International Journal of Nursing Studies 52 (2015) 334344

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Leadership education, certication and resident outcomes in

US nursing homes: Cross-sectional secondary data analysis
Alison M. Trinkoff a,*, Nancy B. Lerner a, Carla L. Storr a, Kihye Han b,
Mary E. Johantgen a, Kyungsook Gartrell a
a
b

School of Nursing, University of Maryland, Baltimore, MD, USA

Red Cross College of Nursing, Chung-Ang University, Seoul, South Korea

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 3 May 2014
Received in revised form 16 September 2014
Accepted 3 October 2014

Background: Leadership is a key consideration in improving nursing home care quality.

Previous research found nursing homes with more credentialed leaders had lower rates of
care deciencies than nursing homes with less credentialed leaders. Evidence that nursing
home administrator (NHA) and director of nursing (DON) education and certication is
related to resident outcomes is limited.
Objectives: To examine associations of education and certication among NHAs and DONs
with resident outcomes.
Design: Cross-sectional secondary data analysis.
Settings: This study used National Nursing Home Survey data on leadership education and
certication and Nursing Home Compare quality outcomes (e.g. pain, catheter use).
Participants: 1142 nursing homes in the survey which represented 16628 nursing homes
in the US.
Methods: Leadership education and certication were assessed separately for NHAs and
DONs. Nursing home resident outcomes were measured using facility-level nursing home
quality indicator rates selected from the Minimum Data Set. Facility-level quality
indicators were regressed onto leadership variables in models that also held constant
facility size and ownership status.
Results: Nursing homes led by NHAs with both Masters degrees or higher and certication
had signicantly better outcomes for pain. Nursing homes led by DONs with Bachelors
degrees or higher plus certication also had signicantly lower pain and catheter use.
Whereas pressure ulcer rates were higher in facilities led by DONs with more education.
Conclusions: Selected outcomes for nursing home residents might be improved by
increasing the education and certication requirements for NHAs and DONs. Additional
research is needed to clarify these relationships.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Certication
Director of nursing
Education
Leadership
Nursing home
Nursing home administrator

Funded by the National Council of State Boards of Nursing Grant R60006 (A. Trinkoff, PI).
* Corresponding author. Tel.: +1 410 706 6549; fax: +1 410 706 0421.
E-mail address: trinkoff@son.umaryland.edu (A.M. Trinkoff).

http://dx.doi.org/10.1016/j.ijnurstu.2014.10.002
0020-7489/ 2014 Elsevier Ltd. All rights reserved.

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

What is already known about the topic:

 Nursing home leaders (e.g., Nursing home administrators and directors of nursing) have the ability to inuence
policy and procedures in their facilities, with the goal of
improving care.
 Nursing home quality indicators have been linked to
leadership style and length of time in the position for
both NHAs and DONs.
What the paper adds:
 Nursing homes led by NHAs and DONs with increased
leadership credentials had signicantly better resident
outcomes for pain, as measured by nursing home quality
indicators.
 Nursing home leaders should be encouraged to expand
their credentials via continuing education and certication efforts, though further study is needed to clarify
these relationships.
1. Introduction
Leadership has been identied as a key consideration in
improving nursing home (NH) quality of care (Siegel et al.,
2010). The Center for Medicare and Medicaid Services
(CMS) identied governance and leadership as a major
element of Quality Assurance/Performance Improvement
(CMS, 2012). Nursing home leaders, i.e., nursing home
administrators (NHAs) and directors of nursing (DONs)
have a responsibility to promote and sustain high-quality,
cost-effective nursing home care (Seigel et al., 2010). DONs
are responsible for the nursing department and all clinical
nursing care provided in the facility including care delivery
and best practices, clinical data collection, appropriate
stafng and hiring. The NHA is responsible for the
administration of all departments and oversight of the
facility to maximize resident quality of life and quality of
care, including costs and budgeting, supervision and
management of staff, facility and physical plant, and
compliance with regulations (US Department of Health
and Human Services, 2009; LTCPLC, 2007).
Both generate policies that implement regulations and
requirements to ensure that residents are provided with
proper care. Yet, often among these leaders there is a lack
of specic education focused on clinical leadership and
health team management (Dwyer, 2011). In the US,
educational qualications vary and are largely predicated
on our system of reimbursement and payment for long
term care. To qualify for reimbursement of care provided,
NHAs must have a Bachelors degree, pass an NHA exam
and have a precepted experience, and DONs must be
registered nurses (RNs) (CMS, 2008). Taking additional
classes through formal education (e.g., Bachelors or
Masters degree programs for DONs and NHAs, respectively) and/or obtaining specialty certications through
targeted coursework and examinations, can allow administrators to be exposed to a wider array of strategies and
resources. Resident outcomes can be inuenced by
organizational components such as the education and
credentials of those managing the facility. The diversity of

