Relationship between the presence of baccalaureate-educated RNs and quality of care: a cross-sectional study in Dutch long-term care facilities

BMC Health Serv Res. 2017 Jan 19;17(1):53. doi: 10.1186/s12913-016-1947-8.


Background: Recent evidence suggests that an increase in baccalaureate-educated registered nurses (BRNs) leads to better quality of care in hospitals. For geriatric long-term care facilities such as nursing homes, this relationship is less clear. Most studies assessing the relationship between nurse staffing and quality of care in long-term care facilities are US-based, and only a few have focused on the unique contribution of registered nurses. In this study, we focus on BRNs, as they are expected to serve as role models and change agents, while little is known about their unique contribution to quality of care in long-term care facilities.

Methods: We conducted a cross-sectional study among 282 wards and 6,145 residents from 95 Dutch long-term care facilities. The relationship between the presence of BRNs in wards and quality of care was assessed, controlling for background characteristics, i.e. ward size, and residents' age, gender, length of stay, comorbidities, and care dependency status. Multilevel logistic regression analyses, using a generalized estimating equation approach, were performed.

Results: 57% of the wards employed BRNs. In these wards, the BRNs delivered on average 4.8 min of care per resident per day. Among residents living in somatic wards that employed BRNs, the probability of experiencing a fall (odds ratio 1.44; 95% CI 1.06-1.96) and receiving antipsychotic drugs (odds ratio 2.15; 95% CI 1.66-2.78) was higher, whereas the probability of having an indwelling urinary catheter was lower (odds ratio 0.70; 95% CI 0.53-0.91). Among residents living in psychogeriatric wards that employed BRNs, the probability of experiencing a medication incident was lower (odds ratio 0.68; 95% CI 0.49-0.95). For residents from both ward types, the probability of suffering from nosocomial pressure ulcers did not significantly differ for residents in wards employing BRNs.

Conclusions: In wards that employed BRNs, their mean amount of time spent per resident was low, while quality of care on most wards was acceptable. No consistent evidence was found for a relationship between the presence of BRNs in wards and quality of care outcomes, controlling for background characteristics. Future studies should consider the mediating and moderating role of staffing-related work processes and ward environment characteristics on quality of care.

Keywords: Long-term care facilities; Nursing homes; Quality of care; Registered nurses; Staffing.

MeSH terms

  • Accidental Falls / statistics & numerical data
  • Aged
  • Antipsychotic Agents / therapeutic use
  • Cross Infection / drug therapy
  • Cross Infection / etiology
  • Cross-Sectional Studies
  • Educational Status
  • Female
  • Hospitals / standards
  • Humans
  • Long-Term Care / standards*
  • Male
  • Netherlands
  • Nurses / standards*
  • Nursing Homes / standards
  • Odds Ratio
  • Pressure Ulcer / etiology
  • Quality of Health Care
  • Skilled Nursing Facilities / standards


  • Antipsychotic Agents