Approximately 600,000 nursing home residents are 85 years and older. It is expected that this number will grow substantially, thereby increasing the demand for gerontological nurses. Projections are that by the year 2040, more than 23 million Americans will be 85 years or older; many will reside in long-term care facilities ('Twice as many," 1 989). Currently, only 5% of all registered nurses (n = 103,100) work in the nation's 1 9, 1 00 nursing homes (US Department of Health, 1989). However, it is anticipated that by the year 2000, more than three times that number will be needed to care for the growing elderly population ("RN shortage," 1988).
Although many nursing homes are adequately staffed, most report difficulty in recruiting and retaining nurses. The nature of nursing home practice, as well as current levels of compensation, are thought to account for some of this difficulty.
Unlike acute care hospitals, which are primarily private not-forprofit organizations, 14,300 (75%) of the nation's nursing homes are proprietary in nature. Of the other 25%, 3,800 (19.7%) are private nonprofit and 1,000 (5.3%) are government owned and operated (US Department of Health, 1989). Although the majority of nursing homes are proprietary, relatively little is known about the clinical practice patterns of nurses employed by proprietary nursing homes, or how these might differ from those of nurses working in the voluntary sector. Nor is it clear whether nurses' wages and benefits differ between the two sectors.
A better understanding of these issues would clarify the nature of nursing home practice and might facilitate the recruitment and retention of long-term care nurses. If certain aspects of clinical practice are found to vary with nursing home ownership, steps could be taken to determine whether there is a corresponding affect on patient outcomes. Nurses could then concentrate on improving those aspects of care that fall under their control. If, however, clinical practice patterns and compensation are found to be unrelated to ownership, nurses could be less concerned about the effect of financial incentives on nursing home care.
The purpose of this article, therefore, is to examine differences in the clinical practice patterns and compensation of nurses employed by proprietary and private nonprofit nursing homes. Specific research questions were:
* Do nurses employed in proprietary and nonprofit nursing homes differ in the amount of time they allocate to their different job responsibilities?
* Do nurses employed in proprietary and nonprofit nursing homes differ in the extent to which they engage in specific direct patient care activities?
* Do nurses employed in proprietary and nonprofit nursing homes receive different types of monetary compensation?
Concerns about poor nursing home care have prompted researchers to examine the relationship between ownership and various quality of care indicators. Historically, the argument has been that nonprofits provide better care because their revenues can be used to improve patient care rather than pay shareholders (Elwell, 1984; Rango, 1982). Although earlier studies found that proprietary and nonprofit homes provided similar care (Holmberg, 1968; Levey, 1973), recent research has suggested that nonprofit homes provide better care.
Using a sample of proprietary nursing homes, Fottler, Smith, and James (1981) found that profitability was inversely related to care quality and staffing levels. As profitability increased, quality of care and staffing levels decreased. In a study that examined both proprietary and nonprofit homes matched for size and resident functional status, Lemke and Moos (1989) found that nonprofits provided better physical environments and social climates. However, although proprietary facilities had greater employee turnover, there were no differences with respect to staffing, services, or personnel policies. In contrast, others (Greene, 1981) have found that proprietary facilities typically provide fewer professional nursing hours.
Although the evidence suggests a link between ownership and certain quality indicators, previous studies have paid little attention to the clinical practice patterns of nurses in these settings. In most instances, quality has been measured as the degree to which a facility meets specific environmental criteria, such as spaciousness and attractiveness; in others, it has been defined in traditional industrial engineering terms, eg, nursing hours per patient day and staff/ resident ratios.
In a departure from the usual approach to the measurement of quality, Burgio et al (1990) examined actual nursing behaviors. Observational procedures were used to measure the amount of time nurses spent in patient care, verbal interactions, and nonwork activities. Although patient care was defined as the performance of both indirect and direct physical care, it was limited to functional activities such as toileting, feeding, linen folding, and paperwork. Clinical practice patterns, such as those embodied in the American Nurses Association (ANA) Standards and Scope of Gerontological Nursing Practice (1987), were not measured. Moreover, their study was limited to a single nursing home and therefore did not examine differences between proprietary and nonprofit homes. Research examining the relationship between practice patterns and nursing home ownership would facilitate our understanding of the factors that contribute to quality patient care, as well as the extent to which gerontological nurses adhere to professional nursing standards. The study reported in this article was undertaken by the authors in order to address these issues.
