Developing today’s (and tomorrow’s) NHA leaders

Nursing home quality reflects significantly on the expertise and commitment of the administrators in charge (AITs) of person-centered organizations. The AIT or practicum experience serves as an essential educational component, facilitating the transition from student to leader.

Although a great deal of variability exists in nursing home administrator (NHA) licensure requirements across state lines, most states require specialized education—an applied field experience commonly referred to as an AIT program—and passing scores on federal and state licensure exams. The content, length and model for these experiences have been driven largely by the National Association of Long Term Care Administrator Boards (NAB), which recommendeds NHA requirements and organizational managerial/technical needs. Even with these recommendations, standards still vary widely from state to state. Educational requirements range from a high school education to a bachelor’s degree, and AIT requirements range from 0 hours in a handful of states to 2,000 hours and beyond in others. 

During a practicum experience, the AIT has an opportunity to rotate through each facility department, developing an understanding of frontline service staff roles, the responsibilities of the departmental managers and how each department integrates with the rest to provide both effective and efficient person-centered care. Students also spend significant time learning about several administrative functions, such as managing the survey process, human resources and financial and information systems. In many programs, they also develop their leadership skills by participating in projects that effect change and produce favorable results.


Long-term care (LTC) administration has an employment cliff: More people are leaving the field than are entering it. Couple that with NHAs being under increasing pressure to transform their communities. These two issues are occurring against a backdrop of increasing consumer demands and dwindling fiscal resources.

The AIT program is an essential educational component, serving as a career transition between student and employment status, and its completion is essential to the success of potential administrators. Contemporary research has found preliminary evidence that the AIT experience is critical to the effective development of administration competencies and leadership skills.

A recent NAB-funded study that we just completed in concert with coauthors from University of Pittsburgh, George Washington University and St. Joseph’s College of Maine has further linked the important educational component of the AIT experience with administrator competency and quality. Our initial analysis found that an optimal level of education and training positively affects the development of successful LTC administrators as well as facilities’ five-star ratings.

Using education and training stringency scores developed for each state based on its NHA licensing requirements and NAB licensing exam data from 2001 through 2009, we found that both higher degree requirements and longer AIT requirements were correlated with better exam scores. Although we believed that exam performance was a good proxy for measuring competency, we wanted to know whether that higher competency translated to better quality in practice. 

As such, we identified the five-star ratings of nursing homes in 17 states where these recent licensees were used. We found that NHAs who earned higher licensing exam scores were leading facilities with better overall five-star ratings and health inspection ratings and had fewer total enforcement actions counts in their current facilities. 

Although this is just a preliminary study, this research strongly suggests that an optimal level of education and field training leads to better-prepared NHAs, resulting in a higher level of quality care and service. It is clear that new administrators need quality practicum/AIT experiences to ensure that they are well prepared for their future careers.


Although, as educators, we have a subjective sense about which practicum sites are excellent, which are good and which are less-than-ideal, we wanted more information to aid in the selection of the best possible sites and preceptors with whom to partner. We also developed resources and practices to support these practitioner-educators to best develop future administrators. 

With funding from the Commonwealth Fund and the NAB Foundation, we conducted a study that helped us discern that the quality of the AIT or practicum experience is influenced by the environment in which the trainee learns. We determined that the experience of the trainee’s preceptor and the “spirit of learning” embodied by the practicum site are two of the most significant driving forces.

To best prepare future leaders, several training site characteristics offer the highest quality experiential learning:

  • The individual serving as the preceptor makes a significant difference in the student’s learning experience. The number of years the preceptor has been with his or her organization, the number of students he or she has mentored, how involved they are in their profession and their level of education are all significant factors towards the student’s success.
  • A positive learning environment—an atmosphere that communicates that the student is wanted, accepted and encouraged to engage with the work of the organization encourages a climate of learning. In addition, stability of department head teams and the level of organizational support encouraging professional development were important factors. Conversely, instability among staff or leadership teams probably served as distractions to the preceptor and inhibited student development.
  • Organizations that emphasize the advancement of culture change, have high customer satisfaction and participate in the Advancing Excellence in America’s Nursing Homes (Advancing Excellence) campaign also seemed to better position students for future success.
  • Finally, those students who were best prepared to lead LTC organizations had obtained their education and training at sites where a variety of services, such as skilled nursing, assisted living, dementia care, senior housing and other community-based services, were provided.


It is imperative we develop high-impact practices to support the education and training of a new generation of leaders in our field. Our recent research has yielded several findings that can be leveraged by state licensing boards, academic programs and corporate AIT directors.

Ample opportunity exists for all stakeholders to work together to develop core competency criteria and standardized tools to help advance quality clinical training experiences for future administrators. Some areas ripe for collaboration might include consideration of:

  • Advancing national licensure requirements or accreditation guidelines regarding educational curriculum, length and structure of AIT experiences. Such requirements or guidelines also were called for by a broad representation of key stakeholders, as part of legislative forum recently held at the National Emerging Leadership Summit in affiliation with the Senate Special Committee on Aging.
  • Establishing appropriate criteria for site and preceptor selection, such as preceptor experience minimums. Additionally, sites that offer diversity in their scope of services, are in good regulatory standing, are embracing resident-centered care philosophies and are actively involved in quality initiatives such as the Advancing Excellence campaign provide superior training opportunities.
  • Providing resources and strategies to help cultivate an organization’s learning environment. NAB could take a leadership role with this effort by encouraging these practices through its accreditation process and sharing these best-practice resources with states, schools and other interested partners.
  • Further developing preceptor training, development or certification programs, and making them available across states and programs. American College of Health Care Administrators (ACHCA) could provide leadership coordination with this effort based on its experience with a certification program and recent launching of a national aging service leadership mentoring program.   

Beyond the education and training experience, many other individual factors likely contribute to a well-prepared, high-quality administrator. A trainee’s own engagement in the field, commitment to preparing for his or her future career and the initiative to develop critical characteristics that quality senior care leaders must possess are important factors. 

The evidence now, however, demonstrates the importance of a strong AIT experience. Because a quality AIT program is heavily influenced by an experienced, educated and committed preceptor, it is critical that academic programs, state boards and professional and/or organizational associations find ways to recruit and develop these candidates.

Consider the broader learning environment for the student, and find ways to help develop this “spirit of learning” culture within training organizations. Sharing and encouraging the use of best practices is a good place to start. Finally, as leadership development for the health and aging services field continues, we need to advance and recognize organizations and sites that are best positioned to offer quality learning experiences.

The positive effect of making these changes far outweighs the modest efforts required by stakeholders involved in the practicum/AIT field experiences. The health and aging services administration profession has an opportunity to advance evidence-based guidelines and standards supporting leadership development. Ultimately, education will be improved, and future LTC leaders will be better prepared to serve the profession.

Jennifer Johs-Artisensi, PhD, MPH, is the Education Committee chair for NAB, an associate professor and program director for the Health Care Administration Program at the University of Wisconsin–Eau Claire and associate director of the Center for Health Administration and Aging Services Excellence.

Douglas Olson, PhD, MBA, NHA, FACHCA, is the director of the Center for Health Administration and Aging Services Excellence and an associate professor for the Health Care Administration Program at the University of Wisconsin–Eau Claire. He serves on the Board and the Academy for Long Term Care Leadership and Development for the American College of Health Care Administrators and also serves on the Board of Overseers for the American Health Care Association's National Quality Award program.

Click on the photo, upper left, to view a photo gallery. Photos are courtesy of the University of Wisconsin–Eau Claire.

Topics: Articles , Executive Leadership , Facility management , Leadership , Staffing