The Gerontologist cite as: Gerontologist, 2015, Vol. 55, No. 5, 748–759 doi:10.1093/geront/gnu003 Advance Access publication February 17, 2014
Research Article
Securing and Managing Nursing Home Resources: Director of Nursing Tactics Downloaded from http://gerontologist.oxfordjournals.org/ at Florida International University on November 15, 2015
Elena O. Siegel, PhD, RN,*,1 Heather M. Young, PhD, RN,1 Leehu Zysberg, PhD,1,2 and Vanessa Santillan, BS1 Betty Irene Moore School of Nursing at UC Davis, Sacramento, California. 2Department of Psychology, Tel Hai College, Upper Galilee, Israel.
1
*Address correspondence to Elena O. Siegel, PhD, RN, Betty Irene Moore School of Nursing at UC Davis, 4610 X Street Suite 4202, Sacramento, CA 95817. E-mail: [email protected] Received May 6, 2013; Accepted January 16, 2014
Decision Editor: Nancy Schoenberg, PhD
Purpose of the Study: Shrinking resources and increasing demands pose managerial challenges to nursing homes. Little is known about how directors of nursing (DON) navigate resource conditions and potential budget-related challenges. This paper describes the demands-resources tensions that DONs face on a day-to-day basis and the tactics they use to secure and manage resources for the nursing department. Design and Methods: We conducted a secondary analysis of data from a parent study that used a qualitative approach to understand the DON position. A convenience sample of 29 current and previous DONs and administrators from more than 15 states participated in semistructured interviews for the parent study. Data analysis included open coding and thematic analysis. Results: DONs address nursing service demands-resources tensions in various ways, including tactics to generate new sources of revenue, increase budget allocations, and enhance cost efficiencies. Implications: The findings provide a rare glimpse into the operational tensions that can arise between resource allocations and demands for nursing services and the tactics some DONs employ to address these tensions. This study highlights the DON’s critical role, at the daily, tactical level of adjusting and problem-solving within existing resource conditions. How DONs develop these skills and the extent to which these skills may improve nursing home quality and value are important questions for further practice-, education-, and policy-level investigation. Key Words: Management, Nursing, Long Term Care, Leadership
Nursing home quality is an ongoing concern, and pressures to improve quality and enhance value (e.g., cost efficiencies) are intensifying. With increasing resident acuity and demand for subacute care (Centers for Medicare & Medicaid Services
[CMS], 2010), services are growing in complexity. At the same time, financial resources are declining and management teams are expected to do more with less, in the context of lower occupancy rates (CMS, 2010), actual and anticipated
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].
748
The Gerontologist, 2015, Vol. 55, No. 5
Theoretical Context Donabedian’s Structure-Process-Outcomes model for quality assessment and monitoring (1980) provides a
theoretical context for this study (Figure 1). Structure reflects the organization-level infrastructure, systems, and resources available for nursing services. DONs work within this Structure, carrying out their roles and responsibilities (Process) to achieve nursing home deliverables, including quality of care and work environment, and other organizational benchmarks (i.e., financial, regulatory) (Outcomes). The DON, as a middle manager, is positioned at a sensitive juncture between resources (Structure) and the organization’s deliverables (Outcomes). DONs rely on fiscal resources to cover the costs of nursing staff and other expenditures needed to achieve the organization’s deliverables; yet, as a middle manager, the DON is not necessarily in a position to fully direct resource allocations. Ideally, nursing department budgets support the delivery of highquality care. However, in practice, inadequate numbers of nursing staff in many nursing homes (Harrington, 2005) suggest that cost-containment measures may be especially pronounced in some settings, with some DONs facing reduced nursing department budgets. For example, facilities with higher proportions of Medicaid (i.e., lower reimbursement rates resulting in reduced revenues) are associated with lower quality (Mor, Zinn, Anelelli, Teno, & Miller, 2004) and for-profit settings are associated with lower staffing and lower quality (Harrington, Olney, Carrillo, & Kang, 2012; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000). Limited evidence suggests that some DONs have little involvement in the budgetary or financial aspects of the nursing department (Mueller, 1998; Siegel, Young, Leo, & Santillan, 2012). To date, research has not addressed how DONs operationalize their role (Process) around this sensitive juncture between resource allocations (Structure) and nursing service deliverables (Outcomes). This is especially critical given evidence that suggests higher quality might not actually require higher costs (Rantz et al., 2004; United States General Accounting Office, 2002; Weech-Maldonado, Mor, & Oluwole, 2004). The purpose of this paper is to describe the nursing service demands-resources tensions that DONs face on a day-today basis and the tactics they use to secure and manage resources for the nursing department.