Population, Survey, and Data Collection
The results of a population survey of registered nurses were used to examine the clinical practice patterns and compensation of nurses working in proprietary and private nonprofit nursing homes (Young, 1990). The survey population was all registered nurses licensed in Illinois in 1990 (response rate of 56%). The present study was confined to a single state; laws regulating nursing home operations vary considerably throughout the nation. Illinois' nursing population parallels that of the nation with respect to educational preparation, income, minority representation, and urban /rural distribution (US Department of Health, 1988; Young, 1988).
The survey, funded by the state for the purpose of gauging nursing trends over time, addressed a variety of issues. The present study examined the responses of those nurses employed by nursing homes, although the complete data base contains responses from all nurses (Young, 1990). Following approval by a university institutional review board, the survey instrument was first reviewed by panels of nurses from the state nurses' association before being pilot tested. The pilot test subjects included nurses with varying levels of education and experience who were employed by a local Veterans Administration hospital. Minor revisions (eg, wording changes for greater clarity) were then made to the survey instrument, which was first used in a related study (Young, 1988).
Sociodemographic Profile of Respondents by ff pe of Nursing Home
The final version of the 55-question scannable survey was sent to all persons licensed as registered nurses in the study state in 1990, along with biennial license renewal materials. Respondents returned completed surveys to the state regulatory agency, which separated the surveys from the renewal materials. Of the 117,796 registered nurses who renewed their licenses, 66,005 responded to the survey (response rate of 56%). Of those, 2,851 (4.3%) held full-time nonmanagerial positions that involved the direct care of patients in proprietary (1,582 or 55.5%) or private nonprofit nursing homes (1,269 or 44.5%). Separate response rates could not be estimated for the two groups because of the need to guarantee anonymity. For similar reasons, follow-up with nonrespondents was not possible. The Table summarizes the sociodemographic characteristics of these respondents.
Clinical practice patterns were operationalized as the amount of time nurses allocate to various job responsibilities (including direct and indirect patient care activities), as well as the percentage of patients for whom they perform specific direct care activities. Allocation of time to different job responsibilities was measured by asking nurses to indicate the actual percentage of time spent on various areas during a typical work week. The job responsibilities were direct patient care, staff supervision, adrninistration, consulting with agencies and professionals, teaching students, teaching staff, and research. Differences were examined with the t-test of significance.
To determine the extent to which nurses engage in specific direct patient care activities, respondents were asked to indicate the percentage of patients for whom they perform each of several direct patient care activities. Consistent with the ANA's Standards of Gerontological Nursing Practice (1987), these activities included the obtaining of health histories, performance of physical examinations, performance of psychosocial examinations, derivation of nursing diagnoses, development of therapeutic plans, and evaluation of patient outcomes.
Respondents were given the following options to indicate the percentage of patients for whom they performed these activities: none; fewer than 10% of all patients; 10% to 50% of all patients; and more than 50% of all patients. Differences were examined with the chi-square test of significance. This categorization scheme is a refinement of an earlier one (Young, 1988) in which respondents were asked whether they performed these activities a lot of the time (more than 50%), some of the time (10% to 50%), rarely (less than 10% but not 0%), or never (0%).
Type and extent of monetary compensation was assessed by asking nurses their hourly wage and to respond to the question, "Do your fringe benefits include pension plan, health insurance, dental insurance, continuing education program costs, tuition reimbursement, day care, parking?" They were asked to check as many as applied. Both chi-square and i-test were used to examine differences in compensation.
Allocation of Time
With the exception of time spent in consultative activities, the results indicate that allocation of work time did not vary with nursing home ownership (p>.05). In other words, nurses employed in nonprofit and proprietary nursing homes allocated their time in similar ways across different job responsibilities. Both groups of nurses reportedly spent the greatest mean percentage of their time in direct patient care activities (mean = 44.4, SD = 33.1 for nonprofit nurses; mean = 41.5, SD = 31.9 for proprietary nurses).
Staff supervision was the second most time-consurning activity, with both groups of nurses spending approximately 30% of their time in this area (mean = 29.5, SD = 22.8 for nonprofit nurses; mean =29.6, SD =21 .7 for proprietary nurses). Nurses spent similarly large amounts of time with administrative responsibilities (mean =25.6, SD = 25.7 for nonprofit nurses; mean = 26.9, SD = 26.0 for proprietary nurses).