335

qualications for nursing home leadership across facilities

provides an opportunity to assess the impact of leadership
credentials, i.e., education and certication, on resident
outcomes.
Nursing home leadership has been linked with care
deciencies that occur when facilities fail to meet certain
federal regulatory care standards, as judged by state
inspection teams (CMS, 2013). Nursing homes with more
highly credentialed directors and leaders (certied by or
belonging to long term care professional associations) had
lower rates of deciencies compared to those with less
credentialed leaders (Castle and Fogel, 2002; Rowland
et al., 2009). Nursing home quality indicators (QIs) have
also been linked to leadership style and length of time in
the position for both NHAs and DONs (Decker and Castle,
2011; Krause, 2012). However, the evidence that educational preparation and certication of NHAs and DONs is
related to quality outcomes is limited. In this study we
explore whether increased leadership credentials (e.g.,
education and certication) for NHAs and DONs are
associated with better NH quality outcomes as measured
by lower QI rates. We also examine the impact of specic
certications on resident outcomes.
Our conceptual framework was based on the Systems
Engineering Initiative for Patient Safety model (Carayon
et al., 2006). This draws from Donabedians structure
process-outcome model (Donabedian, 1972) by emphasizing how work system design (e.g., leadership: education and
certications) are linked to resident outcomes through
greater knowledge and awareness of optimal care processes.
Leaders can use this knowledge to improve care in their
facilities, resulting in better resident outcomes, (e.g., lower
rates of pressure ulcers or pain). For example, geriatric
nursing specialty certication could help leaders to identify
best practices for pain assessment for elderly populations.
Management training, as is presented in Bachelors or
Masters degree programs, could help leaders develop the
ability to articulate a vision of quality care to nursing staff. A
DON or NHA with additional leadership training also might
be better able to motivate others and to serve as a change
agent for best practices (e.g., avoiding catheter use) that will
translate into improved care (Anderson et al., 2003). If
leadership education and certications are related to
improved care, ndings also could support recommendations to improve leadership preparation.
2. Methods
2.1. Design and data sources
This secondary analysis merged data from two national
administrative databases. The 2004 National Nursing
Home Survey (NNHS) was the source for leadership data
and information on facility characteristics (NCHS, 2009).
The NNHS used a complex sampling strategy (e.g., multistage, stratied sampling) to select 1500 nursing homes
representative of the 16,628 nursing homes in the U.S.
(Squillace et al., 2007). Administrators at 1174 of the
selected nursing homes completed computer assisted faceto-face interviews (response rate = 81%) (NCHS, 2009;
Squillace et al., 2007). For this study, data were linked at

336

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

the facility level to nursing home resident QI data. QIs were

derived from the Resident Assessment Instrument (RAI) of
the Minimum Data Set (MDS) and were obtained from CMS
Nursing Home Compare (Abt Associates Inc., 2004). We
used nursing home QIs from the fourth quarter of 2004
(OctoberDecember 2004) to map onto a similar time
frame as the NNHS. This study focused on the 1142 nursing
homes with usable QI data (32 NHs that lacked QI data
were excluded). Study approval was obtained from the
National Center for Health Statistics-Research Data Center
(NCHS-RDC) and the University of Maryland Institutional
Review Board.
2.2. Measures
2.2.1. Leadership variables
Education and certication were examined separately
for NHAs and DONs. Education was dened as the highest
degree completed using three categories: Masters degree
or higher, Bachelors degree, and Associates degree or less.
For certications, a dichotomous summary variable (any
certication) was created where a yes response represented those with at least one certication. In addition, the
specic type of certication was also evaluated and the
focus of each certication is described in Table 1. For NHAs
these were: (1) Certied Nursing home administrators
(CNHA) from the American College of Health Care
Administrators and (2) American Nurses Credentialing
Center (ANCC-unspecied) certication (specialty was
unspecied). For DONs the following certications were
included: (1) National Association of Directors of Nursing
Administration in Long Term Care (NADONA), (2) ANCCgerontological, (3) American Association of Nurse Assessment Coordination (AANAC), (4) other ANCC non-gerontological (ANCC-other), (5) Certied Rehabilitation
Registered Nurse (CRRN), (6) Association for Professionals

in Infection Control and Epidemiology (APIC), and (7)

