Disenchantment among LTC leaders—and its toll on quality

Every day and every night, 17,000 nursing home administrators (NHAs) around the nation bear the awesome responsibility of ensuring quality of life for 1.1 million of our elders. As leaders, they guide and mentor 650,000 CNAs, 300,000 RNs and LPNs, and 400,000 other staff in the art of caring for seniors, half of whom suffer dementia, one in ten having a diagnosed psychiatric condition, and three in four needing help with bathing, dressing, eating, moving from bed to chair, and using the toilet.

NHAs, along with their directors of nursing (DONs), researchers say, are the architects as well as the pillars of long-term care quality, so much so that you can pretty well size up a nursing home (NH) and determine its quality by the number of NHAs that it has lost in recent years and by the length of their tenure. In other words, the best NHs are invariably blessed with stable leadership, and in mediocre NHs you find NHAs at the revolving door entering and departing in rapid succession. Quality is a fragile seedling; it demands care and attention, is slow to come into bud, and blossoms best when tended consistently by the same hand, with no interruption.

Stable leadership is the sine qua non of NH quality because long-term care is quintessentially a people's enterprise. Here success is measured not by the high-tech conquest of disease and curing of illness, but by the high-touch caring that affirms the dignity of residents, even as a steady loss of independence threatens their self-esteem and self-respect. Efficient systems and skilled staff are necessary to deliver appropriate care, but they do not add up to the ambience required to foster quality of life. Creating such a supportive climate calls for a stable and caring leader who can add compassion to skill and can mentor, motivate, and transform the staff into devoted caregivers.

Compassion, whether inborn or cultivated, enables a leader not to see in people their social origin or status, but to connect with the person behind that social mask. Empathic NHAs recognize the high-value person in the low-status CNA role; they assume every person has the same universal human need for self-esteem and respect, the need to achieve and to create, to relate and to bond. Such NHAs, therefore, create a person-centered culture that affirms the dignity of residents and no less of staff, and fosters compassion, mutual caring, and bonds of friendship. Excellent service, competent care, and devoted caregiving are the fruit from the garden tended with care by a compassionate leader.

Both anecdote and research confirm that in the highly personalized world of the NH, systems to monitor quality do not always endure even when they are well designed and competently run. For an NH to perform consistently well and for its quality to always rank high, it has to have an unfailing, durable, supportive culture that is nurtured by a long-lasting, personalized NHA leader.

Thus, when NHAs walk out, they disturb the very underpinnings of quality and leave their facilities on the brink of a cascading crisis. High NHA turnover triggers a domino effect: DONs head toward the exit door, nursing personnel follow, care systems come apart, quality indicators turn negative, family and staff satisfaction slides, and state surveyors witness the quality meltdown and issue citations of increasing scope and severity. And therein lies the root of the chronic quality problems that afflict many a nursing home.

Departing Leaders and the Quality Crisis

More than 7,000 NHAs will walk out of their job this year, as they did last year and the year before. NHA turnover, which averages 40% plus, occurs unevenly; massive turnover in some facilities inflates that overall average, which is nevertheless too high for comfort. At the same time, the talent pool that has replenished their ranks is drying. The number of incoming candidates who take the NHA licensure exam has shrunk 40% in recent years.

These conditions explain why quality-related problems seem endemic, and why most quality improvement programs do not achieve lasting improvement. facilities with high NHA turnover simply lack a solid base on which to erect the edifice of quality. A simpleminded attempt to improve performance in those NHs is like using a Band-Aid to cure a malignancy.

And now a new study* casts an ominous light on this troubling situation. It reports that a malaise has spread among the nation's NHAs and afflicts them so deeply that three in four of them have seriously considered quitting. Half expect to be gone within five years.


Tellis-Nayak, V. The satisfied but disenchanted leaders in long-term care: The paradox of the nursing home administrator. Seniors Housing & Care Journal 2007;15:3-18. As the author of this study, and because of its important message, I requested and am permitted to make wide references to it.

