Copyright 1992 by The Cerontological Society of America The Cerontologist Vol. 32, No. 3, 334-341

This study involved 530 nursing staff working in 25 for-profit and nonprofit nursing homes, two of which failed to meet resident care standards required for state recertification. Staff members' job attitudes, opinions regarding elderly residents, and perceptions of the organization climate varied between the successful for-profit and non-profit homes. The organization climate in the failed homes was significantly different from the climate in either the successful for-profit or successful nonprofit homes. Key Words: Organization climate, Total quality management, Quality of care

Ineffective Staff, Ineffective Supervision, or Ineffective Administration? Why Some Nursing Homes Fail to Provide Adequate Care1 John E. Sheridan, PhD,2 John White,3 and Thomas J. Fairchild, PhD4

The quality of resident care in nursing homes has been one of the most widely studied and publicized topics in gerontology. Previous research has focused largely on identifying macro organization structure variables related to the quality of resident care in different nursing homes. Davis (1991) reported that during the past 2 decades, 21 studies have examined the relationships between organization size and the quality of resident care, 22 studies have examined the relationships between nursing home expenditures and quality, and 5 studies have examined the relationships between staffing factors and quality. This extensive research effort has found little consistent evidence linking organization structure variables with the quality of resident care. Kurowski and Shaughnessy (1985) concluded that this has occurred "because they [structural variables] are intended to measure the capacity for the provision of quality of care but do not necessarily measure whether the capacity is actually used" (p. 107). Another major research effort, representing 23 studies, has investigated the relationships between nursing home ownership and the quality of resident care. Davis (1991) suggested that this research has been based on the economic assumption that profit and quality goals may be incompatible. For-profit nursing homes could have a greater incentive to

reduce cost at the expense of quality enhancement compared with nonprofit homes. Again, while there has been some mixed evidence of significant ownership effects on quality, Davis concluded that "in light of the [published] data, it would be premature to conclude that nonprofit nursing homes provide higher quality care, ceteris paribus" (p. 147). After 20 years' research, the paucity of empirical evidence linking macro organization variables with various quality indices points to the fact that organizational characteristics alone account for very limited explanations of the variance in resident care found between different homes. It would appear that Manard, Kart, and Van Gils's (1975) observation that "if we know that residents are happiest in small homes, new homes, homes with many nurses and homes in rural areas, then we still do not know much about small new homes with many nurses in rural areas" (p. 134) is as relevant today as it was 16 years ago. Kurowski and Shaughnessy (1985) argued that the macro organization perspective is an inappropriate research focus to adequately understand quality assurance since the macro variables provide little insight into the management or resident care practices found within the nursing homes. Moreover, they suggested that any research evidence relating quality indices with macro variables would likely identify organizational factors influencing resident care only in successful nursing homes. Such findings would have few implications for understanding the organizational problems that may cause some nursing homes to fail in their responsibility to meet acceptable quality standards (Kane, 1988). Ultimately, the delivery of high-quality resident care rests with effective administrative practices and

This study was supported by NIH Grant 5 R01 NU00933-02 from the Health Resources Administration. The researchers gratefully acknowledge the assistance of Dr. Mildred Hogstel in the data collection and her constructive comments to earlier drafts. 2 L. R. Jordan Chair of Health Services Administration, School of Health Related Professions, University of Alabama at Birmingham, Birmingham, AL 35294. 3 University of Alabama at Birmingham. ••University of North Texas, Denton, TX.

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effective nursing leadership in facilitating and reinforcing the care provider's work motivation and job performance on a day-to-day basis (Institute of Medicine, 1986). Failure to provide adequate resident care may be related to negative work attitudes and/or poor skills of care providers, ineffective supervision, or ineffective management practices on the part of nursing home administrators. The objective of this paper is to investigate the extent to which the care provider's work attitudes, the supervisor's leadership behavior, and the administration's human resource management practices vary between nursing homes that provide adequate care and those that fail to meet quality standards. Aides have the most frequent interactions with residents as care providers. They comprise 71% of the full-time nursing staff in the nation's nursing homes. LPNs represent an additional 17% of the nursing staff (National Center for Health Statistics, 1989). The work motivation and job performance of these primary care providers are essential to provide a high quality of resident care. Nearly all incidents of resident neglect can be related to careless or callous interactions between these care providers and residents (Pillemer & Moore, 1989; Wagnild, 1986). Two types of work attitudes could be related to poor resident care. First, Storlie (1982) argued that dedicated and compassionate nursing staff are essential for maintaining high-quality care on a day-today basis. The lack of strong financial incentives and sometimes minimal training for new staff members place greater emphasis on the care provider's personal commitment and cooperation among all staff in providing a high quality of resident care (Kane, 1989). Low cohesion among coworkers, little psychological commitment to the nursing home, or high stress at work can create morale problems that ultimately detract from the staff member's job performance (Sheridan, Hogstel, & Fairchild, 1990). Second, staff members may have inaccurate knowledge or negative stereotypes regarding elderly residents. Previous research has provided inconclusive evidence of a strong relationship between the care provider's attitudes toward the elderly and the quality of resident care (Wright, 1988). Wright argued that this finding may simply be a measurement artifact, since many studies inappropriately assessed the care provider's attitudes toward the aged in the general population rather than their attitudes toward the work behaviors needed to care for elderly residents. Measuring attitudes specifically related to the nursing staff's interactions with elderly residents would likely yield much stronger explanations of the quality of resident care. The posited effects of the staff members' work attitudes on the quality of resident care can be stated as:

