Humanism in nursing homes: the impact of top management.
Abstract: We provide a review of ways in which top managers of nursing homes can provide or impact the humanistic component of care provided in their facilities. We describe the nursing home top management team; the role of top managers in nursing homes; the role of top managers as leaders in the nursing home; the literature examining the impact of top managers in nursing homes; and, examine developments in the nursing home industry that are influencing (or could potentially influence) the humanistic components of care. We conclude with suggestions for top managers, nursing home owners, and policy makers to create more caring humanistic environments. Suggestions include resident-directed care initiatives and culture change.
Subject: Nursing homes (Management)
Nursing homes (Services)
Humanism (Analysis)
Nurses (Practice)
Nurses (Services)
Authors: Castle, Nicholas G.
Ferguson, Jamie C.
Hughes, Kevin
Pub Date: 03/22/2009
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2009 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Spring, 2009 Source Volume: 31 Source Issue: 4
Topic: Event Code: 200 Management dynamics; 360 Services information Computer Subject: Company business management
Product: Product Code: 8050000 Nursing & Rest Homes; 8366000 Homes for Aged; 8043100 Nurses NAICS Code: 623 Nursing and Residential Care Facilities; 623312 Homes for the Elderly; 621399 Offices of All Other Miscellaneous Health Practitioners SIC Code: 8051 Skilled nursing care facilities; 8052 Intermediate care facilities; 8059 Nursing and personal care, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 250033748
Full Text: In the U.S., approximately 20,000 nursing homes provide long-term care services to about 3.5 million elderly every year (National Nursing Home Survey, 2004). For some elderly the nursing home provides short-term rehabilitative care; but, for many other elders the nursing home becomes their final home (Castle & Engberg, 2007). Thus, the nursing home industry is in the business of providing both "nursing" (i.e., clinical care) services and "home" (i.e., social or humanistic care) services. These services are provided by a variety of staff, including nurse aides, registered nurses, and licensed practical nurses. In most nursing homes, staff, care, and services are coordinated by a top management team consisting of a nursing home administrator (NHA) and Director of Nursing (DON) (Castle, 2001).

Recent research has begun to show the importance of nursing home top management teams in the lives of residents (Anderson, Issel & McDaniel, 2003; Singh & Schwab, 2000; Zimmerman, Gruber-Baldini, Hebel, Sloane, & Magaziner, 2002). For example, the NHA's background and education is associated with the type of services provided (Castle, 2001). To date, this research has examined the impact of top management on the "nursing" component of care in the nursing home. Very little research has considered the impact of top management on the "home" component of care in the nursing home. However, top managers may be influential in this area. For example, programs such as the Eden Alternative, the Pioneer Network, and the Wellspring Institute provide models for implementing culture change in nursing homes that emphasizes humanistic caring (Stone, 413). In this research, we provide a first attempt at pinpointing ways in which top managers of nursing homes can provide or impact the humanistic component of care provided in their facilities. As noted in the Introduction to this symposium, by humanism we mean:

"Humanism in healthcare is a professional and organizational way of life that focuses on patient and family needs and interests, through quality healthcare, empathy, advocacy, and dedication to serving others... An exemplary healthcare organization will have a strong focus on delivering quality healthcare. The organization will also exhibit caring towards its clients, in empathic and compassionate clinical care, and through fostering positive interpersonal relationships between patients and all members of the organization." In the following sections, we first describe the nursing home top management team. Second, we examine the role of top managers in nursing homes. Third, we examine the role of top managers as leaders in the nursing home. Fourth, we summarize the literature examining the impact of top managers in nursing homes. Fifth, we examine developments in the nursing home industry that are influencing (or could potentially influence) the humanistic components of care. Finally, we provide suggestions for top managers, nursing home owners, and policy makers to create more caring humanistic environments.

THE TOP MANAGEMENT TEAM

Top managers of nursing homes are traditionally defined as the NHA and DON. These top managers serve as the operational leaders of their respective facilities. Although, we note that some recent initiatives have included the Medical Director as part of the top management team. For example, researchers at the University of Pittsburgh have labeled the NHA, DON, and Medical Director as "Three Peas in a Pod," wherein each member of the team complements the other (http://www.aging.pitt.edu/educators/pdf/3-Peas-2003conference-brochure.pdf). However, research in this area is still rudimentary; thus, the NHA and DON are our primary focus.

