How administrator characteristics correlate with licensure exam performance: test results show a changing picture in nursing home administration.

To raise the standards of long-term care in the United States, the public and its representative licensing boards have attempted to give nursing home administrators more accountability. Part of this has involved increasing the minimum qualifications required to practice as an entry-level administrator.

How successful have licensing boards been? Do more educated administrators provide a higher standard of care? Does prior experience as an administrator lead to higher administrative practice standards?

This article will attempt to answer these questions by reviewing available data on the educational and experience of entry-level administrators who sat for the National Association of Board Examiners for Nursing Home Administrators (NAB) licensing examination. It will also contrast the demographic profile of the new administrators with demographic data collected in the past. Finally, it will review how performance on the standardized licensing examination reflects administrators' education and experience.

Most published profiles of nursing home administrators have been limited to specific regions of the United States. For example, a 1969 study surveyed New Hampshire nursing home administrators for demographic variables including age, sex, nursing home ownership, work experience, and education (Stone, 1969). A more recent study examined the background characteristics of long-term care administrators in Oklahoma (Al-Assef, Wilson, & Bachelor, 1992); an analysis of this was published by the authors in the Nov/Dec 1992 issue of NURSING HOMES.

However, Schoon and Gullion (1978) and Schoon and Hayez (1987) reported on the demographic characteristics of nursing home administrators nationally, based on samples of first-time NAB test takers who completed a background questionnaire as part of the licensing examination process. The present study correlates test score data from the NAB licensing examination with information collected from the background questionnaire.

The licensing examination developed by NAB, with technical assistance from the Professional Examination Service (PES), was a 150-item multiple-choice examination covering the following content areas: patient care; personnel management; financial management; marketing and public relations; physical resource management; and laws, regulatory codes, and governing boards. These content areas emerged from a role delineation study completed by NAB in 1986.

NAB test items were written by practicing administrators, long-term care educators, and regulatory board members. To be eligible for inclusion in the NAB item bank, items must have met minimum standards concerning their relevance to entry-level practice and their importance to competent practice by an entry-level nursing home administrator. Content experts also screened NAB items for accuracy and to ensure that they assessed a defined area of the NAB test specifications. PES psychometric and editorial staff reviewed each item to verify that it conformed to accepted principles of item construction and to established rules of grammar and style. Finally, approved items were assembled in examinations for the review and approval of the NAB Examination Committee, a panel of experts in the field of long-term care.

The background questionnaire administered to candidates tested in 1989 consisted of 13 restricted-response items. The number of candidates who responded to all questionnaire items was 1,548. While data were collected on 13 items, this study focused on those yielding the most relevant information: sex, age, amount of experience in the field of nursing home administration, and level of education. These questionnaire items also permitted comparisons to be made to questionnaire results from earlier years.

We analyzed these data in two ways. First, we computed descriptive statistics for the questionnaire items and performance scores on the NAB licensing examination. Second, where appropriate, we employed correlation and regression analyses with these variables.

The results:

Sex. Summary statistics for the NAB examination broken down by candidate sex are presented in Table 1. Men obtained slightly higher average scores on the 1989 NAB examinations than did women. This marginal advantage for men was also observed for nursing home administrator examinations administered in 1983 and 1986. However, test scores for men and women have steadily increased over time.

Age. The performance of 1989 NAB candidates grouped by age is presented in Table 2. Candidates within the age group 30 to 60 achieved the highest average scores on the 1989 NAB examinations. This advantage was also noted for 1986 candidates. Table 3 contains a relative frequency distribution of candidates for licensure as nursing home administrators by age. A slight increase in the percentage of TABULAR DATA OMITTED candidates from 41 to 50 years of age occurred in 1989. In contrast, the percentage of candidates from 21 to 30 years of age declined in 1989 as compared to 1986.

Table 2. Average Test Score
            No. of       Average     Standard    Average
Age Group   Candidates   Raw Score   Deviation   Percent Score
Under 21         5        103.40        4.83         69%
21-30          386        116.42       12.46         78%
31-40          550        118.64       11.15         79%
41-50          439        119.30       12.65         80%
51-60          149        118.40       12.15         79%
Over 61         19        112.32       16.27         75%
Table 3. Age Group Breakdown for Candidates Tested in 1976,
1983, 1986 and 1989
Age Group    1976     1983     1986     1989
21-30        40.9%    36.6%    29.9%    25.2%
31-40        20.7%    36.8%    38.0%    35.5%
41-50        21.3%    17.2%    22.2%    28.4%
51-60        13.7%     8.9%     8.8%     9.6%
Over 60       3.4%     0.5%     1.0%     1.2%

Years of Experience. Table 4 presents summary statistics for the NAB examination performance by 1986 and 1989 candidates, broken down according to years of experience in the nursing home field. For both candidate groups, a slight advantage in test performance is apparent for candidates with 1 to 6 years of experience.