Ineffective supervision can be a second factor contributing to poor resident care. In a typical staffing pattern the care providers report to a supervisor nurse who directly supervises the resident care provided in a nursing home unit during a particular work shift. There is approximately one supervisor for every seven full-time-equivalent staff members (National Center for Health Statistics, 1989). Jones and Jones (1979) indicated that hospital head nurses spend approximately 75% of their time in decisionmaking activities, 15% in informational activities, and 10% in interpersonal activities. Little is known about how nursing supervisors allocate their time in nursing homes. Sheridan, Vredenburgh, and Abelson (1984) refined this taxonomy of leadership activities by identifying seven leadership behaviors that nursing supervisors demonstrate on a day-to-day basis. The decision-making activities include: (a) Direction — assigns specific work responsibilities to staff members and schedules the work in the unit; (b) Delegation — collaborates with staff members in making decisions regarding patient care and encourages staff to exercise their own judgment in completing work assignments; and (c) Assertiveness — asserts her/his formal power in handling disturbances in the unit and resolving staff problems. The informational activities include: (d) Recognition — gives individual recognition and compliments staff members for good job performance; (e) Reprimand — criticizes staff for poor nursing performance; and (f) Liaison — maintains communication channels and personal influence with administrators and other units. The interpersonal activities include: (g) Sensitivity — shows consideration for the staff member's feelings and maintains good relations with her/his immediate staff. These leadership dimensions have been found to have significant effects on the nursing staff's job attitudes and job performance in both hospitals and nursing homes (Sheridan, Vredenburgh, & Abelson, 1984; Sheridan, Hogstel, & Fairchild, 1990). The posited effects of the supervisor's leadership behavior on the quality of resident care can be stated as: Hypothesis 2 — Supervisor nurses employed in homes providing adequate resident care will demonstrate more active behavior on all leadership dimensions than those supervisors working in homes that fail to provide adequate care.

Hypothesis 7 — Nursing staff employed in homes providing adequate resident care will report higher commitment to the nursing home, higher staff cohesion, lower job tension, and more positive opinions regarding elderly residents than those working in homes that fail to provide adequate care. Vol. 32, No. 3,1992

The nursing home's organization climate may also contribute to poor resident care. The organization's core culture values influence how administrators formulate and communicate the human resource management strategy in a nursing home (Kerr & Slocum, 1987; Kopelman, Brief, & Guzzo, 1990). Organization climate is a molar concept that describes the member's shared perceptions of the administration's human resource management policies, practices, and procedures in a particular home, relative to the climates perceived in other nursing homes (Poole, 1985; Reichers & Schneider, 1990). Kopelman, Brief, and Cuzzo (1990) identified several factors that typically distinguish between the

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climates reported in different organizations. These distinguishing factors include: (a) Goal emphasis — administrative policies that clarify the types of objectives to be accomplished and the standards expected of employees; (b) Means emphasis — administrative procedures that specify the methods employees are expected to use in performing their jobs; (c) Reward orientation — administrative practices that distribute rewards on the basis of job performance; (d) Task support — administrative procedures that provide adequate materials, equipment, training, and other resources necessary to perform the jobs as expected; and (e) Socioemotional support — administrative practices that demonstrate concern for the employees' personal welfare and treat employees equally. Sheridan, Vredenburgh, and Fairchild (1984) reported that there were four dimensions among these administrative factors describing how nursing staff perceived the organization climates evident in different hospitals. These four dimensions were: (a) Human relations — the extent that administrative practices demonstrated an interest in the well-being of employees and administrators attempted to improve staff relationships; (b) Task orientation — the extent that administrative practices established clear descriptions of the staff's job responsibilities in patient care and expectations for employee development, and administrators provided feedback and rewards based on individual accomplishments; (c) Laissezfaire climate — the extent that administrative practices failed to establish clear objectives, resource planning was inadequate for efficient day-to-day operations, and reward policies lacked incentives for doing a good job; and (d) Status orientation — the extent that administrative practices emphasized status differences between levels of the organization hierarchy and created conflicts among departments because of vested interest. The posited effects of organization climate on resident care can be stated as: Hypothesis 3 — The organization climate in homes providing adequate resident care will be perceived as being significantly higher on human relations and task orientation dimensions and significantly lower on laissez-faire and status orientation dimensions compared with the organization climate in homes that fail to provide adequate care. Method Twenty-five nursing homes located in Texas and Florida participated in this study. Each home was licensed to provide intermediate and skilled resident care. To assure that the sample represented a balance of exogenous factors that could influence the quality of patient care (Davis, 1991; Kurowski & Shaughnessy, 1985), the convenience sample was selected to include a variety of ownership, size, and location factors. Thirteen homes were for-profit organizations operated by seven different regional or national corporations. The size ranged from 120 beds to 187 beds, 336

