Nursing home staffing has long been a concern because of reports of low levels of staff in many homes. Research shows that higher nurse staffing levels in nursing homes have been associated with higher quality of care. Nursing homes with more RN hours per resident and more total nursing hours have been shown to have many positive outcomes, fewer adverse outcomes, are more likely to be discharged to home, and have fewer admissions to hospitals and emergency rooms.

The evidence from these studies led the Institute of Medicine Committee to recommend higher staffing levels in nursing homes and 24 hour registered nursing care. An expert panel recommended minimum staffing levels of 4.55 hours per patient day, including all RNs, LVNs, and nursing assistants. A report for the Centers for Medicare and Medicaid Services (CMS, 2001) reported that facilities with staffing levels below 4.1 hours per resident day for long stay residents may provide care that results in harm and jeopardy to the residents. A study by Schnelle and colleagues (2004) also supports a threshold level of 4.1 total nursing hours per resident day to ensure that the processes of nursing care are adequate. Ninety-five percent of US nursing homes do not have adequate staffing.

Nursing facilities are required by federal regulation to meet minimum standards, which require a minimum of one registered nurse on duty eight hours per day seven days a week. Facilities must also have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents. Facilities must also provide sufficient numbers of licensed nursing personnel to provide care on a 24 hour basis to all residents in accordance with resident care plans.

A number of states have developed staffing standards that have greater requirements than the federal standards. The following report shows the state staffing standards. Studies have also shown that states with higher staffing standards have more nursing hours of actual care for residents. The adequacy of nurse staffing levels continues to be a major concern in nursing homes and RN staffing levels have dropped by 25 percent since 2000. Advocates are continue to work on staffing improvements in nursing homes especially at the state level.