We used data from the 2004 National Nursing Home Survey (NNHS) and primary data collected by the authors to provide descriptive information of NHAs and DONs. The NNHS is a nationally representative study of nursing homes conducted by the National Center for Health Statistics (http://www.cdc.gov/nchs/nnhs.htm). Most of the facility data was collected during face-to-face interviews conducted at nursing homes. The respondent was usually the NHA, although he/she could designate other personnel to participate in the interview. There were 1,174 nursing homes in the NNHS sample. The primary data (our second source of information to provide descriptive information of NHAs and DONs) came from a mail survey sent to 4,000 NHAs (3,211 responded, giving a response rate of 72%). The sample was randomly selected from all nursing homes in the U.S., and the survey was conducted in 2006 and 2007. Details of this survey are reported by Castle and Engberg (2008).

The summary results of the descriptive characteristics of NHAs and DONs are presented in Table 1. This shows that NHAs most commonly have a baccalaureate degree (50%) as their highest level of education and DONs most commonly have a diploma or associate degree (57%) as their highest level of education. The average age of NHAs is 54 years and for DONs is 51 years. As Castle (2001) has described, the average age of nursing home top management teams is relatively high. This represents a significant opportunity for the nursing home industry. Top managers are retiring, allowing a new group of top managers with different skills and backgrounds to step in and offer an innovative perspective for nursing homes. For example, our data show that younger top managers and those new to the industry are more likely have higher education levels and be more active with professional societies. From a humanistic perspective, this presents itself as an opportunity to offer top management with alternative forms of care (such as the Eden Alternative, described below) and innovative business models (such as Perfecting Patient Care, described below).

The Role of Top Management

NHAs and DONs are believed to be able to influence care in the nursing home in numerous ways. These influences include controlling the budget, implementing staff training, amount of staff training, materials/resources available for training, oversight of care practices, questions asked in meetings, memos sent to staff, and initiating quality assurance projects- to name several. Indeed, Flood, Zinn, and Scott (2006) list areas that are believed to be influenced by top managers.

In research using NHAs and DONs, a survey used the categories listed by Flood, Zinn, and Scott (2006), and examined how much time these top managers devoted to each activity. The primary data came from a mail survey sent to 2,000 NHAs and 2,000 DONs (3,211 responded, giving a response rate of 72%). The sample was randomly selected from all nursing homes in the U.S., and the survey was conducted in 2007.

The summary results of the survey examining how much time NHAs and DONs devoted to different activities is presented in Table 2. This shows that NHAs believe that the majority of their time is spent dealing with external regulation and accreditation (17%), problem management with staff and family (12% and 9%), and acquisitions with current vendors (8%). DON believe that the majority of their time is spent dealing with problem management with staff (16%), resident care policies and practices (16%), problem management with family (12%), and dealing with external regulation and accreditation (12%).

These findings are likely influenced by the size of the nursing home. For example, larger facilities are likely to employ human resource specialists, so fewer hiring decisions may be made by top managers of larger facilities. Nevertheless, these findings do seem to indicate that top managers spend the majority of their time addressing the short-term daily operational needs of the facility. Indeed, the behavior of top managers is often characterized as reactive, and short run agendas consume the majority of the top managers' time (Kotter, 1999). As Mintzberg (1990, p. 22) has described, "if you ask a manager what s/he does, s/he will most likely tell you that s/he plans, organizes, coordinates and controls. Then watch what s/he does. Don't be surprised if you can't relate what you see to those four words." This survey examining how much time NHAs and DONs devoted to different activities was not developed to examine the humanistic component of nursing home care. However, the findings would seem to indicate that relatively little time is spent by top management on the humanistic component of nursing home care. That is, few responses focus on resident and family needs and interests, empathy, or advocacy. Quality of care did seem to be a priority for many top managers; with the top managers' emphasis on external regulation and accreditation. However, the operationalization of quality likely differs from a top management perspective compared with a resident perspective. That is, regulation and accreditation often emphasizes clinical quality, whereas residents often emphasize quality of life (Sangl et al., 2007).

From a humanistic perspective, the activities of top managers could be modified to focus more on resident and family needs and interests, empathy, or advocacy. Quality of care could also be expanded to include quality of life issues, as well as clinical quality. The top manager's available time for handling issues other than immediate day-to-day crises and problems clearly affects care. Top managers with more available time should have much greater flexibility in attending to the long-term goals of the facility, including improving the humanistic component of care. The Perfecting Patient Care initiative (described below), may prove useful in this regard.

