Available online at www.sciencedirect.com

Nur s Out l o o k 6 3 ( 2 0 1 5 ) 1 3 7e 1 4 3www.nursingoutlook.org

Comparing the nurse staffing in Korean and U.S.nursing homes

Hyang Yuol Lee, PhDa, Juh Hyun Shin, PhDb,*, Charlene Harrington, PhDc

aCollege of Nursing, Eulji University, Jung-gu, Daejeon, South KoreabDivision of Nursing Science, College of Health Sciences, Ewha Womans University, Seodaemun-gu, Seoul, South Korea

cDepartment of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA

a r t i c l e i n f o

Article history:Received 11 April 2014Revised 10 July 2014Accepted 4 August 2014Available online 14 August 2014

Keywords:KoreaNursing homeQualityStaffing standardUnited States

* Corresponding author: Juh Hyun Shin, DivisHall 205, EwhaYeodaegil 52, Seoul, Republic

E-mail address: juhshin@ewha.ac.kr (J.H.

0029-6554/$ - see front matter � 2015 Elsevihttp://dx.doi.org/10.1016/j.outlook.2014.08.00

a b s t r a c t

Introduction: The quality of nursing home care has been problematic in both theUnited States and South Korea; quality is limited to inadequate nurse staffinglevels. This article addresses how South Korean nursing home education andtraining requirements, nurse staffing standards, and actual nurse staffing levelscompare with those in the United States.Methods: The study used secondary documents and data to compare the twocountries.Results: Korea has lower registered nurse and certified nursing assistant stan-dards and actual staffing levels than the United States. In contrast, staffingstandards and actual staffing levels for care workers who provide direct care toresidents are higher in Korea than in the United States.Conclusions: Research is needed in Korea to establish an empirical basis foreducational requirements, staffing standards, and staffing levels in nursinghomes.

Cite this article: Lee, H. Y., Shin, J. H., & Harrington, C. (2015, APRIL). Comparing the nurse staffing in

Korean and U.S. nursing homes. Nursing Outlook, 63(2), 137-143. http://dx.doi.org/10.1016/

j.outlook.2014.08.005.

Introduction

Nursing home quality is a major concern in a numberof countries (Harrington et al., 2012). In the UnitedStates, many studies have documented quality prob-lems in nursing homes, such as resident weight loss,pressure ulcers, infections, pain, depression, and othertreatable or preventable problems (Schnelle et al., 2004;U.S. Centers for Medicare and Medicaid Services [CMS],2001; U.S. Government Accountability Office, 2009). Arecent study of nursing home residents found an esti-mated 22% experienced adverse events, and an addi-tional 11% experienced temporary harmful eventsduring their skilled nursing facility stays (U.S.

ion of Nursing Science, Coof Korea.Shin).

er Inc. All rights reserved5

Department of Health and Human Services, Office ofthe Inspector General, 2014). Other studies identifiedpoor quality of care in Canada (Jansen, 2010), in En-gland where new standards and regulatory oversightwere established (Dixon, Kaambwa, Nancarrow,Martin, & Bryan, 2010; U.K. Care Quality Commission,2010), and in Sweden where new guidelines for de-mentia care units were established (Sweden NationalBoard of Health and Welfare, 2009).

A number of research studies have shown a strongrelationship between poor quality of nursing homecare and low nurse staffing levels (U.S. CMS, 2001). Asystematic review of 87 research articles and reportsfrom 1975 through 2003 found that high total staffinglevels, especially of registered nurses (RNs), were

llege of Health Sciences, EwhaWomans University, 120-750 Helen

.

Nur s Out l o o k 6 3 ( 2 0 1 5 ) 1 3 7e 1 4 3138

associated with improved care processes and residentoutcomes for functional ability, pressure ulcers, andweight loss (Bostick, Rantz, Flesner, & Riggs, 2006).Other research reviews and studies found that higherstaffing levels relate to lower deficiencies, better resi-dent outcomes, and less avoidable hospitalizationrates (Bowblis, 2011; Castle, 2008; Kim, Harrington, &Greene, 2009; Kim, Kovner, Harrington, Greene, &Mezey, 2009; Spilsbury, Hewitt, Stirk, & Bowman,2011). Although some study results were mixed andinconsistent, the benefits associated with high nursestaffing underline the importance of nurse staffingstandards and staffing levels (Backhaus, Verbeek, VanRossum, Capezuti, & Hamers, 2014).

