Available online at www.sciencedirect.com
Nurs Outlook 63 (2015) 137e143
www.nursingoutlook.org
Comparing the nurse staffing in Korean and U.S. nursing homes Hyang Yuol Lee, PhDa, Juh Hyun Shin, PhDb,*, Charlene Harrington, PhDc a
b
College of Nursing, Eulji University, Jung-gu, Daejeon, South Korea Division of Nursing Science, College of Health Sciences, Ewha Womans University, Seodaemun-gu, Seoul, South Korea c Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA
article info
abstract
Article history: Received 11 April 2014 Revised 10 July 2014 Accepted 4 August 2014 Available online 14 August 2014
Introduction: The quality of nursing home care has been problematic in both the
Keywords: Korea Nursing home Quality Staffing standard United States
United States and South Korea; quality is limited to inadequate nurse staffing levels. This article addresses how South Korean nursing home education and training requirements, nurse staffing standards, and actual nurse staffing levels compare with those in the United States. Methods: The study used secondary documents and data to compare the two countries. Results: Korea has lower registered nurse and certified nursing assistant standards and actual staffing levels than the United States. In contrast, staffing standards and actual staffing levels for care workers who provide direct care to residents are higher in Korea than in the United States. Conclusions: Research is needed in Korea to establish an empirical basis for educational requirements, staffing standards, and staffing levels in nursing homes. Cite this article: Lee, H. Y., Shin, J. H., & Harrington, C. (2015, APRIL). Comparing the nurse staffing in Korean and U.S. nursing homes. Nursing Outlook, 63(2), 137-143. http://dx.doi.org/10.1016/ j.outlook.2014.08.005.
Introduction Nursing home quality is a major concern in a number of countries (Harrington et al., 2012). In the United States, many studies have documented quality problems in nursing homes, such as resident weight loss, pressure ulcers, infections, pain, depression, and other treatable or preventable problems (Schnelle et al., 2004; U.S. Centers for Medicare and Medicaid Services [CMS], 2001; U.S. Government Accountability Office, 2009). A recent study of nursing home residents found an estimated 22% experienced adverse events, and an additional 11% experienced temporary harmful events during their skilled nursing facility stays (U.S.
Department of Health and Human Services, Office of the Inspector General, 2014). Other studies identified poor quality of care in Canada (Jansen, 2010), in England where new standards and regulatory oversight were established (Dixon, Kaambwa, Nancarrow, Martin, & Bryan, 2010; U.K. Care Quality Commission, 2010), and in Sweden where new guidelines for dementia care units were established (Sweden National Board of Health and Welfare, 2009). A number of research studies have shown a strong relationship between poor quality of nursing home care and low nurse staffing levels (U.S. CMS, 2001). A systematic review of 87 research articles and reports from 1975 through 2003 found that high total staffing levels, especially of registered nurses (RNs), were
* Corresponding author: Juh Hyun Shin, Division of Nursing Science, College of Health Sciences, Ewha Womans University, 120-750 Helen Hall 205, EwhaYeodaegil 52, Seoul, Republic of Korea. E-mail address: [email protected] (J.H. Shin). 0029-6554/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2014.08.005
138
Nurs Outlook 63 (2015) 137e143
associated with improved care processes and resident outcomes for functional ability, pressure ulcers, and weight loss (Bostick, Rantz, Flesner, & Riggs, 2006). Other research reviews and studies found that higher staffing levels relate to lower deficiencies, better resident outcomes, and less avoidable hospitalization rates (Bowblis, 2011; Castle, 2008; Kim, Harrington, & Greene, 2009; Kim, Kovner, Harrington, Greene, & Mezey, 2009; Spilsbury, Hewitt, Stirk, & Bowman, 2011). Although some study results were mixed and inconsistent, the benefits associated with high nurse staffing underline the importance of nurse staffing standards and staffing levels (Backhaus, Verbeek, Van Rossum, Capezuti, & Hamers, 2014). Nursing home quality and staffing concerns have developed in South Korea, as in other industrialized countries. In South Korea, the elderly population is rapidly increasing, and the need for long-term care (LTC) facilities for elders has grown. The government responded to these increasing needs by passing a law establishing a public LTC insurance program for senior citizens in 2008 (Korean National Health Insurance Corporation, 2011). The purpose of LTC insurance is to provide optimal quality of care to beneficiaries and decrease the burden of caregivers (Korean Ministry of Health and Welfare, 2011b). Two types of South Korean LTC facilities were established: (a) nursing homes divided into small homes (with 10e29 residents) and large homes (with 30 or more residents) and (b) senior congregate housing programs that have more than five but fewer than nine residents (Korean National Health Insurance Corporation, 2011). There were 2,610 nursing homes and 1,742 senior housing facilities in 2012 (Korean Statistical Information Service, 2013). To be eligible for the South Korean LTC insurance program, elders must be assessed and determined to need LTC by the Korean National Health Insurance Corporation based on the severity of their disease and need for help with activities of daily living (ADLs). Elders who are totally dependent are classified as grade 1, elders who are mostly dependent are classified as grade 2, and those who are partially dependent are classified as grade 3 (Korean Ministry of Law Legislation, 2013a). Individuals in any of the three grades (1, 2, or 3) are eligible for either institutional or home care depending on their preference, but the payment level varies by the type of benefits the individual receives and the level of need. By the end of 2012, approximately 320,261 elders in Korea were assessed as grade 1 (42,611 elders), grade 2 (73,265 elders), and grade 3 (204,385 elders; Korean Ministry of Law Legislation, 2013a). About 69.7% of residents had diagnoses of chronic disease including hypertension (29.3%), diabetes (9.5%), cerebrovascular disease (19.2%), and mental health disease (35%) in 2011 (Korean Health Insurance Policy Institute, 2012). Korean nursing home residents are quite fragile and have intense health care needs; 69% of residents have chronic diseases including psychological disorders, cerebrovascular accident, and hypertension; about 72.9% of residents used medical services; 32.2% of residents experienced hospitalization
previously; and 20.3% were diagnosed with dementia (Korean Health Insurance Policy Institute, 2012). Also, more than half (56.3%) of the residents required assistance with ADLs because of cognitive impairment and imbalance (Park, Lim, Kim, Lee, & Song, 2011). This article compares nurse staffing in nursing homes in two countries. The article addresses the question of how South Korean nursing home education and training requirements, nurse staffing standards, and actual nurse staffing levels compare with those in the United States. The study used secondary documents and compared data from the two countries. This article describes the findings in the two countries and discusses the need for research in Korea to establish an empirical basis for educational requirements, staffing standards, and staffing levels in nursing homes.
Background Conceptually, staffing is considered a structural measure of quality related to quality process measures (e.g., resident restraints) and quality outcomes (e.g., pressure ulcers; Donabedian, 1980). Many studies of the relationship between nurse staffing and the nursing home process and outcome measures have been conducted in the United States, as described previously, but almost no research studies have been published in Korea. One key question is what should the nurse staffing standards and levels be for nursing homes? One U.S. study performed by the U.S. CMS (2001) found that nursing homes with fewer than 4.1 total nurse staffing hours per resident day (hprd) are more likely to cause harm or jeopardy to residents. Specifically, the study found that staffing levels above the following levels are needed to protect residents: 0.75 RN hours, 0.55 licensed vocational or licensed practical nurse (LPN) hours, and 2.78 certified nursing assistant (CNA) hours. These staffing levels are not required, but they are used by the Medicare Nursing Home Compare website as part of the rating of staffing in the United States (Abt Associates, 2013). In addition to the levels recommended by the U.S. CMS (2001), an expert panel and a consumer organization made similar recommendations for staffing levels in nursing homes (Harrington et al., 2000; National Citizens’ Coalition for Nursing Home Reform, 1999). No studies of staffing standards or levels were identified in South Korea.