Top Managers as Leaders

Top managers may be able to modify their activities, and they may also be able to modify their leadership attributes. Many of the initiatives we describe in this article involve participation by top management, facilitation in training, or modification of behaviors. Many of these initiatives involve modifications of contextual conditions. As Lia, Grady, and Peters (2008) describe, making these modifications involves leadership.

Donoghue and Castle (2008) recently examined the association between NHA leadership style and staff turnover. Primary data from a survey of 2,900 NHAs conducted in 2005 was used. The analyses show that NHAs who are Consensus Mangers (leaders that solicit, and act upon, the most input from their staff) are associated with the lowest staff turnover levels: 7% for registered nurses; 3% for licensed practical nurses and 44% for nurse aides. Shareholder Managers (leaders that do not communicate with their staff about decision making or expectations) are associated with the highest staff turnover levels: 32% for registered nurses; 56% for licensed practical nurses; and 168% for nurse aides. The findings indicate that NHA leadership style is associated with staff turnover, even when the effects of organizational and local economic conditions are held constant. Since leadership strategies are amenable to change, the findings of this study may be used to develop policies for lowering staff turnover. Expanding these implications a little further, leadership style likely also influences many operational components of the nursing home - including the humanistic nature of care.

The Impact of Top Management

Smith, Shortell, and Saxberg (1977, p. 12) describe nursing home administration as "the critical variable affecting quality of care." Top management's leadership abilities are crucial to the success or failure of organizations. A talented top manager can make an organization succeed even under adverse business conditions. Likewise, a talented top manger can turn around a failing company (Whitney, 1987). On the other hand, ineffectual top managers are associated with poor corporate performance, even when good economic conditions prevail (Flood, Zinn, & Scott, 2006; Weiner & Mahoney, 1981).

Castle and Engberg (2008) have presented a conceptual model showing how care processes in the nursing home can influence resident outcomes. We have modified this conceptual model by including top management. That is, this modified conceptual model, shown in Figure 1, helps show how top management can impact quality of care. Specifically, resident outcomes are dependent on quantity of care, coordination, consistency of care, and care practices. This conceptual model also includes facility characteristics (e.g., bed size, ownership, chain membership, occupancy, and Medicaid occupancy) and market characteristics (i.e., competition and unemployment rates), as these factors may also influence the context of care delivery and quality of care. This general approach of including facility and market characteristics is frequently used in empirical studies examining nursing home quality, including those with a focus on top management (e.g., Harrington & Swan, 2003; Schnelle et al., 2004).

[FIGURE 1 OMITTED]

This conceptual model was not developed to examine specific care processes. However, as we discuss previously, care processes can be clinical or humanistic in nature. And, this conceptual model would appear to be pertinent for humanistic care processes. For example, top management influences how much is done and care practices. How much is done could be how much is done to ensure the comfort of residents. Care practices may include an emphasis on quality of life issues. However, the issue still arises as to whether empirical studies have identified top managers as influencing nursing home care.

In Table 3, we summarize the empirical literature examining the impact of top management in nursing homes.

The top manager(s) examined (NHAs, DONs, or both), characteristics of top management examined in each study (e.g., education or tenure), along with the outcome of interest (e.g., staff turnover or quality) are presented. Top management turnover (or tenure) was examined most frequently. This may be because as Singh and Schwab (1998, p. 310) state, high administrative turnover may have a "destabilizing influence." Anderson, Issel and McDaniel (2003) recently determined that longer DON tenure was associated with better resident outcomes. Likewise, Zimmerman and associates (2002) identified a similar relationship. Christensen and Beaver (1996) determined that nursing homes with lower NHA turnover rates had fewer deficiency citations (N=147). Singh, Amidon, Shi, and Samuels (1997) also examined deficiency citations (N=173) and found the same relationship as Christensen and Beaver. Top management's commitment to consistently address and improve deficiencies can be an important part of culture change aiming towards a more humanistic environment.

DEVELOPMENTS INFLUENCING HUMANISTIC CARE

Some hospitals have worked to incorporate humanistic care into their departments. Also, several developments in the nursing home industry are influencing (or could potentially influence) the humanistic components of care. First, what is often called resident-directed care (or culture change) emphasizes many components of humanistic care. Second, quality of life (QoL) as a concept (and measure) has begun to be incorporated into nursing home care processes. Third, Perfecting Patient Care may be an operational approach that may influence care. These influences, hospital developments, resident-directed care, QoL, and Perfecting Patient Care are discussed below.