Nursing home quality and staffing concerns havedeveloped in South Korea, as in other industrializedcountries. In South Korea, the elderly population israpidly increasing, and theneed for long-termcare (LTC)facilities for elders has grown. The governmentresponded to these increasing needs by passing a lawestablishing a public LTC insurance program for seniorcitizens in 2008 (Korean National Health InsuranceCorporation, 2011). The purpose of LTC insurance is toprovide optimal quality of care to beneficiaries anddecrease the burden of caregivers (Korean Ministry ofHealth and Welfare, 2011b). Two types of South KoreanLTC facilities were established: (a) nursing homesdivided into small homes (with 10e29 residents) andlarge homes (with 30 or more residents) and (b) seniorcongregate housing programs that have more than fivebut fewer than nine residents (Korean National HealthInsurance Corporation, 2011). There were 2,610 nursinghomes and 1,742 senior housing facilities in 2012(Korean Statistical Information Service, 2013).

To be eligible for the South Korean LTC insuranceprogram, elders must be assessed and determined toneed LTC by the Korean National Health InsuranceCorporation based on the severity of their disease andneed for helpwith activities of daily living (ADLs). Elderswho are totally dependent are classified as grade 1, el-ders who aremostly dependent are classified as grade 2,and those who are partially dependent are classified asgrade 3 (Korean Ministry of Law Legislation, 2013a). In-dividuals in any of the three grades (1, 2, or 3) are eligiblefor either institutional or home care depending on theirpreference, but the payment level varies by the type ofbenefits the individual receives and the level of need. Bythe end of 2012, approximately 320,261 elders in Koreawere assessed as grade 1 (42,611 elders), grade 2 (73,265elders), and grade 3 (204,385 elders; Korean Ministry ofLaw Legislation, 2013a). About 69.7% of residents haddiagnoses of chronic disease including hypertension(29.3%), diabetes (9.5%), cerebrovascular disease (19.2%),and mental health disease (35%) in 2011 (Korean HealthInsurance Policy Institute, 2012). Korean nursing homeresidents are quite fragile and have intense health careneeds; 69% of residents have chronic diseases includingpsychological disorders, cerebrovascular accident, andhypertension; about 72.9% of residents used medicalservices; 32.2% of residents experienced hospitalization

previously; and 20.3% were diagnosed with dementia(Korean Health Insurance Policy Institute, 2012). Also,more than half (56.3%) of the residents required assis-tance with ADLs because of cognitive impairment andimbalance (Park, Lim, Kim, Lee, & Song, 2011).

This article compares nurse staffing in nursinghomes in two countries. The article addresses thequestion of how South Korean nursing home educationand training requirements, nurse staffing standards,and actual nurse staffing levels compare with those inthe United States. The study used secondary docu-ments and compared data from the two countries. Thisarticle describes the findings in the two countries anddiscusses the need for research in Korea to establish anempirical basis for educational requirements, staffingstandards, and staffing levels in nursing homes.

Background

Conceptually, staffing is considered a structural mea-sure of quality related to quality process measures(e.g., resident restraints) and quality outcomes (e.g.,pressure ulcers; Donabedian, 1980). Many studies ofthe relationship between nurse staffing and thenursing home process and outcome measures havebeen conducted in the United States, as describedpreviously, but almost no research studies have beenpublished in Korea.

One key question is what should the nurse staffingstandards and levels be for nursing homes? One U.S.study performed by the U.S. CMS (2001) found thatnursing homes with fewer than 4.1 total nurse staffinghours per resident day (hprd) are more likely to causeharm or jeopardy to residents. Specifically, the studyfound that staffing levels above the following levels areneeded to protect residents: 0.75 RN hours, 0.55licensed vocational or licensed practical nurse (LPN)hours, and 2.78 certified nursing assistant (CNA) hours.These staffing levels are not required, but they are usedby the Medicare Nursing Home Compare website aspart of the rating of staffing in the United States (AbtAssociates, 2013). In addition to the levels recom-mended by the U.S. CMS (2001), an expert panel and aconsumer organization made similar recommenda-tions for staffing levels in nursing homes (Harringtonet al., 2000; National Citizens’ Coalition for NursingHome Reform, 1999). No studies of staffing standardsor levels were identified in South Korea.

Design and Method

This descriptive study was based on documents andregulations of nursing home staffing standards as wellas actual nurse staffing levels collected by researchersfrom the Internet, government websites, governmentdocuments, research papers, and reports in South

Nur s Ou t l o o k 6 3 ( 2 0 1 5 ) 1 3 7e 1 4 3 139

Korea and the United States. In South Korea, thestandards are established at the national level, andthese were obtained from government sources. Wecollected staffing data at the national level from thegovernment for actual nursing levels.