Design and Method This descriptive study was based on documents and regulations of nursing home staffing standards as well as actual nurse staffing levels collected by researchers from the Internet, government websites, government documents, research papers, and reports in South
Nurs Outlook 63 (2015) 137e143
Korea and the United States. In South Korea, the standards are established at the national level, and these were obtained from government sources. We collected staffing data at the national level from the government for actual nursing levels. In the United States, we obtained data on the federal standards as well as the state standards from a survey of 50 states and the District of Columbia in 2010 (Harrington et al., 2012). Researchers compared the state standards with the federal nursing home staffing standards. We obtained data on actual nurse staffing levels from the Medicare Nursing Home Compare website for 2013 (Abt Associates, 2013). We also collected each country’s nomenclature for nursing homes, the number of homes, and the educational and training requirements. We standardized the available data across states and summarized them for each country for comparative purposes. In the United States, requirements are generally presented as hprd or in ratios of staff to residents. To convert staff ratios to hprd in the United States, each full-time equivalent employee (FTE) was assumed to work 8 hours per day in five 8-hour work shifts. In Korea, the standards are expressed in FTEs, and these were converted to hprd by assuming each FTE worked 40 hours a week or 2,080 hours a year.
Findings South Korean Nurse Staffing South Korean Education and Training Requirements RNs are classified as professional health care providers, along with doctors, dentists, oriental doctors, and midwives. They must have passed a national RN licensing examination and be licensed by the Korean Ministry of Health and Welfare (2013). The scope of RN practice includes helping doctors and providing care to the sick and injured (Korean Ministry of Health and Welfare, 2013). In nursing homes, RNs are involved in clinical practice, disease prevention and health promotion, health education, counseling for family members, and creating a therapeutic environment (Kim, 2011). At present, Korean nursing education has two different systems: 3-year junior college and 4-year university programs (Lee, Kang, Ko, Cho, & Kim, 2014). However, in 2011, a higher education law was passed that is in the process of transforming the 3-year junior college programs to 4-year nursing education programs (Lee et al., 2014). RNs will have to graduate from a university or college that has been accredited by the Korean Accreditation Board of Nursing Education (Lee et al., 2014). The required number of credits for graduation is 103, and at least 1,000 clinical hours are required by February 2017 based on the medical law of 2012 (Lee et al., 2014). As of April 2014, 23 of 201 universities or colleges have been accredited by the Korean Accreditation Board of Nursing Education
139
(2014). RN education and requirements in Korea are similar to those for RNs in the United States (You, 2013). The scope of practice for CNAs in Korean nursing homes includes assisting RNs, administering medication, providing simple wound treatments, transferring residents under the supervision of RNs in emergencies, and providing some care work such as bathing and feeding (Korean Ministry of Health and Welfare, 2013; Korean Ministry of Law Legislation, 2013b). CNA educational requirements are a total of 1,520 hours, including at least 740 hours of classroom study in an occupational high school or a private educational nursing institute and over 780 hours of clinical practice in health care settings (Korean Health Insurance Policy Institute, 2012; Korean Ministry of Law Legislation, 2013b). CNA candidates must pass a qualifying examination to be certified (Korean Health Insurance Policy Institute, 2012). They must also have 8 hours of continuing education per year but are not required to focus on gerontology or nursing home care (Korean Health Insurance Policy Institute, 2012). The job description of CNAs in Korea is similar to that of LPNs in the United States (You, 2013). Care workers are defined as staff who provide direct health care and housekeeping assistance for elders who cannot perform ADLs or have chronic diseases (Korean Ministry of Health and Welfare, 2013). The care worker scope of practice in nursing homes includes feeding, toileting, bathing, transferring, doing laundry, cleaning, observing residents and notifying nurses of resident problems, communicating with residents, and maintaining resident physical and cognitive capacities (Korean Ministry of Health and Welfare, 2011a). They must complete 240 hours in class and practice with detailed training requirements (since April 2010), and there are no prior educational requirements (Korean Ministry of Health and Welfare, 2013). Care worker candidates must complete 40 hours of practice in home care and 40 hours in institutional care like nursing homes (Korean Ministry of Law Legislation, 2013b). The job description of care workers in Korea is similar to the job description of CNAs in the United States.
South Korean Staffing Standards In Korea, the National Health Insurance Corporation established one national nurse staffing standard. The legal minimum requirement of nurse staffing for nursing homes is as follows: (a) for large-size nursing homes (over 30 residents), one RN or CNA to 25 residents (equal to 0.32 hprd) and one qualified care worker to 2.5 residents (equal to 3.2 hprd) and (b) for small-size nursing homes (less than 30 residents), one RN or one CNA (equal to 0.28 hprd) and one care worker to 2.5 residents (equal to 3.2 hprd; Korean National Health Insurance Corporation, 2011). For senior congregate housing, one RN or CNA (equal to 0.90 hprd) and one qualified care worker is required for every three residents (equal to 2.67 hprd). The Korean government provides financial incentives if housing hires more
140
Nurs Outlook 63 (2015) 137e143
RNs, but this incentive is quite limited (Korean Health Insurance Policy Institute, 2012).
South Korean Actual Nurse Staffing After the implementation of LTC insurance, nursing home staff has increased (Kim & Lee, 2013). In June 2013, the 2,610 nursing homes had a total of 118,631 residents per day. These nursing homes had an estimated 9,766 RNs and CNAs and 243,689 care workers (Korean National Health Insurance Corporation, 2013). Each FTE represents 2,080 hours per year or 8 hours per day. However, the total number of nursing staff (9,766 RNs and CNAs) reported did not differentiate between full-time and part-time, and the total number of care workers (243,689) reported also did not differentiate full-time and part-time positions. Thus, the most optimistic estimate is that each Korean resident received an average of 0.47 RN and CNA hprd (28 minutes; 55,653 RN and CNA hours per day divided by 118,631 residents), assuming that all 9,766 nursing staff work full-time. For caregiver hours, each resident received up to 11.7 hprd (1,388,693 hours divided by 118,631) if they were full-time workers. Because many are part-time, the hours are fewer, but data are unavailable. In addition to nursing staff, nursing homes had 1,152 physicians (including visiting doctors), 7,054 social workers, and 1,693 physical therapists and a total of about 263,361 staff (Korean National Health Insurance Corporation, 2013). Nursing home residents receive few physician visits (on average, about once a month). About 64% (2,775/4,327) of total nursing homes and senior housing facilities in Korea do not have any RNs, and the number of RNs has decreased by 4.9%, whereas the number of LTC facilities and residents have increased by 15.4% and 12.8%, respectively, between 2010 and 2012 (Kukmin Daily, 2013). Small-sized nursing homes were more likely to have CNAs than RNs; one RN to 2.6 residents in nursing homes with more than 30 residents; and a ratio of one RN to 4.5 residents for senior congregate housing (Korean National Health Insurance Corporation, 2011). The proportion of RNs among all employees in nursing homes is only 0.1% (Korean National Health Insurance Corporation, 2011).
U.S. Staffing U.S. Education and Training In the United States, RNs usually have at least 2 years of college education, whereas LPNs are only required to have about 1 year of training that focuses on the nursing skills to assist residents (Conant, 2004). The federal government requires only 75 hours of training for CNAs according to the 1987 Nursing Home Reform Act, which is much shorter than the required hours for care workers in South Korea (Harrington et al., 2012; U.S. Department of Health and Human Services, 2008).
U.S. Staffing Standards Since the passage of the Omnibus Budget Reconciliation Act of 1987, federal standards require all U.S. nursing homes to have sufficient nursing staff to provide nursing care and additional services to ensure the highest predictable physical, mental, and psychosocial well-being of each resident. The U.S. federal staffing standards require all certified nursing homes that provide Medicare and Medicaid services to have one RN on duty for 8 consecutive hours 7 days a week (including a full-time director of nursing), one RN, and one licensed nurse (either an RN or LPN) for the two remaining shifts, without adjustment for resident acuity (Harrington et al., 2012; U.S. CMS, 2001). This is equivalent to 0.38 RN and LPN hprd for 100 residents. States may set higher staffing standards than the federal standards (Harrington et al., 2012). Overall, 20 states had higher requirements for RNs than the federal requirements, 15 had the same, and 16 had lower requirements in 2010 (Harrington et al., 2012). In addition, 23 states had higher licensed nurse requirements than the federal government, and three states required 24-hour/day RN coverage (Harrington et al., 2012). Of the total, 34 states set minimum standards for direct care staff or CNAs (who met the federal standards of 75 hours of training or higher in some states). Direct care (including licensed nurses) standards were about 2.0 to 2.5 hprd and varied widely across states (Harrington et al., 2012). Ratios were required for direct care in 18 states where the best standards were a 1:5 direct care to resident ratio during the day, 1:10 in the evening, and 1:15 at night in the District of Columbia and Maine (Harrington et al., 2012). Florida had the highest standard of 3.9 for total nursing staff in 2010 (Harrington et al., 2012).