Frequency of Performance Nurses in Nonprofit Homes
Consistent with prevailing notions that nursing homes are seldom used as clinical rotation sites, both proprietary and nonprofit nurses reportedly spent a very small percentage of their time teaching nursing students (mean =4.3, SD = 12.1 for non-profit nurses; mean =4.1, SD = 12.1 for proprietary nurses). Nurses spent even less time with research-related activities (mean = 2.3, SD = 5.1 for nonprofit; mean = 2.6, SD = 6.5 for proprietary nurses). They spent considerably more time teaching other staff, and there was no difference between proprietary and nonprofit nurses (mean = 10.8, SD = 12.2 for nonprofit nurses; mean = 11.6, SD = 12.0 for proprietary nurses).
Consultation was the only job responsibility for which nonprofit and proprietary nurses allocated different amounts of time (f = -5.9, F =2.89, p<.0001), with nonprofit nurses spending significantly less time consulting with other agencies and health professionals (mean = 8.7, SD = 10.3 for nonprofit nurses; mean = 13.1, SD = 17.4 for proprietary nurses). The large standard deviations for these activities also suggest considerable ingroup variation with respect to how nurses allocate their time.
Frequency of Performance Nurses in Proprietary Homes
Direct Patient Care Activities
The results indicate that, in most instances, nurses employed in proprietary and nonprofit nursing homes did not differ in the extent to which they engage in selected direct patient care activities. Stated differently, nursing home ownership was unrelated to the percentage of patients for whom nurses performed most aspects of direct patient care. In particular, there were no significant differences between nonprofit and proprietary nurses with respect to the performance of health histories (χp 2 = 2.79, df=3, p >.05), psychosocial examinations (χp 2 = 2.68, df=3, p>.05), or nursing diagnoses (χp 2 = 1.42, df=3, p>.05). Moreover, nurses from both groups developed care plans (χp 2 = 1.35, df=3, p>.05) and evaluated health outcomes (χp 2 = .50, df=3, p>.05) for similar proportions of their patients.
Differences were noted, however, with respect to how often nonprofit and proprietary nurses perform physical examinations, with nurses from proprietary homes performing examinations on a significantly greater percentage of their patient population (χp 2 = 13.34, df= 3, p<.005). Specifically, 36.1% of proprietary nurses reportedly perform physical examinations on 10% or more of their patients, compared with 29.4% of nonprofit nurses. It should be noted that these differences are significant even after correcting for multiple comparisons (Sokal, 1981).
In addition to depicting the similarities between nonprofit and proprietary nursing practice, Figures 1 and 2 highlight the fact that most nurses perform these activities for relatively few patients, regardless of nursing home ownership. Taken as a whole, these figures reveal that more than half (52.6%) of all respondents reported that they obtain health histories ("history taking") on less than 10% of their patients, eg, they indicated either that they never take health histories (0%) or that they take them for less than 10% of their patients. An even larger percentage (62.8%) said they perform physical assessments ("physical exam") on less than 10% of their patients, with almost 47% indicating they never perform physical assessments. Perhaps more disconcerting is the fact that more than 75% of all respondents revealed that they conduct psychosocial assessments ("psychosocial exam") on fewer than 10% of their patients.
Interestingly, both nonprofit and proprietary nurses reportedly perform nursing diagnoses ("diagnosis") for a considerable number of patients. More than 42% of all respondents (42% of nonprofit nurses and 43.1% proprietary nurses) said they perform nursing diagnoses for more than 50% of their patients. Only 15.3% reportedly never perform nursing diagnoses. Similarly, 42% indicated they develop care plans ("planning") for more than 50% of their patients, with only 13.5% indicating they never develop plans of care. Even fewer respondents (9.9%) said they never evaluate patients' clinical responses to care ("evaluating") and more than two thirds (67.7%) evaluate outcomes for at least 10% of their patient population.
Compensation of Nurses
The results reveal that nurses' hourly wages do not vary with nursing home ownership. Nurses working in proprietary nursing homes earn an average of $15.90 per hour (SD = 11.62), whereas nurses in nonprofit homes reported a mean hourly wage of $15.77 (SD = 11.84). In contrast to prevailing notions about the compensation of nursing home nurses, the results also suggest that the hourly wages of nursing home and hospital nurses are quite similar.
