State-level minimum nurse staffing requirements for nursing homes

Evidence Rating  
Evidence rating: Expert Opinion

Strategies with this rating are recommended by credible, impartial experts but have limited research documenting effects; further research, often with stronger designs, is needed to confirm effects.

Health Factors  
Date last updated

Minimum staffing requirements for nursing homes are state level regulations that require nursing homes to employ at least a set number of licensed and non-licensed nursing staff. Often set in terms of staff hours per resident day, requirements may be influenced by patient mix and acuity and may apply to registered nurses (RNs), licensed practical/vocational nurses (LPN/LVNs), or certified nursing assistants (CNAs) and other nurse’s aides (NAs). Federal law provides baseline requirements; many states have higher standards.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Improved quality of care

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Increased staffing levels in nursing homes

What does the research say about effectiveness?

Minimum nurse staffing requirements are a suggested strategy to improve quality of care for nursing home patients1. Additional evidence is needed to confirm effects.

Overall, minimum nurse staffing requirements increase staffing levels at nursing homes. A nationwide study of minimum direct care staffing requirements from 1999 to 2004 indicates that mandated staffing levels increase staffing, particularly at homes reliant on Medicaid2. A study of states that implemented new standards between 1998 and 2000 indicates that such mandates only affect facilities that have low staffing levels when standards are introduced3. Studies of individual states yield similar results: Ohio and California’s requirements appear to have increased the amount of direct care provided to patients in homes with low staffing, mainly through hiring a greater number of CNAs4, 5 and LPNs, though some homes with high levels of staff decreased staffing levels4.

Research examining nursing home staffing levels and quality measures indicates a small positive association6 or no association between staffing levels and performance7. This may be due to research designs that do not account for other important factors that can affect quality of care, such as the training and experience of staff, turnover, and use of contracted, temporary (agency) staff6. Effects on quality may also vary by case and skill mix8. For example, one study suggests that increasing the number of RNs can increase quality of care but increasing nurse aides does not9; another study suggests increasing CNAs can benefit quality10. Some studies indicate that increasing state minimum staffing standards may be associated with improvements in some quality indicators, such as regulatory deficiencies in annual inspections, but not improvements in other measures2, 3, 4, and another study found no quality improvements5.

Increases in minimum nurse staffing may lead to decreases in profitability for nursing homes dependent on Medicaid11, and may lead to reductions in other, non-nursing services such as housekeeping, food service, and activities4, 12.

How could this strategy impact health disparities? This strategy is rated no impact on disparities likely.
Implementation Examples

Federal standards require certified nursing homes that provide Medicare and Medicaid services to have a full-time director of nursing (DON), an RN on duty for 8 consecutive hours 7 days a week (this may be the DON), and one RN and licensed nurse (either an RN or LVN/LPN) for the two remaining shifts. While other numbers are not specified, standards require adequate staffing levels to meet the needs of the residents to attain or maintain the highest practicable levels of physical, mental, and psychosocial well-being13. For example, when homes are rated using CMS’s Five-Star Quality Rating System, nursing homes with residents with more severe needs are expected to have higher staffing levels than facilities with less severe resident needs14.

In 2014, there were approximately 15,600 nursing homes in the U.S. serving 1.4 million residents, with an average total of 3.88 nursing hours per resident day: 1.41 nursing hours per resident day by licensed nurses (RNs, LPNs/LVNs) and 2.47 nursing hours per resident day by nurse’s aides15.


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1 IOM-Page 2003 - Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Keeping patients safe: Transforming the work environment of nurses. Page A, ed. Washington, D.C.: Institute of Medicine (IOM) of the National Academies. 2003.

2 Bowblis 2011 - Bowblis JR. Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Services Research. 2011;46(5):1495-516.

3 Park 2009 - Park J, Stearns SC. Effects of state minimum staffing standards on nursing home staffing and quality of care. Health Services Research. 2009;44(1):56-78.

4 Chen 2015 - Chen MM, Grabowski DC. Intended and unintended consequences of minimum staffing standards for nursing homes. Health Economics. 2015;24(7):822–839.

5 Matsudaira 2014 - Matsudaira JD. Government regulation and the quality of healthcare: Evidence from minimum staffing legislation for nursing homes. The Journal of Human Resources. 2014;49(1):32–72.

6 Spilsbury 2011 - Spilsbury K, Hewitt C, Stirk L, Bowman C. The relationship between nurse staffing and quality of care in nursing homes: A systematic review. International Journal of Nursing Studies. 2011;48(6):732-50.

7 Backhaus 2014 - Backhaus R, Verbeek H, van Rossum E, Capezuti E, Hamers JPH. Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies. Journal of the American Medical Directors Association. 2014;15(6):383-93.

8 Cohen 1996 - Cohen JW, Spector WD. The effect of Medicaid reimbursement on quality of care in nursing homes. Journal of Health Economics. 1996;15(1):23–48.

9 Lin 2014 - Lin H. Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach. Journal of Health Economics. 2014;37(1):13-24.

10 Tong 2011 - Tong PK. The effects of California minimum nurse staffing laws on nurse labor and patient mortality in skilled nursing facilities. Health Economics. 2011;20(7):802–816.

11 Bowblis 2015 - Bowblis JR. The cost of regulation: More stringent staff regulations and nursing home financial performance. Journal of Regulatory Economics. 2015;47(3):325–338.

12 Bowblis 2013 - Bowblis JR, Hyer K. Nursing home staffing requirements and input substitution: Effects on housekeeping, food service, and activities staff. Health Services Research. 2013;48(4):1539-1550.

13 CMS 2015 - Centers for Medicare & Medicaid Services. State operations manual: Appendix PP - Guidance to surveyors for long term care facilities. 2015;10(c):10-14.

14 CMS-5 star - Centers for Medicare & Medicaid Services (CMS). Five-star quality rating system.

15 CDC-NCHS-Harris-Kojetin 2016 - Harris-Kojetin L, Sengupta M, Park-Lee E, et al. Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 2013–2014. National Center for Health Statistics (NCHS). Vital Health Statistics. 2016;3(38).