The Disappearing Administrator:Results of a National Survey

The Disappearing Administrator:
Results of a National Survey
What are the state licensing boards seeing? And what are they doing about it?
By John R. Pratt, MHA, FACHE
Over the past several years, there has been a disturbing decrease in the number of new skilled nursing facility administrators entering the profession. That decline, as measured by the number of individuals taking the national licensing exam, has been well documented in several articles in professional publications.

The exam, which is required of all would-be administrators, is developed and administered under the aegis of the National Association of Boards of Examiners of Long-Term Care Administrators (NAB).

NAB, whose mission is “to enhance the effectiveness of state boards of long term care administrators in meeting their statutory and regulatory duties and responsibilities to protect the health, safety, and welfare of the public,” has expressed concern over the decline and is taking a number of steps to address it.

One such effort involved a survey of all NAB member jurisdictions (50 states and the District of Columbia) to ascertain the extent to which they are experiencing the decline and what they are doing to reverse it.

The survey was conducted during the spring and summer of 2001. It was not intended as empirical research, but rather as an attempt to get input into the discussion from the member boards. Much of the information gathered was anecdotal, and as such might be more valuable than simple statistics. Forty-eight responses to the survey were received (47 states and D.C.). For one reason or another, three state boards did not respond. The following summarizes the findings:

Extent of the Decline

Survey participants were asked if they had seen a decline in new applications for licensure and/or applications for endorsement (the process by which an administrator with a license in one jurisdiction applies to transfer that license to another) from administrators already licensed in other states. More than half (56%) of respondents reported experiencing a decline in new licensure applicants and nearly a third (33%) experienced a decline in endorsement applicants, confirming that there is a problem.

The survey results were searched to identify possible regional trends. As Figure 1 shows, several large groups of states are experiencing a decline. However, in numerous instances, neighboring states responded differently. For example, of the six New England states responding, three answered yes to a decline, and three answered no. Similarly, Oregon and Idaho said yes, while Washington said no.

Quantifying the Decline

While some boards were not able to accurately quantify the amount of decline, particularly in the case of endorsement applicants, most could. The extent of the decline ranged from 23 to 75% over the past several years, with many in the 50% range. This further strengthens the impression that the problem has been felt largely on a state-by-state basis. It also speaks to the variation in the boards’ ability to uniformly document trends.

Reasons for the Decline

Respondents were asked why they thought the number of new licensure applicants had dropped off so dramatically. Reasons offered included a punitive regulatory environment, lack of compensation commensurate with responsibility, long hours, staffing shortages, a good economy offering many attractive career options, growth of the assisted living industry as an option, need for industry career path development programs, funding shortages, industry financial distress and negative press.1

What Are They Doing About It?

The remainder of the survey focused on jurisdictional licensing boards’ activities to address the decline, as well as their views on what national organizations such as NAB can do. Answers tended to fall into two general categories: regulatory changes and outreach efforts.

Regulatory changes. A number of the jurisdictions have changed their education requirements or were contemplating doing so to make them more flexible. There was heavy sentiment expressed that they should not decrease the education requirements in any way, but rather should make them more adaptable to ap-plicants with a variety of backgrounds.

NAB has previously, on the recommendation of its Education Committee, endorsed a bachelor’s degree as a minimum requirement.2 Most survey respondents agreed with that and opposed what some referred to as the potential “dumbing down” of the profession. However, numerous state boards have taken steps to make the education requirement less rigid. These include allowing more combinations of education and experience; accepting degrees not directly related to long-term care administration when coupled with additional specialized courses; and adding provisional licensure categories for candidates while they work to meet the education requirement.

Figure 1. Licensing boards showing a decline in new NHA applicants. Source: National Association of Boards of Examiners of Long Term Care Administrators
Figure 2. NAB exam candidates by month. Source: National Association of Boards of Examiners of Long Term Care Administrators, Nov. 2001.
One program cited repeatedly as helping in this area is the NAB Academic Accreditation Program. NAB has developed standards for college-level programs in long-term care administration and accredits those colleges and universities that meet the standards. A growing number of licensing boards have accepted NAB Program Accreditation as automatically meeting their particular education requirements. That greatly simplifies the licensure process for many applicants.

One specific regulatory area often identified by licensure candidates as a disincentive is the requirement for an internship or an administrator-in-training (AIT) program.

The requirements range from none in some states to 6 or 12 months in others. In the survey, the boards were asked if they had made any changes in their AIT requirements to allow more potential candidates to apply.

While 71% responded in the negative, 10 state boards indicated that they have made some changes or are seriously contemplating doing so.

Among the changes cited are allowing more flexible AIT schedules; decreasing the required AIT hours for some candidates with certain degrees; allowing the training programs to be completed over a longer period of time; and seeking ways to provide financial assistance to trainees and training facilities.

