deserve the best care nursing can offer. The reality, unfortunately, is that although nursing homes are settings that bear our professional name, they are sadly constrained in the delivery of our care. At issue is long-standing low nurse staffing levels that are pervasive in most nursing homes (Dellefield et al., 2015). The public is aware of this staffing crisis due to the widely publicized and tragic events that unfolded during the coronavirus disease 2019 pandemic. Public outrage sparked calls for reform, including higher staffing levels (National Academies of Sciences, Engineering, and Medicine, 2022). In addition, President Biden made a campaign promise to improve conditions in nursing homes, and on September 1, 2023, the Centers for Medicare & Medicaid Services (CMS) released a highly anticipated proposed rule entitled, “Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting.”

The CMS rule has three core staffing components:

1) minimum nurse staffing standards of 0.55 hours per resident day (HPRD) for Registered Nurses (RNs) and 2.45 HPRD for Nurse Aides (NAs); 2) a requirement to have an RN onsite 24 hours a day, seven days a week; and 3) enhanced facility assessment requirements.

(CMS, 2023, para. 3)

It is our belief that the proposed rule, specifically the staffing standards, does not go far enough to meet the complex care needs of nursing home residents and more is needed to improve the work environment to attract and retain sufficient numbers of professional nurses. Based on years of experience (Harrington et al., 2016; Kolanowski et al., 2021) and empirical evidence (Backhaus et al., 2014; Castle, 2008; Harrington et al., 2020; Horn et al., 2005; White et al., 2019), including a 2023 Abt study commissioned by CMS (Abt Associates, 2023), we argue for a minimum of 4.2 total nursing HPRD to include: (a) 1.4 total licensed nurses HPRD including at least 0.75 RN HPRD along with licensed practical nurses, and (b) 2.8 total NAs HPRD.

In the spirit of transparency, not everyone, including nurses, agrees with our position or, indeed, the CMS proposed rules. One of the biggest concerns is whether a sufficient workforce will be available when those requirements go into effect. More is needed to recruit and retain RNs in nursing homes, but this is a complex issue that will require time and investment from key constituents. Before we discuss what the nursing profession can do to address this critical shortage, we briefly outline some of the responsibilities of the nursing home industry, that if adequately addressed, will complement the efforts of other groups. We contend that the issue is less about lack of RNs than it is about lack of quality jobs.

First, nursing homes need to ensure parity wages with hospitals. Currently RNs working in nursing homes receive 15% less compensation than RNs in hospitals (U.S. Bureau of Labor Statistics, 2022). This wage gap is a long-standing deterrent to recruitment and retention that calls for greater transparency in how funds providers receive for care are spent. In a letter to CMS, 103 members of the House of Representatives echoed our concern and stated that lifting the veil on spending is necessary “to ensure taxpayers have a more complete accounting of how their hard-earned dollars are used…on direct compensation of care workers and support staff ” (Congress of the United States, 2023, p. 4; Henreckson, 2023). Second, the quality of the work environment has a direct influence on RN recruitment and retention (White et al., 2019). A concerted effort on the part of administrators and nursing home owners to improve the quality of the work environment can bring a significant return on investment. The American Nurses Credentialing Center (n.d.) Pathway to Excellence in Long Term Care^® program has resources that help build a positive work environment, one that fosters shared decision-making, professional development (including career ladders), leadership, safety, and staff and resident well-being, all with the goal of attracting and retaining staff who are committed to quality care.

With that background, here is where the profession can contribute to a sustainable solution by attending to some of the other root causes of the RN staffing shortage.

Historically, nursing education has been slow to integrate geriatric nursing content and nursing home clinical experiences into the undergraduate curriculum. Many programs use the nursing home clinical experience for fundamentals but rarely capitalize on the unique opportunity these settings offer as a laboratory to practice complex assessments and care planning and develop nursing leadership skills within the interdisciplinary team. Thus, many graduates are never exposed to the role of professional nursing in nursing homes. Faculty themselves need preparation in geriatric nursing content and care delivery models appropriate for long-term care to provide these advanced learning opportunities. Few faculty have educational preparation in these areas. Staff development in the delivery of quality care to older adults is also a critical need in nursing homes given the medical complexity and functional limitations of residents and patients in these settings. The stigma of substandard care acts as a deterrent to many professional nurses.

Transforming the way nurses think about the nursing home as a practice site is a challenge that may seem formidable, but there are resources that can mitigate problems that contribute to RN staffing shortages in nursing homes. We offer a few of these resources below.

