Licensed Nursing Home Administrator Preparation and Role Variations

Quality and safety remain major challenges in many nursing homes.^1,2 With a broad spectrum of quality across settings,^3,4 some facilities are able to achieve targeted quality standards while others fall behind. The importance of the nursing home administrator (NHA) position for quality is recognized by federal and state jurisdictions: federal regulations designate the NHA as responsible for facility management,⁵ and state-level licensure is a requirement for this position.⁶ Licensure serves the public interest by implementing a set of standards for knowledge and expertise in positions of high professional responsibility.⁷ NHA licensure requirements include a national examination designed to “protect the public by ensuring that entry-level NHAs have mastered a specific body of knowledge and can demonstrate the skills and abilities essential to competent practice within the profession.”⁶ But additional state-level requirements for formal education (or experience in lieu of education) and training (ie, precepted internships/formal administrator-in-training [AIT] programs) vary considerably across states.⁶

Evidence to the reasoning behind these varied licensure requirements is limited. Studies finding positive associations between NHA education or additional professional development activities and various measures of quality processes and outcomes suggest some NHAs may be inadequately prepared to ensure high quality services.^8-10 A study exploring NHAs’ self-assessed person–job fit revealed a potentially steep learning curve, with 30% of participants reporting they were well-prepared to meet the demands of their first NHA position.¹¹

To expand on these findings, we conducted a study with a subsample of the NHA respondents to better understand the education, training, and experience that supported their preparedness for the NHA role.

Methods

An exploratory, descriptive, qualitative approach¹² was used to collect data from a subsample of participants that completed the parent study questionnaire, which was focused on education, training, and experience to support NHA role preparedness.¹¹ We received approval to conduct this protocol from University of California, Davis, Institutional Review Board.

Sample

We recruited a convenience sample of NHAs from the parent study sample of 175 NHAs. The parent study sampling frame included a random selection of 1000 Medicare- or Medicaid-eligible nursing homes in five states (AR, CA, IA,-OR, PA), stratified by state and for-profit status.¹¹ Of the 175 NHAs that participated in the parent study, 143 provided written permission on their questionnaire for follow-up contact. Consistent with qualitative inquiry, our goal for this current study was to achieve a convenience sample that reflected breadth of perspective; therefore, individuals were recruited based on a broad range of individual characteristics including NHA career tenure, number of NHA positions, ratings of overall preparedness for their first NHA position, and organizational characteristics including profit status and state where the facility is located. We contacted 42 NHAs via email and/or phone to discuss the current study and invite participation. Fourteen NHAs did not respond. Of the 28 that agreed to participate, 26 NHAs completed interviews. Recruiting continued until data saturation was achieved, meaning no new information was gained from the interviews.¹³

The convenience sample of NHAs (N = 26) at nursing homes across five states reflects variation in NHA education, tenure (current position and career), and number of NHA positions (Table 1). In contrast with the parent study, smaller proportions of the current sample were employed by not-for-profit organizations; participated in a precepted, on-the-job internship or practicum; and held a baccalaureate degree or higher.

Procedures

We conducted semi-structured interviews to better understand the responses that participants provided on a questionnaire used to collect data in the parent study. The interviews were structured to parallel the section topics and content covered by the questionnaire (Table 2). A detailed description of the method for developing the questionnaire has been published.¹¹ With a copy of the participant’s completed questionnaire in hand, interviews began with a general summary of each questionnaire topic and a prompt based on the participant’s actual responses (Table 3). The audio-recorded telephone interviews lasted 30-60 minutes and were conducted by an author (EOS) who is experienced in conducting qualitative interviews.

Analysis

The interviews were transcribed verbatim, verified, and uploaded to a qualitative data management software (QSR NVivo 10). EOS and two research assistants conducted the initial data analysis. We began with content analysis,¹⁴ using a priori coding based on the questionnaire topics and response options and open coding¹⁵ for text that did not fit an a priori code. For example, we created the code organizational characteristics for participant comments that differentiated one setting from another. We used thematic analysis¹³ to identify emerging patterns and themes within and across codes. For example, thematic analysis of the data coded as organizational characteristics resulted in the addition of sub-codes, infrastructure/resources, and operational differences in roles across settings. Members of the research team individually coded text and other members of the team reviewed, verified, reconciled, and refined coding practices. We incorporated criteria for establishing trustworthiness of study findings and conclusions from Lincoln and Denzin,¹⁶ through the following activities: (1) the interviewer’s discussions of personal perspectives and biases with the research team throughout data collection and analysis; (2) data collection until saturation was achieved; and (3) a documented audit trail of data collection and analysis.