In the United States, we obtained data on the federalstandards as well as the state standards from a surveyof 50 states and the District of Columbia in 2010(Harrington et al., 2012). Researchers compared thestate standards with the federal nursing home staffingstandards. We obtained data on actual nurse staffinglevels from the Medicare Nursing Home Comparewebsite for 2013 (Abt Associates, 2013). We alsocollected each country’s nomenclature for nursinghomes, the number of homes, and the educational andtraining requirements.

We standardized the available data across statesand summarized them for each country for compara-tive purposes. In the United States, requirements aregenerally presented as hprd or in ratios of staff to res-idents. To convert staff ratios to hprd in the UnitedStates, each full-time equivalent employee (FTE) wasassumed to work 8 hours per day in five 8-hour workshifts. In Korea, the standards are expressed in FTEs,and these were converted to hprd by assuming eachFTE worked 40 hours a week or 2,080 hours a year.

Findings

South Korean Nurse Staffing

South Korean Education and Training RequirementsRNs are classified as professional health care providers,along with doctors, dentists, oriental doctors, andmidwives. They must have passed a national RNlicensing examination and be licensed by the KoreanMinistry of Health and Welfare (2013). The scope ofRN practice includes helping doctors and providingcare to the sick and injured (Korean Ministry of HealthandWelfare, 2013). In nursing homes, RNs are involvedin clinical practice, disease prevention and healthpromotion, health education, counseling for familymembers, and creating a therapeutic environment(Kim, 2011). At present, Korean nursing education hastwo different systems: 3-year junior college and 4-yearuniversity programs (Lee, Kang, Ko, Cho, & Kim, 2014).However, in 2011, a higher education law was passedthat is in the process of transforming the 3-year juniorcollege programs to 4-year nursing education pro-grams (Lee et al., 2014). RNs will have to graduate froma university or college that has been accredited by theKorean Accreditation Board of Nursing Education (Leeet al., 2014). The required number of credits for grad-uation is 103, and at least 1,000 clinical hours arerequired by February 2017 based on the medical law of2012 (Lee et al., 2014). As of April 2014, 23 of 201 uni-versities or colleges have been accredited by theKorean Accreditation Board of Nursing Education

(2014). RN education and requirements in Korea aresimilar to those for RNs in the United States (You,2013).

The scope of practice for CNAs in Korean nursinghomes includes assisting RNs, administering medica-tion, providing simple wound treatments, transferringresidents under the supervision of RNs in emergencies,and providing some care work such as bathing andfeeding (Korean Ministry of Health and Welfare, 2013;Korean Ministry of Law Legislation, 2013b). CNAeducational requirements are a total of 1,520 hours,including at least 740 hours of classroom study in anoccupational high school or a private educationalnursing institute and over 780 hours of clinical practicein health care settings (Korean Health Insurance PolicyInstitute, 2012; Korean Ministry of Law Legislation,2013b). CNA candidates must pass a qualifying exam-ination to be certified (Korean Health Insurance PolicyInstitute, 2012). They must also have 8 hours ofcontinuing education per year but are not required tofocus on gerontology or nursing home care (KoreanHealth Insurance Policy Institute, 2012). The jobdescription of CNAs in Korea is similar to that of LPNsin the United States (You, 2013).

Care workers are defined as staff who provide directhealth care and housekeeping assistance for elderswho cannot perform ADLs or have chronic diseases(KoreanMinistry of Health andWelfare, 2013). The careworker scope of practice in nursing homes includesfeeding, toileting, bathing, transferring, doing laundry,cleaning, observing residents and notifying nurses ofresident problems, communicating with residents, andmaintaining resident physical and cognitive capacities(Korean Ministry of Health and Welfare, 2011a). Theymust complete 240 hours in class and practice withdetailed training requirements (since April 2010), andthere are no prior educational requirements (KoreanMinistry of Health and Welfare, 2013). Care workercandidatesmust complete 40 hours of practice in homecare and 40 hours in institutional care like nursinghomes (KoreanMinistry of Law Legislation, 2013b). Thejob description of care workers in Korea is similar tothe job description of CNAs in the United States.

