The Relationship Between Registered Nurses and Nursing Home Quality

An Integrative Review (2008-2014)

Mary Ellen Dellefield, PhD, RN; Nickolas G. Castle, PhD, MHA; Katherine S. Mcgilton, PhD, RN; Karen Spilsbury, PhD, RN


Nurs Econ. 2015;33(2):95-108. 

In This Article


Implementation of the Affordable Care Act has generated renewed interest in the quality and costs of health care provided to Medicare and Medicaid beneficiaries in skilled nursing facilities (SNFs), commonly referred to as nursing homes (NHs). Nursing home care is expensive; it is second only to acute hospital care for inpatient Medicare costs (Office of Inspector General [OIG], 2014). The increased focus on costs of care accrued by Medicare beneficiaries in NHs presents a valuable opportunity for registered nurses (RNs) to further demonstrate quantitatively the value they add to the capacity of the NH nursing skill mix to provide cost-effective and efficient quality care. Paraprofessionals (nursing assistants [NAs], certified nursing assistants, restorative nursing assistants, and licensed vocational/practical nurses [LVNs/LPNs]) have provided the majority of direct care to NH residents since 1965 (Institute of Medicine [IOM], 1996). Registered nurses increase the skill mix of this workforce. Skill mix refers to differences in education and licensure among nursing staff. It is unclear as to the benefits of this increase in skill mix with respect to costs and quality.

This integrative review is unique in that the RN is the sole focus of the review. By virtue of education and training, the RN is a key contributor to NH quality (Castle & Anderson, 2011; IOM, 2004). Researchers have reported a positive relationship between RN involvement in decision making and better clinical outcomes (Anderson & McDaniel, 1992, 1998, 1999). This is significant because effective care planning is based on the quality of clinical decision making (Centers for Medicare & Medicaid Services [CMS], 2013). Skills in care plan development, care planning, and coordination of care with interdisciplinary team members are codified as core RN competencies within RN state practice acts in the United States (American Nurses Association, 2010).

No prior review has examined the RN as a key contributor to the NH; yet research highlights the multifaceted role of the RN in NHs and their positive impact on residents, relatives, and staff (Heath, 2010). This review of research findings is made in an effort to advance the evidence-base supporting the proposition that RNs add value to NH residents' experiences both directly through the level of RN staffing and indirectly through the clinical leadership they provide to members of the nursing skill mix.