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Going the whole nine innings.

In the long-term care game, the "finesse-pitching" administrator seems the best bet

The cornerstone or "franchise player" on most baseball teams is likely to be the starting pitcher. Comparatively, the administrator of a nursing home may very well be perceived as that team's franchise player. During the past 18 years, I have had occasion to work for (or catch!) two basic types of administrative "pitchers": the fastballer and the artiste.

Each of these approaches to the "Healthcare game" has intrinsic value. However, I would argue that the multi-faceted artiste pitcher is better equipped to bring his or her nursing home out on top "after nine."

It is important to underscore that what is at stake in this crucial game is nothing less than the quality of life experienced by people served by the nursing home -- by residents and, indirectly, their families. This inherent reality should be considered whenever an administrator begins his/her "wind-up," and especially during that necessary hesitation prior to the actual pitch.

The Fastballer

An administrator whose repertoire primarily consists of a fastball often tends to employ an authoritarian or autocratic style of management. It is effective; things do get done, but staff can feel anxious and even intimidated. I recall working for just such an administrator. He was bright, energetic and clearly accomplished but unfortunately, less than approachable. When on the "mound" he dictated the "big show." Input on decision making was often shaken-off and, after a few innings, seldom proffered.

He tended to exercise his authority in two basic ways: through memoranda and through formal committees. Whenever you would ask for information, try to share an idea or seek advice, he would inevitably respond by saying, "Put it in writing" or "There's a committee in place to deal with that!" These types of responses were frequent and further impeded reasonable staff involvement in the general operation of the home.

When he rendered a decision, it was communicated via memo downward to all levels of staff. Hardly ever were there casual opportunities for the upward flow of ideas, concerns or even constructive criticism.

What also sticks in my mind was the often lengthy periods when, for all intents and purposes, he was unavailable. Days, even weeks, could pass without my seeing him (though rest assured he was always accessible via memo!). Such lack of visibility can engender feelings of isolation and even anxiety vis-a-vis job security. His office was more a fortalice (by Webster's definition, a small fort) than an open, available space for staff to share their ideas or to request his assistance.

Most "fastballers" I have worked for or observed are effective in achieving predetermined outcomes but are not overly invested in the process that could improve those outcomes -- an inning-by-inning effort affording the staff "team" valuable feelings of involvement. The chance to be creative and the sense of some ownership of outcomes through genuine decision-making opportunities are just not readily available.

The autocratic leader tends, overtime, to become insulated from the immediate needs and concerns being felt and expressed by residents and their relatives. This perception can have a less than favorable impact on the home team's image. I recall one family member commenting: "I never see 'Mr. 'Smith.' Does he care how his staff works or how my mother feels as a resident here?"

The consequent feelings of isolation of staff from their leader may result in a persistent problem of employee turnover. It is difficult to feel a sense of loyalty when the administrator discourages informal input to the decision-making process or fails to take an active interest in the opinions and thoughts of his players. This, in turn, generally results in less sensitivity and caring on the part of staff as they work with residents on a daily basis.

Overall, the fastballer can deliver the "heat." But the rest of the team may begin to feel insignificant and increasingly irrelevant to the outcome. It certainly can be an impressive style -- Roger Clemens of the Boston Red Sox is a sight to see -- but is the flamethrowing administrator as consistently effective or efficient as Mr. Clemens tends to be? Not in my experience.

The 'Artiste'

I have also had the opportunity to work with skilled and adept "artiste" administrators. This particular style may not be as consistently overwhelming or intense as that of the "fastballer" (though the artistes I have known could "kick-back and throw the heat" when the situation demanded). Rather, I perceive this administrative style to be reflective of a more democratic approach to managing a nursing home. Characteristics of the artiste include flexibility, openness, involving all levels of staff in aspects related to operations, encouraging upward flow of communication and the ability to emphasize with staff as they perform what are often difficult tasks.

The artiste is purposely visible, confident in his/her abilities and immediately accessible to staff, thereby encouraging their input and constructive criticism. One administrator I worked with was affectionately called the "Hallway Man" because he was persistently seen interacting with staff in the halls. Such "dug-out-chats" made staff feel important, involved and part of the decision making process.

During these moments of interaction he would encourage staff to be continually creative in their caregiving and not to be concerned about reasonable risk taking. This style underscored the fact that a partnership truly existed in the team's accomplishing the nursing home's mission.

When one observed his "decentralized" system of operating you could not help but feel staff input was valued and that he was skilled in the complicated art of genuine listening. Staff verbalized how they sincerely appreciated being perceived as responsible employees capable of accomplishing their varied duties in competent, self-directed and sensitive ways.

Returning to the baseball analogy, the artiste administrator is one who has mastered a variety of pitches -- not just the fastball, but the:

1. Change-up - challenges staff to think before acting and then to act on their decisions;

2. Slider - helps staff to reach beyond their perceived limits, to go beyond the confines of custom toward creativity in their work on behalf of residents and their relatives;

3. Curve-ball - teaches staff to anticipate, to plan ahead in order to effectively and efficiently meet identified client needs; and the

4. Knuckleball - encourages staff to properly employ a sense of humor within their daily work schedule, to laugh and to feel good about what they do as members of the home's team.

The artiste administrators I have known were able to tailor the pitch to the demands of the situation. They took the game inning-by-inning and didn't try to impose their will on the outcome. An administrator who is involved with his/her staff on a daily basis will often find positive outcomes evolving naturally, arising from a sense of shared responsibility leading to a will to excel, to win.


The fastball pitchers I have worked with tend not to have staying power. Their single-minded approach to management can result in burn-out or career changes. On the other hand, the artiste administrator has that critical ability to alter his style and approach to management, giving no more or no less than the situation demands. Having worked with both fastball pitchers and with artistes, I am convinced that the latter style is critical to the success of resident-oriented and -directed programs and services, because the sense of democratic process it conveys builds team spirit.

Ultimately, of course, the winner of this game is the resident and his/her family. And over the long run, the pennant is yours.

Ken Lewis, LSW, MSW, is Director of Resident Services at Inglis House, a Philadelphia, PA wheelchair community. He is a prior contributor to NURSING HOMES.
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Title Annotation:nursing home administration
Author:Lewis, Ken
Publication:Nursing Homes
Date:Sep 1, 1992
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