South Korean Staffing StandardsIn Korea, the National Health Insurance Corporationestablished one national nurse staffing standard. Thelegal minimum requirement of nurse staffing fornursing homes is as follows: (a) for large-size nursinghomes (over 30 residents), one RN or CNA to 25 resi-dents (equal to 0.32 hprd) and one qualified care workerto 2.5 residents (equal to 3.2 hprd) and (b) for small-sizenursing homes (less than 30 residents), one RN or oneCNA (equal to 0.28 hprd) and one care worker to 2.5residents (equal to 3.2 hprd; Korean National HealthInsurance Corporation, 2011). For senior congregatehousing, one RN or CNA (equal to 0.90 hprd) and onequalified care worker is required for every three resi-dents (equal to 2.67 hprd). The Korean governmentprovides financial incentives if housing hires more

Nur s Out l o o k 6 3 ( 2 0 1 5 ) 1 3 7e 1 4 3140

RNs, but this incentive is quite limited (Korean HealthInsurance Policy Institute, 2012).

South Korean Actual Nurse StaffingAfter the implementation of LTC insurance, nursinghome staff has increased (Kim & Lee, 2013). In June2013, the 2,610 nursing homes had a total of 118,631residents per day. These nursing homes had an esti-mated 9,766 RNs and CNAs and 243,689 care workers(Korean National Health Insurance Corporation, 2013).Each FTE represents 2,080 hours per year or 8 hours perday. However, the total number of nursing staff (9,766RNs and CNAs) reported did not differentiate betweenfull-time and part-time, and the total number of careworkers (243,689) reported also did not differentiatefull-time and part-time positions. Thus, the mostoptimistic estimate is that each Korean residentreceived an average of 0.47 RN and CNA hprd (28 mi-nutes; 55,653 RN and CNA hours per day divided by118,631 residents), assuming that all 9,766 nursing staffwork full-time. For caregiver hours, each residentreceived up to 11.7 hprd (1,388,693 hours divided by118,631) if they were full-time workers. Because manyare part-time, the hours are fewer, but data areunavailable.

In addition to nursing staff, nursing homes had1,152 physicians (including visiting doctors), 7,054 so-cial workers, and 1,693 physical therapists and a totalof about 263,361 staff (Korean National HealthInsurance Corporation, 2013). Nursing home residentsreceive few physician visits (on average, about once amonth).

About 64% (2,775/4,327) of total nursing homes andsenior housing facilities in Korea do not have any RNs,and the number of RNs has decreased by 4.9%, whereasthe number of LTC facilities and residents haveincreased by 15.4% and 12.8%, respectively, between2010 and 2012 (Kukmin Daily, 2013). Small-sized nursinghomes were more likely to have CNAs than RNs; oneRN to 2.6 residents in nursing homeswithmore than 30residents; and a ratio of one RN to 4.5 residents forsenior congregate housing (Korean National HealthInsurance Corporation, 2011). The proportion of RNsamong all employees in nursing homes is only 0.1%(Korean National Health Insurance Corporation, 2011).

U.S. Staffing

U.S. Education and TrainingIn the United States, RNs usually have at least 2 years ofcollege education, whereas LPNs are only required tohave about 1 year of training that focuses on thenursing skills to assist residents (Conant, 2004). Thefederal government requires only 75 hours of trainingfor CNAs according to the 1987 Nursing HomeReform Act, which is much shorter than the requiredhours for care workers in South Korea (Harringtonet al., 2012; U.S. Department of Health and HumanServices, 2008).

U.S. Staffing StandardsSince the passage of the Omnibus Budget Reconcili-ation Act of 1987, federal standards require all U.S.nursing homes to have sufficient nursing staff toprovide nursing care and additional services toensure the highest predictable physical, mental, andpsychosocial well-being of each resident. The U.S.federal staffing standards require all certified nursinghomes that provide Medicare and Medicaid servicesto have one RN on duty for 8 consecutive hours 7 daysa week (including a full-time director of nursing), oneRN, and one licensed nurse (either an RN or LPN) forthe two remaining shifts, without adjustment forresident acuity (Harrington et al., 2012; U.S. CMS,2001). This is equivalent to 0.38 RN and LPN hprdfor 100 residents.

