Do nursing home administrators need more training? Multiple talents and skills are the key to meeting the needs of the elderly.

Multiple talents and skills are the key to meeting the needs of the elderly

"The atmosphere and effectiveness of most institutions are dependent, in great measure, on the character,, interests, and abilities of the person(s) directing their activities. Nowhere is this fact more evident than in the management of nursing homes, where the very personal services rendered are directly affected by the attitude, sympathy, and dedication of the administrator."[1]

Due to both new regulations and constantly changing demands of the job, interest in the qualifications of nursing home administrators appears to be growing. Well-prepared administrators with many diverse skills, broad experience and good education are going to be in demand in order to meet the multiple needs of the growing elderly population. More so than ever, the quality of the education and training of LTC administrators is a critical factor in determining the quality of health care provided to this nation's older adults.

Due to urgings from the American Association of Retired Persons and others, emphasis was placed in recent legislation and regulations on increasing the qualifications of LTC administrators. The Omnibus Budget Reconciliation Act (OBRA) of 1987[2] defines new standards of education, training and licensure to be applied to LTC administrators in the near future.

But what is the current status of that training and education? Perhaps surprisingly, current information is not easily come by, and we decided to mount our own investigation.

Past Studies

In searching the published literature for similar studies that profiled nursing home administrators, we found only a few, most dating as far back as the 1960s. To give some historical perspective, a review published in 1984[3] cited these studies, which were from Massachusetts, George Washington University, and Cornell University, and offered this picture: The Massachusetts study had found that 10% of the state's nursing home administrators had no formal education, 20% had dropped out of high school and only 18% had Completed college. The response rate was only 41%, and it was thought that the 59% who did not respond could have made those results even worse.

Both the Cornell University and the George Washington University studies concluded that the typical nursing home administrator had only a high school diploma. Only 65% of the administrators who responded to the Cornell study had some education beyond high school. This number was much smaller in the George Washington University study, with only 44% of respondents having an education beyond high school.

This latter study also demonstrated that, as an administrator's education increased, so did the size of the facility which he/she operated. It was also shown that for-profit facilities had twice the rate of non-profits in having administrators with less than a high school degree.

With regard to experience, the George Washington University study found that 58% of those who responded had less than one year of previous administrative experience, and 40% had been in their present position less than five years. The authors concluded those surveyed had less than adequate preparation both in terms of education and experience.

A 1969 study from New Hampshire[1] surveyed nursing home administrators for age, sex, nursing home ownership, prior and present experience, and education. The greatest number of administrators in this study fell between 50-59 years of age, with over 60% being women. For-profit facilities represented the majority of the institutions. Roughly 40% of the administrators who responded had been in their present position for over 10 years. Of the 79 nursing home administrators who responded, 27 had at least a high school diploma and 54 had some formal training beyond that point, while only 6 had completed a college degree.

It is believed that individual state nursing homes associations and/or health departments may have conducted their own LTC administrator profile studies. However, none of the results have been published, leading one to wonder whether they reflect the previous dismal results.

We decided to take a fresh look by developing the most readily available data.

Methodology

In order to profile today's "typical" LTC administrator, we assembled a database of information on LTC administrators in Oklahoma. Though based on so-called "small-area analysis," it is possible that our findings reflect the profile of LTC administrators nationwide. Readers are, of course, free to judge the truth of this.

Our study asked various questions of Oklahoma's LTC administrators: their occupational status, salary, the facility they practice in, their community size, and any special training or education they have received. It addressed correlations between the following variables: 1. Salary level to level of education 2. Salary to facility type and size 3. Education to facility size 4. Education to facility type

A mail-out survey was conducted involving 435 skilled and intermediate nursing homes in Oklahoma (i.e., all the nursing home facilities in the state, based on a comprehensive mailing list furnished by the Oklahoma Nursing Home Association). The mailing included an explanatory letter, the survey tool, and a prepaid return envelope.

The survey instrument addressed three major areas of information in the administrator practice profile: demographic, occupational and educational. No follow-up letters were sent because respondents had been offered anonymity.