Results

Two primary themes emerged from the study findings. First, a broad range of perspectives were reflected with regards to education, training, and experiences that support role preparedness, with varying benefits for or gaps in preparation being attributed to any given type of activity or pathway to the role. Second, with participants’ discussion of role preparedness, an unexpected theme—organizational context—emerged, revealing limited standardization of some aspects of the NHA position and distinctly different role profiles across types of organizations. 

Education, Training, and Experience

In response to questions about actual versus ideal ways to develop competencies for the NHA entry-level position, commonly discussed activities included reference to AIT, educational programs, and previous work experience. Table 4 provides an overview of factors associated with each activity and exemplar quotes revealing participants’ varied experiences and perspectives. The value of AIT programs varied based on program design and content, types of hands-on experience, and broader administrative experiences. AIT preceptor mentoring varied based on the preceptor’s expertise in specific content areas (eg, financial), interest or motivation to serve as a preceptor, and availability. The value attributed to formal education ranged from limited—emphasizing the importance of on-the-job training—to moderate value in relation to benefits associated with specific programs (ie, master’s degree), specific content, or the college experience in general. In addition to AIT programs and/or formal education, several participants spoke about the value of various types of previous experience, with mixed perspectives regarding the applicability of management and leadership experience from previous positions in both health care and non-health care settings. A handful of participants spoke about the value of previous work experience in nursing homes in general or, specifically, working as an assistant NHA.

Organizational Context

In their responses to questions about role preparedness and education, training, and experience, participants commonly described organizational contexts and varied ways the NHA position is structured across settings. Organizational context refers to type (eg, size, ownership) and the infrastructure/resources available to support the NHA. Diversity of job requirements and the role of organizations in setting the scope of the NHA position emerged as a primary theme from these interviews, suggesting limited standardization of the position and distinctly different role profiles and preparation needs across different organizational contexts.

Table 5 provides a summary of terminology and variations attributed to organizational contexts. Corporate and larger facilities were characterized by infrastructure and resources that include multiple layers, including dedicated departments and corporate offices to support finance and human resources (HR); corporate experts (eg, vice president of HR, chief financial officer [CFO], controllers, regional directors) and consultants (eg, nurse consultants, administrative consultants, environment consultants); and established manuals and policies. As one participant stated: “You walk into a corporate job and they have all the manuals there for you…policy….All the handbooks there that tell you how to do everything.” One participant described working for a corporation where extensive support (ie, industry updates) precluded his need to go outside the corporation for information. In contrast, a participant described potential gaps in information about industry changes and regulatory directions for NHAs working for organizations not affiliated with a chain or management company: “…sitting out there, these little lonely nursing homes. Those are the people…they read the bulletins, but they’re not exposed to everything. Maybe some of them have developed their own network,…but they seem behind in things.” Other types of organizations were described in terms of external resources available to support the NHA position, such as management companies or outsourcing service venders for financial and/or certain reporting functions.

Organizational contexts were commonly associated with different ways in which the NHA position is structured. For example, one participant provided a general summary of role differences based on size of the organizations where she received her training and where she was first employed as an NHA:

[It was] very different from where I’m at now, because it was such a big building…it was a different type of administrator job in that I was more managing the department heads and overseeing [them]…I think 23….And here at the job I’m at now, I have 7. So, there’s a lot of hands-on in this job that I didn’t have there.

Another participant spoke about the hands-on nature of working for a stand-alone facility:

[Y]ou need your hand on everything; you need to…help your business office manager if you have turnover in the business office…understand…[and] deal with the medical piece of it…bringing all that back together to the financials and about timely filing and understand[ing] deposits and all that.

Specific examples focused commonly on two of the five job domains:  primarily, the finance job domain, and to a lesser extent, the HR job domain. Table 6 provides quotes illustrating differences in the scope of NHA involvement in finance and HR. Although the majority of participants gave little indication of involvement in changing the structure or functioning of the NHA position, a handful of participants described negotiating for additional resources, revising role structures, and gaining additional education and expertise in order to fulfill role expectations. A participant with a background as a nurse manager recounted her negotiation to add a CFO, claiming she could not be good at both:

I was pretty comfortable with [the HR part]….I came in saying to the board, “If you want me to be the Administrator, then you have to [hire] a CFO. I’m not going to be the combination Administrator/CFO.”…If I had to be the responsible party in…[finance] I wouldn’t take the job. I had talked to the board about that not being my strong forte. They knew that ahead of time and they wanted somebody that had the operations and the clinical management more than the financial. 

Discussion

Our findings describe NHAs’ perspectives regarding their education, training, and experience in preparation for their first licensed position, as well as various ways in which the NHA position is operationalized across different organizational contexts, with implications for how NHAs are prepared. The findings can inform directions for further research to support NHA preparedness for positions across different organizations, as well as licensure requirements. In addition, the findings will be useful to NHAs seeking new employment, as they consider how these organization-level variations will impact the way they function in their positions and the extent to which they are adequately prepared for role demands.