The Teaching Nursing Home Initiative (Jewish Healthcare Foundation, 2023) is designed to support academic/practice partnerships with the goal of improving the clinical experience of undergraduate students as well as faculty and staffs' ability to implement quality person-centered care. The Institute for Healthcare Improvement ( https://www.ihi.org/about/history) and National Hartford Center of Gerontological Nursing Excellence ( https://www.nhcgne.org) are other organizations that offer resources for improving age-friendly care delivery in nursing homes and certification of faculty as Distinguished Educators in Gerontological Nursing, respectively. It is our belief that with adequate preparation of faculty, improved staff delivery of care, and greater clinical exposure of students to quality nursing home practice, more nurses may come to see these settings as viable options for employment.

The “health” of nursing homes is important to all nurses. The people we care for in hospitals and home health agencies often receive intermittent or long-term care in these settings. A sufficient number of well-prepared RNs in well-performing nursing homes helps ensure quality transitions across the health care continuum and has the potential to lower the cost of health care. As geriatric nurse leaders, we responded to the CMS proposed rule, seeing it as an opportunity for all nurses, regardless of specialty or setting, to raise their voices and advocate for solutions to RN staffing shortages. Staffing shortages in nursing homes affect all of us.

Ann Kolanowski, PhD, RN, FAAN

Professor Emerita

Ross and Carol Nese College of Nursing

The Pennsylvania State University

University Park, Pennsylvania

Barbara Bowers, PhD, RN, FAAN

University of Wisconsin - Madison

Madison, Wisconsin

Christine Mueller, PhD, RN, FGSA, FAAN

University of Minnesota School of Nursing

Minneapolis, Minnesota

Charlene Harrington, PhD, RN, FAAN

University of California San Francisco

San Francisco, California

• Abt Associates. (2023, June). Nursing home staffing study: Comprehensive report. https://www.cms.gov/files/document/nursing-home-staffing-study-final-report-appendix-june-2023.pdf
  > Google Scholar
• American Nurses Credentialing Center. (n.d.). Pathway to Excellence in Long Term Care®. https://www.nursingworld.org/organizational-programs/pathway/overview/pathway-to-excellence-in-long-term-care/
  > Google Scholar
• Backhaus R., Verbeek H., van Rossum E., Capezuti E., & Hamers J. P. (2014). Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies. Journal of the American Medical Directors Association, 15(6), 383–393. 10.1016/j.jamda.2013.12.080 PMID:24529872
  > Crossref MedlineGoogle Scholar
• Castle N. G. (2008). Nursing home caregiver staffing levels and quality of care: A literature review. Journal of Applied Gerontology, 27(4), 375–405. 10.1177/0733464808321596
  > CrossrefGoogle Scholar
• Centers for Medicare & Medicaid Services. (2023). Medicare and Medicaid programs: Minimum staffing standards for long-term care facilities and Medicaid institutional payment transparency reporting (CMS 3442-P). https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid?tcs-token=3a36881f45261b1343335f85aef9e93df5cb5e16dceb3cc29b85254a015b77e2
  > Google Scholar
• Congress of the United States. (2023, November 6). Letter to Administrator Brooks-LaSure, Centers for Medicare & Medicaid Services. https://doggett.house.gov/sites/evo-subsites/doggett.house.gov/files/evo-media-document/house-nursing-home-safe-staffing-rule-comment-letter-final-compressed.pdf
  > Google Scholar
• Dellefield M. E., Castle N. G., McGilton K. S., & Spilsbury K. (2015). The relationship between registered nurses and nursing home quality: An integrative review (2008–2014). Nursing Economic$, 33(2), 95–108, 116. PMID:26281280
  > MedlineGoogle Scholar
• Harrington C., Ross L., Chapman S., Halifax E., Spurlock B., & Bakerjian D. (2020). Nursing staffing and coronavirus infections in California nursing homes. Policy, Politics, & Nursing Practice, 21(2), 174–186. 10.1177/1527154420938707
  > Crossref MedlineGoogle Scholar
• Harrington C., Schnelle J. F., McGregor M., & Simmons S. F. (2016). The need for higher minimum staffing standards in U.S. nursing homes. Health Services Insights, 9, 13–19. 10.4137/HSI.S38994 PMID:27103819
  > Crossref MedlineGoogle Scholar
• Henreckson J. (2023, November 10). More than 100 House members call for increase to 4.2 daily nursing hours in staffing proposal. McKnights. https://www.mcknights.com/news/more-than-100-house-members-call-for-40-percent-increase-in-nurse-hours-in-staffing-proposal/
  > Google Scholar
• Horn S. D., Buerhaus P., Bergstrom N., & Smout R. J. (2005). RN staffing time and outcomes of long-stay nursing home residents: Pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. American Journal of Nursing, 105(11), 58–70. 10.1097/00000446-200511000-00028 PMID:16264305
  > Crossref MedlineGoogle Scholar
• Jewish Healthcare Foundation. (2023, May 20). Revisiting the Teaching Nursing Home Initiative celebrates successes during final grant review. https://www.jhf.org/news-blog-menu/entry/revisiting-the-teaching-nursing-home-initiative-celebrates-successes-during-final-grant-review
  > Google Scholar
• Kolanowski A., Cortes T. A., Mueller C., Bowers B., Boltz M., Bakerjian D., Harrington C., Popejoy L., Vogelsmeier A., Wallhagen M., Fick D., Batchelor M., Harris M., Palan-Lopez R., Dellefield M., Mayo A., Woods D. L., Horgas A., Cacchione P. Z., Gerdner L. (2021). A call to the CMS: Mandate adequate professional nurse staffing in nursing homes. American Journal of Nursing, 121(3), 22–25. 10.1097/01.NAJ.0000737292.96068.18 PMID:33625007
  > Crossref MedlineGoogle Scholar
• National Academies of Sciences, Engineering, and Medicine. (2022). The national imperative to improve nursing home quality: Honoring our commitment to residents, families, and staff. The National Academies Press. 10.17226/26526
  > CrossrefGoogle Scholar
• U.S. Bureau of Labor Statistics. (2022). Occupational employment and wages, May 2022—29-1141 registered nurses. https://www.bls.gov/oes/current/oes291141.htm
  > Google Scholar
• White E. M., Aiken L. H., & McHugh M. D. (2019). Registered nurse burnout, job dissatisfaction, and missed care in nursing homes. Journal of the American Geriatrics Society, 67(10), 2065–2071. 10.1111/jgs.16051 PMID:31334567
  > Crossref MedlineGoogle Scholar