U.S. Actual Staffing Levels The United States has 15,653 nursing homes and a searchable Medicare Nursing Home Compare website that rates the quality of nursing homes (U.S. CMS, 2014). Nurse staffing levels in U.S. nursing homes increased after the implementation of the Nursing Home Reform Act (Zhang & Grabowski, 2004). Since the Medicare Nursing Home Compare 5-Star Quality rating system was established, actual staffing levels have continued to improve (Abt Associates, 2013). The total median nurse staffing levels in all U.S. nursing homes steadily increased from 3.6 hprd in January 2008 to 3.85 hprd in October 2011. These levels were significantly below the 4.1 hprd in 2008 and the 4.2 hprd in 2011 that the U.S. CMS estimated was needed based on the reported resident case mix (acuity) levels in nursing homes (Abt Associates, 2013). Median RN staffing in January 2008 was reported at 0.51 hprd, and this increased to 0.63 hprd in 2011, but it was well below the expected RN staffing levels (1.08 hprd in 2008 and 1.12 hprd in 2011). Median LPN hours were 0.78 hprd in 2011 and 0.80 hprd in 2011. This was above the expected hours for LPNs of 0.65 hprd in 2008
Nurs Outlook 63 (2015) 137e143
and 0.68 hprd in 2011. Finally, median CNA staffing was 2.29 hprd in January 2008, and this increased to 2.38 hprd in July 2011. These levels were well below the expected hours of 2.37 in January 2008 and 2.43 hours in October 2011 (Abt Associates, 2013).
Discussion The study showed that Korea and the United States have established educational and training requirements for nursing staff in nursing homes. The training requirements of CNAs in Korea are similar to those for LPNs in the United States, whereas care workers in Korea have training well above the equivalent CNAs in the United States. This study found that Korea has lower RN and CNA (equivalent to LPNs in the United States) standards and actual staffing levels that are much lower than in the United States. In contrast, staffing standards and actual staffing levels for care workers (who provide direct care to residents) appear to be higher in Korea than in the United States. The Korean Health Insurance Policy Institute (2012) determined that nursing homes need to have higher staffing levels with advanced nurse practitioners because nursing residents have increasing resident acuity and few physician visits, and the consistent assessment of residents is limited (Korean Health Insurance Policy Institute, 2012). Thus, current Korean nursing homes cannot meet the health care needs of residents promptly and appropriately (Korean Health Insurance Policy Institute, 2012). To meet growing health care needs effectively and efficiently, the Korean Health Insurance Policy Institute (2012) proposed a new staffing standard to improve nursing homes, but this has not been approved. The proposed standards include (a) a ratio of one RN or CNA per 20 residents (instead of 25 residents) and (b) the mandated use of advanced practice nurses (family, geriatric, psychiatric, or hospice) for large-sized nursing homes (over 30 residents). Although RN and CNA requirements are still grouped in one category, there is a new proposal that one RN should be hired for every two CNAs while maintaining the 1:25 ratio of RNs (Korean Health Insurance Policy Institute, 2012). Furthermore, the Institute proposed that RN responsibilities and rights should be expanded to include Foley catheter insertion and other special treatments that RNs are allowed to conduct in general hospitals under the supervision of a physician. This could reduce the transfers of nursing home residents to hospitals for specific treatments, which could reduce the burden of nursing staff and family members in making the transfers. Thus, RNs may become more independent and expand the professional practice of nursing, especially because most nursing home residents do not have access to physicians (Korean Ministry of Law Legislation, 2013a). Korean staffing requirements do not differentiate between RNs and CNAs. Because elders in Korean
141
nursing homes have high-care needs, it seems logical that more RNs should be required in nursing homes. Research in the United States makes a strong case that RNs have a stronger impact on improving nursing home quality over LPNs (Bostick et al., 2006; Spilsbury et al., 2011; U.S. CMS, 2001), probably because they have longer and higher training requirements. Some experts suggested that decisions to combine RN and CNA staffing standards in Korea, although the qualifications and educational requirements for RNs and CNAs are notably different, were made because of the high cost of hiring RNs. Even if the new proposed nursing home staffing requirements by the Korean National Health Insurance Corporation have not suggested separate standards for RNs and CNAs and have not proposed to differentiate between full-time and part-time or contract nurses, so the exact calculation of hours is not possible. In the future, a mandated reporting system of the staffing should be required. No research in Korea has been conducted on required staffing levels in Korean nursing homes or to compare the relationship of RNs and CNAs with quality of care. A top priority for future research in Korea should be to study the relationship between staffing levels and the mix of nurse staffing (RNs and CNAs) to develop a strong foundation for policy decisions. Thus, it is very timely to study staffing standards and quality for nursing home residents. Unlike U.S. nursing home service consumers, Korea has not developed consumer information about nursing home characteristics, staffing levels, and quality outcomes. This leaves consumers with a lack of access to information about staffing levels and quality that is available to consumers in the United States. Korean researchers and policy makers should also examine options for developing consumer information systems that inform consumers about staffing and quality. The caregiver workforce is still problematic in South Korea (Kim, Kim, & Jeong, 2010). Many unqualified education centers train care workers (Um, 2011). Furthermore, educational lecturers can be any social worker who has more than 3 years of experience or RNs with any experience (Kim, Shin, & Ha, 2010). Educational centers must meet national standards, and faculty members must be qualified to teach the clinical training needed for care workers (Kim et al., 2010). Some researchers suggested that the education requirement of 240 hours is not long enough for potential care workers to have adequate knowledge, skill, and ethical training (Kim et al., 2010; Kim et al., 2010). They also argued that continuing education programs for CNAs should be changed to increase the mandated number of hours and to tailor the training contents to geriatric care because in many nursing homes CNAs substitute for RNs in Korea (Korean Health Insurance Policy Institute, 2012). Both countries should also consider other factors that would improve the nursing home workforce such as increasing salaries, education levels, continuing education requirements, and the supervision of care
142
Nurs Outlook 63 (2015) 137e143
workers because care workers provide the majority of care to elders in nursing homes (Castle & Anderson, 2011; Kim et al., 2010). Reports of the caregiver workforce in Korea have found that workers are not satisfied with their low incomes (Lim, 2012), suffer from too much work, and complain about an inability to perform their basic duties (Kim et al., 2010). They must have reasonable salaries, adequate benefits and compensation, a good working environment, and continuing education to be qualified caregivers (Cho, 2009). In summary, more research is needed to develop and improve nursing home staffing standards and actual staffing for optimal care. The increasing care needs of nursing home residents and the demand for nursing home care show the importance of research and policy making that focuses on improving the quality of staffing levels and the quality of care in nursing homes.
Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (Grant number 2-2014-1221-001-1). This paper was supported by Eulji University in 2013.