Figure 1. Theoretical context: adaptation of Donabedian’s structure-process-outcomes framework (1980).
Downloaded from http://gerontologist.oxfordjournals.org/ at Florida International University on November 15, 2015
reductions in reimbursement, and movement toward valuebased purchasing (CMS, 2012a). Shrinking resources and greater demands pose unique challenges, straining top management teams more than ever before. The director of nursing (DON) and the nursing home administrator (NHA) represent the top management team in most nursing homes. DONs serve as second-tier managers, reporting directly to the NHA. The DON’s critical role in leading and managing nursing services (American Association of Long-term Care Nursing, 2009; American Health Care Association, 2007) is well acknowledged by the Institute of Medicine (Wunderlich & Kohler, 2001; Wunderlich, Sloan, & Davis, 1996) and experts in gerontological nursing practice in nursing homes (Dellefield, 2008; Harvath et al., 2008; Siegel, Mueller, Anderson, & Dellefield, 2010). Studies of the top management team and nursing home resources have concentrated heavily on ways in which NHAs and DONs interact with the employees under their charge. Findings highlight the positive impact that leadership style and managerial approaches (i.e., communication, empowerment, relationship-building) can have on quality of care (Anderson, Issel, & McDaniel, 2003; Castle & Decker, 2011; Dellefield, 2008; Dwyer, 2011; Forbes-Thompson, Leiker, & Bleich, 2007; Rosemond, Hanson, Ennett, Schenck, & Weiner, 2012; Toles & Anderson, 2011) and quality of the work environment (i.e., job satisfaction, retention/turnover) (Anderson, Corazzini, & McDaniel, 2004; Eaton, 2001; Tellis-Nayak, 2007). Although there has been much attention to the importance of leadership and interpersonal interactions, little is known about how top managers work—practically speaking—within the context of the fiscal resources available to nursing services. Such questions are germane to current circumstances where the need for quality improvement is exacerbated by industrywide declining resources. This paper provides important insights into the ways DONs secure and manage resources to meet demands for nursing services.
749
The Gerontologist, 2015, Vol. 55, No. 5
750
Procedures
Design and Sample
Interview Guide For the parent study, a semistructured interview guide (Figure 2) was developed based on the standard types of questions used by industrial and organizational psychologists to analyze jobs, focusing on: needs for a specific employment position; main tasks; knowledge, skills, and abilities; and barriers and resources (McCormick & Jeanneret, 1988). The questions were pilot tested and refined with a focus group of DONs and NHA (n = 7), recruited by convenience at an American College of Health Care Administrators conference. Focus group participants received one continuing education credit from the National Association of Long Term Care Administrator Boards.
This study is a secondary analysis (Heaton, 2004) of data from a parent study that used a qualitative approach to examine the DON position, including: roles, responsibilities, and job designs; facilitators and barriers to role enactment; and requisite knowledge, skills, and abilities. The findings related to DON functional roles and responsibilities are published elsewhere (Siegel et al., 2012). Secondary analysis is the “theoretical analysis of previously collected data for any purpose, depending on what emerges” (Glaser, 1978, p. 53). During our primary analysis (parent study), tactics related to nursing resources emerged as a compelling theme, warranting this secondary analysis. We used the complete data set for this secondary analysis; as such, the parent study’s sampling and recruitment activities are also applicable to this secondary analysis. The sampling goal was to attain multiple perspectives regarding DON roles and responsibilities, including participants with experience as a DON or knowledge and expertise regarding the DON position. A sample of 29 current and previous DONs and NHAs from more than 15 states participated in in-depth interviews. For the parent study, researcher E. O. Siegel identified and recruited participants by convenience and snowballing sampling, with networking and referrals from colleagues, nursing home leaders, previous study participants, and attendees at professional conferences. Recruitment continued until data saturation was achieved, meaning the information heard during interviews was repetitive and did not offer new information pertaining to the categories of interest (Morse, 1991). Of the eligible individuals who sought information about the study, all agreed to participate. The Research Integrity offices at Oregon Health & Science University and University of California, Davis approved the study protocol.
Figure 2. Interview guide.