The most frequent change enacted, however, involves allowing more combinations of education and experience in lieu of formal AIT programs or as substitutions for parts of them. As with the education requirements, most survey respondents were favorable to making the AIT requirements more flexible, but not reducing them.

Survey participants were asked if they were doing anything to simplify endorsement. Ten of them responded in the affirmative. All 10 indicated that they have accepted certification by the American College of Health Care Administrators as meeting endorsement requirements, although candidates must meet all other relevant state requirements.

For example, some states have a state licensing exam in addition to the NAB exam. One innovative state’s (California) response indicated that administrators with a good record in another state can be given a one-year provisional license prior to taking the state exam.

A common theme throughout many of the survey responses was the difficulty faced by state boards in making substantive changes to their regulations. In some jurisdictions the regulations are statutory, meaning that it would take an act of the legislature to change them-generally a very time-consuming and often highly politicized process.

Even where legislation is not required, the rule-making process in most states is difficult and lengthy. While some licensing boards were proceeding with planned changes in spite of these roadblocks, it is likely that some others were discouraged from even trying.

Outreach efforts. The survey asked what, if anything, licensing boards are doing to reach out to the profession to increase the number of licensed administrators. While a couple answered frankly that this wasn’t their job, others demonstrated considerable initiative in this area. Eight of the respondents indicated that they are working with trade or professional organizations in their states on efforts ranging from sharing of information to joint development of a model AIT program.

Fifteen boards (with considerable overlap with the eight working with other organizations) are working with academic institutions to encourage future administrator applicants. They provide information to the colleges, attend career nights and/or have academics serve as members of the licensing boards. Several that do not have current outreach programs in place are exploring options with area colleges.

Other outreach efforts cited included publishing articles in newsletters, educating schools and colleges about the licensure candidate decline, using AIT preceptors to recruit potential candidates and developing Web sites with pertinent information.

Overall Impressions

Respondents offered suggestions and comments about the cause of the decline and potential solutions. It is not feasible to include them all here, but several were common enough to warrant noting, including:

Confronting the unattractiveness of the job. Many respondents noted that the position of nursing home administrator is made difficult by the regulatory process, the fear of liability and the negative image of nursing homes portrayed in the media.

Suggestions for improvement, other than the expected calls to reform the regulatory process, included marketing the profession, making the application process less cumbersome and lengthy, and looking for new sources of candidates, such as people working in the field in other positions.

Marketing the profession. A common theme among the anecdotal comments is the need for more work to market the profession, both to employees in the field other than administrators (e.g., assistant administrators, nursing directors) and to newcomers from other fields or academia. This confirms actions taken by the NAB Education Committee at the 2000 Mid-Year Meeting creating a NAB marketing task force that, at this writing, is actively pursuing a marketing program.

Recognizing the attraction of assisted living. Several respondents reported that some current and potential nursing facility administrators are moving to the assisted living/residential care field because it is not as highly regulated, if regulated at all. Some suggested, though, that this is a temporary phenomenon, reckoning that the regulatory process and all of its inherent difficulties will catch up with assisted living eventually.

Is the Decline Leveling Off?

The decline in the number of people taking the NAB examination seems to have leveled off as of late, showing an essentially flat, even slightly upward, trend for the first 10 months of 2001, contrasted with the sharp downward trend throughout 2000. This supports accounts from several of the survey respondents that the decline had been at its worst two to five years ago, and was now beginning to reverse itself in their jurisdictions. Even if an upward trend is in fact ongoing, there is still much to be done. A number of the survey respondents observed-and it’s a point well taken-that an unusually high number of nursing home administrators are retiring, and this is likely to continue for several years to come.


The role of the individual licensing boards is to protect the health, safety and welfare of the public, particularly consumers of long-term care services. Much could be done to ease the frustration attendant to many of the licensing processes, as well as to simplify the procedure of moving from one state to another. There is certainly room for more uniformity among licensing regulations, without jeopardizing the integrity of individual licensing boards.

NAB is working to address these issues in a number of ways, including development of a model licensure application, an on-line licensure application program and a model practice act. Also, NAB recently held a national “Summit on the Decline in the Recruitment and Retention of LTC Administrators,” which, hopefully, will result in more collaborative efforts by the in-dustry, the profession, academia and government to address this critical issue. NH

John R. Pratt, MHA, FACHE, is director of the Long-Term Care Management Institute at Saint Joseph’s College of Maine. He also serves on the NAB Education Committee and conducted the survey described in this article. For further information, phone (207) 893-7983.


1. National Association of Boards of Examiners of Long Term Care Administrators (NAB). Nursing home administrators: A vanishing profession [news release]. Washington, D.C.: January 30, 2001.
2. Will K, Nicovich P. The best way to ensure long-term care’s future. Balance 2001 Mar/Apr:10.

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