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Continuity is so important in the field of long-term care. You’re trying to build long-term relationships with your residents, with your family members, to inspire confidence and provide good care. And turnover interrupts that.
Bill McGinley, Certified Nursing Home Administrator (CNHA), President and CEO of the American College of Health Care Administrators
Nursing home administration has a problem with high turnover. As far back as 2001, research found the average annual turnover rate for nursing home administrators (NHAs) to be 43 percent. That turnover can create instability within a nursing home, and an increasing body of research has found that it can lead to negative effects on nursing home residents.
Research published in the Journal of Nursing Regulation (JNR) in 2014 found significant correlations between the turnover of NHAs and survey deficiencies in the homes where they serve. (Survey deficiencies are when regulatory requirements around care, safety, and standardized procedures are not met, leading to varying levels of harm to residents.)
According to the study, nursing homes and long-term care facilities where the administrator had been in the job for less than a year were more than twice as likely to have a deficiency, compared to a facility where the administrator had been on the job for 15 or more years. The results couldn’t be explained by a gap in general experience, either: even if the administrator had years of experience elsewhere, a short tenure at the facility in question was still a significant indicator of increased deficiencies.
“I have no doubt that there’s a higher number of deficiencies in nursing homes with high administrative turnover,” McGinley says. “When an administrator leaves, there’s a lot of knowledge in their head. Some of it is codified in policies and procedures and regulations, but a lot of it is just in the mind of the administrator. When that person goes, things can fall through the cracks.”
Turnover hasn’t improved significantly since 2001. The JNR study from 2014 found that the average tenure of an NHA is less than three years and about 40 percent of NHAs leave their post every year. Several contributing factors exist.
Meet the Expert: Bill McGinley, CNHA, CALA, CAS, FACHCA
Bill McGinley is a 40-year veteran of nursing home administration. He earned his BS in biology from the University of Massachusetts, Boston, and his MBA with a concentration in healthcare management from Boston University’s Questrom School of Business.
McGinley now serves as the President and CEO of the American College of Health Care Administrators (ACHCA). He is a Fellow of the American College of Health Care Administrators (FACHCA), a Certified Nursing Home Administrator (CNHA), a Certified Administrator of Sub-Acute Care (CAS), and a Certified Assisted Living Administrator (CALA).
He also holds the distinction of being just the third person in the country to achieve the Health Services Executive (HSE) credential from the National Association of Long Term Care Administrator Boards (NAB). In 2010, he was named Outstanding Member of the ACHCA, and in 2017, ACHCA named him as the recipient of the Distinguished Assisted Living Administrator Award.
Why is Nursing Home Administration Turnover an Issue?
“It’s an extremely hard job, and it’s somewhat unique in the healthcare continuum,” McGinley says. “The nursing home administrator has an awful lot on their plates. The nursing home industry in the US is the second most heavily regulated of all industries. The first is nuclear power.”
Nursing home administrators have to deal with complex payment schemes, high general staff turnover, multiple stakeholders, and regulatory oversight at practically every turn. Nursing home administrators are expected to be on-call 24 hours a day. Burnout is a major issue.
“Even when you’re off duty as a nursing home administrator, you’re at work,” McGinley says.
“Most nursing home administrators sleep with their cell phone resting next to their bed somewhere. It’s a way of life.”
If one puts aside turnover and focuses on simply reducing deficiencies, then cross-sectional analysis in the International Journal of Nursing Studies suggests that NHAs with rigorous education and certification improve outcomes for residents.
But a 2009 study in Health Care Management Review explored factors related to short-tenure versus long-tenure in nursing home administrators and found that nursing home administrators with a higher level of education were more likely to have short tenures. The findings suggest that hiring the best-educated candidates is advantageous, but only when coupled with significant initiatives aimed at boosting retention.
How Can Nursing Home Organizations Combat Worker Burnout and Improve Employee Retention?
“The nursing home ownership, whether it’s private single-home ownership or large corporate ownership, has to be supportive of the administrator, and provide the necessary continuing education to keep the person current in the field and help maintain his or her license,” McGinley says. “I am a big believer that one of the things that can and should be done is to provide membership in the administrator’s professional organization, and that would be the ACHCA.”
A 2014 survey of Pennsylvania’s NHAs found that high levels of cynicism, emotional exhaustion, and feelings of professional inefficacy were the biggest indicators of NHAs being likely to leave their jobs. According to the survey’s designer, these signs of burnout were related to low workload manageability, high pressure, and a weak sense of support from upper management. The findings suggest that nursing homes need to balance bottom-line values with a commitment to fostering community and support. Too much focus on impersonal metrics can be alienating and harmful.
The Unique Challenges of the COVID-19 Pandemic
Further surveys found that NHAs with a higher level of autonomy and an alignment with a nursing home’s values showed higher levels of commitment to their current workplace. But the COVID-19 pandemic, which has ravaged America’s nursing homes, threatens to take the concept of NHA burnout to an entirely new level.
“This pandemic has exacerbated the whole issue of burnout,” McGinley says. “I talk to nursing home administrators who literally haven’t had a day off in 80, 90, 100 days. I’m very worried about the mental health of the profession right now.”
In McGinley’s view, today’s nursing home administrators are in the middle of the greatest professional crisis they’re ever likely to face. A few have confided in McGinley that after the pandemic is over— if it is ever truly over—they will consider transitioning out of their current career.
Others have begun to internalize and feel guilt over the deaths that have occurred due to circumstances outside of their control. The economic impact of the pandemic only increases the pressure on nursing home administrators further. Part of the answer, according to McGinley, lies in the professional community.
“Sometimes, in this profession, it’s really helpful to be able to have a conversation with someone who doesn’t work for the same company you do,” McGinley says. “It allows you to have a broader perspective on things.”
The Important Work of the American College of Health Care Administrators (ACHCA)
The ACHCA considers NHA turnover a major issue, and it’s working to relieve the stressors that many NHAs face. In 2017, they released a position statement directly opposing the concept of “strict liability,” wherein an NHA may be held criminally, professionally, and/or personally responsible for the actions or inactions of other people in their facility. Nursing home administration is already a high-pressure occupation and highly regulated. Adding additional strict liability for individual administrators would create an added barrier for those entering the profession, increase emotional exhaustion, and reduce retention. And retention is particularly critical in light of the recent pandemic.
“The nursing home administrators who are working right now have gained a unique experience,” McGinley says. “They’re doing something that no one has ever done before, and they’ll have an opportunity to educate the people that will come down the road in later years.”
To combat NHA turnover requires a holistic approach. A mix of autonomy, compassion, and community support for and amongst NHAs will further increase the chances of administrator retention. If nursing homes can commit themselves to empowering their administrators, resident outcomes will benefit. And if nursing home administrators band together, they can push through the hardest of times, collectively.
“If administrators really want to be the best that they can be, they should do things that allow themselves to be surrounded by like-minded individuals, and one of those things would be to join their professional organization,” McGinley says.
“If you’re working for a small family business, you’ll be able to meet people from a large, national, publicly-held corporation. Or maybe you’re working for a for-profit company, and it’ll give you opportunities to talk to people on the non-profit side. The more you can talk to people and learn how they do things, the better equipped you’ll be in your career.”
Matt is a writer and researcher from Southern California. He’s been living abroad since 2016. Long spells in Eastern Europe, Southeast Asia, and Latin America have made the global mindset a core tenet of his perspective. From conceptual art in Los Angeles, to NGO work on the front lines of Eastern Ukraine, to counterculture protests in the Southern Caucasus, Matt’s writing subjects are all over the map, and so is he.