Semistructured Interviews For the parent study, interviews lasting up to 1 hr were conducted by phone and audio-taped by researcher E. O. Siegel who has experience conducting in-depth semistructured interviews with DONs and NHAs. Participant responses to general questions were followed with three types of prompts. The following examples are relevant to the data analyzed for this study. First, prompts were used to seek additional information about a specific statement. For example, a participant’s remarks about general budget constraints might be followed with the prompt, “How do you handle that [budget constraints]?” Other prompts elicited information beyond the specific focus of a participant’s remarks. For example, “What about the nursing budget—can you talk about DON involvement in budget preparation, planning, execution?” The third type of prompt involved a negative case example: if the participant described successfully challenging corporate budgets, a follow-up prompt might be, “We sometimes hear ‘Our hands are tied, corporate decides … or the problem is reimbursement.’ What do you think?”
Downloaded from http://gerontologist.oxfordjournals.org/ at Florida International University on November 15, 2015
Methods
The Gerontologist, 2015, Vol. 55, No. 5
751
Results
For the parent study, the interviews were transcribed, verified, and uploaded to a qualitative data management program, NVivo 9 (QSR International) and reread multiple times, before, during, and subsequent to data coding. For this secondary analysis, we used open coding to highlight the concepts of interest in the raw data and to subcode the concepts into categories (Corbin & Strauss, 2008). For example, Resources was subcoded for type (i.e., Fiscal, Human). We used thematic analysis (Morse & Field, 1995) to identify emerging themes representing “some level of patterned response or meaning within the data set” (Braun & Clarke, 2006, p. 82) and to develop a graphic representation of themes (Figure 3). For example, we collapsed the subcodes for Fiscal resources into themes reflecting the originating source (Revenue or Budget allocations) and we identified themes across concepts (e.g., Demands-resources tensions). The research team regularly reviewed, discussed, and revised coding practices and definitions, text interpretations, emerging themes, and the graphic representation of findings. We continued to sample and analyze the raw data until saturation was achieved (Morse, 1991), the point at which no new related concepts emerged and we attained variations in concept categories. This notion of saturation—based on concepts not study participants—is consistent with other approaches to achieving saturation from previously collected data (Corbin & Strauss, 2008; Glaser, 1978). To ensure saturation after the analysis was complete, we audited the raw data for related new concepts and additional variations in concept categories.
Participants (n = 29) varied in experience, age, and education (Table 1). Twenty participants had current or previous experience as a DON and nine had current or previous experience as an NHA. Participants’ ages ranged from 34 to 64 years, and the majority were women (83%). Experience working in the nursing home industry ranged from
Research Article
Securing and Managing Nursing Home Resources: Director of Nursing Tactics Downloaded from http://gerontologist.oxfordjournals.org/ at Florida International University on November 15, 2015
Elena O. Siegel, PhD, RN,*,1 Heather M. Young, PhD, RN,1 Leehu Zysberg, PhD,1,2 and Vanessa Santillan, BS1 Betty Irene Moore School of Nursing at UC Davis, Sacramento, California. 2Department of Psychology, Tel Hai College, Upper Galilee, Israel.
1
*Address correspondence to Elena O. Siegel, PhD, RN, Betty Irene Moore School of Nursing at UC Davis, 4610 X Street Suite 4202, Sacramento, CA 95817. E-mail: [email protected] Received May 6, 2013; Accepted January 16, 2014
Decision Editor: Nancy Schoenberg, PhD
Purpose of the Study: Shrinking resources and increasing demands pose managerial challenges to nursing homes. Little is known about how directors of nursing (DON) navigate resource conditions and potential budget-related challenges. This paper describes the demands-resources tensions that DONs face on a day-to-day basis and the tactics they use to secure and manage resources for the nursing department. Design and Methods: We conducted a secondary analysis of data from a parent study that used a qualitative approach to understand the DON position. A convenience sample of 29 current and previous DONs and administrators from more than 15 states participated in semistructured interviews for the parent study. Data analysis included open coding and thematic analysis. Results: DONs address nursing service demands-resources tensions in various ways, including tactics to generate new sources of revenue, increase budget allocations, and enhance cost efficiencies. Implications: The findings provide a rare glimpse into the operational tensions that can arise between resource allocations and demands for nursing services and the tactics some DONs employ to address these tensions. This study highlights the DON’s critical role, at the daily, tactical level of adjusting and problem-solving within existing resource conditions. How DONs develop these skills and the extent to which these skills may improve nursing home quality and value are important questions for further practice-, education-, and policy-level investigation. Key Words: Management, Nursing, Long Term Care, Leadership
Nursing home quality is an ongoing concern, and pressures to improve quality and enhance value (e.g., cost efficiencies) are intensifying. With increasing resident acuity and demand for subacute care (Centers for Medicare & Medicaid Services
[CMS], 2010), services are growing in complexity. At the same time, financial resources are declining and management teams are expected to do more with less, in the context of lower occupancy rates (CMS, 2010), actual and anticipated
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].
