Position on Direct Care Staffing in Nursing Homes

Resolution and Position Statements
March 1, 2002

Statement H02
Becomes Policy March 2002


The primary focus of this statement is to:

  • Expand upon AMDA's 2000 position on minimum staffing standards in nursing homes (AMDA House of Delegates Resolution A00);
  • Affirm the value of direct caregivers in the long term care continuum; and
  • Encourage the Centers for Medicare and Medicaid Services (CMS) to provide funding increases for any federally mandated staffing levels.


In recent years, workforce dynamics along with a growing elder population have resulted in nurse staffing shortages across the long term care continuum. Nurse staff shortages are particularly endemic to America's nursing homes and extend to registered nurses (RN), licensed practical nurses (LPN), as well as certified nursing assistants (CNA). Adequate nurse staffing is critical to providing quality patient care. In this context, adequate nursing staff can be defined as the appropriate number of well trained, properly supervised individuals who meet the personal [direct] care needs of nursing home residents.1 Presently, nursing assistants provide 80 to 90 percent of direct patient care.2 Direct patient care includes assisting the patient with feeding, drinking, ambulating, grooming, toileting, dressing, and socializing.

Studies show that residents and their families directly relate the interaction between the nursing assistant and the resident to the level of satisfaction experienced in the nursing home. Clearly, well-trained CNAs have an important role in providing direct patient care in nursing homes. Similarly, published studies positively correlate RN participation in direct caregiving, providing hands-on guidance to CNAs, and improvements in the quality of patient care.3 As licensed nursing professionals, RNs and LPNs are crucial in providing guidance and supervision in the nursing home environment.

Staffing Levels

Current federal law requires facilities to have an adequate number of licensed and qualified staff to provide care and services to residents. The level of care must be sufficient for each resident to attain or maintain their highest practicable physical, mental and psychosocial well-being.4 In addition to the federal government's general requirement for adequate staffing, some state laws explicitly mandate staffing levels by requiring a minimum number of nursing staff for a specific number of residents. State staffing mandates vary.5 In some states, the staff-to-resident ratio is solely based on the number of residents in a facility. In other states, the ratio depends upon the case-mix of a facility's residents. Until recently, there has been little quantitative data to suggest specific ratios at which quality is either compromised or significantly enhanced.6 Ongoing research to collect clinical and scientific data purposes to determine staffing levels that will best achieve desired outcomes as well as to develop recommendations that are sensitive to changes in case-mix and acuity. AMDA recognizes that if federal staffing guidelines are developed, the following points should be taken into account:

  • The acuity of the patient population;
  • The functional level of the patient and the services provided;
  • The existence of staffing shortages for some types of staff in some geographic locations, and, for temporary staffing shortages due to such events as employee illness or termination; and
  • The quality, education, and training of the staff.7

Training Standards

Minimum training standards for nursing assistants were codified in the Omnibus Reconciliation Act of 1987 (OBRA '87). Seventy-five hours of training in specifically designated areas are mandated for CNAs who work in long term care facilities receiving Medicare or Medicaid funding. In addition, 12 hours per year of continuing education must be provided by the facility. Approximately, one third of states have additional nursing assistant training requirements. Required curriculum content varies substantially between the states. There is very limited research that defines the specific number of hours and curriculum content that will produce the most competent paid caregiver.8 Both the paucity of formal training hours and the variability of curriculum content are felt to be inadequate by consumer and professional organizations including the National Citizens Coalition for Nursing Home Reform, the Certified Nursing Assistant Program, and the Direct Care Alliance.

AMDA is dedicated to the education, training, and professional development of those practicing in the long term care continuum. AMDA encourages continued research and demonstration projects that will define the relationship between expanded training hours and standardized curriculum content for CNAs and higher quality resident care. AMDA also recognizes that adequate supervision by licensed staff is critical to the continuing education process for CNAs and that "best practices" for ratios of licensed to unlicensed staff need to be established to promote the highest quality of patient care.

Supply of Caregivers

Many solutions have been proposed to increase adequate staffing in nursing facilities. They include:

  • Hiring of single task workers;
  • Mandating federal staffing levels or ratios; and
  • Changing federal immigration laws to permit the use of foreign workers.

However, AMDA cautions against the implementation of the any one recommendation without consideration of the broader issues mentioned in the Institute of Medicine's (IOM) March 2001 report. Several groups have suggested that "single task workers" be employed by nursing homes to enable facilities to provide care without hiring additional CNAs. Presently, federal regulation does not allow this practice.9 Historically, AMDA has expressed concern about the utilization of single task workers in nursing homes. To date, there is insufficient evidence to determine the impact of single task workers on the overall quality of patient care in nursing facilities. In the absence of such evidence, AMDA has been reluctant to endorse the use of the single task workers in the care continuum. A lack of training relative to other direct care providers and the potential to undermine the spirit of professionalism among CNAs are additional areas of concern. AMDA encourages CMS to address the complex marketplace dynamics affecting nursing home staffing and would support a small-scale demonstration research project to study the impact of single task workers on care quality in nursing homes.