The study analyzes the experience of 685 NHAs across the nation. It fleshes out its quantitative findings with ethnographic detail drawn from the NHAs' incisive comments on their profession: what attracted them to elder care, the rewards they get from making a difference, the source of their satisfaction, the nature of their frustration and its impact on their work and their morale.

The Fault Line at the Heart of Leadership

The analysis reveals a widening fault line that splits the role of NHAs and strains their commitment. On the one hand, NHAs affirm their satisfaction in their role: They often speak of an inner urge to serve and the rewards that come when they relate, bond, and make a difference. It is that challenge they responded to once and that sustains them now. They take pride in the close-knit family they have created inch by inch, with dedication and persistence.

(Among the verbatim responses) The opportunity to make a difference in the lives of the residents, their families, and the staff provides rewards that cannot be measured in dollars.

On the other hand, their joy fades and their idealism gives way to skepticism as a harsh imperative intrudes: The low-tech, high-touch, person-centered community they have built is but a cog in the healthcare political economy; if only to survive, an NH has to march to the dictates of its external faceless masters. NHAs have barely a say in the wide untamed arena where big players compete and collide for high stakes. The Centers for Medicare & Medicaid Services (CMS), state surveyors, investors, insurers, advocates, trial lawyers, accrediting agencies, unions, labor and one's corporate managers are driven by an agenda and plays by rules not always those of the caregivers.

The destructive working environment sucks out of me and others who really care the enjoyment of this “calling.”

That is not the vision that attracted NHAs to long-term care, nor is it what their training prepared them for, nor is it what many NHAs have an appetite for. But they cannot duck that challenge, even as it tests their virtue and their integrity. And worse, that pitiless environment on which hangs their facility's survival demands a commitment that draws them ever farther from their calling; it imposes on them priorities that, in effect, turn an NHA into a compliance officer, risk manager, and entrepreneur all rolled into one.

I came to care for people, not to fight these battles…. I don't have to put up with this abuse….

The Four Sources of Frustration

The NHAs speak with emotion about this unforgiving world to which their lifeline is hitched. Its uncaring ways run counter to the values they promote, its uncompromising priorities eclipse their vision and mission, its bureaucratic prescriptions devalue their professionalism. In short, their growing alienation stifles the joy they find in serving the elderly. They bear witness to their growing estrangement in sharp and biting words directed at four sources of their disaffection, as expressed in the following comments:

After a very successful first career as an Air Force officer, I searched for another ‘rewarding’ career in healthcare. I've been a successful administrator. I am the residents' biggest proponent, work in excess of 60 hours and do everything to protect them. Many would thank me…. I'm almost embarrassed when people ask me what I do for a living. The outrageous media hype, the ridiculous survey system! I have considered leaving for several years, and doubt that I will last more than five. I am scared that someone will sue me as criminally liable. It's not a profession that I would recommend.

After 24 years I will soon be in a new career! … Who would want to enter this field of LTC…the bottom of the food chain?

First, the NHAs resent that the state survey is designed to sniff out faults, not to encourage quality. It is confrontational and leaves no room for collaboration. It is uncaring and punitive, not educational.

This is a form of structural evil…. The DOH [Departmentof Health] makes you feel like the enemy.

Second, the NHAs contend that regulation is often well intentioned but it defies common sense; it pulls caregivers away from the bedside to ensure paper compliance. It breeds an amoral culture by forcing honest caregivers to create useless care plans that they have no time to implement.

Regulation, as surveyors interpret it, makes our positions unbearable. This is the only industry where the term “assure” is interpreted as 365/24/7, with no opportunity for error, where you are penalized for what occurred months ago, and you get no credit for making the correction.

Third, NHAs assert that corporate, regional, and community boards and managers need to micromanage; in doing so, they stifle creativity, and they show no loyalty to and scant respect for NHAs. They siphon off dollars to sustain their overhead.

They give no training, they have no loyalty, they do not give recognition. In their eyes, we are as disposable as Kleenex…. We live with the threat of being replaced. No job security, we are a dime a dozen.

Fourth, NHAs lament that professional liability that can absorb up to 47% of a state's Medicaid reimbursement takes a crippling toll, adds fear, and shifts the caregivers' focus from the bedside to the courtroom, from caregiving to paper compliance.