States may set higher staffing standards than thefederal standards (Harrington et al., 2012). Overall, 20states had higher requirements for RNs than the fed-eral requirements, 15 had the same, and 16 had lowerrequirements in 2010 (Harrington et al., 2012). In addi-tion, 23 states had higher licensed nurse requirementsthan the federal government, and three states required24-hour/day RN coverage (Harrington et al., 2012). Ofthe total, 34 states set minimum standards for directcare staff or CNAs (who met the federal standards of75 hours of training or higher in some states). Directcare (including licensed nurses) standards were about2.0 to 2.5 hprd and varied widely across states(Harrington et al., 2012). Ratios were required for directcare in 18 states where the best standards were a 1:5direct care to resident ratio during the day, 1:10 in theevening, and 1:15 at night in the District of Columbiaand Maine (Harrington et al., 2012). Florida had thehighest standard of 3.9 for total nursing staff in 2010(Harrington et al., 2012).

U.S. Actual Staffing LevelsThe United States has 15,653 nursing homes and asearchable Medicare Nursing Home Compare websitethat rates the quality of nursing homes (U.S. CMS,2014). Nurse staffing levels in U.S. nursing homesincreased after the implementation of the NursingHome Reform Act (Zhang & Grabowski, 2004). Since theMedicare Nursing Home Compare 5-Star Quality ratingsystem was established, actual staffing levels havecontinued to improve (Abt Associates, 2013). The totalmedian nurse staffing levels in all U.S. nursing homessteadily increased from 3.6 hprd in January 2008 to 3.85hprd in October 2011. These levels were significantlybelow the 4.1 hprd in 2008 and the 4.2 hprd in 2011 thatthe U.S. CMS estimated was needed based on the re-ported resident case mix (acuity) levels in nursinghomes (Abt Associates, 2013).

Median RN staffing in January 2008 was reported at0.51 hprd, and this increased to 0.63 hprd in 2011, but itwas well below the expected RN staffing levels (1.08hprd in 2008 and 1.12 hprd in 2011). Median LPN hourswere 0.78 hprd in 2011 and 0.80 hprd in 2011. This wasabove the expected hours for LPNs of 0.65 hprd in 2008

Nur s Ou t l o o k 6 3 ( 2 0 1 5 ) 1 3 7e 1 4 3 141

and 0.68 hprd in 2011. Finally, median CNA staffingwas2.29 hprd in January 2008, and this increased to 2.38hprd in July 2011. These levels were well below theexpected hours of 2.37 in January 2008 and 2.43 hoursin October 2011 (Abt Associates, 2013).

Discussion

The study showed that Korea and the United Stateshave established educational and training re-quirements for nursing staff in nursing homes. Thetraining requirements of CNAs in Korea are similar tothose for LPNs in the United States, whereas careworkers in Korea have training well above the equiv-alent CNAs in the United States. This study found thatKorea has lower RN and CNA (equivalent to LPNs in theUnited States) standards and actual staffing levels thatare much lower than in the United States. In contrast,staffing standards and actual staffing levels for careworkers (who provide direct care to residents) appearto be higher in Korea than in the United States.

The Korean Health Insurance Policy Institute (2012)determined that nursing homes need to have higherstaffing levels with advanced nurse practitionersbecause nursing residents have increasing residentacuity and few physician visits, and the consistentassessment of residents is limited (Korean HealthInsurance Policy Institute, 2012). Thus, currentKorean nursing homes cannot meet the health careneeds of residents promptly and appropriately (KoreanHealth Insurance Policy Institute, 2012).

To meet growing health care needs effectively andefficiently, the KoreanHealth Insurance Policy Institute(2012) proposed a new staffing standard to improvenursing homes, but this has not been approved. Theproposed standards include (a) a ratio of one RN or CNAper 20 residents (instead of 25 residents) and (b) themandated use of advanced practice nurses (family,geriatric, psychiatric, or hospice) for large-sizednursinghomes (over 30 residents). Although RN and CNA re-quirements are still grouped in one category, there is anew proposal that one RN should be hired for every twoCNAs while maintaining the 1:25 ratio of RNs (KoreanHealth Insurance Policy Institute, 2012). Furthermore,the Institute proposed that RN responsibilities andrights should be expanded to include Foley catheterinsertion and other special treatments that RNs areallowed to conduct in general hospitals under the su-pervisionof a physician. This could reduce the transfersof nursing home residents to hospitals for specifictreatments, which could reduce the burden of nursingstaff and family members in making the transfers.Thus, RNs may becomemore independent and expandthe professional practice of nursing, especially becausemost nursing home residents do not have access tophysicians (Korean Ministry of Law Legislation, 2013a).