Hospital Developments

A belief has developed by prominent organizations influencing hospital care that patients and their families should be at the center of clinical decisions. These prominent organizations: The Institute for Healthcare Improvement (IHI), Institute of Medicine (IOM), Institute for Family-Centered Care (IFCC), the Agency for Healthcare Research and Quality (AHRQ), and the Joint Commission (formerly JACHO, or the Joint Commission for Accreditation of Healthcare Organizations).

The IHI states that, "Patient-centered care ensures that transitions between providers, departments, and health care settings are respectful, coordinated, and efficient (IHI, 2008). The IFCC believes that it is important to incorporate dignity and respect, information sharing, participation, and collaboration into each facilities care model (IFCC, 2008). Further, the IOM has named patient-centered care as one of the six domains of quality.

A business case is also developing for humanistic care. As such, hospital administration has advocated that front line staff members, physicians, and management need to stop putting "efficiency before courtesy" (Lee, 2004). Studies have shown patient-centered care enhances efficiency (i.e., decreased diagnostic tests) and improves the health status of patients (Stewart et al., 2000).

Organizations recognizing the positive aspects of patient centered care include AHRQ and the Joint Commission. In August 2008, the Joint Commission began working towards accreditation standards that will encourage patient-centered care in hospitals. The project is to last through January 2010, at which time the standards are hoped to be incorporated into the current standards of the Joint Commission (Joint Commission, 2008).

An organization that is currently encouraging patient-centered care in hospitals around the world is Planetree. Planetree formed the Patient-Centered Hospital Designation Program to acknowledge hospitals that have implemented patient-centered care. The program not only concentrates on the patient experience, but also encourages hospitals to "focus on supporting the professional and personal aspirations of their staff members, who can more effectively care for patients if they are cared for themselves (Planetree, 2008)." Resident-Directed Care

In a typical nursing home, a bureaucratic structure has been traditionally found with a definitive top-down structure. The rigid structure of the traditional nursing home was originally created to maximize efficiency and quality of healthcare (often modeled after hospitals). Since the early 1990's, some nursing homes have embraced a change in philosophy that is different from the traditional nursing home. These top managers have adopted resident-directed philosophies (or resident-directed care). Resident directed care aims to reduce negative resident feelings/conditions such as loneliness, helplessness and boredom, while enabling residents to make choices in a more home-like environment (Eden Alternative, 2008). Organizations, such as Action Pact, Inc. and Eden Alternative, have fostered the growth of resident-directed care that could have implications on improving the humanistic nature of care.

Nursing homes participating in resident-directed care have altered their organizational focuses by inverting the traditional top-down hierarchical structure of nursing homes by making resident care the most important aspect within the organization. Also, these organizations encourage the flattening of relationships among employees, while empowering nurse aides to make decisions with the residents, cross-training employees and supporting a team approach of providing care. More nurse aide involvement in the provision of resident care is considered important because these staff provide 80-90% of resident care (Baker, 63).

Other modifications to nurse aide care processes are also part of resident-directed care. For example, the movement towards resident-directed care encourages nurse aides to work consistently with the same group of residents, which fosters better relationships. A survey conducted by The Commonwealth Fund in 2007 found that 74% of DONs claim to consistently assign nurse aides to the same group of residents (Doty, 2007). However, further improvements in this area can still be made. Consistent assignment is often synonymous with assignment to the same unit, not necessarily the same residents. Also, assignments often change when agency staff (i.e., temporary staff) are used.

Basic resident-directed care models encourage nurse aides and residents to work together in planning the residents' daily routines. The Commonwealth Fund reported that 30-40% of all nursing homes have implemented some measures to allow residents to determine their schedules (Doty, 2007). By allowing nurse aides to make decisions with the resident, top management is more able to address other operational issues. Also, resident-directed care models allow staff to share responsibility in outcomes. This is believed to have further positive consequences: for example, ensuring management is educating and training staff properly and showing staff they are being supported in their new roles (Norton, 2008).