Education. As illustrated in Table 5, amount of education and performance on the NAB examination for 1986 and 1989 candidates are positively correlated. Table 6 compares the extent of education of licensing candidates for 1976, 1983, 1986, and 1989. Over the years, the amount of education of candidates taking the nursing home administrator licensing examination has steadily increased.

Table 7 shows the intercorrelations of the following variables with test scores: sex, age, experience, and education. The variable with the largest positive correlation with the examination score is education. On the other hand, there are small but significant correlations between experience and age and test score -- but these correlations virtually disappear when education is factored out. (The partial correlations between experience and age with scores TABULAR DATA OMITTED TABULAR DATA OMITTED reduce to 0 when the amount of education is removed.)

Of the variables examined in this study, then, the one with the largest correlation with test score is education. Neither sex, age, nor amount of experience in and of itself appears to be related to the score on the examination. This finding was also confirmed by a regression analysis, with education being the largest contributor to the degree of explained variance among test scores.

The significant positive correlation between education and sex indicates that male candidates had more education than female candidates. The significant negative correlation between education and experience indicates that the more experienced candidates tended to have less education.

Conclusion

The trend for new administrators to be from older age groups suggests interesting possibilities. It may indicate, for example, that many people are entering nursing home administration as a second or even third career choice; nurses, for instance, are becoming administrators in their 30s and 40s. The greater relevance of education than age to test scores may also reflect administrators' acquiring further education later in life. As for the negative correlation of test scores with experience, this may simply be the nature of the licensing examination process, which is geared toward entry-level administrators. Also, many administrators tend to become more specialized as they advance in their careers.

In general, however, the current analysis found results very similar to those of previous investigations (Schoon & Gullion, 1978; Schoon & Hayez, 1987) -- most significantly, the importance of education to achieving higher test scores compared with the relative unimportance of age, sex or experience.

In light of this, it is encouraging to note that the amount of education of candidates for the NAB licensing examination has steadily increased over the years. Over 70% of candidates now have at least a bachelor's degree, as compared with only 56% in 1976. Only 9% of the 1989 candidates reported highest education level attained as "some high school" or "high school graduate," compared with 27% of the candidates in 1976. These results suggest that licensing boards have been successful in raising the minimum qualifications of entry-level administrators, and that more educated administrators are emerging to meet the challenges of nursing home care in the 1990's.

Suggested Reading

Al-Assef AF, Wilson CN, Bachelor DM. Do nursing home administrators need more training? Nursing Homes 1992 (Dec.); 29-32.

Schoon CG, Gullion CM. Analysis of characteristics of candidates for licensure as long-term care administrators. Journal of Long-Term Care Administration 1978; 6(2):61-67.

Schoon CG, Hayez SK. The entry-level role of the nursing home administrator. Journal of Long-Term Care Administration 1987; 15(3): 15-19.

Stone MD. Profile of nursing home administrators in New Hampshire. Nursing Homes 1969 (Nov.):14.

The authors gratefully acknowledge the helpful comments provided by Mr. Phil Newberg and Mr. Jerry Miller on earlier drafts of this article.

Craig G. Schoon, PhD is President, and J. Patrick Jones, PhD is Vice President for Programs, of Professional Examination Service, a New York City-based non-profit corporation performing testing services for various professions. Michael O. Kittleson, MA, is Administrator and Chief Executive Office of Grand View Home, Washington, DC, and immediate past president of the National Association of Boards of Examiners for Nursing Home Administrators.

Table 6. Education Breakdown for Candidates Tested in 1976,
1983, 1986 and 1989
Level of
Education           1976     1983     1986     1989
Some High School    21.1%     9.6%    14.7%     8.8%
or High School
Graduate
Some College        18.6%    21.1%    20.3%    20.3%
Bachelor's Degree   23.1%    42.4%    40.5%    42.3%
Graduate Degree     31.2%    26.9%    24.5%    28.7%

TABULAR DATA OMITTED