Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review

Eric Jutkowitz, Adrienne Landsteiner, Edward Ratner, Tetyana Shippee, Caroline Madrigal, Kristen Ullman, Eric Linskens, Timothy J. Wilt, Wei Duan-Porter

Research output: Contribution to journalReview articlepeer-review

6 Scopus citations


Objectives: To evaluate the evidence on effects of nurse staffing in nursing homes on resident outcomes. Design: Systematic review. Setting and Participants: Studies evaluating the effects of nurse staffing levels, total staffing, or skill mix on pressure ulcers, nursing home associated infections, and pain outcomes for adult residents in US nursing homes. Methods: We searched MEDLINE, Embase, CINAHL, and the Cochrane Database for English-language articles published between January 2000 and May 2021. We also searched for gray literature and sought expert referrals. Two reviewers participated in determination of eligibility, assessment of methodological quality, and abstraction of data. Abstracted data included study design; setting and population characteristics; and resident outcomes. We rated overall certainty of evidence (very low, low, moderate, and high) for each outcome using GRADE. Results: Of 9152 unique citations, 378 articles underwent full-text review. We identified 22 eligible studies that addressed pressure ulcers (k = 15), COVID-19 cases and/or mortality (k = 4), other infections (k = 8), and moderate-severe pain among residents (k = 7); some examined multiple outcomes. Most studies (k = 17) were rated moderate or high quality. All studies were observational. Overall, registered nurse (RN) staffing was probably associated with fewer pressure ulcers (moderate certainty) and possibly fewer COVID-19 infections/mortality (low certainty), other infections (low certainty) and lower rates of moderate-severe pain (low certainty). Higher skill mix was probably associated with fewer pressure ulcers, higher resident COVID-19 infections, fewer other infections, and lower rates of moderate-severe pain (low certainty for all outcomes). Conclusions and Implications: Higher RN staffing and skill mix may be associated with better nursing home resident outcomes, while results were mixed for total staffing. Increasing RN staffing levels and skill mix are one of a variety of approaches to improve nursing home care.

Original languageEnglish (US)
Pages (from-to)75-81.e11
JournalJournal of the American Medical Directors Association
Issue number1
StatePublished - Jan 2023

Bibliographical note

Funding Information:
This report was prepared by the Evidence Synthesis Program Center located at the Minneapolis VA Health Care System, directed by Timothy J. Wilt, MD, MPH and Wei Duan-Porter, MD, PhD and funded by the Department of Veterans Affairs , Health Services Research and Development . This work was also partially supported by the VA Office of Academic Affiliation Advanced Fellowship in Health Services Research (Dr. Madrigal).

Publisher Copyright:
© 2022


  • Long-term care
  • Nursing
  • nursing homes
  • staffing ratios

PubMed: MeSH publication types

  • Systematic Review
  • Journal Article
  • Review
  • Research Support, U.S. Gov't, Non-P.H.S.


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