With respect to fringe benefits (Figure 3), nurses working in nonprofit homes are more likely to receive pension plans (χp 2 = 186.72, df=1, p< .000001). Approximately 41% of nonprofit nurses receive pension plan benefits, in contrast to only 17.7% of proprietary nurses. Nonprofit nurses are also more likely to receive dental insurance (χp 2 = 17.15, df= 1, p<.00005), with 31.9% receiving this benefit compared with 24.9% of proprietary nurses. Almost 54% of nonprofit nurses received free parking privileges as an employee benefit, significantly more than the 44.6% of proprietary nurses who received this benefit (χp 2 = 23.35, df=1, p< .000001). In short, nonprofit nurses are more likely to receive pension plan benefits, dental insurance, and parking privileges.
Despite these differences, nonprofit and proprietary nurses were equally likely to receive health insurance, with approximately 60% of all nurses in both groups receiving this benefit. However, these nurses were equally unlikely to receive child care, with only 1% reporting they received this benefit, regardless of full- or part-time status. And although nonprofit and proprietary nurses differed significantly in terms of whether they are reimbursed for continuing education (χp 2 = 5.19, df=1, p<.05) and tuition expenses (χp 2=4.02, df=1, p<.05), these differences disappear when corrected for multiple comparisons.
Fringe Benefits of Nurses Working in Proprietary Versus Nonprofit Nursing Homes
The clinical practice patterns of nurses from proprietary and nonprofit homes are quite similar. However, although these nurses also receive similar hourly wages, nurses from nonprofit homes are likely to receive more fringe benefits.
DISCUSSION AND IMPLICATIONS
One limitation of this study is the possibility of different response rates for proprietary and nonprofit nurses. It is unknown whether nurses from proprietary homes were more or less likely to respond than nurses from nonprofit homes because surveys were returned with licensure materials (thereby necessitating that anonymity be guaranteed). Another limitation is that not all respondents answered all questions. Again, anonymity precluded further contact with respondents for additional data. Lastly, it may be that nurses were unable to accurately estimate their allocation of time or percentage of patients for whom they engaged in specific nursing activities. On the other hand, the anonymous reporting might have allowed nurses to provide a more "true" picture of their clinical activities apart from those performed for the benefit of an observer.
Taking these limitations into consideration, the findings suggest that nurses from proprietary and nonprofit homes have strikingly similar clinical practice patterns. In most instances, ownership type was unrelated to either allocation of work time or extent to which they engaged in direct patient care activities. Nurses from proprietary and nonprofit homes allocated their time in almost identical ways, with direct patient care accounting for the greatest amount of time, eg, 42% to 44%. Interestingly, this amount coincides with an earlier study in which registered nurses in nursing homes were observed to spend slightly less than 50% of their time providing direct patient care (Burgio, 1990).
Perhaps more interesting is the fact that both proprietary and nonprofit nurses spend almost 55% of their time in supervisory and administrative activities. Although not surprising, this finding raises some concerns in that most of the nurses in this study were graduates of associate and diploma nursing programs, neither of which prepares nurses for managerial responsibilities (without additional education). Nursing home administrators need to assess the educational preparation of those staff nurses engaged in supervisory and administrative activities and make appropriate changes. These nurses could be encouraged to obtain additional formal and continuing education aimed at providing them with the managerial skills needed to perform their jobs.
As expected, the results indicate that nurses allocate an extraordinarily small amount of their time to teaching and research. This supports the prevailing notion that nursing homes are seldom used as clinical education sites and almost never are involved in research. In addition to the overall important contributions of education and research-related activities, these activities often provide staff nurses with social stimulation and professional challenge, both of which have been linked to job satisfaction and retention (Chiriboga, 1986; McCloskey, 1990). Additional work is needed to determine the effect of these activities on resident outcomes, if any. At the very least, administrators, nurse educators, and nurse researchers may want to increase collaborative efforts aimed at bridging the gap that currently exists between most nursing homes and academia. These groups may also wish to determine whether nurse recruitment is hampered by the current lack of student exposure to nursing home practice.