references
Abt Associates. (2013). Nursing home compare 5-start quality rating system: Year three report. Retrieved from http://www.cms.gov/ Medicare/Provider-Enrollment-and-Certification/ CertificationandComplianc/Downloads/FSQRS-Report.pdf. Backhaus, R., Verbeek, H., Van Rossum, E., Capezuti, E., & Hamers, J. P. H. (2014). Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies. Journal of the American Medical Directors Association, 15(6), 383e393. Bostick, J. E., Rantz, M. J., Flesner, M. K., & Riggs, C. J. (2006). Systematic review of studies of staffing and quality in nursing homes. Journal of the American Medical Directors Association, 7, 366e376. Bowblis, J. R. (2011). Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Services Research, 46, 1495e1516. Castle, N. G. (2008). Nursing home caregiver staffing levels and quality of care: A literature review. Journal of Applied Gerontology, 27, 375e405. Castle, N. G., & Anderson, R. A. (2011). Caregiver staffing in nursing homes and their influence on quality of care: Using dynamic panel estimation methods. Medical Care, 49, 545e552. Cho, W. H. (2009). Suggestions from the care worker system in JapandAn analysis through a comparison with the nursing care system in Korea. Korean Association of Philippine Studies, 11(3), 243e262. Conant, S. M. (2004). Is ‘skilled nursing home’ a misnomer? Least educated providers constitute largest proportion of workforce. American Journal of Nursing, 104(6), 11. Dixon, S., Kaambwa, B., Nancarrow, S., Martin, G. P., & Bryan, S. (2010). The relationship between staff skill mix, costs, and
outcomes in intermediate care services. BMC Health Services Research, 10, 221e226. Donabedian, A. (1980). Exploration in quality assessment and monitoring. Volume 1: The definition of quality and approaches to assessment. Ann Arbor, MI: Health Administration Press. Harrington, C., Choiniere, J., Goldmann, M., Jacobsen, F. F., Lloyd, L., McGregor, M., . Szebehely, M. (2012). Nursing home staffing standards and staffing levels in six countries. Journal of Nursing Scholarship, 44, 88e98. Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Burger, S., Mohler, M., . Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the United States. The Gerontologist, 40, 5e16. Jansen, I. (2010). Residential long-term care: Public solutions to access and quality problems. HealthcarePapers, 10(4), 1e22. Kim, J., & Lee, S. Y. (2013). A study on care workers’ job performance and competency at long-term care homes. Health and Social Welfare Review, 33(2), 243e273. Kim, H., Harrington, C., & Greene, W. H. (2009). Registered nurse staffing mix and quality of care in nursing homes: A longitudinal analysis. The Gerontologist, 49, 81e90. Kim, H., Kovner, C., Harrington, C., Greene, W., & Mezey, M. (2009). A panel data analysis of the relationships of nursing home staffing levels and standards to regulatory deficiencies. Journal of Gerontology, 64B, 269e278. Kim, J. H. (2011). Knowledge and attitude toward the elderly in medical welfare facilities for older people: Comparison between nurses and nursing assistants. Seoul, South Korea: Myungji University Graduate School of Social Work. (Master’s thesis). Kim, S. H., Shin, J. H., & Ha, J. M. (2010). The experience of longterm caregiver education courses. Korean Gerontological Society, 3(1), 1e20. Kim, Y. T., Kim, H. U., & Jeong, M. H. (2010). Improvement and recognition of caregiver’s human management at a long-term care center for the elderly. Journal of Welfare for the Aged, 50, 243e262. Korean Accreditation Board of Nursing. (2014). Nursing education accreditation. Retrieved from http://www.kabon.or.kr/eng/ kabon02/index.php. Korean Health Insurance Policy Institute. (2012). Policy proposals about health care needs of long term care residents. Seoul, South Korea: Author. Korean Ministry of Health and Welfare. (2011a). 2011: The first care workers’ qualifying examination. Retrieved from http://www. mw.go.kr/front/al/sal0301vw.jsp?PAR_MENU_ID¼ 04&MENU_ID¼0403&CONT_SEQ¼248222&page¼1. Korean Ministry of Health and Welfare. (2011b). Major statistics on long term care insurance. Retrieved from http://www.khiss.go. kr/board/bbs_read.jsp?tname¼MINBOARD358&bbsid¼ B301&cat_bbsid¼&bbs_seq¼367&jkey¼&jword¼&pg¼1&htxt_ code¼12536978062659050219061516896964&wj_vcs¼. Korean Ministry of Health and Welfare. (2013). Medical law. Retrieved from http://www.law.go.kr/DRF/lawService.do? OC¼lrzh&target¼law&MST¼107499&type¼HTML. Korean Ministry of Law Legislation. (2013a). Long term care insurance enforcement ordinance. Retrieved from http://www. law.go.kr/lsSc.do?menuId¼0&subMenu¼1&query¼%EB%85% B8%EC%9D%B8%EC%9E%A5%EA%B8%B0%EC%9A%94%EC% 96%91%EB%B3%B4%ED%97%98#liBgcolor2. Korean Ministry of Law Legislation. (2013b). Rules of certified nurse aides and para health care professionals. Retrieved from http:// www.law.go.kr/lsInfoP.do?lsiSeq¼104690#AJAX. Korean National Health Insurance Corporation. (2011). Long term care insurance. Retrieved from http://www.longtermcare.or.kr/ portal/site/nydev/MENUITEM_SERVICE/.
Nurs Outlook 63 (2015) 137e143
Korean National Health Insurance Corporation. (2013). Long term care insurance dictionary. Retrieved from http:// www.longtermcare.or.kr/portal/site/nydev/MENUITEM_ TERMS/. Korean Statistical Information Service. (2013). Number of long term welfare facilities for the elderly. Retrieved from http://kosis.kr/ statHtml/statHtml.do?orgId¼117&tblId¼DT_117 N_B00003&vw_cd¼MT_ZTITLE&list_id¼101_11736&scrId¼ &seqNo¼&lang_mode¼ko&obj_var_id¼&itm_id¼&conn_ path¼E1. Kukmin Daily. (2013). The revision of long term care insurance in Korea. Retrieved from http://news.kukinews.com/article/view.asp? page¼1&gCode¼cul&arcid¼0007462007&cp¼nv. Lee, T., Kang, K. H., Ko, Y. K., Cho, S. H., & Kim, E. Y. (2014). Issues and challenges of nursing workforce policy: Critical review and implication. Journal of Korean Academy Nursing Administration, 20(1), 106e116. Lim, W. Y. (2012). The factors affecting recognition of professionalism of caregivers. Journal of Welfare and Counseling Education, 1(1), 65e80. National Citizens’ Coalition for Nursing Home Reform. (1999). Consumers’ minimum standard for nurse staffing in nursing homes. Washington, DC: Author. Park, A. J., Lim, N. Y., Kim, Y. S., Lee, Y. K., & Song, J. H. (2011). Incidence and predictors of falls in institutionalized eldery. Journal of Muscle and Joint Health, 18(1), 50e62. Schnelle, J. F., Simmons, S. F., Harrington, C., Cadogan, M., Garcia, E., & Bates-Jensen, B. (2004). Relationship of nursing home staffing to quality of care. Health Services Research, 39, 225e250. Spilsbury, K., Hewitt, C., Stirk, L., & Bowman, C. (2011). The relationship between nurse staffing and quality of care in nursing homes: A systematic review. International Journal of Nursing Studies, 48, 732e750. Sweden National Board of Health and Welfare. (2009). Va˚rd Och ¨ ldre. La¨gesrapport Fo¨r 2008. [Care and services to Omsorg Fo¨r A
143
older persons. Status report 2008]. Stockholmlm, Sweden: Socialstyrelsen. U.K. Care Quality Commission. (2010). Guidance about compliance: Essential standards of quality and safety. London, England: Author. Um, K. W. (2011). Study on problems and improvement of the training and certification system of the care worker. Research for Community Development, 10(1), 87e112. U.S. Centers for Medicare and Medicaid Services. (2001). Report to Congress: Appropriateness of minimum nurse staffing ratios in nursing homes. Retrieved from http://www.cms.hhs.gov/ medicaid/reports/rp700hmp.asp. U.S. Centers for Medicare and Medicaid Services. (2014). Nursing home compare. Retrieved from https://data.medicare.gov/ Nursing-Home-Compare/Provider-Info/hq9i-23gr. U.S. Department of Health and Human Services. (2008). Nursing aides, home health aides, and related health care occupationsdnational and local workforce shortages and associated data needs. Retrieved from http://bhpr.hrsa.gov/ healthworkforce/reports/nursing/nurseaides/chapt5.htm. U.S. Department of Health and Human Services, Office of the Inspector General. (2014). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries (OEI-06-11-00370). Retrieved from https://oig.hhs.gov/oei/ reports/oei-06-11-00370.pdf. U.S. Government Accountability Office. (2009). Nursing homes: Addressing the factors underlying understatement of serious care problems requires sustained CMS and state commitment (GAO10e70). Retrieved from http://www.gao.gov/new.items/d1070. pdf. You, S. J. (2013). Comparisons of the nursing workforce with Japan, and the U.S. Journal of Digital Policy & Management, 11(6), 275e287. Zhang, X., & Grabowski, D. C. (2004). Nursing home staffing and quality under the Nursing Home Reform Act. The Gerontologist, 44, 13e23.