Regarding technical considerations for the survey (for those who are interested), survey replies were coded for each of the different questions in the survey. As each reply was received it was dated and entered into the University's M600 Data General computer. This database was established using the Text Editor (TED), the Interactive Data Entry System (IDES), and the Statistical Analysis System (SAS). Data was entered into the computer in designated fields which were organized specifically for each variable character, length of response field, type of response, and position in the database. Data entry was carried out along the designated fields for each questionnaire.

Once data entry was complete, two different analyses were carried out: 1. Frequency analysis: Mean, mode, percentages, and totals. 2. Correlation analysis: The Spearman rank order correlation coefficient to test for a significant relationship between two or more variables, i.e., salary and size of facility, salary and education, etc.

Results

Two hundred twenty-six (226) responses were received - a response rate of 51%.

Table 1 shows the frequency statistics of the respondent's demographics (age, race, sex), level of experience in administration, length in present position, and their educational level. With regard to demographics, most respondents (approx. 72%) were under 50 years of age; 67% were female; only 3.5% were non-whites; and 73.3% were married.

Of the respondents, only one answered as being not active in nursing home administration. Most (93.5%) had the title of administrator, two were executive directors, one was president, two were owners, and 4 were directors of nursing.

Table 1 includes the respondents' level of experience. More than 70% had over 4 years of long-term care administrative experience, with more than one-third (39.3%) having over ten years. However, about one in five of the respondents had been in their present administrative position for less than a year.

Table 1 also reflects the educational level of the respondents, with almost half (49.8%) having attained only a high school education and 29.6% a college degree. Undergraduate college majors were in business (32 respondents), education (9), and nursing studies (10). Of the 22 respondents with graduate degrees, six listed a degree in health care administration and four an MBA.

Table 1. Summary Statistics of Survery
         Respondents
                         FREQUENCY    PERCENTAGE
A. Age Group (n=222)
   20 - 30                 19            8.6
   31 - 40                 61           27.5
   41 - 50                 80           36.0
   51 - 60                 42           18.9
   61 - 70                 17            7.7
   71+                      3            1.4
B. Race (n=226)
   Black                    4            1.8
   Indian                   3            1.3
   Mexican                  1            0.4
   White                  218           96.5
C. Sex (n=225)
   Female                 150           66.6
   Male                    75           33.4
D. Marital Status (n=225)
   Married                165           73.3
   Divorced                35           15.6
   Single                  15            6.7
   Widowed                 10            4.4
E. Level of Experience in Administration (n=219)
   <1 Year                 19            8.7
   1 - 4 Years             46           21.0
   4 - 10 Years            68           31.1
   10 + Years              86           39.3
F. Length in Present Administrative Position (n=220)
   <1 Year                 46           20.9
   1 - 4 Years             74           33.6
   4 - 10 Years            51           23.2
   10 + Years              49           22.3
G. Educational Level (n=223)
   High School            111           49.8
   Associate               46           20.6
   Bachelor                44           19.7
   Master                  22            9.9
Note: All categories may not equal 100% because of
rounding errors.

With regard to facility-related information, Table 2 (A thru E) shows the type of respondent's facility, primary sponsorship/ownership, affiliation, and type of community. The "typical" facility was a for-profit (78%) intermediate care (86%) facility with a corporate affiliation (60%), and had more than 50 beds (88%). Overall, occupancy rate of LTC facilities averaged 87%; urban facilities averaged a 91%, while rural averaged 85%.

[TABULAR DATA OMITTED]

On the question regarding training, interestingly, only 172 respondents answered this question. Sixty-six percent (66%) (114) had attended a workshop on administration/management within the last 12 months, 52% (90) had attended a financial/budget seminar, 77% (132) had been to a clinical/patient care workshop, and 86% (148) had attended a state/ federal regulatory seminar.

One hundred ninety (190) respondents declared their annual salaries. Salaries ranged from $12,000-$80,000, with an average annual salary of $28,502 (mode = $24,000).