Korean staffing requirements do not differentiatebetween RNs and CNAs. Because elders in Korean

nursing homes have high-care needs, it seems logicalthat more RNs should be required in nursing homes.Research in the United States makes a strong case thatRNs have a stronger impact on improving nursinghome quality over LPNs (Bostick et al., 2006; Spilsburyet al., 2011; U.S. CMS, 2001), probably because theyhave longer and higher training requirements. Someexperts suggested that decisions to combine RN andCNA staffing standards in Korea, although the qualifi-cations and educational requirements for RNs andCNAs are notably different, were made because of thehigh cost of hiring RNs. Even if the new proposednursing home staffing requirements by the KoreanNational Health Insurance Corporation have not sug-gested separate standards for RNs and CNAs and havenot proposed to differentiate between full-time andpart-time or contract nurses, so the exact calculation ofhours is not possible. In the future, a mandatedreporting system of the staffing should be required.

No research in Korea has been conducted onrequired staffing levels in Korean nursing homes or tocompare the relationship of RNs and CNAswith qualityof care. A top priority for future research in Koreashould be to study the relationship between staffinglevels and the mix of nurse staffing (RNs and CNAs) todevelop a strong foundation for policy decisions. Thus,it is very timely to study staffing standards and qualityfor nursing home residents.

Unlike U.S. nursing home service consumers, Koreahasnotdevelopedconsumer informationaboutnursinghome characteristics, staffing levels, and quality out-comes. This leaves consumers with a lack of access toinformation about staffing levels and quality that isavailable to consumers in the United States. Koreanresearchers and policy makers should also examineoptions for developing consumer information systemsthat inform consumers about staffing and quality.

The caregiver workforce is still problematic in SouthKorea (Kim, Kim, & Jeong, 2010). Many unqualified ed-ucation centers train care workers (Um, 2011).Furthermore, educational lecturers can be any socialworkerwho hasmore than 3 years of experience or RNswith any experience (Kim, Shin, & Ha, 2010). Educa-tional centers must meet national standards, and fac-ulty members must be qualified to teach the clinicaltraining needed for care workers (Kim et al., 2010).Some researchers suggested that the educationrequirement of 240 hours is not long enough for po-tential care workers to have adequate knowledge, skill,and ethical training (Kim et al., 2010; Kim et al., 2010).They also argued that continuing education programsfor CNAs should be changed to increase the mandatednumber of hours and to tailor the training contents togeriatric care because in many nursing homes CNAssubstitute for RNs in Korea (Korean Health InsurancePolicy Institute, 2012).

Both countries should also consider other factorsthat would improve the nursing home workforce suchas increasing salaries, education levels, continuing ed-ucation requirements, and the supervision of care

Nur s Out l o o k 6 3 ( 2 0 1 5 ) 1 3 7e 1 4 3142

workers because care workers provide the majority ofcare to elders in nursing homes (Castle & Anderson,2011; Kim et al., 2010). Reports of the caregiver work-force in Korea have found that workers are not satisfiedwith their low incomes (Lim, 2012), suffer from toomuch work, and complain about an inability to performtheir basic duties (Kim et al., 2010). They must havereasonable salaries, adequate benefits and compensa-tion, a good working environment, and continuing ed-ucation to be qualified caregivers (Cho, 2009).

In summary,more research is needed to develop andimprove nursing home staffing standards and actualstaffing for optimal care. The increasing care needs ofnursing home residents and the demand for nursinghome care show the importance of research and policymaking that focuses on improving the quality of staff-ing levels and the quality of care in nursing homes.

Acknowledgments

This research was supported by Basic Science ResearchProgram through the National Research Foundation ofKorea (NRF) funded by the Ministry of Science, ICT &Future Planning (Grant number 2-2014-1221-001-1).This paper was supported by Eulji University in 2013.

r e f e r e n c e s

Abt Associates. (2013). Nursing home compare 5-start quality ratingsystem: Year three report. Retrieved from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/FSQRS-Report.pdf.

Backhaus, R., Verbeek, H., Van Rossum, E., Capezuti, E., &Hamers, J. P. H. (2014). Nurse staffing impact on quality of carein nursing homes: A systematic review of longitudinal studies.Journal of the American Medical Directors Association, 15(6),383e393.

Bostick, J. E., Rantz, M. J., Flesner, M. K., & Riggs, C. J. (2006).Systematic review of studies of staffing and quality in nursinghomes. Journal of the American Medical Directors Association, 7,366e376.

Bowblis, J. R. (2011). Staffing ratios and quality: An analysis ofminimum direct care staffing requirements for nursinghomes. Health Services Research, 46, 1495e1516.

Castle, N. G. (2008). Nursing home caregiver staffing levels andquality of care: A literature review. Journal of AppliedGerontology, 27, 375e405.