Nurs Outlook 63 (2015) 137e143
www.nursingoutlook.org
Comparing the nurse staffing in Korean and U.S. nursing homes Hyang Yuol Lee, PhDa, Juh Hyun Shin, PhDb,*, Charlene Harrington, PhDc a
b
College of Nursing, Eulji University, Jung-gu, Daejeon, South Korea Division of Nursing Science, College of Health Sciences, Ewha Womans University, Seodaemun-gu, Seoul, South Korea c Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA
article info
abstract
Article history: Received 11 April 2014 Revised 10 July 2014 Accepted 4 August 2014 Available online 14 August 2014
Introduction: The quality of nursing home care has been problematic in both the
Keywords: Korea Nursing home Quality Staffing standard United States
United States and South Korea; quality is limited to inadequate nurse staffing levels. This article addresses how South Korean nursing home education and training requirements, nurse staffing standards, and actual nurse staffing levels compare with those in the United States. Methods: The study used secondary documents and data to compare the two countries. Results: Korea has lower registered nurse and certified nursing assistant standards and actual staffing levels than the United States. In contrast, staffing standards and actual staffing levels for care workers who provide direct care to residents are higher in Korea than in the United States. Conclusions: Research is needed in Korea to establish an empirical basis for educational requirements, staffing standards, and staffing levels in nursing homes. Cite this article: Lee, H. Y., Shin, J. H., & Harrington, C. (2015, APRIL). Comparing the nurse staffing in Korean and U.S. nursing homes. Nursing Outlook, 63(2), 137-143. http://dx.doi.org/10.1016/ j.outlook.2014.08.005.
Introduction Nursing home quality is a major concern in a number of countries (Harrington et al., 2012). In the United States, many studies have documented quality problems in nursing homes, such as resident weight loss, pressure ulcers, infections, pain, depression, and other treatable or preventable problems (Schnelle et al., 2004; U.S. Centers for Medicare and Medicaid Services [CMS], 2001; U.S. Government Accountability Office, 2009). A recent study of nursing home residents found an estimated 22% experienced adverse events, and an additional 11% experienced temporary harmful events during their skilled nursing facility stays (U.S.
Department of Health and Human Services, Office of the Inspector General, 2014). Other studies identified poor quality of care in Canada (Jansen, 2010), in England where new standards and regulatory oversight were established (Dixon, Kaambwa, Nancarrow, Martin, & Bryan, 2010; U.K. Care Quality Commission, 2010), and in Sweden where new guidelines for dementia care units were established (Sweden National Board of Health and Welfare, 2009). A number of research studies have shown a strong relationship between poor quality of nursing home care and low nurse staffing levels (U.S. CMS, 2001). A systematic review of 87 research articles and reports from 1975 through 2003 found that high total staffing levels, especially of registered nurses (RNs), were
* Corresponding author: Juh Hyun Shin, Division of Nursing Science, College of Health Sciences, Ewha Womans University, 120-750 Helen Hall 205, EwhaYeodaegil 52, Seoul, Republic of Korea. E-mail address: [email protected] (J.H. Shin). 0029-6554/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2014.08.005
138
Nurs Outlook 63 (2015) 137e143
associated with improved care processes and resident outcomes for functional ability, pressure ulcers, and weight loss (Bostick, Rantz, Flesner, & Riggs, 2006). Other research reviews and studies found that higher staffing levels relate to lower deficiencies, better resident outcomes, and less avoidable hospitalization rates (Bowblis, 2011; Castle, 2008; Kim, Harrington, & Greene, 2009; Kim, Kovner, Harrington, Greene, & Mezey, 2009; Spilsbury, Hewitt, Stirk, & Bowman, 2011). Although some study results were mixed and inconsistent, the benefits associated with high nurse staffing underline the importance of nurse staffing standards and staffing levels (Backhaus, Verbeek, Van Rossum, Capezuti, & Hamers, 2014). Nursing home quality and staffing concerns have developed in South Korea, as in other industrialized countries. In South Korea, the elderly population is rapidly increasing, and the need for long-term care (LTC) facilities for elders has grown. The government responded to these increasing needs by passing a law establishing a public LTC insurance program for senior citizens in 2008 (Korean National Health Insurance Corporation, 2011). The purpose of LTC insurance is to provide optimal quality of care to beneficiaries and decrease the burden of caregivers (Korean Ministry of Health and Welfare, 2011b). Two types of South Korean LTC facilities were established: (a) nursing homes divided into small homes (with 10e29 residents) and large homes (with 30 or more residents) and (b) senior congregate housing programs that have more than five but fewer than nine residents (Korean National Health Insurance Corporation, 2011). There were 2,610 nursing homes and 1,742 senior housing facilities in 2012 (Korean Statistical Information Service, 2013). To be eligible for the South Korean LTC insurance program, elders must be assessed and determined to need LTC by the Korean National Health Insurance Corporation based on the severity of their disease and need for help with activities of daily living (ADLs). Elders who are totally dependent are classified as grade 1, elders who are mostly dependent are classified as grade 2, and those who are partially dependent are classified as grade 3 (Korean Ministry of Law Legislation, 2013a). Individuals in any of the three grades (1, 2, or 3) are eligible for either institutional or home care depending on their preference, but the payment level varies by the type of benefits the individual receives and the level of need. By the end of 2012, approximately 320,261 elders in Korea were assessed as grade 1 (42,611 elders), grade 2 (73,265 elders), and grade 3 (204,385 elders; Korean Ministry of Law Legislation, 2013a). About 69.7% of residents had diagnoses of chronic disease including hypertension (29.3%), diabetes (9.5%), cerebrovascular disease (19.2%), and mental health disease (35%) in 2011 (Korean Health Insurance Policy Institute, 2012). Korean nursing home residents are quite fragile and have intense health care needs; 69% of residents have chronic diseases including psychological disorders, cerebrovascular accident, and hypertension; about 72.9% of residents used medical services; 32.2% of residents experienced hospitalization
previously; and 20.3% were diagnosed with dementia (Korean Health Insurance Policy Institute, 2012). Also, more than half (56.3%) of the residents required assistance with ADLs because of cognitive impairment and imbalance (Park, Lim, Kim, Lee, & Song, 2011). This article compares nurse staffing in nursing homes in two countries. The article addresses the question of how South Korean nursing home education and training requirements, nurse staffing standards, and actual nurse staffing levels compare with those in the United States. The study used secondary documents and compared data from the two countries. This article describes the findings in the two countries and discusses the need for research in Korea to establish an empirical basis for educational requirements, staffing standards, and staffing levels in nursing homes.
Background Conceptually, staffing is considered a structural measure of quality related to quality process measures (e.g., resident restraints) and quality outcomes (e.g., pressure ulcers; Donabedian, 1980). Many studies of the relationship between nurse staffing and the nursing home process and outcome measures have been conducted in the United States, as described previously, but almost no research studies have been published in Korea. One key question is what should the nurse staffing standards and levels be for nursing homes? One U.S. study performed by the U.S. CMS (2001) found that nursing homes with fewer than 4.1 total nurse staffing hours per resident day (hprd) are more likely to cause harm or jeopardy to residents. Specifically, the study found that staffing levels above the following levels are needed to protect residents: 0.75 RN hours, 0.55 licensed vocational or licensed practical nurse (LPN) hours, and 2.78 certified nursing assistant (CNA) hours. These staffing levels are not required, but they are used by the Medicare Nursing Home Compare website as part of the rating of staffing in the United States (Abt Associates, 2013). In addition to the levels recommended by the U.S. CMS (2001), an expert panel and a consumer organization made similar recommendations for staffing levels in nursing homes (Harrington et al., 2000; National Citizens’ Coalition for Nursing Home Reform, 1999). No studies of staffing standards or levels were identified in South Korea.