Other: i.e., certications not listed above. Some DON
certications have a specic targeted area of knowledge
that can include care practices, (e.g., ANCC-gerontological,
APIC) while others focus more on leadership, long term
care regulations and MDS quality inspections and requirements (AANAC).
2.2.2. Nursing home resident outcomes
Outcomes were measured using facility-level nursing
home QI rates selected from MDS version 2.0. (Abt
Associates Inc., 2004). This study focuses on ve nursing
home QIs, selected because they have been related to
nursing home characteristics in previous studies, providing some evidence that these indicators are sensitive to
facility-level attributes (Bostick et al., 2006; Collier and
Harrington, 2008; Horn et al., 2010). QIs were expressed as
percentages (i.e., the number of cases per 100 residents)
with higher values indicating a larger proportion of
residents experiencing such adverse outcomes (Zimmerman et al., 1995). While QIs are not risk-adjusted overall,
some are divided into low- and high-risk to account for
differences in frailty across nursing home populations
(CMS, 2012). QIs assessed included high-risk pressure
ulcersdened as the proportion of residents with stage I
IV pressure ulcers who were impaired in bed mobility or
transfer, comatose, or suffering malnutrition. The next QI
was low-risk pressure ulcers, which was the designation
for all residents that are not high-risk. Pain was dened as
the proportion of long-stay residents who in the last 7 days
reported either almost constant or frequent moderate to
severe pain, or any very severe/horrible pain. Catheter use
measured the proportion of residents with indwelling
urinary catheters, and urinary tract infection (UTI)
measured the proportion of residents with a UTI in the
last 7 days.

Table 1
Topical focus of NHA and DON certications.
Type of certication

Focus of the certication

Nursing home administrator

CNHA
Certied nursing home administrators from the
American College of Health Care Administrators
ANCC

Director of Nursing
NADONA

American Nurses Credentialing Center

National Association of Directors of Nursing

Administration in Long Term Care

ANCC-Gero

American Nurses Credentialing

Center-Gerontological

AANAC

American Association of Nurse Assessment

Coordination
Association for Professionals in Infection Control
and Epidemiology
Association of Rehabilitation Nurses

APIC
CRRN

Resident care services including nursing care, health information

management, human resources, nance, leadership including
strategic planning, goal setting, accountability and managing change
Certication for nurses available in numerous specialty practice
areas representing expertise in the clinical area of certication

Leadership, communication, resident care, MDS assessment,

standards of care, wounds, ADL, risk management, quality
control, nance, employee management
Assessment, plans of care, health promotion, professional
practice and person-centered care for gerontological
populations
Management and leadership training including quality care
initiatives and MDS data collection programs
Focused on best practices in infection prevention and control,
and improved patient care
Rehab nursing models, functional health patterns and assessment,
standards of care, interventions, economic and ethical issues

Sources: AANAC: http://www.aanac.org/certication-education; ANCC: http://www.nursecredentialing.org/; http://www.nursecredentialing.org/GeroNurseTCO2015; APIC: http://www.apic.org/Education-and-Events/Certication; CNHA: http://www.achca.org/content/pdf/CerticationHandbook__130926_
temp.pdf; CRRN: http://www.rehabnurse.org/certication/content/CRRN-Renewal.html; NADONA: https://www.nadona.org/cart/products.php?cat=21.

