Nurses -- United States, Nursing home care -- United States, Nursing homes -- Law and legislation -- United States, Nursing homes -- Standards -- United States, Nursing homes -- United States, Nursing services -- Standards -- United States


The purpose of this dissertation is to examine nursing homes‟ compliance with state minimum nurse staffing standards and its relation to quality-of-care deficiencies. Specifically, this study, reviewing staffing standards from 50 states and the District of Columbia for the year 2007, proposes a unique algorithm to calculate the states‟ expected nurse staffing levels for individual nursing homes in order to investigate their compliance with the state nurse staffing standards. By using hierarchical linear modeling method, this study attempts to capture the impact of the staffing standards on actual nurse staffing levels under resource dependence perspectives. Path analysis using structural equation modeling was conducted to investigate both direct and indirect effects of the staffing standards on nurse staffing levels and quality-of-care deficiencies. The major findings were as follows: (1) nursing homes in states with higher state staffing standards for the categories of RN, LN, and total nurse were found to have higher RN, LN, and total staffing levels, respectively; (2) higher nurse staffing levels resulting from higher state staffing standards were significantly associated with better quality of care (less quality-of-care deficiencies cited) in nursing homes; and (3) state staffing standards were found to have much stronger contribution to nurse staffing levels than any other organizational or contextual factors while nurse staffing levels, particularly licensed staff, were found to have stronger contribution to quality-of-care deficiencies than any other organizational factors. The study findings suggest that if the goal is to increase nurse staffing levels for better quality, increasing the stringency of both federal and state nurse staffing standards would be the iv most effective way. However, the staffing standards first need technical changes to reduce their ambiguity and ensure their fairness. If the goal is to achieve better quality, merely increasing nurse staffing levels may not be effective since the variation of the quality-of-care deficiencies explained by exogenous variables was smaller than random variation 5%. If state Medicaid reimbursements can be utilized for financial incentives for better performing nursing homes, nursing homes may improve their productivity by efficiently managing organizational personnel or increasing job satisfaction among nursing practitioners. Lastly, longitudinal analysis, considering variation in length of state staffing policy implementations, is encouraged to investigate the long-term effects of state staffing standards on nurse staffing levels and quality of care.


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Graduation Date





Wan, Thomas T. H.


Doctor of Philosophy (Ph.D.)


College of Health and Public Affairs








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Doctoral Dissertation (Open Access)


Dissertations, Academic -- Health and Public Affairs, Health and Public Affairs -- Dissertations, Academic

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