Design and Method This descriptive study was based on documents and regulations of nursing home staffing standards as well as actual nurse staffing levels collected by researchers from the Internet, government websites, government documents, research papers, and reports in South
Nurs Outlook 63 (2015) 137e143
Korea and the United States. In South Korea, the standards are established at the national level, and these were obtained from government sources. We collected staffing data at the national level from the government for actual nursing levels. In the United States, we obtained data on the federal standards as well as the state standards from a survey of 50 states and the District of Columbia in 2010 (Harrington et al., 2012). Researchers compared the state standards with the federal nursing home staffing standards. We obtained data on actual nurse staffing levels from the Medicare Nursing Home Compare website for 2013 (Abt Associates, 2013). We also collected each country’s nomenclature for nursing homes, the number of homes, and the educational and training requirements. We standardized the available data across states and summarized them for each country for comparative purposes. In the United States, requirements are generally presented as hprd or in ratios of staff to residents. To convert staff ratios to hprd in the United States, each full-time equivalent employee (FTE) was assumed to work 8 hours per day in five 8-hour work shifts. In Korea, the standards are expressed in FTEs, and these were converted to hprd by assuming each FTE worked 40 hours a week or 2,080 hours a year.
Findings South Korean Nurse Staffing South Korean Education and Training Requirements RNs are classified as professional health care providers, along with doctors, dentists, oriental doctors, and midwives. They must have passed a national RN licensing examination and be licensed by the Korean Ministry of Health and Welfare (2013). The scope of RN practice includes helping doctors and providing care to the sick and injured (Korean Ministry of Health and Welfare, 2013). In nursing homes, RNs are involved in clinical practice, disease prevention and health promotion, health education, counseling for family members, and creating a therapeutic environment (Kim, 2011). At present, Korean nursing education has two different systems: 3-year junior college and 4-year university programs (Lee, Kang, Ko, Cho, & Kim, 2014). However, in 2011, a higher education law was passed that is in the process of transforming the 3-year junior college programs to 4-year nursing education programs (Lee et al., 2014). RNs will have to graduate from a university or college that has been accredited by the Korean Accreditation Board of Nursing Education (Lee et al., 2014). The required number of credits for graduation is 103, and at least 1,000 clinical hours are required by February 2017 based on the medical law of 2012 (Lee et al., 2014). As of April 2014, 23 of 201 universities or colleges have been accredited by the Korean Accreditation Board of Nursing Education
139
(2014). RN education and requirements in Korea are similar to those for RNs in the United States (You, 2013). The scope of practice for CNAs in Korean nursing homes includes assisting RNs, administering medication, providing simple wound treatments, transferring residents under the supervision of RNs in emergencies, and providing some care work such as bathing and feeding (Korean Ministry of Health and Welfare, 2013; Korean Ministry of Law Legislation, 2013b). CNA educational requirements are a total of 1,520 hours, including at least 740 hours of classroom study in an occupational high school or a private educational nursing institute and over 780 hours of clinical practice in health care settings (Korean Health Insurance Policy Institute, 2012; Korean Ministry of Law Legislation, 2013b). CNA candidates must pass a qualifying examination to be certified (Korean Health Insurance Policy Institute, 2012). They must also have 8 hours of continuing education per year but are not required to focus on gerontology or nursing home care (Korean Health Insurance Policy Institute, 2012). The job description of CNAs in Korea is similar to that of LPNs in the United States (You, 2013). Care workers are defined as staff who provide direct health care and housekeeping assistance for elders who cannot perform ADLs or have chronic diseases (Korean Ministry of Health and Welfare, 2013). The care worker scope of practice in nursing homes includes feeding, toileting, bathing, transferring, doing laundry, cleaning, observing residents and notifying nurses of resident problems, communicating with residents, and maintaining resident physical and cognitive capacities (Korean Ministry of Health and Welfare, 2011a). They must complete 240 hours in class and practice with detailed training requirements (since April 2010), and there are no prior educational requirements (Korean Ministry of Health and Welfare, 2013). Care worker candidates must complete 40 hours of practice in home care and 40 hours in institutional care like nursing homes (Korean Ministry of Law Legislation, 2013b). The job description of care workers in Korea is similar to the job description of CNAs in the United States.
South Korean Staffing Standards In Korea, the National Health Insurance Corporation established one national nurse staffing standard. The legal minimum requirement of nurse staffing for nursing homes is as follows: (a) for large-size nursing homes (over 30 residents), one RN or CNA to 25 residents (equal to 0.32 hprd) and one qualified care worker to 2.5 residents (equal to 3.2 hprd) and (b) for small-size nursing homes (less than 30 residents), one RN or one CNA (equal to 0.28 hprd) and one care worker to 2.5 residents (equal to 3.2 hprd; Korean National Health Insurance Corporation, 2011). For senior congregate housing, one RN or CNA (equal to 0.90 hprd) and one qualified care worker is required for every three residents (equal to 2.67 hprd). The Korean government provides financial incentives if housing hires more
140
Nurs Outlook 63 (2015) 137e143
RNs, but this incentive is quite limited (Korean Health Insurance Policy Institute, 2012).
South Korean Actual Nurse Staffing After the implementation of LTC insurance, nursing home staff has increased (Kim & Lee, 2013). In June 2013, the 2,610 nursing homes had a total of 118,631 residents per day. These nursing homes had an estimated 9,766 RNs and CNAs and 243,689 care workers (Korean National Health Insurance Corporation, 2013). Each FTE represents 2,080 hours per year or 8 hours per day. However, the total number of nursing staff (9,766 RNs and CNAs) reported did not differentiate between full-time and part-time, and the total number of care workers (243,689) reported also did not differentiate full-time and part-time positions. Thus, the most optimistic estimate is that each Korean resident received an average of 0.47 RN and CNA hprd (28 minutes; 55,653 RN and CNA hours per day divided by 118,631 residents), assuming that all 9,766 nursing staff work full-time. For caregiver hours, each resident received up to 11.7 hprd (1,388,693 hours divided by 118,631) if they were full-time workers. Because many are part-time, the hours are fewer, but data are unavailable. In addition to nursing staff, nursing homes had 1,152 physicians (including visiting doctors), 7,054 social workers, and 1,693 physical therapists and a total of about 263,361 staff (Korean National Health Insurance Corporation, 2013). Nursing home residents receive few physician visits (on average, about once a month). About 64% (2,775/4,327) of total nursing homes and senior housing facilities in Korea do not have any RNs, and the number of RNs has decreased by 4.9%, whereas the number of LTC facilities and residents have increased by 15.4% and 12.8%, respectively, between 2010 and 2012 (Kukmin Daily, 2013). Small-sized nursing homes were more likely to have CNAs than RNs; one RN to 2.6 residents in nursing homes with more than 30 residents; and a ratio of one RN to 4.5 residents for senior congregate housing (Korean National Health Insurance Corporation, 2011). The proportion of RNs among all employees in nursing homes is only 0.1% (Korean National Health Insurance Corporation, 2011).
U.S. Staffing U.S. Education and Training In the United States, RNs usually have at least 2 years of college education, whereas LPNs are only required to have about 1 year of training that focuses on the nursing skills to assist residents (Conant, 2004). The federal government requires only 75 hours of training for CNAs according to the 1987 Nursing Home Reform Act, which is much shorter than the required hours for care workers in South Korea (Harrington et al., 2012; U.S. Department of Health and Human Services, 2008).
U.S. Staffing Standards Since the passage of the Omnibus Budget Reconciliation Act of 1987, federal standards require all U.S. nursing homes to have sufficient nursing staff to provide nursing care and additional services to ensure the highest predictable physical, mental, and psychosocial well-being of each resident. The U.S. federal staffing standards require all certified nursing homes that provide Medicare and Medicaid services to have one RN on duty for 8 consecutive hours 7 days a week (including a full-time director of nursing), one RN, and one licensed nurse (either an RN or LPN) for the two remaining shifts, without adjustment for resident acuity (Harrington et al., 2012; U.S. CMS, 2001). This is equivalent to 0.38 RN and LPN hprd for 100 residents. States may set higher staffing standards than the federal standards (Harrington et al., 2012). Overall, 20 states had higher requirements for RNs than the federal requirements, 15 had the same, and 16 had lower requirements in 2010 (Harrington et al., 2012). In addition, 23 states had higher licensed nurse requirements than the federal government, and three states required 24-hour/day RN coverage (Harrington et al., 2012). Of the total, 34 states set minimum standards for direct care staff or CNAs (who met the federal standards of 75 hours of training or higher in some states). Direct care (including licensed nurses) standards were about 2.0 to 2.5 hprd and varied widely across states (Harrington et al., 2012). Ratios were required for direct care in 18 states where the best standards were a 1:5 direct care to resident ratio during the day, 1:10 in the evening, and 1:15 at night in the District of Columbia and Maine (Harrington et al., 2012). Florida had the highest standard of 3.9 for total nursing staff in 2010 (Harrington et al., 2012).