with the median size being 135 beds. Nine were located in urban areas (population greater than 500,000); four were located in small towns (population less than 30,000). The remaining 12 homes were nonprofit organizations affiliated with nine different religious groups. The size of the nonprofit homes ranged from 100 beds to 264 beds, with the median size being 130 beds. Eight were located in urban areas, and four in small towns. By happenstance, two of the participating nursing homes failed to pass periodic state inspections required for recertification. Both of these failures occurred within a 3-month period following the questionnaire survey. The two failures occurred in for-profit homes located in urban areas in Texas. Each failed home had 120 beds, but each was operated by a different corporation. The state inspections of the two failed facilities cited the following deficiencies in the resident care: (a) the nursing home did not provide 24-hour nursing services sufficient to meet total needs; (b) a high number of bed sores were reported in residents because of a lack of proper prevention and treatment by the staff; (c) improper documentation for control and administration of medicine, including a failure to administer medicine in proper quantities or to keep an adequate supply of medicine on hand; and (d) clinical records lacked documentation to reflect the actual condition of residents. The state regulatory agency suspended Medicaid payments until the resident care problems were corrected. The remaining 11 for-profit homes and 12 nonprofit homes were recertified during the year following the questionnaire survey. Based on the state inspections, these successful homes at least met minimal quality standards, whereas the two failed homes were operating below minimal resident care standards. A pilot study had demonstrated the importance of researchers collecting the employee data during work hours to assure complete survey responses. The questionnaire was, therefore, administered directly by the researchers during day and evening work shifts over a 2- or 3-day period in each home. The respondents included a total of 558 nursing staff who had direct responsibility for resident care. The number of respondents in each home ranged from 11 to 34. This sample represented from 19% to 49% of the full-time-equivalent nursing staff employed in each home, with the median sample proportion being 32%. There were no significant differences in the sampling proportions between the for-profit and nonprofit homes or between the homes located in urban areas and small towns. The mean sampling proportion of 26.5% in the two failed homes, however, was somewhat lower than the mean sampling proportion of 32.3% in the 23 successful homes. A total of 28 respondents (5%) were deleted from the data analysis because of missing data (two items or more) on different measurement scales. This resulted in a final sample size of 530 employees who had complete data on all variables. The Gerontologist

Measures

that care providers felt that elderly residents should be discouraged from being involved in social and personal care activities, that they are difficult to understand, and that they need to be closely monitored; and (b) Vitality opinion — five items that measured the extent that care providers believed that elderly residents should be involved in activities of daily living, should be encouraged to lead an active life, and could be understood if given adequate attention. The coefficient alphas for each scale were .86 and .81. The staff members described how often (percentage of time) their immediate supervisor demonstrated leadership behaviors using an instrument originally developed by Kruse and Stogdill (1973) and modified by Sheridan, Vredenburgh, and Abelson (1984). A varimax factor analysis of the responses to this 32-item leadership instrument confirmed the same seven-dimension factor structure reported by Sheridan, Vredenburgh, and Abelson (1984) for hospital nursing staff. The coefficient alphas for each leadership behavior scale ranged from .72 to .88. The organization climate in each home was measured using a 28-item Likert-type instrument originally developed by Pritchard and Karasick (1973) and modified for use in health care organizations by Sheridan, Vredenburgh, and Abelson (1984). A varimax factor analysis confirmed the same fourdimension factor structure reported by Sheridan, Vredenburgh, and Abelson (1984) for hospital organizations. The coefficient alphas for each climate scale ranged from .77 to .84. A preliminary one-way MANOVA verified the as-