748
The Gerontologist, 2015, Vol. 55, No. 5
Theoretical Context Donabedian’s Structure-Process-Outcomes model for quality assessment and monitoring (1980) provides a
theoretical context for this study (Figure 1). Structure reflects the organization-level infrastructure, systems, and resources available for nursing services. DONs work within this Structure, carrying out their roles and responsibilities (Process) to achieve nursing home deliverables, including quality of care and work environment, and other organizational benchmarks (i.e., financial, regulatory) (Outcomes). The DON, as a middle manager, is positioned at a sensitive juncture between resources (Structure) and the organization’s deliverables (Outcomes). DONs rely on fiscal resources to cover the costs of nursing staff and other expenditures needed to achieve the organization’s deliverables; yet, as a middle manager, the DON is not necessarily in a position to fully direct resource allocations. Ideally, nursing department budgets support the delivery of highquality care. However, in practice, inadequate numbers of nursing staff in many nursing homes (Harrington, 2005) suggest that cost-containment measures may be especially pronounced in some settings, with some DONs facing reduced nursing department budgets. For example, facilities with higher proportions of Medicaid (i.e., lower reimbursement rates resulting in reduced revenues) are associated with lower quality (Mor, Zinn, Anelelli, Teno, & Miller, 2004) and for-profit settings are associated with lower staffing and lower quality (Harrington, Olney, Carrillo, & Kang, 2012; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000). Limited evidence suggests that some DONs have little involvement in the budgetary or financial aspects of the nursing department (Mueller, 1998; Siegel, Young, Leo, & Santillan, 2012). To date, research has not addressed how DONs operationalize their role (Process) around this sensitive juncture between resource allocations (Structure) and nursing service deliverables (Outcomes). This is especially critical given evidence that suggests higher quality might not actually require higher costs (Rantz et al., 2004; United States General Accounting Office, 2002; Weech-Maldonado, Mor, & Oluwole, 2004). The purpose of this paper is to describe the nursing service demands-resources tensions that DONs face on a day-today basis and the tactics they use to secure and manage resources for the nursing department.
Figure 1. Theoretical context: adaptation of Donabedian’s structure-process-outcomes framework (1980).
Downloaded from http://gerontologist.oxfordjournals.org/ at Florida International University on November 15, 2015
reductions in reimbursement, and movement toward valuebased purchasing (CMS, 2012a). Shrinking resources and greater demands pose unique challenges, straining top management teams more than ever before. The director of nursing (DON) and the nursing home administrator (NHA) represent the top management team in most nursing homes. DONs serve as second-tier managers, reporting directly to the NHA. The DON’s critical role in leading and managing nursing services (American Association of Long-term Care Nursing, 2009; American Health Care Association, 2007) is well acknowledged by the Institute of Medicine (Wunderlich & Kohler, 2001; Wunderlich, Sloan, & Davis, 1996) and experts in gerontological nursing practice in nursing homes (Dellefield, 2008; Harvath et al., 2008; Siegel, Mueller, Anderson, & Dellefield, 2010). Studies of the top management team and nursing home resources have concentrated heavily on ways in which NHAs and DONs interact with the employees under their charge. Findings highlight the positive impact that leadership style and managerial approaches (i.e., communication, empowerment, relationship-building) can have on quality of care (Anderson, Issel, & McDaniel, 2003; Castle & Decker, 2011; Dellefield, 2008; Dwyer, 2011; Forbes-Thompson, Leiker, & Bleich, 2007; Rosemond, Hanson, Ennett, Schenck, & Weiner, 2012; Toles & Anderson, 2011) and quality of the work environment (i.e., job satisfaction, retention/turnover) (Anderson, Corazzini, & McDaniel, 2004; Eaton, 2001; Tellis-Nayak, 2007). Although there has been much attention to the importance of leadership and interpersonal interactions, little is known about how top managers work—practically speaking—within the context of the fiscal resources available to nursing services. Such questions are germane to current circumstances where the need for quality improvement is exacerbated by industrywide declining resources. This paper provides important insights into the ways DONs secure and manage resources to meet demands for nursing services.