U.S. Actual Staffing Levels The United States has 15,653 nursing homes and a searchable Medicare Nursing Home Compare website that rates the quality of nursing homes (U.S. CMS, 2014). Nurse staffing levels in U.S. nursing homes increased after the implementation of the Nursing Home Reform Act (Zhang & Grabowski, 2004). Since the Medicare Nursing Home Compare 5-Star Quality rating system was established, actual staffing levels have continued to improve (Abt Associates, 2013). The total median nurse staffing levels in all U.S. nursing homes steadily increased from 3.6 hprd in January 2008 to 3.85 hprd in October 2011. These levels were significantly below the 4.1 hprd in 2008 and the 4.2 hprd in 2011 that the U.S. CMS estimated was needed based on the reported resident case mix (acuity) levels in nursing homes (Abt Associates, 2013). Median RN staffing in January 2008 was reported at 0.51 hprd, and this increased to 0.63 hprd in 2011, but it was well below the expected RN staffing levels (1.08 hprd in 2008 and 1.12 hprd in 2011). Median LPN hours were 0.78 hprd in 2011 and 0.80 hprd in 2011. This was above the expected hours for LPNs of 0.65 hprd in 2008
Nurs Outlook 63 (2015) 137e143
and 0.68 hprd in 2011. Finally, median CNA staffing was 2.29 hprd in January 2008, and this increased to 2.38 hprd in July 2011. These levels were well below the expected hours of 2.37 in January 2008 and 2.43 hours in October 2011 (Abt Associates, 2013).
Discussion The study showed that Korea and the United States have established educational and training requirements for nursing staff in nursing homes. The training requirements of CNAs in Korea are similar to those for LPNs in the United States, whereas care workers in Korea have training well above the equivalent CNAs in the United States. This study found that Korea has lower RN and CNA (equivalent to LPNs in the United States) standards and actual staffing levels that are much lower than in the United States. In contrast, staffing standards and actual staffing levels for care workers (who provide direct care to residents) appear to be higher in Korea than in the United States. The Korean Health Insurance Policy Institute (2012) determined that nursing homes need to have higher staffing levels with advanced nurse practitioners because nursing residents have increasing resident acuity and few physician visits, and the consistent assessment of residents is limited (Korean Health Insurance Policy Institute, 2012). Thus, current Korean nursing homes cannot meet the health care needs of residents promptly and appropriately (Korean Health Insurance Policy Institute, 2012). To meet growing health care needs effectively and efficiently, the Korean Health Insurance Policy Institute (2012) proposed a new staffing standard to improve nursing homes, but this has not been approved. The proposed standards include (a) a ratio of one RN or CNA per 20 residents (instead of 25 residents) and (b) the mandated use of advanced practice nurses (family, geriatric, psychiatric, or hospice) for large-sized nursing homes (over 30 residents). Although RN and CNA requirements are still grouped in one category, there is a new proposal that one RN should be hired for every two CNAs while maintaining the 1:25 ratio of RNs (Korean Health Insurance Policy Institute, 2012). Furthermore, the Institute proposed that RN responsibilities and rights should be expanded to include Foley catheter insertion and other special treatments that RNs are allowed to conduct in general hospitals under the supervision of a physician. This could reduce the transfers of nursing home residents to hospitals for specific treatments, which could reduce the burden of nursing staff and family members in making the transfers. Thus, RNs may become more independent and expand the professional practice of nursing, especially because most nursing home residents do not have access to physicians (Korean Ministry of Law Legislation, 2013a). Korean staffing requirements do not differentiate between RNs and CNAs. Because elders in Korean
141
nursing homes have high-care needs, it seems logical that more RNs should be required in nursing homes. Research in the United States makes a strong case that RNs have a stronger impact on improving nursing home quality over LPNs (Bostick et al., 2006; Spilsbury et al., 2011; U.S. CMS, 2001), probably because they have longer and higher training requirements. Some experts suggested that decisions to combine RN and CNA staffing standards in Korea, although the qualifications and educational requirements for RNs and CNAs are notably different, were made because of the high cost of hiring RNs. Even if the new proposed nursing home staffing requirements by the Korean National Health Insurance Corporation have not suggested separate standards for RNs and CNAs and have not proposed to differentiate between full-time and part-time or contract nurses, so the exact calculation of hours is not possible. In the future, a mandated reporting system of the staffing should be required. No research in Korea has been conducted on required staffing levels in Korean nursing homes or to compare the relationship of RNs and CNAs with quality of care. A top priority for future research in Korea should be to study the relationship between staffing levels and the mix of nurse staffing (RNs and CNAs) to develop a strong foundation for policy decisions. Thus, it is very timely to study staffing standards and quality for nursing home residents. Unlike U.S. nursing home service consumers, Korea has not developed consumer information about nursing home characteristics, staffing levels, and quality outcomes. This leaves consumers with a lack of access to information about staffing levels and quality that is available to consumers in the United States. Korean researchers and policy makers should also examine options for developing consumer information systems that inform consumers about staffing and quality. The caregiver workforce is still problematic in South Korea (Kim, Kim, & Jeong, 2010). Many unqualified education centers train care workers (Um, 2011). Furthermore, educational lecturers can be any social worker who has more than 3 years of experience or RNs with any experience (Kim, Shin, & Ha, 2010). Educational centers must meet national standards, and faculty members must be qualified to teach the clinical training needed for care workers (Kim et al., 2010). Some researchers suggested that the education requirement of 240 hours is not long enough for potential care workers to have adequate knowledge, skill, and ethical training (Kim et al., 2010; Kim et al., 2010). They also argued that continuing education programs for CNAs should be changed to increase the mandated number of hours and to tailor the training contents to geriatric care because in many nursing homes CNAs substitute for RNs in Korea (Korean Health Insurance Policy Institute, 2012). Both countries should also consider other factors that would improve the nursing home workforce such as increasing salaries, education levels, continuing education requirements, and the supervision of care
142
Nurs Outlook 63 (2015) 137e143
workers because care workers provide the majority of care to elders in nursing homes (Castle & Anderson, 2011; Kim et al., 2010). Reports of the caregiver workforce in Korea have found that workers are not satisfied with their low incomes (Lim, 2012), suffer from too much work, and complain about an inability to perform their basic duties (Kim et al., 2010). They must have reasonable salaries, adequate benefits and compensation, a good working environment, and continuing education to be qualified caregivers (Cho, 2009). In summary, more research is needed to develop and improve nursing home staffing standards and actual staffing for optimal care. The increasing care needs of nursing home residents and the demand for nursing home care show the importance of research and policy making that focuses on improving the quality of staffing levels and the quality of care in nursing homes.
Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (Grant number 2-2014-1221-001-1). This paper was supported by Eulji University in 2013.