AMDA recognizes that policymakers may begin looking outside of the United States for nursing staff to help ease the staffing shortages in nursing homes and other places of care. If this strategy is implemented, AMDA encourages state and federal policy makers to remain committed to current educational requirements for nursing staff.

Federally Mandated Staffing Levels

Federally mandated minimum staffing and training levels do have the potential to raise the quality of care for nursing home residents, a goal that AMDA has consistently promoted. However, the overall impact of new federal mandates is far from clear and could result in unintended consequences. For example, a shortage of available workers in the labor force may make compliance with federal mandates difficult. A consensus statement widely endorsed across the care continuum delineates the multiple interrelated factors that contribute to the current staffing shortage. These factors include:

  • Inadequate Medicare and Medicaid payment systems;
  • Job image and quality;
  • Wages and benefits;
  • Education;
  • Workload and the facility's management philosophy;
  • Workplace safety;
  • Advancement opportunities;
  • External and personal issues for the low income worker; and
  • Public perception.10

Post-baby boom demographics over the next 30 years reveal a widening care gap between the rapidly growing population of long term care consumers and the shrinking supply of direct care workers.11 Clearly, any federal mandates to improve staffing levels in nursing homes will need to address the broader systemic issues that limit the availability of trained and qualified nursing staff.

AMDA's Recommendations

The conclusions outlined in the IOM in the report entitled, "Improving the Quality of Long Term Care," published in March 2001, specifically examine the relationship between the quality of nursing home care and staffing levels. AMDA endorses many of their recommendations as outlined below.

  • AMDA highly values direct caregivers in our nation's nursing homes. Their hands-on care determines whether a resident's care plan will achieve its goal: the highest possible functional level. Our daily experience as physicians affirms that the quality of a resident's life is profoundly affected by whether they are treated in a competent, compassionate manner by the nurses and nursing assistants who are responsible for their care.
  • AMDA supports the continued research regarding mandated staffing levels (number and skill mix) for direct care based on case-mix-adjusted standards that will optimally meet the needs of residents in nursing homes. Staffing levels based only on resident-to-worker ratios are simplistic and will not adequately assess or meet resident needs. Workforce issues including wages and benefits, job design, quality of training and supervision, career development and workplace safety must be addressed before a labor pool of adequately trained licensed and unlicensed staff will be available to allow facilities to comply with staffing mandates.
  • AMDA agrees with the IOM's conclusion that "the amounts and ways we pay for long term care are probably inadequate to support a work force sufficient in numbers, skills, stability, and commitment to provide adequate clinical and personal services for the increasingly frail or complex populations using long term care."12 Any mandated changes in staffing levels and training requirements must be accompanied by federal and state funding increases specifically targeted to achieve these goals.


  1. Wunderlich, G.S., Kohler, P.O. (2001). Improving the Quality of Long-Term Care. Washington, D.C.: National Academy Press.
  2. Committee on Nursing Home Regulation. (1986). Improving the Quality of Care in Nursing Homes.Gerontologist (34) 1994: 235-244; as well as "Infopack: Staffing Issues in Long Term Care" published by the American Health Care Association in 1998.
  3. Wunderlich, G.S., Sloan, F. et al. (1996). Nursing Staff in Hospitals and Nursing Homes: Is it Adequate? Washington, D.C.: National Academy Press.
  4. Social Security Act of 1935. U.S.C.A. §1395i-3 et seq. (www4.law.cornell.edu/uscode/).
  5. See "Nursing Homes Staffing Standards in State Statutes and Regulations", a report prepared by Charlene Harrington in conjunction with the National Citizens' Coalition for Nursing Home Reform, May 2001.
  6. Health Care Financing Administration. (2000). Report to Congress: The Appropriateness of Minimum Staffing Ratios in Nursing Homes, Phase I. (Department of Health and Human Services). Washington, D.C.: Government Printing Office.
  7. American Medical Directors Association. (2000). House of Delegate Resolution A00.
  8. Noel, MA, Pearce GL, et al. (2000). Frontline Workers in Long-Term Care: The Effect of Educational Interventions and Stabilization of Staffing Ratios on Turnover and Absenteeism. Journal of the American Medical Directors Association, 1(6), 241-247.
  9. On June 28, 2001, the Secretary of the Department of Health and Human Services, Tommy Thompson indicated in testimony before the Senate Special Committee on Aging that CMS, formerly the Health Care Financing Administration (HCFA), will offer assistance to states to allow greater utilization of single task workers.
  10. Campaign for Quality Care. (March, 2001). Staffing Crisis in Nursing Homes: A Consensus Statement. Washington, D.C.: Author.
  11. Dawson, Steven L., Surpin, R. (2001) Direct Care Health Workers: The Unnecessary Crisis in Long Term Care. Washington, D.C.: Domestic Strategy Group of the Aspen Institute.
  12. Wunderlich, G.S., Kohler, P.O. (2001).