Three measures of the staff member's job attitudes were included in the questionnaire: (a) Organization commitment — 14-item scale developed by Porter and Steers (1973) that measured the extent to which the employee had internalized the nursing home's objectives, desired to maintain employment in the nursing home, and was motivated to work hard for the nursing home; (b) Job tension — 16-item scale developed by Kahn et al. (1964) that measured the frequency with which various stressors occurred at work, such as role conflict or ambiguity, work overload, and inadequate resources or skills to perform the job as expected; and (c) Cohesion — six-item scale developed by Kruse and Stogdill (1973) that measured the extent to which coworkers were congenial and cooperated with each other in providing care to all the residents in the nursing home. All instruments measuring the staff members' job attitudes had acceptable internal reliability, with coefficient alphas for each scale ranging from .79 to .83. Following Wright's (1988) suggestion, each staff member's opinions regarding his or her interactions with elderly residents were measured by a Likerttype instrument developed by McCaffree and Harkins (1976). A varimax factor analysis was made of responses to the 15 items in this instrument. A Scree test indicated that there were two primary factors that explained over 30% of the variance in the item scores. Table 1 reports the factor loadings for each scale item. The two primary factors were labeled: (a) Maintenance opinion — ten items that reflected the extent

Table 1. Rotated Factor Loadings for Care Provider's Opinions Regarding Elderly Residents Factor 1 Maintenance opinion

Scale item Any conversation among residents about death should be discouraged. The formation of small social groups among residents should be discouraged. It is a waste of staff time to attempt to alleviate symptoms of chronic confusion on the part of residents. Residents should be discouraged from taking extended visits away from the nursing home since adjustment problems occur when the resident returns. Residents should be discouraged from showing an interest in the opposite sex. We can make some improvement, but generally the conditions of nursing homes are about as good as they can be. The quiet resident is demonstrating a good adjustment to the nursing home. The quiet resident does not need as much attention as a demanding one. As soon as an elderly person shows signs of chronic confusion, he or she should be placed in a nursing home. We cannot expect to understand the behavior of elderly people. Residents should be encouraged to engage in voluntary activities, such as reading to other residents. It is the responsibility of staff to encourage residents to participate in community activities, such as hobby fairs or voting, etc. It is necessary to discover the reason for, not just to control, disruptive behavior among elderly residents. An effective way of handling problems that arise in the course of daily living would be to have regular meetings where the residents could discuss their problems. Residents need to be encouraged to make their own decisions for daily living. Eigenvalue Note. Underlining indicates scale items included in each factor.

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Factor 2 Vitality opinion

.51 ^50

.18 .05

J7

-.11

_32

-.01

J4

-.05

.41 ^56

.07 .14 .01

.41 ^53

-.06 -.04

-.07 -.03 -.26 -.15 -.09

.62 .45

3.94

2.39

sumption that staff members shared the same perceptions of the organization climate within different nursing homes. The measures of organization climate varied significantly across the 25 homes, compared with relatively little variation within each home (multivariate F = 2.84, p =£ .01). Significant univariate differences were found on each of the four climate dimensions.

three comparison groups. Therefore, while relatively small deviations from normality may have confounded the Box M tests, the overall evidence suggests that the underlying MANOVA assumptions were met (Stevens, 1986).

Data Analysis For analytical purposes the sample was partitioned into three comparison groups: (a) 26 staff who were employed in the two for-profit homes that failed state inspections, (b) 206 staff employed in the 11 successful for-profit homes, and (c) 298 staff who worked in the 12 successful nonprofit homes. A one-way MANOVA design was used to test the three hypotheses. Since previous research had reported ownership effects on resident care., the MANOVA design included planned contrast effects to test whether the failed homes varied significantly from both the successful for-profit homes and successful nonprofit homes. The first contrast effect compared the successful for-profit and nonprofit homes (MANOVA groups coded 0 , - 1 , 1 ) . The second contrast effect compared the failed for-profit group with the successful f o r - p r o f i t group (MANOVA groups coded - 1 , 1 , 0 ) . The third contrast effect compared the failed for-profit group with the successful nonprofit group (MANOVA groups coded - 1 , 0 , 1 ) . The observation of nursing home failures was a relatively unlikely occurrence. Consequently, this quasiexperimental field test represented an unbalanced experimental design. The number of respondents {n = 26) employed in the failed homes was only a fraction of the sample sizes in the two groups from the successful homes (n = 206 and 298, respectively). To control for confounding statistical limitations of testing an unbalanced design, the MANOVA sums of squares were calculated using regression methods. Two underlying assumptions of the MANOVA analysis are: (a) there are homogeneous variancecovariance matrices within the sets of multivariate dependent variables across the three comparison groups; and (b) the dependent variables have multivariate normal distributions. A preliminary analysis failed to support the assumption of homogeneous covariance matrices by revealing significant Box's M values for work attitude and organization climate variables. Box's M, however, is very sensitive to nonnormality. The assumption may be easily rejected because of a lack of multivariate normality, not because the covariance matrices are different (Stevens, 1986). Further analysis revealed slight variation from normality, but none of the dependent variable distributions had skewness or kurtosis indices that varied significantly from a normal distribution. The BartlettBox F statistic also indicated that, with the exception of the cohesion measure, the variance in all other dependent variables was homogeneous across the 338

