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Position Statements

IMPORTANT UPDATE: On August 10, 2022, AMDA issued a new Position on Staffing in Long Term Care

 View Updated Position Statement

Provisions of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) specifically require nursing facilities to have registered nurse coverage for at least 8 hours per day and 24-hour licensed nurse coverage per day. The general requirement is that staffing must be sufficient to meet the needs of nursing home residents.

Recently, HCFA contracted with Abt Associates to collect quantitative data that will decide whether or not regulations on staffing levels or ratios in nursing homes are warranted. Unlike the Institute of Medicines' report in 19961 and the National Citizens' Coalition for Nursing Home Reform's staffing guidelines2, Abt is looking for empirical staffing and outcomes data to determine if there is a level for which--if you fall below it--residents are at risk for poor outcomes. If a threshold is found and HCFA recommends staffing levels, then Abt will perform a cost analysis of what it will take to staff at that level. In addition to looking at dollars for the cost analysis, Abt will look at availability of staff.


Excluding the specific and general staffing requirements outlined in the OBRA '87 provisions, AMDA withholds its support of staffing standards for nursing homes until the Abt Associates nursing home staffing project provides empirical data on the justification for or against staffing standards and their affect on patient outcomes. While too little staffing may lead to poor outcomes, there currently is no proven correlation between higher staffing levels and improved outcomes.

Until the scientific and clinical data is defensible, the development of staffing levels or ratios should be approached with an appropriate level of caution. AMDA recognizes that if one must develop guidelines, the following points should be taken into account:

  • the complexity of the patient population;
  • the functional level of the patient and the services required;
  • 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.


  1. Wunderlich GS, Sloan F, et al. (1996). Nursing Staff in Hospitals and Nursing Homes: Is it Adequate? Washington, D.C.: National Academy Press.
  2. National Citizens Coalition for Nursing Home Reform. (1998). Proposed Minimum Staffing Standards for Nursing Homes. Washington, D.C.: National Citizens Coalition for Nursing Home Reform.