Date of Award
2025
Degree Name
Business Administration
College
College of Business
Type of Degree
D.B.A.
Document Type
Dissertation
First Advisor
Dr. Alberto Coustasse-Hencke
Second Advisor
Dr. Dennis Emmett
Third Advisor
Dr. E. Michael Robie
Abstract
Nurse staffing levels have been shown to have a critical impact on nursing quality in skilled nursing facilities (SNFs). Sociodemographic disparities in Appalachian areas have the potential to impact SNF nurse staffing levels and quality. This study examined the relationship between nurse staffing levels and quality in Appalachian SNFs, as well as compliance with the Biden Administration’s minimum staffing mandates as set forth in CMS-3442-F enacted on June 24, 2024.
The study applied Resource Dependency Theory (RDT) through Donabedian’s Structure-Process-Outcome (SPO) conceptual framework to assess how external resource constraints and regulatory policies impact nurse staffing levels and quality in Appalachian SNFs. This cross-sectional study analyzed publicly available CMS data from 14,817 Medicare-certified nursing homes. Descriptive statistics and multiple regression analysis were used to examine the relationship between nurse staffing levels (total, RN, and NA), compliance with federal staffing mandates, and quality ratings. Geographic and organizational control variables were incorporated to assess disparities across rural and non-rural Appalachian SNFs.
Findings indicated that RN staffing levels were a strong predictor of quality, while NA staffing levels were not significantly associated with quality ratings. Total nurse staffing levels showed a positive correlation with quality, but facility compliance with CMS-3442-F was low, with only 12% of Appalachian SNFs meeting mandated staffing minimums. Rural Appalachian SNFs exhibited lower quality ratings and greater compliance challenges than their non-rural counterparts. Compliance with CMS-3442-F was associated with improved quality outcomes, but rural Appalachian SNFs continued to struggle.
These findings underscore the need for targeted policy interventions, including RN recruitment incentives, flexible staffing models, and financial assistance to support rural SNFs in meeting federal requirements. Future research should explore long-term compliance trends and the effectiveness of alternative staffing solutions in Appalachian SNFs.
Subject(s)
Nursing.
Nursing homes.
Nursing -- Employment.
Nursing homes -- Quality.
Nursing -- Quality.
Medical care -- Appalachian Region.
Rural population -- Health aspects.
Appalachian Region.
Recommended Citation
Pulice, Eric, "A question for the ages: the relationship between nurse staffing and quality in Appalachian skilled nursing facilities" (2025). Theses, Dissertations and Capstones. 1934.
https://mds.marshall.edu/etd/1934