Results The MANOVA results reported in Table 2 indicate that the staff members' work attitudes varied significantly between the successful for-profit and nonprofit homes (multivariate F = 2.81, p =s .05). This difference was attributed primarily to the evidence that organization commitment was much higher in the successful nonprofit homes than in the successful for-profit homes. The findings suggest only weak support for Hypothesis 1. The differences in work attitudes were large but not significantly different between the failed homes and the successful forprofit homes (multivariate F = 1.83, p *£ .10) and

between the failed homes and the successful nonprofit homes (multivariate F = 1.95, p ^ .10). Figure 1 illustrates the significant univariate effects indicating that the differences between failed and successful homes were largely attributed to the evi-

Table 2. MANOVA Results for Care Provider's Work Attitudes in Nursing Homes That Failed to Be Recertified Compared with Those That Succeeded Ftest for contrast between Successful for-profit vs. Failed vs. Failed vs. nonprofit for-profit nonprofit Multivariate F Univariate F Organization commitment Cohesion Job tension Maintenance opinion Vitality opinion

2.81*

1.83

1.95

11.25** 1.45 2.36 3.49 .01

.00 3.13 1.01 3.73* .01

2.03 5.45* 2.90 1.29 .01

*p< .05; **p< .01.

4.0 ^

3.5

Nonprofit

• For-profit • Failed

3.0 2.5 2.0 1.5

Figure 1. Work attitudes of care providers in successful nonprofit and for-profit nursing homes and failed nursing homes. Maintenance opinions were significantly higher in the failed homes (p = .05) and staff cohesion was significantly lower (p = .05) than in the successful nonprofit homes.

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Table 3. M A N O V A Results for Supervisor's Leadership Behaviors in Nursing Homes That Failed to Be Recertified Compared with Those That Succeeded

Table 4. M A N O V A Results for Organization Climate Dimensions in Nursing Homes That Failed to Be Recertified Compared with Those That Succeeded

F test for contrast between

F test for contrast between

Successful for-profit vs. nonprofit

Failed vs. for-profit

Failed vs. nonprofit

2.03*

1.13

1.18

.00 .15 .00 .04 10.96** .08 .00

.35 .25 .76 .15 .54 2.33 .99

.35 .47 .80 .09 .52 2.03 1.04

Multivariate F Univariate F Direction Delegation Assertiveness Recognition Reprimand Liaison Sensitivity

Successful for-profit vs. nonprofit Multivariate F Univariate F Human relations climate Task orientation Laissez-faire climate Status orientation

Failed vs. for-profit

Failed vs. nonprofit

9.39**

1.97

7.69**

27.47** 2.54 7.54** 7.67**

3.68* .15 2.69* .80

18.28** 1.20 8.33** 4.57*

* p < .05; * * p < .01.

*p*s .05; **p^ .01.

dence that the maintenance opinion was significantly higher in the failed homes than in the successful forprofit homes, while cohesion was significantly lower in the failed homes than in the successful nonprofit homes. To a lesser extent (p =s .10), job tension was also higher and cohesion lower in the failed homes than in the successful nonprofit and for-profit homes, respectively. Table 3 indicates that the supervisor's leadership behavior varied significantly between the successful for-profit and nonprofit homes (multivariate F = 2.03, p ^ .05). This significant effect was attributed solely to the evidence that the supervisor's reprimand behaviors were much more frequent in the successful for-profit homes than in the nonprofit homes. The findings, however, did not support Hypothesis 2: there were no significant differences between the leadership behaviors demonstrated in the failed homes compared with either the successful for-profit or nonprofit homes. The Table 4 data indicate that organization climate measures varied significantly between the successful for-profit and nonprofit homes (multivariate F = 9.39, p =£ .01). Figure 2 illustrates that these differences were attributed to the evidence that the successful nonprofit homes were perceived as having significantly higher scores on the human relations climate dimension and lower scores on laissez-faire and status orientation climate dimensions than the successful for-profit homes. The Table 4 results also indicate that organization climate measures varied significantly between the failed homes and successful nonprofit homes (multivariate F = 7.69, p =s .01). Figure 2 illustrates that Hypothesis 3 was supported. The failed homes had significantly lower scores on the human relations climate dimension and significantly higher scores on laissez-faire and status orientation climate dimensions compared with the successful nonprofit homes. The differences in organization climate between the failed homes and successful for-profit homes were smaller (multivariate F = 1.97, p =s .10) Vol. 32, No. 3,1992