中文翻译：

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疗养院注册护士人员短缺：护理是解决方案的一部分

介绍

居住在我们国家疗养院的老年人应该得到护理所能提供的最好的护理。不幸的是，现实是，尽管疗养院是以我们的专业名称命名的，但它们在提供我们的护理方面却受到了可悲的限制。问题在于大多数疗养院长期以来普遍存在护士人员配备不足的问题（Dellefield 等，2015）。由于 2019 年冠状病毒病大流行期间发生的广为人知的悲惨事件，公众意识到了这场人员危机。公众的愤怒引发了改革的呼声，包括提高人员配备水平（美国国家科学院、工程院和医学院，2022）。此外，拜登总统在竞选时承诺改善疗养院的条件，2023 年 9 月 1 日，医疗保险和医疗补助服务中心 (CMS) 发布了一项备受期待的拟议规则，题为“长期护理的最低人员配备标准”设施和医疗补助机构支付透明度报告。”

CMS 规则具有三个核心人员配置组成部分：

1) 注册护士 (RN) 的最低护士人员配备标准为每住院日 0.55 小时 (HPRD)，助理护士 (NA) 的最低护士人员配备标准为 2.45 HPRD；2) 要求 RN 每周 7 天、每天 24 小时在现场；3) 加强设施评估要求。

（CMS，2023，第 3 段）

我们认为，拟议的规则，特别是人员配置标准，不足以满足疗养院居民复杂的护理需求，需要采取更多措施来改善工作环境，以吸引和留住足够数量的专业护士。基于多年的经验（Harrington 等人，2016 年；Kolanowski 等人，2021 年）和经验证据（Backhaus 等人，2014 年；Castle，2008 年；Harrington 等人，2020 年；Horn 等人，2005 年；White等，2019），包括 CMS 委托进行的 2023 年 Abt 研究（Abt Associates，2023），我们认为至少 4.2 名护理 HPRD 包括： (a) 1.4 名持照护士 HPRD，其中至少 0.75 名 RN HPRD拥有执业执业护士，以及 (b) 总 NA HPRD 2.8。

本着透明的精神，并非所有人（包括护士）都同意我们的立场，或者实际上 CMS 提出的规则。最令人担忧的问题之一是，当这些要求生效时，是否有足够的劳动力。需要采取更多措施来招募和留住疗养院的注册护士，但这是一个复杂的问题，需要关键成员的时间和投资。在我们讨论护理行业可以采取哪些措施来解决这一严重短缺之前，我们简要概述了疗养院行业的一些责任，如果得到充分解决，这些责任将补充其他团体的努力。我们认为，问题不在于缺乏注册护士，而在于缺乏优质工作。

