Using a few agency nursing assistants to fill in as needed doesn’t seem to hurt care quality in nursing homes, but relying too heavily on them does, according to a report in Medical Care Research and Review. Homes that used more than 14 full-time equivalent (FTE) agency nursing assistants per 100 residents within the past year did worse on all 14 of the quality measures studied.

“Nurse Aide Agency Staffing and Quality of Care in Nursing Homes” is only the second study to look at agency staffing in nursing homes – and the first to focus on nursing assistants rather than licensed nurses. (A 2006 report found that facilities where more than 5 percent of the LPNs or RNs were temps had more deficiency citations.) The new study found the influence of nursing assistant agency staffing on care quality to be “pervasive and in many cases of significant magnitude.”

“Levels of NA agency use levels above 14 FTEs per 100 residents do appear to have a large negative impact on quality of care, and corporate management and facility owners could be mindful of this ‘tipping point,’” say researchers Nicholas G. Castle and colleagues.

The authors also suggest that regulators and policy makers:

• Look for high levels of NA agency use as “a signal for additional licensure and certification survey activities (e.g., special emphasis inspections)”; 
• Include NA agency staffing levels on nursing home report cards; and
• When drafting mandating minimum staffing level laws or regulations, make sure nursing homes can’t meet the requirements simply by increasing the amount of agency staff.

Using agency staff can make it harder on residents and permanent staff in several ways, the authors say. The premium facilities must pay for their services make less money available for care delivery or for hiring more permanent staff. Permanent workers are often moved to new positions to make way for agency staff, which interferes with continuity of care and decreases job satisfaction. Bringing on too many temporary workers may also decrease teamwork and increase workloads for permanent staff, who have to do more to compensate for the agency workers’ inexperience or lack of familiarity with the facility and its residents. And temp workers’ lack of familiarity with residents and with facility protocol can also lower care quality and “cause psychological distress for some residents.”

There’s a chicken-and-egg question here: could the facilities that use the most agency staff be the ones that had the most problems and delivered the worst care to begin with? That’s possible, the authors acknowledge, adding that more studies are needed to answer that question. “Low-quality facilities may have difficulty attracting NAs, poorly managed facilities may have difficulty retaining current NAs, facilities administratively understaffed may not have the ability to hire new NAs, and poorly managed facilities may devalue human resources NA recruitment efforts,” the authors acknowledge. “In these cases, the use of agency staff may simply be the result of other organizational difficulties.”

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Elise Nakhnikian is PHI’s Senior Online Editor