Mandate without means: An evaluation of Connecticut’s short-lived RN staffing policy in nursing homes

Abstract

Staffing levels in U.S. nursing homes often affect resident outcomes. Despite this, federal requirements remain low, which leaves states to set their own standards. In 2023, Connecticut put in place a rule requiring 0.84 hours of the required 3.0 hours of total direct care per resident-day to come specifically from Registered Nurses (RNs) as opposed to lower-cost aides. The policy was repealed after 10 months due to cost and workforce concerns. We used panel data from 207 facilities (2021 to 2024) and employed fixed-effects regression models to analyze the policy’s effect on registered nurse hours, aide hours, total direct-care hours, and resident fall rates. We hypothesized that the mandate would increase RN staffing and reduce falls with injury. However, RN hours actually decreased significantly by 0.084 hours per resident-day. Aide hours rose slightly but not significantly. Total direct-care hours and fall rates remained unchanged, and RN staffing did not have much effect on quality outcomes. Instead of improvements in care quality, we merely saw shifts in labor composition post-policy. The results show that sudden, underfunded staffing requirements do not always work. This is because there are not enough workers, and regulatory uncertainty in the policy limits compliance. Noticeable improvements in care quality require realistic timelines, stable funding, and workforce capacity, all features missing in the 2023 CT mandate.