Unlike traditional nursing homes, an important characteristic of top managers operating resident-directed nursing homes is their ability to delegate responsibility and ensure that the other employees have the skills and resources necessary to make the best decisions with the residents. Empowering employees exists as a possible solution to addressing high turnover rates amongst employees. Providing leadership training and subsequently allowing nurse aides to use their skills to address residents' problems may focus on some reasons for turnover, such as a lack of respect and limited involvement in decision making (Doty, 2007). In order to implement these resident-directed changes into the nursing home industry, guidelines and successful models have been created (e.g., Eden Alternative and the Pioneer Network, discussed below).

It is important for top management teams to carefully train their employees. Employees play a vital role in caring for the nursing homes' residents. Resident-directed changes include management teams creating a sense of family and community in their nursing homes. Traditional nursing homes are thought to be schedule oriented and somewhat regimented. When focusing on resident-directed care, the residents must have a say in their care. Staff play a very important part in this. There must be mutual respect, honesty, and a sense of trustworthiness between the residents and the staff that care for them.

Traditional nursing homes are also believed to have rules and restrictions that residents and staff must follow. They are very time and schedule oriented. This can take away from the personal bonds between the staff and residents. Many residents have family that live far away and are unable to visit. Personal communication is very important to ones health. Staff often do not have time to sit and talk with a resident, let alone get to know the resident because of the fear that they will be reprimanded for not completing other tasks. When talking with residents, staff can uncover what the residents need and want, making the staff more capable of delivering the appropriate care.

Top management needs to educate staff on how to create a strong bond with the residents. Open communication is critical for everyone to become part of one community. There should be no division between top management and staff. Staff should have a voice when it comes to diffusing problems and developing a better atmosphere for the nursing home. All complaints and suggestions should be voiced with a sense of encouragement. To create a more humanistic environment, it is important that "everyone works like a family (Baker, 2007)." Eden Alternative, seeks to improve resident well-being by creating a home-like setting, using systematic introduction of pets, plants, and children, accompanied by the engagement and empowerment of staff in affecting this change (Eden Alternative, 2008). In order to initiate a change towards resident-directed care teamwork and stability are considered important (Yale, 2003). Empowering front-line staff, nurses and nurse aides, to make decisions regarding a resident's care contrasts with typical training (especially for nurse aides). Typical training focuses on regimented care that a resident would receive in an institution, such as a hospital. In order to facilitate a change towards resident-directed care, re training is generally required. Currently, over 15,000 people have been certified as Eden Associates, indicating the completion of a three day training course on resident-directed practices of Eden Alternative, and 300 registered nursing homes are claimed by Eden Alternative (Eden Alternative, 2008).

Other programs and organizations also promote resident-directed care. Action Pact, Inc. introduces itself as "a company of trainers, consultants and educators who assist nursing homes in becoming resident-directed". The founder of Eden Alternative, Bill Thomas, is a member of Action Pact, Inc. which aids organizations in their culture change transition towards resident-directed care by "encouraging the development of small, familiar communities which provide more opportunities for elders to give care, make decisions and have control over their daily lives" (Action Pact, Inc.). Action Pact, Inc. helps organizations in creating teams that manage themselves and collaborate to provide resident-care. Another culture change organization, Pioneer Network, "is a national grass roots network of individuals in the field of aging, working for deep systemic change" (Fagan, 125).

The benefits of culture change have proven difficult to gauge. After a one year study comparing the first year of implementation of the Eden Alternative and a control nursing home run by the same organization, very few quantitative differences existed, but a staff member said, "The atmosphere here changed the day the animals came into the facility... It has certainly changed the attitudes of the workers as well as the residents" (Coleman, M426). The Commonwealth Fund study found positive results for those nursing homes implementing seven or more culture change initiatives. For example, 78% of these nursing homes reported an improvement in competitive advantage in their market, while half decreased staff absenteeism, and 60% improved occupancy rates (Doty, 20). While the Commonwealth Fund study did not examine changes in resident satisfaction, QoL indicators may more clearly gauge whether resident-directed care improves the lives of long-term care residents.

Quality of Life

Quality in nursing homes has characteristically emphasized clinical aspects of care. For example, use of physical restraints, pressure ulcers, pain, use of psychoactive drugs, and falls are all common indicators of quality (Castle & Engberg, 2008). More recently, the importance of residents' quality of life (QoL) has been recognized (Kane et al., 2005). QoL for nursing home residents is seldom defined (Kane, 2003); however, it is proposed to consist of 14 domains: "physical functioning, self-maintenance, usual activities, social functioning, sexual functioning and intimacy, psychological well-being and distress, cognitive functioning, pain and discomfort, energy/fatigue, sleep, self-esteem, sense of mastery, perceived health, and life satisfaction" (Kane, 2003, p. 30).