Castle, N. G., & Anderson, R. A. (2011). Caregiver staffing innursing homes and their influence on quality of care: Usingdynamic panel estimation methods. Medical Care, 49, 545e552.

Cho, W. H. (2009). Suggestions from the care worker system inJapandAn analysis through a comparison with the nursingcare system in Korea. Korean Association of Philippine Studies,11(3), 243e262.

Conant, S. M. (2004). Is ‘skilled nursing home’ a misnomer? Leasteducated providers constitute largest proportion of workforce.American Journal of Nursing, 104(6), 11.

Dixon, S., Kaambwa, B., Nancarrow, S., Martin, G. P., & Bryan, S.(2010). The relationship between staff skill mix, costs, and

outcomes in intermediate care services. BMC Health ServicesResearch, 10, 221e226.

Donabedian, A. (1980). Exploration in quality assessment andmonitoring. Volume 1: The definition of quality and approachesto assessment. Ann Arbor, MI: Health AdministrationPress.

Harrington, C., Choiniere, J., Goldmann, M., Jacobsen, F. F.,Lloyd, L., McGregor, M., . Szebehely, M. (2012). Nursing homestaffing standards and staffing levels in six countries. Journal ofNursing Scholarship, 44, 88e98.

Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Burger, S.,Mohler, M., . Zimmerman, D. (2000). Experts recommendminimum nurse staffing standards for nursing facilities in theUnited States. The Gerontologist, 40, 5e16.

Jansen, I. (2010). Residential long-term care: Public solutionsto access and quality problems. HealthcarePapers, 10(4),1e22.

Kim, J., & Lee, S. Y. (2013). A study on care workers’ jobperformance and competency at long-term care homes. Healthand Social Welfare Review, 33(2), 243e273.

Kim, H., Harrington, C., & Greene, W. H. (2009). Registered nursestaffing mix and quality of care in nursing homes: Alongitudinal analysis. The Gerontologist, 49, 81e90.

Kim, H., Kovner, C., Harrington, C., Greene, W., & Mezey, M.(2009). A panel data analysis of the relationships of nursinghome staffing levels and standards to regulatory deficiencies.Journal of Gerontology, 64B, 269e278.

Kim, J. H. (2011). Knowledge and attitude toward the elderly inmedical welfare facilities for older people: Comparison betweennurses and nursing assistants. Seoul, South Korea: MyungjiUniversity Graduate School of Social Work. (Master’sthesis).

Kim, S. H., Shin, J. H., & Ha, J. M. (2010). The experience of long-term caregiver education courses. Korean Gerontological Society,3(1), 1e20.

Kim, Y. T., Kim, H. U., & Jeong, M. H. (2010). Improvement andrecognition of caregiver’s human management at a long-termcare center for the elderly. Journal of Welfare for the Aged, 50,243e262.

Korean Accreditation Board of Nursing. (2014). Nursing educationaccreditation. Retrieved from http://www.kabon.or.kr/eng/kabon02/index.php.

Korean Health Insurance Policy Institute. (2012). Policy proposalsabout health care needs of long term care residents. Seoul, SouthKorea: Author.

Korean Ministry of Health and Welfare. (2011a). 2011: The first careworkers’ qualifying examination. Retrieved from http://www.mw.go.kr/front/al/sal0301vw.jsp?PAR_MENU_ID¼04&MENU_ID¼0403&CONT_SEQ¼248222&page¼1.

Korean Ministry of Health and Welfare. (2011b). Major statistics onlong term care insurance. Retrieved from http://www.khiss.go.kr/board/bbs_read.jsp?tname¼MINBOARD358&bbsid¼B301&cat_bbsid¼&bbs_seq¼367&jkey¼&jword¼&pg¼1&htxt_code¼12536978062659050219061516896964&wj_vcs¼.

Korean Ministry of Health and Welfare. (2013). Medical law.Retrieved from http://www.law.go.kr/DRF/lawService.do?OC¼lrzh&target¼law&MST¼107499&type¼HTML.

Korean Ministry of Law Legislation. (2013a). Long term careinsurance enforcement ordinance. Retrieved from http://www.law.go.kr/lsSc.do?menuId¼0&subMenu¼1&query¼%EB%85%B8%EC%9D%B8%EC%9E%A5%EA%B8%B0%EC%9A%94%EC%96%91%EB%B3%B4%ED%97%98#liBgcolor2.

