Leadership education, certification and resident outcomes in US nursing homes: Cross-sectional secondary data analysis☆
Introduction
Leadership has been identified as a key consideration in improving nursing home (NH) quality of care (Siegel et al., 2010). The Center for Medicare and Medicaid Services (CMS) identified governance and leadership as a major element of Quality Assurance/Performance Improvement (CMS, 2012). Nursing home leaders, i.e., nursing home administrators (NHAs) and directors of nursing (DONs) have a responsibility to promote and sustain high-quality, cost-effective nursing home care (Seigel et al., 2010). DONs are responsible for the nursing department and all clinical nursing care provided in the facility including care delivery and best practices, clinical data collection, appropriate staffing and hiring. The NHA is responsible for the administration of all departments and oversight of the facility to maximize resident quality of life and quality of care, including costs and budgeting, supervision and management of staff, facility and physical plant, and compliance with regulations (US Department of Health and Human Services, 2009, LTCPLC, 2007).
Both generate policies that implement regulations and requirements to ensure that residents are provided with proper care. Yet, often among these leaders there is a lack of specific education focused on clinical leadership and health team management (Dwyer, 2011). In the US, educational qualifications vary and are largely predicated on our system of reimbursement and payment for long term care. To qualify for reimbursement of care provided, NHAs must have a Bachelor's degree, pass an NHA exam and have a precepted experience, and DONs must be registered nurses (RNs) (CMS, 2008). Taking additional classes through formal education (e.g., Bachelor's or Master's degree programs for DONs and NHAs, respectively) and/or obtaining specialty certifications through targeted coursework and examinations, can allow administrators to be exposed to a wider array of strategies and resources. Resident outcomes can be influenced by organizational components such as the education and credentials of those managing the facility. The diversity of qualifications for nursing home leadership across facilities provides an opportunity to assess the impact of leadership credentials, i.e., education and certification, on resident outcomes.
Nursing home leadership has been linked with care deficiencies that occur when facilities fail to meet certain federal regulatory care standards, as judged by state inspection teams (CMS, 2013). Nursing homes with more highly credentialed directors and leaders (certified by or belonging to long term care professional associations) had lower rates of deficiencies compared to those with less credentialed leaders (Castle and Fogel, 2002, Rowland et al., 2009). Nursing home quality indicators (QIs) have also been linked to leadership style and length of time in the position for both NHAs and DONs (Decker and Castle, 2011, Krause, 2012). However, the evidence that educational preparation and certification of NHAs and DONs is related to quality outcomes is limited. In this study we explore whether increased leadership credentials (e.g., education and certification) for NHAs and DONs are associated with better NH quality outcomes as measured by lower QI rates. We also examine the impact of specific certifications on resident outcomes.
Our conceptual framework was based on the Systems Engineering Initiative for Patient Safety model (Carayon et al., 2006). This draws from Donabedian's structure process-outcome model (Donabedian, 1972) by emphasizing how work system design (e.g., leadership: education and certifications) are linked to resident outcomes through greater knowledge and awareness of optimal care processes. Leaders can use this knowledge to improve care in their facilities, resulting in better resident outcomes, (e.g., lower rates of pressure ulcers or pain). For example, geriatric nursing specialty certification could help leaders to identify best practices for pain assessment for elderly populations. Management training, as is presented in Bachelor's or Master's degree programs, could help leaders develop the ability to articulate a vision of quality care to nursing staff. A DON or NHA with additional leadership training also might be better able to motivate others and to serve as a change agent for best practices (e.g., avoiding catheter use) that will translate into improved care (Anderson et al., 2003). If leadership education and certifications are related to improved care, findings also could support recommendations to improve leadership preparation.
Section snippets
Design and data sources
This secondary analysis merged data from two national administrative databases. The 2004 National Nursing Home Survey (NNHS) was the source for leadership data and information on facility characteristics (NCHS, 2009). The NNHS used a complex sampling strategy (e.g., multi-stage, stratified sampling) to select 1500 nursing homes representative of the 16,628 nursing homes in the U.S. (Squillace et al., 2007). Administrators at 1174 of the selected nursing homes completed computer assisted
Nursing home characteristics
According to these nationally representative data, 32% of NHAs had a Master's degree or higher and 43% of DONs had Bachelor's degrees or higher (Table 2). Just over a quarter of NHAs (28%) had at least one of the examined certifications; proportion of NHAs certified by CNHA and ANCC-unspecified were 25% and 3%, respectively. Whereas among DONs, nearly half (43%), had at least one certification, with NADONA (15%) and ANCC-gerontological (10%) most common. Ten percent of DONs had one of these
Discussion
Our study provides important findings relating leadership education and certification to nursing home resident outcomes. Nursing homes led by NHAs with both certification (CNHA and/or ANCC-unspecified) and a Master's degree or higher had better resident outcomes for pain. Education alone also was important among NHAs in relation to decreased adverse outcomes. For NHAs with ANCC certification, better resident outcomes for low-risk pressure ulcers were noted. Because ANCC certification is only
Conflict of interest
None declared.
Funding
This study was funded by the National Council of State Boards of Nursing (Grants R40009 and R60006).
Ethical approval
The Institutional Review Board of the University of Maryland, Baltimore reviewed and approved this study (IRB protocol number: HP-00049284).
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Funded by the National Council of State Boards of Nursing Grant R60006 (A. Trinkoff, PI).