A systematic review of the association between nursing staff and nursing-sensitive outcomes in long-term institutional care

Astrid Tuinman*, Mathieu H. G. De Greef, Evelyn J. Finnema, Petrie F. Roodbol

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

10 Citations (Scopus)
128 Downloads (Pure)


Aims To examine the association between type of nursing staff and nursing-sensitive outcomes in long-term institutional care.

Design This systematic review included studies published in English, German, and Dutch between January 1997 and January 2020.

Data sources The databases Medline (PubMed), CINAHL, PsycINFO, Embase, and the Cochrane Library were searched. Original quantitative studies were included.

Review methods The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were followed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to critically appraise the reporting of the studies.

Results Fifteen articles were included. Of 33 quality of care outcomes, 21 were identified as nursing-sensitive outcomes of which 13 showed a significant association with nursing staff, specifically: Activities of daily living, aggressive behavior, bladder/bowel incontinence, contractures, expressive language skills, falls, infection (including vaccination), range of motion, pain, pressure ulcers, and weight loss. However, studies reported inconsistent results regarding the association among RNs, LPNs, CNAs, and HCAs and these nursing-sensitive outcomes, evidence shows that more RNs have a positive impact on nursing-sensitive outcomes. As to the evidence regarding the other type of nursing staff, especially HCA, findings regularly showed a negative association.

Conclusion Future research should be expanded with structure and process variables of which the mediating and moderating effect on nursing-sensitive outcomes is known. These may explain variances in quality of care and guide quality improvement initiatives. Researchers should consider fully applying Donabedian's structure-process-outcomes framework as it is a coherent entirety for quality assessment.

Impact This review provides an overview of quality of care outcomes that are responsive to nursing interventions in long-term institutional care. As the effects can be monitored and documented, quality assessment should focus on these nursing-sensitive outcomes. The inconclusive results make it difficult to provide recommendations on who should best perform which care.

Original languageEnglish
Pages (from-to)3303-3316
Number of pages14
JournalJournal of Advanced Nursing
Issue number8
Publication statusPublished - Aug-2021


  • literature review
  • long&#8208
  • term care
  • nursing homes
  • nursing outcomes
  • nursing staff
  • outcome assessment (health care)
  • skill mix
  • standardized nursing terminology
  • systematic review

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