Korean Ministry of Law Legislation. (2013b). Rules of certified nurseaides and para health care professionals. Retrieved from http://www.law.go.kr/lsInfoP.do?lsiSeq¼104690#AJAX.

Korean National Health Insurance Corporation. (2011). Long termcare insurance. Retrieved from http://www.longtermcare.or.kr/portal/site/nydev/MENUITEM_SERVICE/.

Nur s Ou t l o o k 6 3 ( 2 0 1 5 ) 1 3 7e 1 4 3 143

Korean National Health Insurance Corporation. (2013).Long term care insurance dictionary. Retrieved from http://www.longtermcare.or.kr/portal/site/nydev/MENUITEM_TERMS/.

Korean Statistical Information Service. (2013). Number of long termwelfare facilities for the elderly. Retrieved from http://kosis.kr/statHtml/statHtml.do?orgId¼117&tblId¼DT_117N_B00003&vw_cd¼MT_ZTITLE&list_id¼101_11736&scrId¼&seqNo¼&lang_mode¼ko&obj_var_id¼&itm_id¼&conn_path¼E1.

Kukmin Daily. (2013). The revision of long term care insurance in Korea.Retrieved from http://news.kukinews.com/article/view.asp?page¼1&gCode¼cul&arcid¼0007462007&cp¼nv.

Lee, T., Kang, K. H., Ko, Y. K., Cho, S. H., & Kim, E. Y. (2014). Issuesand challenges of nursing workforce policy: Critical reviewand implication. Journal of Korean Academy NursingAdministration, 20(1), 106e116.

Lim, W. Y. (2012). The factors affecting recognition ofprofessionalism of caregivers. Journal of Welfare and CounselingEducation, 1(1), 65e80.

National Citizens’ Coalition for Nursing Home Reform. (1999).Consumers’ minimum standard for nurse staffing in nursing homes.Washington, DC: Author.

Park, A. J., Lim, N. Y., Kim, Y. S., Lee, Y. K., & Song, J. H. (2011).Incidence and predictors of falls in institutionalized eldery.Journal of Muscle and Joint Health, 18(1), 50e62.

Schnelle, J. F., Simmons, S. F., Harrington, C., Cadogan, M.,Garcia, E., & Bates-Jensen, B. (2004). Relationship of nursinghome staffing to quality of care. Health Services Research, 39,225e250.

Spilsbury, K., Hewitt, C., Stirk, L., & Bowman, C. (2011). Therelationship between nurse staffing and quality of care innursing homes: A systematic review. International Journal ofNursing Studies, 48, 732e750.

Sweden National Board of Health and Welfare. (2009). Vard OchOmsorg For Aldre. Lagesrapport For 2008. [Care and services to

older persons. Status report 2008]. Stockholmlm, Sweden:Socialstyrelsen.

U.K. Care Quality Commission. (2010). Guidance about compliance:Essential standards of quality and safety. London, England:Author.

Um, K. W. (2011). Study on problems and improvement of thetraining and certification system of the care worker. Researchfor Community Development, 10(1), 87e112.

U.S. Centers for Medicare and Medicaid Services. (2001). Report toCongress: Appropriateness of minimum nurse staffing ratios innursing homes. Retrieved from http://www.cms.hhs.gov/medicaid/reports/rp700hmp.asp.

U.S. Centers for Medicare and Medicaid Services. (2014). Nursinghome compare. Retrieved from https://data.medicare.gov/Nursing-Home-Compare/Provider-Info/hq9i-23gr.

U.S. Department of Health and Human Services. (2008). Nursingaides, home health aides, and related health careoccupationsdnational and local workforce shortages and associateddata needs. Retrieved from http://bhpr.hrsa.gov/healthworkforce/reports/nursing/nurseaides/chapt5.htm.

U.S. Department of Health and Human Services, Office of theInspector General. (2014). Adverse events in skilled nursingfacilities: National incidence among Medicare beneficiaries(OEI-06-11-00370). Retrieved from https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf.

U.S. Government Accountability Office. (2009). Nursing homes:Addressing the factors underlying understatement of serious careproblems requires sustained CMS and state commitment (GAO-10e70). Retrieved from http://www.gao.gov/new.items/d1070.pdf.

You, S. J. (2013). Comparisons of the nursing workforce withJapan, and the U.S. Journal of Digital Policy & Management, 11(6),275e287.

Zhang, X., & Grabowski, D. C. (2004). Nursing home staffing andquality under the Nursing Home Reform Act. The Gerontologist,44, 13e23.