首先，疗养院需要确保与医院的工资平等。目前，在疗养院工作的注册护士获得的报酬比在医院工作的注册护士少 15%（美国劳工统计局，2022 年）。这种工资差距长期以来一直阻碍着招聘和保留，因此需要提高医疗服务提供者的资金使用方式的透明度。在给 CMS 的一封信中，103 名众议院议员回应了我们的担忧，并表示有必要揭开支出的面纱，“以确保纳税人更完整地了解他们辛苦赚来的钱是如何使用的……直接补偿护理”工人和支持人员”（美国国会，2023 年，第 4 页；Henreckson，2023 年）。其次，工作环境的质量对注册护士的招募和保留有直接影响（White et al., 2019）。管理人员和疗养院业主共同努力改善工作环境质量可以带来显着的投资回报。美国护士资格认证中心 (nd) 长期护理卓越之路^®计划拥有有助于建立积极的工作环境的资源，该环境可以促进共同决策、专业发展（包括职业阶梯）、领导力、安全和员工以及居民的福祉，所有这些都是为了吸引和留住致力于优质护理的员工。

在此背景下，该行业可以通过解决注册护士人员短缺的其他一些根本原因，为可持续的解决方案做出贡献。

从历史上看，护理教育在将老年护理内容和疗养院临床经验纳入本科课程方面进展缓慢。许多项目以疗养院的临床经验为基础，但很少利用这些环境作为实验室提供的独特机会来实践复杂的评估和护理计划，并在跨学科团队中培养护理领导技能。因此，许多毕业生从未接触过疗养院专业护理的角色。教师本身需要准备适合长期护理的老年护理内容和护理提供模式，以提供这些高级学习机会。很少有教师在这些领域做好教育准备。鉴于医疗复杂性以及居民和患者的功能限制，为老年人提供优质护理的人员发展也是疗养院的一项关键需求。不合格护理的耻辱对许多专业护士来说是一种威慑。

改变护士对疗养院作为实践场所的看法是一项看似艰巨的挑战，但有一些资源可以缓解导致疗养院注册护士人员短缺的问题。我们在下面提供了其中一些资源。

教学疗养院计划（犹太医疗保健基金会，2023）旨在支持学术/实践合作伙伴关系，目标是提高本科生的临床经验以及教职员工实施优质以人为本的护理的能力。医疗保健改善研究所 (https://www.ihi.org/about/history) 和国家哈特福德老年护理卓越中心 (https://www.nhcgne.org) 是其他为改善老年友好性提供资源的组织分别在疗养院提供护理服务和教师认证为老年护理杰出教育工作者。我们相信，通过充分的教师准备、改进的员工护理服务以及让学生更多地接触优质疗养院实践的临床机会，更多的护士可能会将这些环境视为可行的就业选择。

疗养院的“健康”对所有护士都很重要。我们在医院和家庭保健机构照顾的人经常在这些环境中接受间歇性或长期护理。绩效良好的疗养院中有足够数量准备充分的注册护士有助于确保整个医疗保健连续体的质量过渡，并有可能降低医疗保健成本。作为老年护士领导者，我们对 CMS 提议的规则做出了回应，认为这是所有护士的一个机会，无论专业或环境如何，都可以发出自己的声音并倡导解决 RN 人员短缺问题。疗养院人员短缺影响到我们所有人。