The results also indicate that nurses from proprietary and nonprofit homes perform specific direct patient care functions for almost identical percentages of their respective patient populations. Yet, it is important to note that both proprietary and nonprofit nurses were likely to obtain health histories and perform physical and psychosocial assessments for similarly small numbers of patients, eg, less than 10%. This suggests that the majority of these nurses do not practice in accordance with professional nursing standards, which call for gerontological nurses to collect physical and psychosocial data, make nursing diagnoses, develop plans of care, and evaluate outcomes for their older clients (ANA, 1987). Additional research is needed to determine whether this failure to adhere to professional standards is related in any way to resident outcomes, or whether it simply reflects the relatively stable, chronic nature of the clinical population.
In general, the clinical practice of nurses employed by proprietary and nonprofit homes is highly similar. Although previous investigators have not examined clinical nursing practice patterns per se, their findings have suggested that nonprofit homes provide better care (Greene, 1981; Lemke, 1989). However, the results of the present study suggest that the relationship between home ownership and patient care may be less clear than originally presumed. At the very least, the results indicate that the construct of "quality" should incorporate more than environmental and functional nursing activities.
Finally, the results suggest that although nurses from proprietary and nonprofit homes received almost identical hourly wages, nonprofit nurses typically reported more fringe benefits. Specifically, nurses from nonprofit homes were more likely to participate in pension plans and receive dental insurance and free parking. Whether or not these additional benefits influence job tenure is unclear. Additional work is needed to clarify the relationship between fringe benefits and nurses' degree of job satisfaction. It may be that nurses from proprietary homes are compensated in another way that possibly "makes up" for fewer monetary rewards. On the other hand, further investigation may suggest that proprietary homes need to offer additional rewards if they wish to compete effectively for gerontological nurses.
- American Nurses Association. Standards and scope of gerontological nursing practice. Kansas City, MO: American Nurses' Association, 1987.
- Burgio, L. D., Engel, B. T., Hawkins, ?., McCormick, K., Scheve, A. A descriptive analysis of nursing home staff behaviors in a teaching nursing home: Differences among NAs, LPNs, and RNs. Gerontologist 1990; 30:107-112.
- Chiriboga, D., Baily, J. Stress and burnout among critical-care and medical-surgical nurses: A comparative study. Crit Care Q 1986; 9:84-92.
- Elwell, F. The effects of ownership on institutional services. Gerontologist 1984;24:77-83.
- Fortler, M.D., Smith, H.L., James, W.L. Profits and patient care quality in nursing homes: Are they compatible? Gerontologist 1981; 21:532-538.
- Greene, V.L., Monahan, D.J. Structural and operational factors affecting quality of patient care in nursing homes. Pub Pol 1981; 29:399-415.
- Holmberg, R.H., Anderson, N.N. Implications of ownership for nursing home care. Med Care 1968; 6:300-307.
- Lemke, S., Moos, R.H. Ownership and quality of care in residential facilities for the elderly. Gerontologist 1989; 29:209-215.
- Levey, S., Ruchlin, H.S., Stotsky, B.A., Kinloch, D.R., Oppenheimer, W. An appraisal of nursing home care. / Gerontol 1973; 41:268-276.
- McCloskey, J.C. Two requirements for job contentment: Autonomy and social integration. Image: Journal of Nursing Scholarship 1990; 22:140-143.
- Rango, N. Nursing home care in the United States: Prevailing conditions and policy impUcations. N Engl } Med 1982; 307:883-890.
- "RN shortage on the increase in nursing homes." Geriatr Nurs 1988; 9:319.
- Sokal, R.R., Rohlf, FJ. Biometry. New York: Freeman, 1981.
- "Twice as many as expected?" Geriatr Nurs 1989; 10:9.
- US Department of Health and Human Services. 77k registered nurse population: Findings from the national sample survey of registered nurses. Springfield, VA: National Technical Information Service, 1988.
- US Department of Health and Human Services. The 1985 national nursing home survey. Hyattsville, MD: National Center for Health Statistics, 1989. Accession No. PHS 89-1758.
- Young, W.B., Marcantonio, R.A., Hughes, K.K., Chomick, N.L. 1990 biennial survey of Illinois registered nurses: Data tape. Springfield, IL: Illinois Department of Professional Regulation, 1990.
- Young, W.B., Minnick, A. 1988 biennial survey of Illinois registered nurses: Data tape. Springfield, IL: Illinois Department of Professional Regulation, 1988.
Sociodemographic Profile of Respondents by ff pe of Nursing Home