State Experiences with Minimum Nursing Staff Ratios for Nursing Facilities: Findings from Case Studies of Eight States


This paper reports on (1) what is known about the status of states' minimum nursing staff ratios and (2) findings from case studies that examine states' experiences with implementing or modifying these standards in a selected number of states. A review of the published and unpublished literature on state standards identified 36 states with established minimum ratios in 2003, with the District of Columbia scheduled to implement its ratios in 2005. Since 1997, 23 states have made changes to their minimum nursing staff ratios. The authors chose 10 states out of the total 23 with a recent change to their minimum nursing staff ratios to find out why the states set, modified, or eliminated their staffing ratios; how the standard in question was implemented; how compliance was monitored; and the perceived effects of the standards. The 10 case study states — Arkansas, Arizona, California, Delaware, Minnesota, Missouri, Nevada, Ohio, Vermont, and Wisconsin — represent a diverse group in terms of population size and geographic area. Of these states, Vermont instituted new staffing ratios; Arkansas, California, Delaware, Minnesota, Ohio, and Wisconsin modified existing ratios; and Arizona, Missouri, and Nevada eliminated their ratios. Guided discussions were held with a set of state officials and key stakeholders in each state. In eight of the 10 states, they were able to have discussions with most state officials and key stakeholders; however, they were not able to hold a sufficient number of discussions in Arizona and Nevada to include these states in the analysis. Findings from our research reveal that staffing ratios can be implemented or removed in different ways, including through passage of new legislation, as part of new regulations, through written administrative policy or procedures, or through the Medicaid reimbursement structure. Among the eight case study states, all but Vermont had some form of a minimum staffing ratio in place prior to the change in their requirement. Recent changes to state ratios typically came about as a reaction to publicity about quality problems in nursing homes and with the goal of improving the quality of resident care in nursing facilities. However, the authors found considerable variation across the study states in the type of ratio, measurement of the ratio, adjustment for case mix, monitoring and enforcement of the ratio, and payment for ratios, with substantial disagreement about the best approach among various stakeholder groups. [97 PDF pages]

View HTML report


"8state.pdf" (pdf, 2.06Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®