Human relations

i-a.asez-faire

Status orientation

Figure 2. Organization climate dimensions as perceived by care providers in successful nonprofit and for-profit nursing homes and failed nursing homes. Climate scores were significantly lower on the human relations dimension (p = .01) and significantly higher on the laissez-faire dimension (p = .01) in the failed homes than in either the successful for-profit or nonprofit homes.

but still supported Hypothesis 3. Figure 2 illustrates the significant univariate effects indicating that the failed homes had lower scores on the human relations climate and higher scores on laissez-faire climate compared with the successful for-profit homes. Discussion

Recent estimates indicate that half the women and almost one-third of the men turning 65 in 1990 will require nursing home care during their life. As a result of an aging population and increasing life expectancy, the number of elderly residents in nursing homes could nearly double by the year 2020 (Kemper & Murtaugh, 1991). The magnitude of this growing demand has sparked considerable debate over the costs and adequacy of the nation's nursing homes to deliver quality care. Much of the discussion has centered on facility and human resource capacity issues. For example, projections of the number of full-time-equivalent RNs needed to supervise nursing home care by the year 2000 range from 260,000 to slightly over 1 million, if one assumes greater RN responsibility in providing direct resident care in the future (National Institute on Aging, 1987). By contrast, there were only 92,000 full-time339

equivalent RNs employed in nursing homes in 1984. While more human resources are essential, it is unlikely that simply having more care providers and supervisors in nursing homes will resolve the concerns with quality care. There is a need to closely examine the role that nursing homes should play in the nation's long-term care system and how these homes can be effectively managed (Kane & Kane, 1991). This study takes initial steps in examining the human resource management factors that may explain why some homes fail to provide adequate care. The findings suggest that the administration's human resource management policies, practices, and procedures are the underlying factors contributing to poor care in some nursing homes. Poor resident care did not appear to be a consequence of inadequate or inappropriate supervision. The nursing supervisor's leadership behaviors were essentially the same in homes that provided adequate care and homes that failed to provide adequate care. The organization climate in the failed homes, however, was perceived as being significantly lower in human relations and higher in laissez-faire and status orientation dimensions than the climate in the successful for-profit and nonprofit homes. Additional research will obviously be needed to verify whether these differences can be generalized to other homes that fail to provide adequate care. The organization climate dimensions in the failed homes described the administration as being inattentive to staff motivation, demonstrating inadequate planning, providing few resources to enhance the quality of resident care, and showing disdain for lower-level care providers. Given this type of organization climate, it is not surprising that staff members in the failed homes reported significantly lower cohesion and stronger maintenance opinions regarding the care of elderly residents compared with staff working in the successful homes. The ineffective human resource management practices, in turn, foster cold and impersonal feelings and interactions among care providers and the elderly residents. Tellis-Nayak and Tellis-Nayak (1989) vividly described the "vicious cycle" of staff discontent and poor resident care that can occur in this type of organization climate.

providing inadequate resident care have prompted more nursing homes to adopt formal risk management and quality assurance programs (Kapp, 1990). It is somewhat ironic that these programs typically focus on monitoring resident interactions with care providers and increasing in-service training for care providers and supervisors under the assumption that inadequate supervision or untrained care providers are the causes of poor resident care (Kapp, 1990). The present findings suggest that these attempts may be short-sighted. Administrators cannot blame ineffective staff members or supervisors for poor care. Often the management system is the root cause of poor quality (Berwick, 1989). The nursing home's human resource management policies, practices, and procedures, therefore, must also come under close scrutiny in any risk management system (McLaughlin & Kaluzny, 1990; Milakovich, 1991). Second, nursing home administrators should look beyond their own industry to seek new ideas for managing resident care (Batalden & Buchanan, 1989; Berwick, 1989; Laffel & Blumenthal, 1989). Foreign competition, particularly from the Japanese, has provided important lessons for American businesses about the importance of building strong organization climates to encourage world-class product and/ or service quality. In their widely publicized book, In Search of Excellence, Peters and Waterman (1982) concluded that, "without exception, the dominance and coherence of organization culture proved to be an essential quality of excellent companies." As suggested in this study, the nursing home's organization climate may also prove to be a fundamental distinction between homes that provide high-quality resident care and those that fail to meet acceptable quality standards. Weak human relations practices and strong laissez-faire and status orientation climates in the failed homes foster the feelings of staff powerlessness and diminished self-worth that Tellis-Nayak and Tellis-Nayak (1989) aptly described. In that type of climate, the supervisor's leadership behavior is rendered ineffectual, whereas strong human relations and task orientation climates enhance the care provider's sense of self-worth and reinforce the supervisor's leadership effectiveness (Sheridan, Hogstel, & Fairchild, 1990). Hospital organizations have learned to apply patient care redesign strategies and a Total Quality Management (TQM) philosophy, adapted from industrial organizations, to build this type of organization climate (Batalden & Buchanan, 1989; Sahney et al., 1991). These same job design concepts can also be successfully implemented in nursing home care (Brannon et al., 1988; Roundtree & Deckard,1986). Building strong human relations and task orientation climates may be even more challenging under the nursing home reform mandated by the Omnibus Budget Reconciliation Act of 1987 (OBRA). The thrust of OBRA's nursing home regulations was improving resident care by developing a comprehensive care plan that will permit residents to function at their maximum physical, mental, and social levels. The

