The American Health Care Association reported that more than 63% of nursing home patients now come from acute care hospitals (Selby, 1988). Because of state and federal regulations and standards, nursing homes have become a very regulated industry. The increased need for skilled care in nursing homes and the growing complexity of regulations and standards have placed a tremendous demand on nurse administrators (the director of nursing or chief nursing officer) in long-term care facilities (Riskin, 1989).
Nurse administrators (NAs) must have the managerial knowledge and skills to handle the complex care of patients in long-term care facilities today. The majority of NAs in longterm care have either a diploma or associate degree (Riskin, 1989; Simms, 1987). These types of nursing programs prepare the nurse for bedside care of patients, but not for the managerial aspects of nursing. It is extremely important, therefore, that long-term care NAs acquire - through continuing education - the managerial knowledge and skills required to meet the demands of the job.
The nurse educator at an Area Health Education Center in a rural area of Arkansas was approached by several long-term care NAs about the need for continuing education in the area of management. The NAs, however, indicated they would have extreme difficulty in leaving their facilities to travel a distance for such a program because of the shortage of nursing home staff to cover for them while they were gone. The nurse educator suggested a guided self-learning experience through the use of modules as a possible format. The purpose of this study was to determine the need and support for a guided self-learning management education program and the content areas for the program, as identified by NAs and chief executive officers (CEOs) of long-term care facilities in Arkansas.
REVIEW OF UTERATURE
A survey conducted in 1981, as part of a grant from the American Nurses' Foundation and the W.K. Kellogg Foundation, found that 63% of NAs in long-term care facilities desired continuing education in management and supervision, administrative skills, and human resources (Lodge, 1987). A Delphi survey was conducted to identify research priorities as perceived by directors of nursing and inservice program educators in nursing homes and home health care agencies in Southeast Florida (Brower, 1985). The majority of the areas identified were clinical in nature. However, two items related to nursing administration were seen as extremely important: strategies for attracting and retaining knowledgeable, interested staff; and leadership skill of the professional staff.
Alford (1989) reported that an increased knowledge of basic management skills was identified as a high priority for future learning among NAs in long-term care. Warren (1987) supported this learning priority when she noted "more and more regulating agencies are requiring directors of nursing to assume more 'administrative' duties . . . ," including budgeting, policy making, and staffing analysis.
Giordano and Panfil (1987) found that directors of nursing in longterm care facilities are under "mountains of pressure." Examples include "... a flux of state inspectors, dominating administrators, revenueconscious owners, understaffing, long hours, excessive paperwork, high staff turnover and 24-hour oncall responsibility," to name a few. They distributed a questionnaire to NAs of skilled care facilities in Illinois requesting information in four areas: attitude, education, salary, and job satisfaction.
Although only 20% of the questionnaires were returned, the findings are of interest. Most of the 45 respondents chose their position because of dedication and commitment to geriatrics, the challenge of the position, and/or physical proximity to home. Some chose it because of the opportunity for a position in management and to be a change agent. Eighty-two percent viewed the position as an attractive career objective. The three most important goals identified by the respondents were to improve the quality of care, bring their facilities into compliance with federal and state regulations, and /or improve the organization of the nursing department.
The educational background of the respondents in the study varied, with 45% of the NAs having an associate or baccalaureate degree. Seventyeight percent believed that their education prepared them adequately for their job responsibilities. However, when asked, over 73% identified at least one area lacking in their education. Budgeting and business administration were cited as areas of greatest educational need.
During the 1988-1989 academic year, Riskin and Zenas (1989) reviewed all schools, colleges, and universities offering a nursing curriculum in Michigan and found that 65% had no classes in management education. They also conducted two surveys of NAs in long-term care during the same period and found a need for greater management education. Fifty-one percent of the respondents in the 1988 survey indicated they had "weak" educational training in management. In the second survey, the NAs were asked to identify content areas for a management program. Content perceived as important by the majority of the respondents included the following:
* Communicating with superiors and subordinates;
* Motivating and retraining staff;
* Dealing with difficult people and managing conflict;
* Dealing with legal and ethical issues surrounding long-term care;
* Conducting performance evaluations and cHsdplining staff;
* Projecting a professional image; and
* Understanding leadership style and management theory.
Only 52% and 44% perceived budgeting and understanding union contracts, respectively, as being important content for a management training program.