Ann Kolanowski，博士，注册护士，FAAN

名誉教授

罗斯和卡罗尔内斯护理学院

宾夕法尼亚州立大学

宾夕法尼亚大学公园

芭芭拉·鲍尔斯 (Barbara Bowers)，博士、注册护士、FAAN

威斯康星大学麦迪逊分校

威斯康星州麦迪逊

Christine Mueller，博士、注册护士、FGSA、FAAN

明尼苏达大学护理学院

明尼苏达州明尼阿波利斯

Charlene Harrington，博士、注册护士、FAAN

加州大学旧金山分校

加利福尼亚州旧金山

• 阿布特联营公司。（2023 年6月）。疗养院人员配置研究：综合报告。https://www.cms.gov/files/document/nursing-home-staffing-study-final-report-appendix-june-2023.pdf
  >谷歌学术
• 美国护士资格认证中心。（另）。长期护理卓越之路®。https://www.nursingworld.org/organizational-programs/pathway/overview/pathway-to-excellence-in-long-term-care/
  >谷歌学术
• Backhaus R.、Verbeek H.、van Rossum E.、Capezuti E. 和 Hamers JP（2014 年）。护士人员配置对疗养院护理质量的影响：纵向研究的系统评价。美国医疗主任协会杂志，15 (6), 383–393。10.1016/j.jamda.2013.12.080PMID：24529872
  >交叉引用 Medline 谷歌学术
• NG城堡（2008）。疗养院护理人员的人员配置水平和护理质量：文献综述。应用老年学杂志，27 (4), 375–405。10.1177/0733464808321596
  >交叉引用谷歌学术
• 医疗保险和医疗补助服务中心。（2023）。医疗保险和医疗补助计划：长期护理机构和医疗补助机构支付透明度报告的最低人员配备标准 (CMS 3442-P)。https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid?tcs-token=3a36881f45261b1343335f85aef9e93df5cb5e16dceb3cc29b85254a015b77e 2
  >谷歌学术
• 美国国会。（2023 年11月 6 日）。致医疗保险和医疗补助服务中心管理员布鲁克斯-拉苏尔的信。https://doggett.house.gov/sites/evo-subsites/doggett.house.gov/files/evo-media-document/house-nursing-home-safe-staffing-rule-comment-letter-final-compressed。 pdf
  >谷歌学术
• Dellefield ME、Castle NG、McGilton KS 和 Spilsbury K. ( 2015 )。注册护士与疗养院质量之间的关系：综合评价（2008-2014）。护理经济$ , 33 (2), 95–108, 116. PMID:26281280
  > Medline谷歌学术
• Harrington C.、Ross L.、Chapman S.、Halifax E.、Spurlock B. 和 Bakerjian D.（2020 年）。加州疗养院的护理人员配置和冠状病毒感染。政策、政治和护理实践，21 (2), 174–186。10.1177/1527154420938707
  >交叉引用 Medline 谷歌学术
• Harrington C.、Schnelle JF、McGregor M. 和 Simmons SF ( 2016 )。美国疗养院需要更高的最低人员配置标准。卫生服务洞察，9，13-19。10.4137/恒指.S38994PMID：27103819
  >交叉引用 Medline 谷歌学术
• 亨雷克森J。（2023 年11月 10 日）。100多名众议院议员在人员配置提案中呼吁将每天的护理时间增加到4.2小时。麦克奈茨。https://www.mcknights.com/news/more-than-100-house-members-call-for-40-percent-increase-in-nurse-hours-in-staffing-proposal/
  >谷歌学术
• Horn SD、Buerhaus P.、Bergstrom N. 和 Smout RJ（2005 年）。注册护士的人员配备时间和长期入住疗养院居民的结果：由于注册护士花更多的时间在直接患者护理上，因此发生压疮和其他不良结果的可能性较小。美国护理杂志，105（11），58-70。10.1097/00000446-200511000-00028PMID：16264305
  >交叉引用 Medline 谷歌学术
• 犹太医疗保健基金会。（2023 年5月 20 日）。重新审视疗养院教学计划庆祝最终拨款审查期间取得的成功。https://www.jhf.org/news-blog-menu/entry/revisiting-the-teaching-nursing-home-initiative-celebrates-successes-during-final-grant-review
  >谷歌学术
• Kolanowski A.、Cortes TA、Mueller C.、Bowers B.、Boltz M.、Bakerjian D.、Harrington C.、Popejoy L.、Vogelsmeier A.、Wallhagen M.、Fick D.、Batchelor M.、Harris M. ，Palan-Lopez R.，Dellefield M.，Mayo A.，Woods DL，Horgas A.，Cacchione PZ，Gerdner L.（2021）。向 CMS 发出呼吁：要求疗养院配备足够的专业护士人员。美国护理杂志，121（3），22-25。10.1097/01.NAJ.0000737292.96068.18PMID：33625007
  >交叉引用 Medline 谷歌学术
• 美国国家科学院、工程院和医学院。（2022）。提高疗养院质量的国家当务之急：兑现我们对居民、家庭和员工的承诺。美国国家科学院出版社。10.17226/26526
  >交叉引用谷歌学术
• 美国劳工统计局。（2022）。职业就业和工资，2022 年 5 月—29-1141 注册护士。https://www.bls.gov/oes/current/oes291141.htm
  >谷歌学术
• White EM、Aiken LH 和 McHugh MD（2019）。注册护士倦怠、工作不满以及疗养院错过护理。美国老年医学会杂志，67 (10)，2065–2071。10.1111/jgs.16051PMID：31334567
  >交叉引用 Medline 谷歌学术