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

2.2.3. Control variables

Contextual factors found to be associated with patient
outcomes were also examined: (1) NH size based on the
number of beds (<50; 5099; 100199 vs. 200+ beds) and
(2) ownership status (for prot vs. not for-prot). Both
have been related to resident outcomes and could affect
the relationship among leadership education, certications
and outcomes.
2.3. Data analysis
After an extensive review of our analysis plans, NCHSRDC merged the datasets using the facility identiers and
provided us with remote access to the data for analysis
(RDC, 2012). Analyses conducted using NNHS data
incorporate weights and survey analytic procedures that
account for the complex sampling design. In order to
produce national estimates, advanced survey analytic
procedures within SAS-callable SUDAAN (version 10.0.1)
were used.
Analysis began by reviewing the quality and consistency of the data. Before generating models, we examined
descriptive data for the study variables including bivariate
relationships between education and certications using
Chi-square tests. Facility-level QIs were regressed onto the
leadership variables and followed up with models that also
held constant facility size and prot status. Next we
created a combination variable of leadership education
and any certication to explore possible effects of both in
relation to nursing home QIs. Models were tested using
SAS Proc Genmod for generalized linear models with
Generalized Estimating Equations (GEE) along with a
negative binomial log link for over-dispersion of the count
type dependent variables (DeMaris, 2004). For all models
we used an independent correlation structure (no differences were found versus an exchangeable structure) and
checked that model assumptions were met.
Because the dependent variables reect the percentage
of adverse resident outcomes, regression model estimates
in support of our hypotheses should show a negative
coefcient [b]. For example, a negative coefcient for
education indicates that the prevalence of the adverse
outcome decreases with an increase in education. The
exponentiated coefcient exp(b) represents the percentage change in nursing home QIs that indicates an
independent variable is associated with the outcome
variable relative to a reference category, using the
formula{[exp(b) 1]  100} (Decker and Castle, 2011;
DeMaris, 2004).
3. Results

337

Table 2
Leadership and nursing home (NH) characteristics.
%**
Education (highest degree)
Nursing home administrator (NHA)a
Masters or higher
Bachelors
Associates degree or less
Director of nursing (DON)b
Masters or higher
Bachelors
Associates degree or less
Type of certication
NHAc
Any certication*
Yes
No
CNHA
Yes
No
ANCC-unspecied
Yes
No
DONd
Any certication*
Yes
No
NADONA
Yes
No
ANCC-gerontological
Yes
No
AANAC, ANCC-other, CRRN, or APIC
Yes
No
Other (not listed above)
Yes
No
NH Contextual variables
NH size: number of beds
<50
5099
100199
200+
Ownership
For-prot
Not for-prot

32.2
50.4
17.4
7.4
35.6
57.0

27.8
72.2
25.4
74.6
3.0
97.0

42.5
57.5
14.5
85.5
10.0
90.0
10.4
89.6
16.7
83.3

14.0
37.7
42.0
6.3
61.6
38.4

* Any certicationhave one or more NHA or DON certications

among those listed.
** Complex sampling design taken into account to obtain national
estimates.
Missing, n (%): a 64(5.5%), b 77(6.6%), c 26(2.2%), d 98(8.3%).
CNHA = certied nursing home administratorAmerican College of
Health Care Administrators. ANCC = American Nurses Credentialing
Center. NADONA = National Association of Directors of Nursing Administration in Long term Care. AANAC = American Association of Nurse
Assessment Coordination. ANCC-other = other non-gerontological ANCC
certications. CRRN = certied rehabilitation registered nurse. APIC = Association for Professionals in Infection Control and Epidemiology.

3.1. Nursing home characteristics

According to these nationally representative data, 32%
of NHAs had a Masters degree or higher and 43% of DONs
had Bachelors degrees or higher (Table 2). Just over a
quarter of NHAs (28%) had at least one of the examined
certications; proportion of NHAs certied by CNHA and
ANCC-unspecied were 25% and 3%, respectively. Whereas among DONs, nearly half (43%), had at least one

certication, with NADONA (15%) and ANCC-gerontological (10%) most common. Ten percent of DONs had one of
these certications: AANAC, ANCC-other, CRRN or APIC,
and 17% of DONs had other certications not listed above.
As seen in Table 3, the proportion of NHAs with any
certication did not differ by highest degree earned:
among those with Masters degrees or higher, 29% were
also certied, compared to 25% with an Bachelors degree

338

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

Table 3
Proportion of certied nursing home administrators (NHA) & directors of nursing (DON) by educational preparation.
Type of Certication

Education (highest degree)