A QoL scale will likely be included in the updated Minimum Data Set (MDS). The MDS is a summary assessment of nursing home residents. It was created to measure residents' functional status, health conditions, services received, demographics, and payer source. The MDS also has nearly 400 data elements, including cognitive function, communication/hearing problems, physical functioning, continence, psychosocial well-being, mood state, activity and recreation, disease diagnoses, health conditions, skin conditions, special treatments, and medication use. All Medicare- and Medicaid-certified nursing facilities are required to use the MDS on at least three occasions: (a) on admission, (b) at least annually, and (c) if the resident shows "significant change." In addition, all residents are assessed quarterly on a subset of the MDS (Mor, 2004). Currently, nursing homes use the MDS 2.0. The Center for Medicare and Medicaid Services (CMS) is currently developing the MDS 3.0, which reportedly includes items assessing resident QoL (www.cms.hhs.gov/nursinghomequalityinits); which is a departure from the primarily clinical focus of most of the items in the current MDS 2.0.

The inclusion of QoL items in the MDS 3.0 will likely be an important development for humanistic care. The resulting MDS QoL data could be used: by surveyors when inspecting facilities; by facilities themselves to improve care; and, in report cards such as Nursing Home Compare.

Clearly, when surveyors inspect facilities if they focus on QoL issues, then in turn facilities will attempt to alleviate any such issues. Facilities are inspected as part of the Medicare and/or Medicaid certification process, and unfavorable inspections can lead to fines and/or termination from these programs (General Accounting Office, 1998).

Many nursing homes have instituted quality improvement activities. Data needs to be collected for these activities (i.e., for tracking progress over time and for benchmarking [Wiener, 2003]). The MDS QoL data could be incorporated into these quality improvement activities.

In November of 2002, CMS released the Nursing Home Compare report card (www.Medicare.gov/NHCompare/) on the world-wide web. Nursing Home Compare provides standardized information for almost every nursing home in the U.S. This information reported on Nursing Home Compare includes standardized quality information presented in a series of quality measures (in 2008 nineteen measures were included). Including QoL information in Nursing Home Compare would allow consumers to choose a facility based on quality and QoL. Presumably, nursing homes would improve QoL to attract potential residents. Some evidence exists showing that this improvement has already occurred for the quality measures (Castle, Liu, & Engberg, 2008).

Perfecting Patient Care

Perfecting Patient Care (PPC) is derived from one of the most successful business improvement models in the world--TPS (i.e., the Toyota Production System). That is, TPS is credited with making Toyota a leader in key productivity and operating measures among the major automakers (Chalice, 2007). PPC was shown to be successful at the University of Pittsburgh Medical Center in improving patient safety (Thompson, Wolf, & Spear, 2003), reducing infections (Thompson, Wolf, & Spear, 2003), reducing deaths (Spear, 2005), improving analytic procedures (Persoon, Zaleski, & Frerichs, 2006), and reducing diagnostic errors (Raab et al., 2006). Moreover, the effective use of TPS was recently reported in nursing homes (Castle, 2008).

The basic principle behind PPC is process redesign. That is, process redesign involves improving the way work practices are conducted. For example, improved work practices could involve eliminating wasted time, eliminating wasted materials, and eliminating duplication. This would seem particularly appropriate for nursing homes, given their endemic understaffing, high absenteeism rates, and high turnover (Decker, 2006). The elimination of waste serves to free time for top management to attend to other responsibilities and goals. This could include devoting more time towards creating a more humanistic care model.

CREATING MORE CARING HUMANISTIC ENVIRONMENTS

Finally, we provide suggestions for top managers, nursing home owners, and policy makers to create more caring humanistic environments. Suggestions above include resident-directed care (i.e., empowering nurse aides, consistent resident assignments, teamwork, leadership, training) quality of life (i.e., use by surveyors when inspecting facilities, by facilities themselves to improve care, and, on report cards), and using Perfecting Patient Care. We provide further comment on implementing culture change.