Correlations

As mentioned, this study determined relationships between the following variables: (1) salary and facility type, (2) salary and level of education, (3) education and facility type, (4) salary and facility bed size, and (5) education and facility bed size. Other correlations may be drawn from the results of this study; however, they are beyond the scope of this article and will form the basis for future studies.

Table 3 shows the correlation between facility type, salary, and level of education. It is apparent that salaries of respondents were higher by 58% for those administering skilled nursing facilities (SNFs) than for those administering intermediate care facilities (ICFs). Also, the proportion of respondents administering SNFs who had college degrees is 86%, compared with the 29% of those who administered ICFs.

[TABULAR DATA OMITTED]

Table 4 summarizes the results of mean annual salaries as related to the level of education of the respondents. Again, those respondents with more advanced degrees had higher salaries (R = .4, P = <.1001). Further, those respondents who had a college degree made an average of $7,000 more than those who had only a high school diploma. Those with graduate degrees made $7,500 more than those with bachelor's degrees.

Tables 5 and 6 relate the respondents' facility bed size to the average annual salary and level of education, respectively. Table 5 shows a significant positive correlation between bed size and salary, i.e., the bigger the facility (in terms of bed size), the higher the average annual salary of the administrator (R = .36, P = <.001), except, interestingly enough, for facilities with less than 25 beds.

That is possibly explained by Table 6, which shows no significant statistical correlation between bed size and education level at P = 0.05 level. Table 6 shows that those administrators of facilities with less than 25 beds had a higher level of education than any other group (80% had a college degree). Further research revealed that these smaller facilities are hospital-based. Hospital administrators have, as a general rule, attained higher levels of education than their counterparts in LTC facilities.

From the above, we found that there is a positive significant correlation between average annual salaries and both education level and, with the above exception, facility bed size. This supports the assumption that education not only increases the knowledge of administrators and probably prepares them to manage more resources, it can also reward them with potentially higher salaries - as much as $7,000 more for a bachelor's degree and over $14,000 more for a master's degree. It is also obvious that the larger the facility in bed size, the more complex the administrator's job, justifying a higher salary.

Conclusion

Clearly, a larger study is needed nationally to compare and enlarge the data-base base collected from this Oklahoma LTC administrator profile study. Further research is needed, as well, to study the correlation between the quality of care in long-term care (LTC) facilities and the qualifications of nursing home administrators.

However, this study does indicate an apparent need for increased education and training for LTC administrators in Oklahoma, and perhaps nationwide, as the challenges of long-term care intensify.

Table 4. Salary to Level of Education
                    No.        Mean      Salary Range
Variable          Admin.*     Salary     Min.     Max.
1. High School     100       $24,947    $14,000 - $60,000
2. Associate        38       $29,165    $12,000 - $70,000
3. Bachelor         39       $31,797    $16,800 - $71,000
4. Master           17       $39,165    $24,000 - $80,000
Table 5. Facility Bed Size to Average Annual Salaries
               Number of         Average
Bed Size     Administrators    Annual Salary
>150             10              $41,274
100 - 149        58              $32,787
50 - 99         106              $27,733
25 - 49          16              $23,300
<25               3              $29,566
TOTAL           193              $29,614

References

[1.] Stone MD. Profile of Nursing Home Administrators in New Hampshire. Nursing Homes, November 1969, p. 14. [2.] Omnibus Budget Reconciliation Act 1987, U.S. Congress. [3.] Dickler RM. Nursing Home Administrator Licensure: The Law Outputs and Outcomes, Washington, D.C. Association of University Programs in Health Administration, January 1984, p. 2.

A.F. Al-Assaf, MD, MPH, is Assistant Professor and Interim Chair of the Department of Health Administration at the University of Oklahoma Health Sciences Center, as well as Oklahoma State Director for the American Academy of Medical Administrators. He is also a licensed Oklahoma nursing home administrator. C. Nick Wilson, PhD, FACHE, is Chair of the Department of Health at the University of North Florida, Jacksonville. Donald M. Batchelor, MSHA, is Director of Provider Recruitment and Referrals with ProAmerica, Fort Worth, TX.