Masters or higher

Bachelors

Associates or less

p-value

NHA
Any certication* (yes)
CNHA (yes)
ANCC-unspecied (yes)

29.3
25.5
4.6

25.1
23.9
1.6

30.8
28.1
4.0

0.505
0.853
0.026

DON
Any certication* (yes)
NADONA (yes)
ANCC-gerontological (yes)
AANAC, ANCC-other, CRRN, or APIC (yes)
Other (not listed above) (yes)

57.9
19.8
6.9
20.4
23.2

46.2
16.8
8.9
11.7
20.6

37.4
12.7
10.9
8.1
12.7

<0.001
0.126
0.348
0.017
0.003

* Any certicationhave one or more NHA or DON certications among those listed.
CNHA = certied nursing home administratorAmerican College of Health Care Administrators; ANCC = American Nurses Credentialing Center;
NADONA = National Association of Directors of Nursing Administration in Long term Care; AANAC = American Association of Nurse Assessment
Coordination; ANCC-other = other non-gerontological ANCC certications; CRRN = certied rehabilitation registered nurse; APIC = Association for
Professionals in Infection Control and Epidemiology.

and 31% with a Associates degree. For ANCC-unspecied,

5% of NHAs with a Masters or higher, 4% of NHAs with an
Associates or less, and only 2% of NHAs with a Bachelors
degree had this certication (p = 0.026). For DONs with a
Masters degree, 58% also had any certication vs. 46%
among Bachelors and 37% of Associates degree holders
(p < 0.001); there were no differences in NADONA or
ANCC-gerontological certication by education. Among
DONs with Masters degrees, 20% were certied by AANAC,
ANCC-other, CRRN, or APIC compared to only 12% with a
Bachelors and 8% with an Associates degree (p = 0.017).
Among DONs with a Masters or Bachelors, 23% and 21%,
respectively had other certications vs. only 13% among
DONs with an Associates degree (p = 0.003).
Most nursing home QIs were relatively uncommon, as
they represent adverse outcomes of care. The weighted
means for the QIs ranged from a low of 3 per 100 for lowrisk pressure ulcers to 13 per 100 for high-risk pressure
ulcers, with pain (6 per 100), catheter use (6 per 100) and
UTIs (9 per 100) falling in between.
3.2. Nursing home administrator credentials and resident
outcomes
We rst created unadjusted models for the relation of
NHA credentials to outcomes (see Appendix) and then
generated models that adjusted for possible confounding
factors. As seen in Table 4, NHA education of a Masters
degree or higher was signicantly associated with lower
rates of pain, catheter use and UTI, after adjustment for
nursing home size (i.e., number of beds) and ownership
status. Nursing homes led by such NHAs had an
estimated 10.8% decrease in pain (p = 0.003), a 10.1%
decrease in catheter use (p = 0.018), and a 5.2% decrease
in UTIs (p = 0.003), compared to nursing homes led by
those with less than a Masters degree. A signicant
reduction in pain (p = 0.018) and catheter use (p = 0.005),
representing an 18.7% decrease in pain prevalence and a
9.3% decrease in catheter use was found in nursing homes
led by NHAs with any certication compared to those
without certications.

The combination of education and certication for

NHAs conferred additional benets in terms of reduced
adverse outcomes. Nursing homes led by NHAs with a
Masters degree or higher and any certication (CNHA or
ANCC-unspecied) had signicant reductions in pain
prevalence (p = 0.015), representing a 21.4% decrease in
pain prevalence after adjustment for nursing home size
and ownership (Table 4). An exploration of specic
certications (Table 5), indicated that nursing homes led
by CNHA-certied NHAs showed a 17.1% decrease in pain
(p = 0.028) and a 10.3% decrease in catheter use (p = 0.002).
For NHAs with ANCC-unspecied certication, there was a
16.4% decrease in low-risk pressure ulcers (p = 0.035).
3.3. Director of nursing credentials and resident outcomes
We examined DON education using two denitions: (1)
Masters degree or higher vs. Bachelors or less and (2)
Bachelors degree or higher vs. Associates or less. Due to
the smaller proportion of DONs with Masters degrees, we
chose to present results for DON education using the
second denition. Nursing homes led by DONs with
Bachelors degrees or higher had decreased pain rates
(p = 0.020) compared to those led by DONs with Associates
degrees or less (See Appendix: Table A1). After adjustment
for nursing home size and prot status, these ndings were
no longer signicant (Table 4).
For DONs, having any certication was signicantly
associated with reductions in high-risk pressure ulcers
(p = 0.001) and catheter use (p < 0.001) (Table 4). That is,
nursing homes led by certied DONs had an estimated 7.4%
decrease in high-risk pressure ulcers and a 16.7% decrease
in catheter use compared to nursing homes led by DONs
without certication. Furthermore, decreases in adverse
outcomes were seen in nursing homes led by DONs who
had both Bachelors or higher and a certication: a 12.9%
decrease in pain (p = 0.046) and a 9.2% decrease in catheter
use (p = 0.008) compared to nursing homes with DONs
without both credentials. On the other hand, relationships
for pressure ulcers among DONs were signicant in the
opposite direction, indicating that high and low-risk