references
Abt Associates. (2013). Nursing home compare 5-start quality rating system: Year three report. Retrieved from http://www.cms.gov/ Medicare/Provider-Enrollment-and-Certification/ CertificationandComplianc/Downloads/FSQRS-Report.pdf. Backhaus, R., Verbeek, H., Van Rossum, E., Capezuti, E., & Hamers, J. P. H. (2014). Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies. Journal of the American Medical Directors Association, 15(6), 383e393. Bostick, J. E., Rantz, M. J., Flesner, M. K., & Riggs, C. J. (2006). Systematic review of studies of staffing and quality in nursing homes. Journal of the American Medical Directors Association, 7, 366e376. Bowblis, J. R. (2011). Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Services Research, 46, 1495e1516. Castle, N. G. (2008). Nursing home caregiver staffing levels and quality of care: A literature review. Journal of Applied Gerontology, 27, 375e405. Castle, N. G., & Anderson, R. A. (2011). Caregiver staffing in nursing homes and their influence on quality of care: Using dynamic panel estimation methods. Medical Care, 49, 545e552. Cho, W. H. (2009). Suggestions from the care worker system in JapandAn analysis through a comparison with the nursing care system in Korea. Korean Association of Philippine Studies, 11(3), 243e262. Conant, S. M. (2004). Is ‘skilled nursing home’ a misnomer? Least educated providers constitute largest proportion of workforce. American Journal of Nursing, 104(6), 11. Dixon, S., Kaambwa, B., Nancarrow, S., Martin, G. P., & Bryan, S. (2010). The relationship between staff skill mix, costs, and
outcomes in intermediate care services. BMC Health Services Research, 10, 221e226. Donabedian, A. (1980). Exploration in quality assessment and monitoring. Volume 1: The definition of quality and approaches to assessment. Ann Arbor, MI: Health Administration Press. Harrington, C., Choiniere, J., Goldmann, M., Jacobsen, F. F., Lloyd, L., McGregor, M., . Szebehely, M. (2012). Nursing home staffing standards and staffing levels in six countries. Journal of Nursing Scholarship, 44, 88e98. Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Burger, S., Mohler, M., . Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the United States. The Gerontologist, 40, 5e16. Jansen, I. (2010). Residential long-term care: Public solutions to access and quality problems. HealthcarePapers, 10(4), 1e22. Kim, J., & Lee, S. Y. (2013). A study on care workers’ job performance and competency at long-term care homes. Health and Social Welfare Review, 33(2), 243e273. Kim, H., Harrington, C., & Greene, W. H. (2009). Registered nurse staffing mix and quality of care in nursing homes: A longitudinal analysis. The Gerontologist, 49, 81e90. Kim, H., Kovner, C., Harrington, C., Greene, W., & Mezey, M. (2009). A panel data analysis of the relationships of nursing home staffing levels and standards to regulatory deficiencies. Journal of Gerontology, 64B, 269e278. Kim, J. H. (2011). Knowledge and attitude toward the elderly in medical welfare facilities for older people: Comparison between nurses and nursing assistants. Seoul, South Korea: Myungji University Graduate School of Social Work. (Master’s thesis). Kim, S. H., Shin, J. H., & Ha, J. M. (2010). The experience of longterm caregiver education courses. Korean Gerontological Society, 3(1), 1e20. Kim, Y. T., Kim, H. U., & Jeong, M. H. (2010). Improvement and recognition of caregiver’s human management at a long-term care center for the elderly. Journal of Welfare for the Aged, 50, 243e262. Korean Accreditation Board of Nursing. (2014). Nursing education accreditation. Retrieved from http://www.kabon.or.kr/eng/ kabon02/index.php. Korean Health Insurance Policy Institute. (2012). Policy proposals about health care needs of long term care residents. Seoul, South Korea: Author. Korean Ministry of Health and Welfare. (2011a). 2011: The first care workers’ qualifying examination. Retrieved from http://www. mw.go.kr/front/al/sal0301vw.jsp?PAR_MENU_ID¼ 04&MENU_ID¼0403&CONT_SEQ¼248222&page¼1. Korean Ministry of Health and Welfare. (2011b). Major statistics on long term care insurance. Retrieved from http://www.khiss.go. kr/board/bbs_read.jsp?tname¼MINBOARD358&bbsid¼ B301&cat_bbsid¼&bbs_seq¼367&jkey¼&jword¼&pg¼1&htxt_ code¼12536978062659050219061516896964&wj_vcs¼. Korean Ministry of Health and Welfare. (2013). Medical law. Retrieved from http://www.law.go.kr/DRF/lawService.do? OC¼lrzh&target¼law&MST¼107499&type¼HTML. Korean Ministry of Law Legislation. (2013a). Long term care insurance enforcement ordinance. Retrieved from http://www. law.go.kr/lsSc.do?menuId¼0&subMenu¼1&query¼%EB%85% B8%EC%9D%B8%EC%9E%A5%EA%B8%B0%EC%9A%94%EC% 96%91%EB%B3%B4%ED%97%98#liBgcolor2. Korean Ministry of Law Legislation. (2013b). Rules of certified nurse aides and para health care professionals. Retrieved from http:// www.law.go.kr/lsInfoP.do?lsiSeq¼104690#AJAX. Korean National Health Insurance Corporation. (2011). Long term care insurance. Retrieved from http://www.longtermcare.or.kr/ portal/site/nydev/MENUITEM_SERVICE/.
Nurs Outlook 63 (2015) 137e143
Korean National Health Insurance Corporation. (2013). Long term care insurance dictionary. Retrieved from http:// www.longtermcare.or.kr/portal/site/nydev/MENUITEM_ TERMS/. Korean Statistical Information Service. (2013). Number of long term welfare facilities for the elderly. Retrieved from http://kosis.kr/ statHtml/statHtml.do?orgId¼117&tblId¼DT_117 N_B00003&vw_cd¼MT_ZTITLE&list_id¼101_11736&scrId¼ &seqNo¼&lang_mode¼ko&obj_var_id¼&itm_id¼&conn_ path¼E1. Kukmin Daily. (2013). The revision of long term care insurance in Korea. Retrieved from http://news.kukinews.com/article/view.asp? page¼1&gCode¼cul&arcid¼0007462007&cp¼nv. Lee, T., Kang, K. H., Ko, Y. K., Cho, S. H., & Kim, E. Y. (2014). Issues and challenges of nursing workforce policy: Critical review and implication. Journal of Korean Academy Nursing Administration, 20(1), 106e116. Lim, W. Y. (2012). The factors affecting recognition of professionalism of caregivers. Journal of Welfare and Counseling Education, 1(1), 65e80. National Citizens’ Coalition for Nursing Home Reform. (1999). Consumers’ minimum standard for nurse staffing in nursing homes. Washington, DC: Author. Park, A. J., Lim, N. Y., Kim, Y. S., Lee, Y. K., & Song, J. H. (2011). Incidence and predictors of falls in institutionalized eldery. Journal of Muscle and Joint Health, 18(1), 50e62. Schnelle, J. F., Simmons, S. F., Harrington, C., Cadogan, M., Garcia, E., & Bates-Jensen, B. (2004). Relationship of nursing home staffing to quality of care. Health Services Research, 39, 225e250. Spilsbury, K., Hewitt, C., Stirk, L., & Bowman, C. (2011). The relationship between nurse staffing and quality of care in nursing homes: A systematic review. International Journal of Nursing Studies, 48, 732e750. Sweden National Board of Health and Welfare. (2009). Va˚rd Och ¨ ldre. La¨gesrapport Fo¨r 2008. [Care and services to Omsorg Fo¨r A
143
older persons. Status report 2008]. Stockholmlm, Sweden: Socialstyrelsen. U.K. Care Quality Commission. (2010). Guidance about compliance: Essential standards of quality and safety. London, England: Author. Um, K. W. (2011). Study on problems and improvement of the training and certification system of the care worker. Research for Community Development, 10(1), 87e112. U.S. Centers for Medicare and Medicaid Services. (2001). Report to Congress: Appropriateness of minimum nurse staffing ratios in nursing homes. Retrieved from http://www.cms.hhs.gov/ medicaid/reports/rp700hmp.asp. U.S. Centers for Medicare and Medicaid Services. (2014). Nursing home compare. Retrieved from https://data.medicare.gov/ Nursing-Home-Compare/Provider-Info/hq9i-23gr. U.S. Department of Health and Human Services. (2008). Nursing aides, home health aides, and related health care occupationsdnational and local workforce shortages and associated data needs. Retrieved from http://bhpr.hrsa.gov/ healthworkforce/reports/nursing/nurseaides/chapt5.htm. U.S. Department of Health and Human Services, Office of the Inspector General. (2014). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries (OEI-06-11-00370). Retrieved from https://oig.hhs.gov/oei/ reports/oei-06-11-00370.pdf. U.S. Government Accountability Office. (2009). Nursing homes: Addressing the factors underlying understatement of serious care problems requires sustained CMS and state commitment (GAO10e70). Retrieved from http://www.gao.gov/new.items/d1070. pdf. You, S. J. (2013). Comparisons of the nursing workforce with Japan, and the U.S. Journal of Digital Policy & Management, 11(6), 275e287. Zhang, X., & Grabowski, D. C. (2004). Nursing home staffing and quality under the Nursing Home Reform Act. The Gerontologist, 44, 13e23.