Culture Change

Implementing culture change is fraught with numerous barriers (Peters, 2007; Robinson & Rosher, 2006). Implementation of change can be difficult because it requires traditional leaders (i.e., top management) to relinquish power, while forcing traditional front-line workers (i.e., nurse aides) to think independently regarding the care of residents. Several recommendations have been put forward as useful in implementing successful change initiatives, including: developing a vision, empower those closest to the residents, provide education, develop an orientation program, and select an easily implemented practice first (Robinson & Rosher, 2006).

In order to address the barriers, Bill Thomas believes that a belief in culture change must permeate an entire organization. Senior leadership must accept culture change to steer the organization, while nurse aides must believe in the system to ensure that residents receive the full benefit of resident-directed care. A variety of organizational stakeholders must be exposed and subsequently believe in culture change for organizations to succeed in providing resident-directed care.

In order to implement resident-directed care in traditional long-term care facilities, culture change organizations have developed different methods to cultivate resident-directed care. Eden Alternative has developed Certified Eden Associate Training. The three day training program "teaches the Ten Principles of the Eden Alternative and gives specific suggestions and guidelines for putting them into practice" (Eden Alternative, 2008). Full implementation of resident-directed care can be difficult even with certified Eden Associates readily available. For example, the issue of introducing animals into the long-term care environment can be an obstacle (Sampsell, 41).

One movement that could provide a model for nursing homes is Planetree. Planetree was developed to "integrate humanistic care into our technologically advanced medical institutions" (Kimball, 1992, p. 5). This approach emphasizes the responsibility of nurses, which includes the ability to modify the environment, education, family involvement, nutrition, and interaction with physicians.

Another model for nursing homes is the Wellspring Institute which is an organization that encourages healthcare environments to allow staff to partake in decision making leading to an increase in resident and employee satisfaction and reduction of turnover (Wellspring, 2008). The Wellspring facilities foster an environment in which "traditional management" is replaced and the leaders are expected to become teachers, advisers, and facilitators. Care Resource Teams (CRTs) are formed by a group of staff that is educated on how to make healthcare decisions for the residents they serve. All of the above is accomplished through an organizational culture change. To be successful, the entire facility must commit to changes including staff gathering data, evaluating the results, and developing improved care processes. The entire program is overseen quarterly by clinical experts (Wellspring, 2008).

Dr. Bill Thomas created another program, the Green House Project, which requires management to deinstitutionalize and create a more social atmosphere to allow residents to "focus on life" (The Green House Project, 2008). The Green House is a group home that houses approximately eight to ten elders. The homes deliver the needed clinical care while supporting privacy, independence, and choice. The frontline staff are heavily involved in the residents' care; they are even encouraged to eat their meals with the residents. The Green House Project encourages resident directed care and staff responsibility and accountability.

CONCLUSION

Studies have shown that nursing homes top management teams play a vital role in the care of their residents. As stated earlier, the nursing home industry is needed to provide both clinical and humanistic care to residents. The results of the literature show that top management can be very influential in promoting the more unfamiliar humanistic care component. As seen through Action Pact, Inc., Eden Alternative, and the Pioneer Network, top management is needed to provide education, training, and support for culture changes and staff empowerment.

Few studies have been completed to examine the humanistic approach in nursing homes. While, top management teams appear to play a crucial role, more studies are needed to enhance these findings. It is important to find how staff empowerment affects the decision making process which ultimately affects the residents.

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NICHOLAS G. CASTLE

JAMIE C. FERGUSON

KEVIN HUGHES

University of Pittsburgh
Table 1
Descriptive Characteristics of Nursing Home
Administrators and Directors of Nursing

                            Nursing Home     Directors of
                           Administrators      Nursing

                            Mean    (SE)     Mean    (SE)

Tenure (in months) (a)     62.74   (2.34)   40.94   (1.65)
Administrator
education (a)
  High school or           17.29   (1.10)     --      --
associate degree
  Baccalaureate            50.49   (1.52)     --      --
degree
  Master's or              32.22   (1.43)     --      --
higher degree
Director of nursing
education (a)
  Diploma or                 --      --     57.08   (1.50)
associate degree
  Baccalaureate or           --      --     42.92   (1.50)
higher degree
Age (in years) (b)           54      (8)      51      (9)
Race (% Caucasian) (b)       67      --       73      --
Gender (% Male) (b)          69      --       15      --
Member of                    83      --       96      --
professional society (b)

(a) Source = National Nursing Home Survey [NNHS] (N=1,093)

(b) Source = Primary data (N= 3,211)

Table 2
Summary of Activities Performed by Nursing Home
Administrators and Directors of Nursing