Table 4
Adjusteda estimates of the relationship between leadership education/certication and nursing home (NH) resident outcomes.
NH resident outcomes:
continuous

High risk pressure ulcer

b*

Low risk pressure ulcer

% Change p Value b*

Pain (moderate-severe)

% Change p Value b*

Catheter use

% Change p Value b*

Urinary tract infections

% Change p Value b*

% Change p Value

Nursing home administrator

Certication
Model 2

Higher education
(masters
vs. bachelors)

0.007

0.7

0.704

0.015

1.5

0.911

0.115

10.8

0.003

0.107

10.1

0.018

0.053

5.2

0.003

Any certicationb
(yes vs. no)

0.033

3.3

0.535

0.128

12.0

0.096

0.207

18.7

0.018

0.097

9.3

0.005

0.008

0.7

0.828

Both higher education

and any certicationb
(both vs. all othersc)

0.001

0.1

0.989

0.080

7.7

0.701

0.241

21.4

0.015

0.115

10.9

0.109

0.020

2.0

0.663

Higher education
(bachelors

0.088

9.2

<0.001

0.110

11.6

<0.001

0.027

2.7

0.218

0.012

1.2

0.739

0.029

2.9

0.608

Any certicationd
(yes vs. no)

0.077

7.4

0.001

0.116

12.3

0.242

0.041

4.0

0.619

0.182

16.7

<0.001

0.019

1.9

0.511

Both higher education

and any certicationd
(both vs. all otherse)

0.068

7.0

0.012

0.057

5.8

0.542

0.138

12.9

0.046

0.097

9.2

0.008

0.021

2.0

0.678

Education 
certication
Model 3

Director of
nursing (DON)
Education
Model 1

vs. associates)
Certication
Model 2
Education  certication
Model 3

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

(NHA)
Education
Model 1

Coefcient.
a
Adjusted for nursing home size and type of ownership.
b
One or more certication from CNHA or ANCC-unspecied.
c
Reference group = Masters  any certication (No),  Bachelors  any certication (yes or no).
d
One or more certication among NADONA, ANCC-gerontological, AANAC, ANCC-other, CRRN, APIC, or other not listed.
e
Reference group = Bachelors  any certication (no), Associates  any certication (yes or no).

339

* Coefcient.
a
adjusted for nursing home size and type of ownership.
CNHA = Certied Nursing home administratorAmerican College of Health Care Administrators; ANCC = American Nurses Credentialing Center; NADONA = National Association of Directors of Nursing
Administration in Long term Care; AANAC = American Association of Nurse Assessment Coordination; ANCC-other = other non-gerontological ANCC certications; CRRN = Certied Rehabilitation Registered Nurse;
APIC = Association for Professionals in Infection Control and Epidemiology.