The study described herein ventured into a so-called “uncharted territory.” The findings suggest an immense organizational influence over the very nature of the NHA position, with limited standardization and distinctly different role profiles across organizations. These role variations might explain, in part, the lack of consensus reported with regards to the value attributed to any one activity or pathway to role preparation. While role variations across organizations are common for some professions and may reflect appropriate need for flexibility, limited standardization of the NHA position across organizations raises questions regarding: (1) the extent to which current state NHA licensure requirements (ie, AIT, licensure exam) adequately prepare—or should prepare—NHAs for role flexibility in practice; and (2) the extent of role flexibility that is intended to fall within the scope of NHA licensure.^5,6 

Using the NHA financial role as an example, the national NHA licensure examination highlights the financial role as one of five key job domains for the NHA.⁶ The examination covers content that suggests a broad financial management scope, including knowledge to support administrative functioning (eg, billing, accounts receivable/payable, resident trust funds) and higher-level responsibilities (eg, financial statements, operating margins, cash flow, staffing, budgeting, and financial planning).⁶ How this broad financial scope translates in settings where much of the higher-level responsibilities are handled by others in the organization (ie, at “corporate” level) is not clear and warrants further inquiry in terms of licensed NHAs’ actual financial roles in practice and linkages to quality. For example, studies revealing associations between for-profit facilities and lower quality^17-19 and employment of NHAs with less expertise as compared with NHAs hired by not-for-profit facilities²⁰ provide a basis for inquiry that examines the NHAs’ actual role in financial management of nursing home operations and the underlying forces that drive the NHA financial role in a given setting: is it licensure, organizational or individual characteristics, or a combination? Evidence from the organizational arena supports the notion of organizational structure, goals, and culture as highly potent driving forces shaping both jobs and work outcomes in organizations.²¹ How these forces align with an NHA’s individual expertise and the underlying intent of NHA licensure “to protect the public”⁶ is an area requiring further inquiry. 

Although fewer participants referenced the NHA’s role in HR compared with their financial role, the findings related to HR role variations are worthy of further investigation. Effective HR management practices are critical to the functioning of any organization. In nursing homes, where annual job turnover across the workforce averages 43.9% overall,²² HR complexities are heightened. Further research is needed to examine the extent to which NHAs possess the essential and unique skill sets needed to not only tackle the personnel and operational issues associated with a revolving workforce, but to also build the stability and functioning of a well-trained workforce across settings within a context of the varying levels of HR management resources available to the NHA. 

The generalizability of the findings are limited because they reflect perspectives of a convenience sample of NHAs who participated in a parent study. Considering the small sample used for this study, the tests of statistical differences in sample characteristics for this study and the parent study should be interpreted with caution. Notwithstanding, the recruiting goals for this qualitative study were achieved, and the sample reflects breadth of perspectives from participants with a wide range of characteristics. The interview prompts focused primarily on topics covered by the parent study questionnaire. As one example, the respondents’ explanations related to variations across different organizational contexts were commonly unprompted and focused on the finance and HR job domains.  Follow-up prompts focused specifically on the other domains may have expanded the study findings. Although all interview questions began the same way, the directions taken in each interview varied in response to individual participant comments. The findings might be different if interview questions were consistent across participants and if follow-up prompts were expanded to topics beyond the parent study questionnaire. We did not ask questions about NHA preparation to ensure high-quality services or, in fact, if the NHA’s performance is associated with high-quality services; thus, the findings cannot be interpreted in this regard. Finally, the perspectives shared by participants about organizational contexts were not verified with other data sources; thus, we cannot confirm that the organizational contexts are accurate representations of what happens in organizations. Aside from these limitations, the findings provide important directions for future research with a larger, more representative sample of NHAs and organizations. 

Conclusion

This study offers a first, preliminary glance into the nuances and complex nature of the reality in which NHAs operate and offers a guide to future practice- , education- , and policy-level research in best practices to support NHA preparedness to ensure the delivery of high-quality nursing home services. Distinctly different responsibilities and role demands for NHAs across organizational settings have critical implications for how NHAs are prepared for this important top management position. For example, NHAs working in settings where they have limited involvement in higher-level financial management require a very different skill set than NHAs working in settings where they oversee all financial aspects of the nursing home. Is it reasonable to presume that we can adequately prepare NHA licensure candidates with a set of competencies that supports this full range? The national NHA licensure examination emphasizes competent practice within the profession,⁶ but what is competent practice? Does licensure represent the same measure of competencies across organizations with different role requirements for the NHA, as revealed in this study? Research is needed to examine the extent of actual NHA practice variations across settings and how these practice variations align with the standards set forth for NHA licensure. This line of inquiry should be conducted in tandem with research that examines the essential elements of NHA licensure needed to advance the quality and safety of health care services provided in nursing homes. 

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