                                        Nursing Home     Directors of
Activity                                Administrators   Nursing

External regulation and accreditation   17%              12%
Organizational mission and culture      4%               2%
Human resources development             2%               <1%
New product development                 <1%              <1%
New market development                  <1%              <1%
Acquisitions (new)                      4%               3%
Acquisitions (current vendors)          8%               6%
Organizational design                   <1%              <1%
Wage and salary administration          7%               5%
Capital investment strategy             1%               <1%
Financial goals                         5%               3%
Marketing plans                         1%               <1%
Resident care policies and practices    8%               16%
Problem identification                  2%               1%
Problem management
  With residents                        6%               11%
  With family                           9%               12%
  With staff                            12%              16%
Conflict management practices           1%               <1%
Quality assurance practices and
policies                                4%               6%
Hiring decisions                        4%               6%
Staffing decisions                      2%               12%
Legal developments                      1%               <1%
Other                                   3%               4%

Source = Primary data (N= 3,211) Note, percent of activities does not
sum to 100% due to rounding error

Table 3
Summary of Studies Examining the Impact of Top
Managers of Nursing Homes

                   NHA        DON      Samples          Top
Author(s)       examined   examined     used         management
                                                 characteristic(s)
                                                      examined

Castle              X                 419        NHA turnover
                                      nursing
                                      homes

Castle &            X         --      406        Job tenure (+),
Shugarman                             NHAs       education (0),
                                      from 5     membership in
                                      states     professional
                                                 association (+)

Anderson,           X          X      164        Climate (+),
Corazzini,                            nursing    communication
&                                     homes in   (+), DON
McDaniel                              TX         tenure (+)

Castle &            X         --      14,440     Administrative
Banaszak-                             nursing    resources (+)
Holl                                  homes

Anderson,          --          X      164        Management
Issel, &                              nursing    practices (+)
McDaniel                              homes in
                                      TX

Zimmerman           X          X      59         NHA turnover
et al.                                nursing    (0), DON
                                      homes in   turnover (0)
                                      MD

Castle &            X         --      15,927     Professional
Fogel                                 nursing    association
                                      homes      membership
                                                 (+)

Angelelli           X         --      832        NHA turnover
et al.                                nursing    (+)
                                      homes in
                                      NY

Castle              X         --      420        Turnover (+)
                                      nursing
                                      homes in
                                      5 states

Singh &             X         --      290        NHA tenure
Schwab                                NHAs in    (+)
                                      MI and
                                      IN

Singh &             X         --      173        NHA turnover
Schwab                                nursing    (+)
                                      homes in
                                      SC

Rubin &            --          X      72 NHAs    NHA turnover
Shuttlesworth                         in TX      (+)

Christensen &       X         --      147        NHA turnover
Beaver                                nursing    (+)
                                      homes in
                                      OR

Singh et al.        X         --      173        Education (+),
                                      nursing    administrative
                                      homes in   effort (+),
                                      SC         stability (+)

                    Outcomes
Author(s)           examined

Castle          Staff turnover

Castle &        Turnover
Shugarman

Anderson,       Staff turnover
Corazzini,
&
McDaniel

Castle &        Quality
Banaszak-       (pressure
Holl            ulcers,
                urethral
                catheters,
                psychoactive
                drug use)

Anderson,       Quality
Issel, &        (aggressive
McDaniel        behavior,
                restraint use,
                immobility of
                complications
                fractures)

Zimmerman       Infection,
et al.          hospitalization

Castle &        Quality
Fogel           (deficiency
                citations)

Angelelli       Health
et al.          deficiencies,
                total
                deficiencies

Castle          Quality
                (restraint use,
                pressure
                ulcers,
                urethral
                catheterizatio
                n psychoactive
                drug use, code
                violations)

Singh &         Realized
Schwab          expectations,
                commitment,
                skill
                compatibility,
                career
                opportunities
                and rewards,
                personal time,
                performance
                outcomes,
                community
                attachment

Singh &         Job
Schwab          environment
                (see above)

Rubin &         25 personal
Shuttlesworth   factors

Christensen &   Health and
Beaver          safety
                deficiencies

Singh et al.    Quality
                (deficiency
                citations)

X = examined; (+) indicates significant relationship identified:
(0) indicates no significant relationship identified

DON = Director of Nursing; NHA = Nursing Home Administrator
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