In the initial phase of the STARFISH study, a systematic review of reviews was conducted to offer a comprehensive summary of existing research on the staffing-outcome relationship, with a particular emphasis on resident safety-related indicators. Our findings identified several challenges in the measurement and reporting of staffing and revealed pressure ulcers and falls (often undifferentiated with or without injuries) as the two most prominently evaluated resident safety indicators.

In the second phase of STARFISH, we explored pre-, peri- and post-pandemic trends and variation of staffing within a multisite LTCF in Switzerland. This investigation addressed a significant gap prior to analyzing the relationship with outcome indicators, as longitudinal analyses based on operational staffing data are not available for the Swiss LTC setting. The analysis of direct care staffing confirmed international high-level trends indicating a decline in workforce availability and revealed increased and prolonged staff absences, alongside a heightened reliance on temporary staff within a major Swiss LTC organization. The study described a decreasing staff availability in later study years and revealed how organizational strategies to stabilize staff levels influenced the skill mix of direct and indirect care teams towards lower skill mix.

Finally, considering the shifting staff mix in direct care and increasing RN staff time in indirect care, we specifically evaluated the effect of RNs in expanded roles (RNX) as part of indirect care, as well as the interplay with staffing configurations of the direct care team. Our findings highlight despite an observed overall increase in pressure ulcer incidence, that clinical supervisory shift by RNX reduce the risk of pressure ulcers. The positive effect has become more pronounced in recent years, highlighting the importance of these roles in addressing current LTC challenges. Our results support the consideration of RNX working clinical supervisory shifts into staffing regulations for LTC in Switzerland. With regard to the staffing configurations of the direct care team, we emphasize the difference in optimal configurations in the presence and absence of an RN in the expanded role, and the interplay between different staff groups.

This dissertation presented a novel approach to investigate the relationship between staffing and resident safety, matched to the contextual situation of available data and research on residential LTC in Switzerland. The exploratory goal of this work was to describe current staffing trends and variations based on granular operational data, and to pilot a novel data-driven approach to investigate the impact of staffing on resident safety in Switzerland.