In too many nursing homes the institutional culture prevails. Within it aides are only the hired hands; no one provides for their affective needs nor cares if it alienates them. And being in constant company of dependent elderly residents, the aides, too, begin to individualize their problems. They make their wards the ready target of their discontent and resentment. And that completes the vicious cycle. Two parties, both powerless, little respected, and hardly recognized by society, are made to face each other in a difficult setting not of their own making. They are bound in an intimate association, but enjoy little intimacy. Neither party controls the institutional environment in which they exist, neither can break the negative cycle, and so the problem feeds on itself, (p. 312) What can be done to prevent this cycle from occurring in some homes? First, the legal consequences of 340

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intent of these reforms was to improve the quality of care by increasing resident input and autonomy. Initial reaction to OBRA has been perceived by many administrators as creating an organization climate that restricts management initiative and emphasizes the punitive consequences of staff shortcomings in providing resident care. OBRA has not eliminated any regulations but rather added regulations that may constrain administrators from trying new management approaches. It is unlikely that regulatory actions, no matter how well intentioned, can assure a high quality of nursing home care (Berwick, 1989; Eskildson & Yates, 1991; O'Leary, 1991). This can occur only when the nursing home administrators build an organization climate where all staff members are committed to learning how to achieve the highest quality standards (Batalden, 1991). This goal is inherent in the Malcolm Baldridge National Quality Award criteria, which place nearly 30% weight on the leadership and human resource management actions needed to build a strong organization climate (National Institute of Standards and Technology, 1990). The TQM philosophy, based on Deming's (1986) principles, requires a foundation of effective human resource management policies, practices, and procedures. The success of TQM programs in health care (Batalden & Buchanan, 1989; Sahney et al., 1991) makes it clear that building strong organization climates may ultimately prove as important as any regulatory strategy in enhancing the quality of care in the nation's nursing homes. References Batalden, P. B. (1991). Organizationwide quality improvement in health care. Topics in Health Record Management, 11(3), 1-12. Batalden, P. B., & Buchanan, E. D. (1989). Industrial models of quality improvement. In N. Coldfield & D. B. Nash (Eds.), Providing quality care: The challenge to clinicians. Philadelphia: American College of Physicians. Berwick, D. M. (1989). Continuous improvement as an ideal in health care. New England Journal of Medicine, 320(1), 53-56. Brannon, D., Smyer, M., Cohn, M., Borchardt, L, Landry, J., Jay, C , Carfein, A., Malonebeach, E., & Walls, C. (1988). A job diagnostic survey of nursing home caregivers: Implications for job redesign. The Gerontologist, 28, 246-252. Davis, M. A. (1991). On nursing home quality: A review and analysis. Medical Care Review, 48(2), 129-166. Deming, W. E. (1986). Out of crisis. Cambridge, MA: MIT Press. Eskildson, L, & Yates, G. C. (1991). Lessons from industry: Revising organizational structure to improve health care quality assurance. Quality Review Bulletin, 17(2), 38-41. Institute of Medicine. (1986). Improving the quality of care in nursing homes. Washington, DC: National Academy Press. Jones, N. K., & Jones, J. W. (1979). The head nurse: A managerial definition of the activity role set. Nursing Administration Quarterly, 3, 45-59. Kahn, R. L, Wolfe, D. M., Quinn, R. P., Snook, J. D., & Rosenthal, R. A. (1964). Organizational stress: Studies in role conflict and ambiguity. New York: John Wiley and Sons. Kane, R. A. (1988). Assessing quality in nursing homes. Clinics in Geriatric Medicine, 4, 655-666. Kane, R. A. (1989). Toward competent, caring, paid caregivers. The Gerontologist, 29, 291-292. Kane, R. L, & Kane, R. A. (1991). A nursing home in your future? New England Journal of Medicine, 324(9), 627-628.