The literature supports the need for management education for NAs in long-term care facilities. Nurse administrators who are diploma and associate degree prepared, in general, have not received the education necessary to meet the managerial demands and responsibilities of directors of nursing in long-term care. Also, NAs in long-term care experience difficulty in obtaining the additional preparation in management because of limited funds available to cover the costs involved: travel expenses, staff coverage in their absence, and the educational programs themselves. The need, therefore, is for accessible continuing education in nursing management for longterm care NAs.
The data for this descriptive study were collected by the survey method. Two questionnaires were used: one for the NAs and one for the CEOs of all skilled nursing and intermediate care facilities (N = 229) in Arkansas. The instruments were developed by the investigators based on the literature and identified needs of NAs in long-term care. Content and face validity were established by a panel of five nurses familiar with instrument development and content and administration in gerontology. Reliability was not established due to the nature of the instrument.
Three mailings were sent 3 weeks apart to obtain the highest return rate possible. Of the 229 questionnaires sent to NAs, 178 (78%) were returned. Of the 229 questionnaires sent to the chief executive officers, 127 (55%) were returned. A total of 305 questionnaires were returned for an overall return rate of 67%.
Each mailing included a questionnaire with a stamped, return-addressed envelope. The cover letter presented information about the purpose of the study, approval of the study by the human subjects review board for the College of Nursing, and confidentiality of the data, and stated that return of the questionnaire was construed as consent.
The turnover of NAs in long-term care facilities in Arkansas is high and the majority do not have the educational preparation for management in long-term care facilities. Both executive officers and NAs indicated the need for management education for NAs in long-term care facilities.
Chief Executive Officers
The number of different NAs hired between 1984 and 1989 ranged from "no change" to "over 10." Seventyfive percent of the CEOs had hired between 1 and 5 new NAs, while 11% had hired 6 to 12. Only 14% of the CEOs indicated "no change" during that period. The top three reasons why the NAs left their positions were "not enough pay and too much responsibility" (22%), "stress and burnout" (18%), and "increased regulations" (12%).
The characteristics identified by the majority (66%) of the CEOs as being most important when hiring an NA were related to management in long-term care: experience in administration, management, leadership ability, ability to work with other people and to make decisions, and knowledge of geriatrics. The second most important set of characteristics identified by CEOs (31%) were personal in nature, including loyalty, dependability, honesty, responsibility, and caring.
When asked if the CEOs believed that the NAs hired between 1984 and 1989 had the management skills necessary to be successful in the position, 49% indicated "yes" and 45% indicated "no." Several CEOs indicated "yes and no," which could be interpreted to mean that the NAs have skills necessary in some areas and not in others.
Since the purpose of this study was to determine the support of management education for the NAs, several questions were asked relating to the use of and payment for a guided self-learning management education program. Ninety-eight percent of the CEOs indicated that they would encourage their NAs to participate in the program, 97% indicated that they would pay for the program, and 77% indicated that the NAs could use time at work to complete the learning modules.
Eight areas of content for the management education program were presented for the CEOs to select as important or as areas they expected to be covered. The top three areas identified were "human relation skills," "nurse as manager," and "monitoring the facility." All of the suggested content areas were important to a majority of the CEOs except "budgeting" and "unions."
Chief Executive Officer (CEO) and Nurse Administrator (NA) Responses to Content Areas for a Management Education Program for NAs in Long-Term Care Facilities
The NAs indicated they had been in their positions anywhere from 1 week to over 29 years. However, 45% had been in the position 1 year or less, and over half (58%) of those for 6 months or less. The majority (83%) received their initial nursing preparation at the diploma (33%) or associate degree (50%) level. Only 9% were initially prepared at the BSN level, while 8% were prepared at the LPN level. An encouraging finding was that all but one of the NAs prepared at the LPN level had returned for further education; however, 93% of those who received further education obtained the associate degree. Only 11% of the sample had completed further education at the baccalaureate and master's level in nursing and non-nursing fields.
The majority (66%) of the current NAs indicated that this was the first time they had been an NA in a longterm facility. Seventy-six percent of those indicated that they had not been an NA in any other healthrelated institution. Of those who had been an NA at another long-term care facility, 62% had been there for 5 years or less; 38% of those had been in another long-term care facility for 1 year or less.
Of the current NAs, 71% believed they had the necessary management skills to be successful in their positions. This response is different from the CEOs, who believed that only 49% of the NAs had the necessary skills. Even though the NAs thought they had the necessary management skills, 94% indicated they would participate in a guided self-learning management education program. The majority (84%) indicated that they would participate even if they had to pay a nominal fee for the program, but the participation increased to 95% if the CEO would cover the expenses.