0.156
5.9
0.061
11.0
0.8
2.9
0.030

0.381

0.008

0.951

0.008

0.8

0.948

0.117

0.028

0.685
1.3
0.013
14.5
40.3
4.9
0.048

0.380

0.339

<0.001

0.095

9.9

0.202

0.157

0.006

0.351
0.286
3.4
4.7
0.034
0.045
15.0
6.1
7.4
13.4

Director of nursing (DON)

Model 1
NADONA (yes vs. no)
Model 2
ANCC-gerontological
(yes vs. no)
Model 3
AANAC, ANCC-other,
CRRN, or APIC (yes vs. no)
Model 4
Other (not listed above)
(yes vs. no)

0.077
0.144

0.020
<0.001

0.008
0.271

0.8
31.2

0.932
0.010

0.004
0.084

0.4
8.0

0.965
0.418

0.163
0.063

0.015
0.147

0.841

0.497
5.6

0.7
0.007

0.057
0.472
8.5
0.081

0.002
10.3
0.109

0.101

0.028
17.1

20.1
0.224

0.188
0.164

0.035
16.4

10.7
0.114

0.179
0.821

0.636
3.0

2.7
0.027

0.030
CNHA (yes vs. no)

ANCC-unspecied
(yes vs. no)
Model 2

Nursing home
administrator (NHA)
Model 1

% Change p Value b

Catheter use

% Change p Value b*

Pain (moderate-severe)

% Change p Value b*

Low risk pressure ulcer

% Change p Value b*

b*

High risk pressure ulcer

NH resident outcomes: continuous

Table 5
Adjusteda estimates of specic certications in relation to nursing home (NH) resident outcomes.

% Change p Value

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

Urinary tract infections

340

pressure ulcers were related to facilities led by DONs that

had additional education (p < 0.001)
For specic types of certication, nursing homes with
NADONA certied DONs had a 7.4% decrease in high-risk
pressure ulcers (p = 0.020) and a 15.0% decrease in catheter
use (p = 0.015) (Table 5). Nursing homes with DONs
certied by ANCC-gerontological nursing had 13.4% lower
prevalence of high-risk pressure ulcers (p < 0.001). Nursing homes led by DONs with certications from AANAC,
ANCC-other, CRRN, or APIC had a 14.5% decrease in
catheter use (p = 0.006) and those with other certications
not listed above had an 11.0% decrease in catheter use
(p = 0.028). In contrast, for low-risk pressure ulcers,
facilities led by DONs with AANC-gerontological and other
certications were signicantly more likely to have higher
rates of low-risk pressure ulcers (p = 0.010 and p < 0.001,
respectively).
4. Discussion
Our study provides important ndings relating leadership education and certication to nursing home resident
outcomes. Nursing homes led by NHAs with both
certication (CNHA and/or ANCC-unspecied) and a
Masters degree or higher had better resident outcomes
for pain. Education alone also was important among NHAs
in relation to decreased adverse outcomes. For NHAs with
ANCC certication, better resident outcomes for low-risk
pressure ulcers were noted. Because ANCC certication is
only available to RNs (ANCC, 2013) this shows that in the
NNHS sample, at least 3% of NHAs also were RNs. Although
U.S. data on the proportion of NHAs who are also RNs is not
readily available, Siegel et al. (2014) found 17% of NHAs in
their study of 5 U.S. states also were RNs.
Nursing homes led by DONs with certication and at
least a Bachelors degree had lower rates of pain and
catheter use. Among specic certications NADONA and
ANCC-gerontological were both related to reduced highrisk pressure ulcers; most certications were also related
to lower catheter use. In general, DONs with higher
education were also more likely to be certied, though
education alone did not show a decrease in adverse
outcomes after adjustment for nursing home size and
ownership status.
Consideration of the results also suggests that work
experience could be another important factor in this
relationship. We examined facility leadership tenure and
found increased tenure was signicantly related to lower
odds of having higher rates of nursing home deciencies
(Lerner et al., 2014) though it was unrelated to the nursing
home QIs. Future studies may want to examine whether
nursing homes led by NHAs and DONs who both have more
education and/or certications would lead to a synergistic
relationship to improve care outcomes.
The association of higher rates of high-risk pressure
ulcers in facilities led by DONs with more education was in
the opposite direction from what was hypothesized, as was
the association of more low-risk pressure ulcers with
ANCC-gerontological certication. We suggest that increased knowledge may be related to an increased ability
to detect such ulcers, especially among the low-risk