Legal liability is a “loaded gun” that is held to my and my staff's heads every day…. Solve tort and you unlock the misery of the profession! Every line item is infected. We look at every new admission as a risk. It is a virus that has infected every aspect of this profession…. They are wheelchair chasers. Get the lawyers out of nursing home care. They are a scourge.

Where Does the Quality Buck Stop?

The study ends on a practical note; it makes a recommendation on a pervasive and persistent NHA concern: Where should the quality buck stop? When a citation is levied, the surveyor may trace its cause to an error that occurred on one unit. The surveyor may even hold the DON and the NHA responsible for the understaffing that caused the lapse on that unit. But the surveyor will not reach across 1,500 miles and pin the responsibility for that survey citation on the CEO of the company who mandated the staffing cuts and whose decisions flashed on the survey radar half a continent away. Why should accountability stop at the DON's and the NHA's door, and not further up the authority ladder from whence strategy, policies, budgets, and mandates flow?

NHAs contend that, although they do preside over their NHs, often they are just a front for the CEOs of the profit or not-for-profit chains, their boards, their senior officers, and their regional managers. These senior managers make life-and-death decisions about a facility—whether to sell, to merge, to downsize—without consultation with or consent of those affected. They make staffing decisions with a concern more for Wall Street than for resident well-being. They control the dynamics of quality to the extent that an NH's culture becomes less a reflection of the NHA's values and more a measure of the commitment of the senior managers.

The senior managers are the invisible elite of long-term care. They do not participate in programs, conventions, seminars, and workshops, which are tailored for NH-level operatives. We know that corporate decisions affect bedside quality. But we do not plan conferences for senior executives on leadership, quality, responsibility, and accountability. The mountains of educational material we produce and the myriads of conferences we hold—to teach the what, the how, and the why of leadership—all talk to an audience at the NH level, as if long-term care authority reaches its highest level there; they place the ultimate responsibility for quality on the DON and NHA.

Even regulators who look askance at corporate managers and know where the accountability trail ends participate in this game of head-in-the-sand pretense. CMS does not lack zeal; rather, its surveyors ferret out slipups with uncommon zeal—and direct it solely toward caregivers. But the survey and other monitoring processes lack even rudimentary mechanisms to track responsibility through the maze of legal firewalls that shield corporate managers from nettlesome trial lawyers.

Thus, in effect, we all collude in and silently endorse the gated-community approach of the power-elite and never refer to their noninvolvement in any dialogue on quality. Their impregnable isolation hides from our view, and wipes out from our mind, the fact that there are indeed invisible levers of power behind many visible outcomes at the bedside.

It is a tale of two settings: Effective control, no accountability, and legal immunity for corporate heads on the one hand and, on the other, delegated authority, full involvement, and risk of liability for caregivers and their managers—a noxious mix that corrodes morale and fuels resentment. A real solution, not a patchwork compromise, would call for an out-of-the-box proposal and uncommon courage to implement it. Nevertheless, the study ventures a recommendation, and directs it toward three parties.

To researchers, it recommends an agenda, investigating: What constitutes an external influence on internal NH life? What form does that influence take—or hide under? How do we measure the “scope and severity” of its impact and apportion responsibility for its outcome to external dictates versus in-house leadership?

To advocates, quality promoters, and other such powers, it suggests the use of a judicious mix of rewards, pressure, and sanctions to draw this “invisible elite” into regular dialogue with caregivers and their managers, with the goal that both sides listen, share, and learn about the quality-related dilemmas that each side faces.

To regulators, it recommends amending the survey protocol to permit outright legal immunity to the corporate elite in return for a genuinely collaborative search for measures of responsibility to be used in surveys to promote real accountability.

Our intent is to give voice to NHAs' concerns. Let one speak for the many: “It is great if you offer a survey, but it is totally meaningless if you don't act on the information.”

V. Tellis-Nayak, PhD, is a Medical Sociologist who has been a university professor, researcher, and author in the long-term care field

To send your comments to the author and editors, e-mail tellis-nayak1007@nursinghomesmagazine.com.

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