The NAs were also asked to identify the content they considered important for a management education program (Table). The top three content areas identified were the same as those chosen by the CEOs, with "human relation skills" listed first. "Monitoring the facility" was seen as more important than the "nurse as manager." As the CEOs, the NAs identified all content as important except "budgeting" and "unions."
DISCUSSION, IMPLICATIONS AND CONCLUSIONS
The findings cannot be generalized beyond the sample of this study - and the state of Arkansas - but may describe a fairly typical picture of nursing administration in long-term care facilities in rural areas of this country. Nurse administrators in long-term care settings today find their responsibilities to go far beyond the delivery of routine care to elderly patients (Riskin, 1989). The majority (94%) of NAs in this study, as those in other studies (Alford, 1989; Brower, 1985; Giordano, 1987; Riskin, 1989), did identify a need for management education.
The CEOs identified this educational need as well. The majority of the CEOs were willing to provide money for the program and some were willing to have the program completed during work hours.
One reason for this current need for management education by NAs in long-term care facilities in rural settings might be the level of their nursing preparation. The majority of the NAs in this study and other studies had a nursing degree either at the associate degree or diploma level (Riskin, 1989; Simms, 1987). In Arkansas 83% of NAs were either diploma or associate degree nursing graduates. The curricula in these nursing programs do not include management theory or practice; therefore, the only way NAs can obtain this knowledge is through continuing education or further academic education.
The lack of knowledge about management may be one explanation for the high turnover rate of NAs in longterm care facilities. In 1983, Alford (1989) found a turnover rate of NAs approaching 60% in five southern states. Seventy-five percent of the CEOs in this study had hired one to five NAs between 1984 and 1989. Not only was-the average number of NAs high, but also they had little previous experience in nursing service administration in a health care institution. This finding certainly suggests that the current level of management experience of NAs in Arkansas long-term care facilities is limited.
The content perceived as important by both CEOs and NAs in the current study was consistent with the findings of Riskin and Zenas (1989). The content included the nurse's role as a manager, human relation skills, staffing and scheduling, monitoring the facility, regulations and standards, and legal considerations. However, both the current study and the one by Riskin and Zenas found that budget and unions were not considered as important as other management topics. In contrast, Giordano and Panfil (1987) found that a majority of NAs did want more information on budgeting.
Based on the findings of this study, the conclusions are:
* Nurse administrators in longterm care settings in Arkansas experience fairly short tenure periods in this role.
* Since the majority of NAs in longterm care facilities have initial nursing preparation at the diploma or associate degree level, they do not receive educational preparation in leadership and management in their nursing education programs.
* There is a need for management education of NAs in long-term care facilities in Arkansas, as perceived by the CEOs and the NAs.
This study has several implications for nursing. The major implication is that the need for a management education program for NAs in longterm care facilities has been established and "the content for the program has been identified by both NAs and CEOs. If NAs in long-term care had managerial knowledge and skills, they could participate more fully in decisions, ie, conflict management, time management, quality assurance, and standards and regulations, thus providing more job satisfaction and a decrease in turnover rate. This decrease in turnover rate would affect the cost of long-term care and the consistency and quality of care provided to patients.
The need for a management education program for NAs in longterm care settings in Arkansas has been confirmed and the content areas identified. Since the mission of Area Health Education Centers is to provide educational opportunities for nurses and other health professionals in rural areas of the state, a challenge lies ahead.
- Alford, P. Turnover rate slows with creative training program. Provider 1989; 12:43-44.
- Brower, H., Crist, M. Research priorities in gerontologie nursing for long-term care. Image: The Journal of Nursing Scholarship 1985; 17:22-27.
- Giordano, L., Panfil, A. Directors of nursing speak out. D.O.N. 1987; 10:6-9.
- Lodge, M. Professional education and practice of nurse administrators/directors of nursing in long-term care. Kansas City, KS: American Nurses' Foundation; 1987.
- Riskin, C, Zenas, C. Nursing education: Management training needs unmet for LTC nurses. Contemporary LTC 1989; 7:49-50, 53.
- Selby, T. Long-term care poses challenges for nurses. The American Nurse 1988; 11/12:1, 26.
- Simms, L., Price, S., Pfoutz, S. Creating the research climate: A key responsibility of nurse executives. Nursing Economics 1987; 5:174-178.
- Warren, J. Today's D.O.N.: On a new frontier. D.O.N. 1987; 10:42.
Chief Executive Officer (CEO) and Nurse Administrator (NA) Responses to Content Areas for a Management Education Program for NAs in Long-Term Care Facilities