Leadership preparation in relation to resident outcomes in US nursing homes

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1 Leadership preparation in relation to resident outcomes in US nursing homes Alison Trinkoff, ScD, RN, FAAN; Nancy B. Lerner, DNP, RN; Carla L. Storr, ScD; Kihye Han, PhD, RN; Meg Johantgen, PhD, RN; Kyungsook Gartrell, MSN, RN Funded by the National Council of State Boards of Nursing, #R40009.

Storr, ScD; Kihye Han, PhD, RN; Meg Johantgen, PhD, RN; Kyungsook

2 Objective To examine the associations of education and certification among Nursing Home Administrators (NHAs) and Directors of Nursing (DONs) with resident outcomes. We hypothesized that NHs led by NHAs or DONs with certifications or higher education would have better resident outcomes.

3 Background Nursing home leaders have a responsibility to design and promote policies to ensure quality resident care. Yet, many have not received training focused on leadership and management skills. (Dwyer, 2011) Formal education programs (e.g. Bachelor s, Master s degree) and specialty certifications can provide additional knowledge, strategies and resources. Evidence that NHA and DON education and certification is related to resident outcomes is limited. Variation in NH leadership preparation provided an opportunity to examine this question.

4 Study Design Secondary data analysis using data from two national databases: National Nursing Home Survey (NNHS), NH leadership education and certification Nursing Home Compare Oct-Dec, Quality Indicators (QIs) -Resident outcomes Data were linked by NCHS using facility identifier.

education and certification Nursing Home Compare Oct-Dec, 2004 -Quality

5 Sampling NNHS used a multi-stage, stratified sampling strategy, and collected data by computer assisted face-to-face interview. 1,500 NHs selected, representing 16,628 NHs in the US Our study included 1,142 NHs with useable QI data among 1,174 selected NHs.

1,500 NHs selected, representing 16,628 NHs in the US Our study

6 Measures Leadership preparation (NHA, DON) (Source: NNHS) - Education: highest degree completed using three categories: Master s degree or higher, Bachelor s degree, and Associate s degree or less - Certifications: a dichotomous variable (Any certification) with a Yes (those with at least one certification) vs. No - Combination of education plus certification

Associate s degree or less - Certifications: a dichotomous variable (Any certification)

7 Resident outcome measures QIs: from CMS Nursing Home Compare Derived from Resident Assessment Instrument (RAI) of the Minimum Data Set (MDS)

8 QIs and definitions: Pressure ulcers: high-risk: stage I-IV pressure ulcers in residents impaired in bed mobility or transfer; comatose, or suffering malnutrition low-risk: all other pressure ulcers Pain: proportion in the last 5 days with almost constant or frequent moderate to severe pain, or any very severe/horrible pain. Catheter use: proportion with indwelling catheters Urinary tract infections: past 7 days.

proportion in the last 5 days with almost constant or frequent moderate to severe pain, or any very

9 Control variables - NH size: defined as number of beds (<50; 50-99; vs beds) - Profit status: for profit vs. not for-profit

10 Data Analysis Descriptive: proportion of NHAs, DONs by education and certification Models: Regressed facility-level QIs onto leadership preparation Adjusted for facility size and profit status Model testing: SAS Proc Genmod for Generalized Linear Models with Generalized Estimating Equations (GEE) Negative binomial log link: correct over-dispersion of count-type dependent variables

status Model testing: SAS Proc Genmod for Generalized Linear Models with Generalized Estimating

11 NHA, DON: Education NHAs: 32% had Master s degree or higher DONs: 43% had Bachelor s degrees or higher

12 NHA: Certifications About one quarter (28%) had at least one certification. Certified Nursing Home Administrator (CNHA) =25% ANCC-unspecified= 3% (nurses).

13 DON: Certifications Nearly half (42.5%) had 1 or more certifications. Most common: National Association of Directors of Nursing (NADONA) (15%) ANCC-Gerontological (10%)

14 NHA, DON: Certification by Education

15 NHA, DON: Certification by Education NHAs Any certification: did not differ by education. ANCC-unspecified: highest for Master s & Associate s (p=0.026) DONs Any certification: highest for Master s (58%), Bachelor s (48%), then Associate s (37%) (p<0.001) NADONA, ANCC-gero: did not differ by education. AANAC, ANCC-other, CRRN, APIC, Other: Master s or Bachelor s significantly higher than Associate s

026) DONs Any certification: highest for Master s (58%), Bachelor s (48%), then Associate s (37%)

16 NHAs: Education + Certification & Resident Outcomes* NHs led by NHAs with Master s or higher AND certification had 21% lower pain rates (p=0.015) vs. homes led by NHAs with <Master s degrees and/or no certifications *adjusted for nursing home size & profit status

17 DONs: Education + Certification & Resident Outcomes* NHs led by DONs with Bachelor s or Master s AND certification had 13% lower pain (p=0.046) and 9% lower catheter use (p=0.008) vs. NH led by DONs with Bachelor s or Master s degrees and no certification, or Associate s with or without certification. *adjusted for nursing home size & profit status

18 Limitations Cross-sectional design, so cannot draw causal conclusions Characteristics of NHs and leaders were from 2004 so may not reflect the latest NH parameters Data collected may reflect potential errors related to coding, measurement, and missing data

so may not reflect the latest NH parameters Data collected may

19 Conclusions Findings suggest investment in education and certification for NHAs and DONs has potential to improve quality of resident care. In-service and professional development leading to NHA & DON certification might have a positive impact on resident outcomes. Tuition support and release-time to obtain higher degrees also may benefit NHs.

In-service and professional development leading to NHA & DON certification might have

Do Training Regulations for Certified Nursing Assistants Influence Job Satisfaction?

NCSBN scientific symposium 2014 (April 10, 2014) Do Training Regulations for Certified Nursing Assistants Influence Job Satisfaction? Kihye Han, Alison M. Trinkoff, Carla L. Storr, Nancy Lerner, Meg Johantgen,