749
The Gerontologist, 2015, Vol. 55, No. 5
750
Procedures
Design and Sample
Interview Guide For the parent study, a semistructured interview guide (Figure 2) was developed based on the standard types of questions used by industrial and organizational psychologists to analyze jobs, focusing on: needs for a specific employment position; main tasks; knowledge, skills, and abilities; and barriers and resources (McCormick & Jeanneret, 1988). The questions were pilot tested and refined with a focus group of DONs and NHA (n = 7), recruited by convenience at an American College of Health Care Administrators conference. Focus group participants received one continuing education credit from the National Association of Long Term Care Administrator Boards.
This study is a secondary analysis (Heaton, 2004) of data from a parent study that used a qualitative approach to examine the DON position, including: roles, responsibilities, and job designs; facilitators and barriers to role enactment; and requisite knowledge, skills, and abilities. The findings related to DON functional roles and responsibilities are published elsewhere (Siegel et al., 2012). Secondary analysis is the “theoretical analysis of previously collected data for any purpose, depending on what emerges” (Glaser, 1978, p. 53). During our primary analysis (parent study), tactics related to nursing resources emerged as a compelling theme, warranting this secondary analysis. We used the complete data set for this secondary analysis; as such, the parent study’s sampling and recruitment activities are also applicable to this secondary analysis. The sampling goal was to attain multiple perspectives regarding DON roles and responsibilities, including participants with experience as a DON or knowledge and expertise regarding the DON position. A sample of 29 current and previous DONs and NHAs from more than 15 states participated in in-depth interviews. For the parent study, researcher E. O. Siegel identified and recruited participants by convenience and snowballing sampling, with networking and referrals from colleagues, nursing home leaders, previous study participants, and attendees at professional conferences. Recruitment continued until data saturation was achieved, meaning the information heard during interviews was repetitive and did not offer new information pertaining to the categories of interest (Morse, 1991). Of the eligible individuals who sought information about the study, all agreed to participate. The Research Integrity offices at Oregon Health & Science University and University of California, Davis approved the study protocol.
Figure 2. Interview guide.
Semistructured Interviews For the parent study, interviews lasting up to 1 hr were conducted by phone and audio-taped by researcher E. O. Siegel who has experience conducting in-depth semistructured interviews with DONs and NHAs. Participant responses to general questions were followed with three types of prompts. The following examples are relevant to the data analyzed for this study. First, prompts were used to seek additional information about a specific statement. For example, a participant’s remarks about general budget constraints might be followed with the prompt, “How do you handle that [budget constraints]?” Other prompts elicited information beyond the specific focus of a participant’s remarks. For example, “What about the nursing budget—can you talk about DON involvement in budget preparation, planning, execution?” The third type of prompt involved a negative case example: if the participant described successfully challenging corporate budgets, a follow-up prompt might be, “We sometimes hear ‘Our hands are tied, corporate decides … or the problem is reimbursement.’ What do you think?”
Downloaded from http://gerontologist.oxfordjournals.org/ at Florida International University on November 15, 2015
Methods
The Gerontologist, 2015, Vol. 55, No. 5
751
Results
For the parent study, the interviews were transcribed, verified, and uploaded to a qualitative data management program, NVivo 9 (QSR International) and reread multiple times, before, during, and subsequent to data coding. For this secondary analysis, we used open coding to highlight the concepts of interest in the raw data and to subcode the concepts into categories (Corbin & Strauss, 2008). For example, Resources was subcoded for type (i.e., Fiscal, Human). We used thematic analysis (Morse & Field, 1995) to identify emerging themes representing “some level of patterned response or meaning within the data set” (Braun & Clarke, 2006, p. 82) and to develop a graphic representation of themes (Figure 3). For example, we collapsed the subcodes for Fiscal resources into themes reflecting the originating source (Revenue or Budget allocations) and we identified themes across concepts (e.g., Demands-resources tensions). The research team regularly reviewed, discussed, and revised coding practices and definitions, text interpretations, emerging themes, and the graphic representation of findings. We continued to sample and analyze the raw data until saturation was achieved (Morse, 1991), the point at which no new related concepts emerged and we attained variations in concept categories. This notion of saturation—based on concepts not study participants—is consistent with other approaches to achieving saturation from previously collected data (Corbin & Strauss, 2008; Glaser, 1978). To ensure saturation after the analysis was complete, we audited the raw data for related new concepts and additional variations in concept categories.
Participants (n = 29) varied in experience, age, and education (Table 1). Twenty participants had current or previous experience as a DON and nine had current or previous experience as an NHA. Participants’ ages ranged from 34 to 64 years, and the majority were women (83%). Experience working in the nursing home industry ranged from
