# Exploring the Relationship Between Nursing Staff and Family Members’ Appraisal of Resident Care in Nursing Homes: The Role of Facility Ownership

## TL;DR

This study finds that meeting CNA staffing requirements improves family members' perceptions of nursing home care quality, while RN staffing levels do not.

## Contribution

The study examines how facility ownership and staffing levels affect family appraisals of care quality under new U.S. regulations.

## Key findings

- Facilities meeting CNA staffing requirements received better family ratings in overall quality and subdomains like staffing and care.
- Meeting RN staffing requirements was not associated with improved family ratings.
- For-profit status did not moderate the relationship between staffing and family ratings.

## Abstract

Background/Objectives: To address long-standing staffing challenges and elevating care standards in the United States, new legislation will require a minimum of 0.55 h per resident day (HPRD) of registered nurse (RN) care, 2.45 HPRD of certified nursing aide (CNA) care, and a combined total of 3.48 HPRD across any combination of nursing staff. We examine differences in family members’ views of care quality between facilities meeting the minimum staffing requirements and those that do not and whether there is any difference in those associations by facility ownership. Methods: This cross-sectional study utilized public data from 218 Medicare and Medicaid-certified nursing facilities in Maryland, collected in 2023. We used regression analyses to examine the association between staffing requirements and quality of care ratings, considering facility ownership status as a potential moderator. Results: Compared to facilities with CNA staffing levels below the cut off, facilities that met the CNA staffing requirement were rated more favorably by family members in overall quality and across the subdomains of staffing, care, activities, and security. In contrast, meeting the RN 0.55 cut off was not associated with family ratings across any quality domain. A facility for-profit status did not moderate the relationship between staffing and family ratings. Conclusions: These results suggest that CNA staff time is a significant driver of care quality and that non-profit facilities may already be closer to meeting new federal requirements. These findings highlight the need for regulations that support the minimum nursing staffing requirements to enhance care quality. Future research should identify the specific factors contributing to higher quality care in non-profit facilities and explore ways to implement these practices in for-profit settings.