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Kapp, M. B. (1990). Legal risk-management programs in nursing homes: Who has them and do they work? Hospital and Health Services Administration, 35, 603-610. Kemper, P., & Murtaugh, C. M. (1991). Lifetime use of nursing home care. New England Journal of Medicine, 324(9), 595-601. Kerr, J. L., & Slocum, J. W., Jr. (1987). Managing corporate cultures through reward systems. Academy of Management Executive, 2, 99-108. Kopelman, R. E., Brief, A. P., & Cuzzo, R. A. (1990). The role of climate and culture in productivity. In B. Schneider (Ed.), Organizational climate and culture. San Francisco: Jossey Bass. Kruse, L. C , & Stogdill, R. M. (1973). The leadership role of the nurse. Columbus: Ohio State University Research Foundation. Kurowski, B., & Shaughnessy, P. (1985). The measurement and assurance of quality. In R. Vogel & H. Palmer (Eds.), Long-term care: Perspectives from research and demonstrations. Rockville, MD: Aspen Systems Corporation. Laffel, G., & Blumenthal, D. (1989). The case for using industrial quality management science in health care organization. Journal of the American Medical Association, 262(20), 2869-2873. Manard, B. B., Kart, C. S., & Van Gils, P. W. L. (1975). Old age institutions. New York: D. C. Heath and Co. McCaffree, L. M., & Harkins, E. B. (1976). Final report for evaluation of the outcomes of nursing home care (NCHSR 77-118). Health Resources Administration, Division of Long-Term Care. Washington, DC: U.S. Government Printing Office. McLaughlin, C. P., & Kaluzny, A. D. (1990). Total quality management in health: Making it work. Health Care Management Review, 15, 7-14. Milakovich, M. D. (1991). Creating a total quality health care environment. Health Care Management Review, 16(2), 9-20. National Center for Health Statistics. (1989). The 1985 National Nursing Home Study (DHHS PHS 89-1758). Washington, DC: U.S. Government Printing Office. National Institute of Standards and Technology. (1990). Application guidelines for Malcolm Baldridge National Quality Award. Gaithersburg, MD: U.S. Department of Commerce. National Institute on Aging, Committee on Personnel for Health Needs of the Elderly. (1987). Personnel for health needs of the elderly through the year2020. Bethesda, MD: Administrative Document. O'Leary, D. (1991). Accreditation in the quality improvement mold — A vision for tomorrow. Quality Review Bulletin, 17(3), 72-77. Peters, T. J., & Waterman, R. H. (1982). In search of excellence. New York: Harper & Row. Pillemer, K., & Moore, D. (1989). Abuse of patients in nursing homes: Findings from a survey of staff. The Gerontologist, 29, 314-320. Porter, L. W., & Steers, R. M. (1973). Organizational, work, and personal factors in employee turnover and absenteeism. Psychological Bulletin, 80,151-176. Poole, M. S. (1985). Organizational climates. In R. D. McPhee & R. K. Tompkins (Eds.), Organizational communications: Traditional themes and new directions. Beverly Hills, CA: Sage. Pritchard, R. D., & Karasick, B. W. (1973). The effect of organizational climate on managerial job performance and satisfaction. Organizational Behavior and Human Performance, 9, 126-146. Reichers, A. E., & Schneider, B. (1990). Climate and culture: An evolution of constructs. In B. Schneider (Ed.), Organizational climate and culture. San Francisco: Jossey Bass. Roundtree, B. H., & Deckard, G. J. (1986). Nursing in long-term care: Dispelling a myth. Journal of Long-Term Care Administration, 14,15-19. Sahney, V. K., Warden, G. L., James, B. C , Berwick, D. M., & Wolford, C. R. (1991). The process of total quality management in health care. Frontiers of Health Services Management, 7(4), 2-56. Sheridan, J. E., Hogstel, M., & Fairchild, T. J. (1990). Organization climate in nursing homes: Its impact on nursing leadership and patient care. In L. R. Jauch & J. L. Wall (Eds.), Best papers proceedings 1990 (pp. 90-94). San Francisco: Academy of Management. Sheridan, J. E., Vredenburgh, D. J., & Abelson, M. A. (1984). Contextual model of leadership influence in hospital units. Academy of Management Journal, 27, 57-58. Stevens, J. (1986). Applied multivariate statistics for the social sciences. Hillsdale, NJ: Lawrence Erlbaum. Storlie, F. J. (1982). The reshaping of the old. Journal of Gerontological Nursing, 8, 555-559. Tellis-Nayak, V., & Tellis-Nayak, M. (1989). Quality of care and the burden of two cultures: When the world of the nurse's aide enters the world of the nursing home. The Gerontologist, 29, 307-313. Wagnild, G. (1986). Personal-care complaints: A descriptive study. Journal of Long-Term Care Administration, 14, 27-29. Wright, L. K. (1988). A reconceptualization of the "negative staff and poor care in nursing homes" assumption. The Gerontologist, 28, 813-820.

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Ineffective staff, ineffective supervision, or ineffective administration? Why some nursing homes fail to provide adequate care.

This study involved 530 nursing staff working in 25 for-profit and nonprofit nursing homes, two of which failed to meet resident care standards requir...
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