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

pressure ulcer populations, creating a form of detection

bias reected in higher rates. Additional research is needed
to more clearly delineate what aspects of education and
certication are important for which aspects of care
quality.
While evidence that resident outcomes are related to
educational preparation and certication of nursing home
leadership is limited, the literature suggests that additional
education confers knowledge that can lead to improved
care in other settings. For example, in hospital settings
lower patient mortality was found to be associated with a
higher proportion of Bachelors prepared nurses (Aiken
et al., 2003; Van den Heede et al., 2009). Decreased fall
event rates were associated with certication (KendallGallagher and Blegen, 2009), and having higher education
(Bachelors degree) and certication also was associated
with improved patient outcomes, such as lower mortality
and failure to rescue rates (Kendall-Gallagher et al., 2011).
Nonetheless, ndings regarding educational preparation in
direct care may not be generalizable those in leadership
positions.
Although increased education for DONs has been
recommended since the 1990s (Siegel et al., 2010;
Wunderlich et al., 1996) the relatively high proportion
of DONs with only an Associates degree continues. ANCC
stipulates a Bachelor of Science in Nursing (BSN) as
preparation for DONs in its Pathway to Excellence
application, though they allow participation if the DON
submits an action plan and timeline for BSN completion
(ANCC, 2013).
Though there is debate regarding nursing education for
entry into practice, less attention has been paid to
knowledge and skills needed for management and
administrative positions in nursing homes (Siegel et al.,
2010). Currently, for DONs the most important credential
for reducing adverse resident outcomes appears to be the
specialty certications. In addition to certication, DONs in
NHs can participate in a variety of independent, regional,
and national professional development opportunities
(Siegel et al., 2010). Providing on-line professional
development opportunities may be benecial for leaders
considering limited organizational resources (e.g., time
and money).
Krause (Krause, 2012) suggested additional research
with an expanded number of quality outcome measures to
inform policy and support intervention research, in order
to better understand the inuence of leadership on care
quality. Efforts to improve quality in nursing homes are
underway through the culture change movement (White
et al., 2012) and increased regulatory attention to Quality
Assurance and Quality Improvement (CMS, 2012). Despite
emerging consensus on the importance of leadership in
improved nursing home care, the resources available to

341

improve leadership are inconsistently utilized (Siegel et al.,

2010).
While a strength of the study is that it analyzed linked
data from two national surveys in the same time frame,
due to the cross-sectional design we cannot draw causal
conclusions. In addition, characteristics of nursing home
facilities and their leaders examined in this study were
from 2004 and may not reect the latest nursing home
parameters. Data were collected via two self-reporting
mechanisms for different purposes and may reect
potential errors related to coding, measurement, and
missing data (Collier and Harrington, 2008; Castle, 2006).
Furthermore, the 3 month time period for resident
outcomes data may be less stable compared to those from
longer time periods, and rates can vary seasonally (Barry et
al., 2008). The analysis did not adjust for case mix as MDS
developers account for this with the risk stratication
approach, and our concern was that such adjustment could
overcorrect for differences when nursing homes are held to
the same quality standards. Nonetheless, if nursing homes
with higher case mix are more likely to have leadership
with higher credentials, case mix could be a potentially
confounding variable.
Our study suggests that investment in education and
specialty certication for NHAs and DONs in nursing
homes might have the potential to improve the quality of
resident care. Providing in-service and professional development education leading to certication for NHAs and
DONs could thus have a positive impact on resident
outcomes. Suggestions by others to improve leadership
have also included increasing educational preparation for
NHAs and DONs (Siegel et al, 2010; Castle and Engberg,
2006; Resnick et al., 2009).
Conict of interest
None declared.
Funding
This study was funded by the National Council of State
Boards of Nursing (Grants R40009 and R60006).
Ethical approval
The Institutional Review Board of the University of
Maryland, Baltimore reviewed and approved this study
(IRB protocol number: HP-00049284).
Appendix A. Appendix
Tables A1 and A2.

342

Table A1
Unadjusted estimates of the relationship between leadership education/certication and nursing home (NH) resident outcomes.
NH resident outcomes: continuous

Certication
Model 2
Education 
Certication
Model 3

Director of
nursing (DON)
Education
Model 1

Certication
Model 2
Education 
Certication
Model 3

Low risk pressure ulcer

Pain (moderate-severe)

Catheter use

b*

b*

b*

b*

% Change

p Value

% Change

p Value

% Change

Higher education
(Masters
vs. Bachelors)

0.003

0.3

0.860

0.010

0.9

0.950

0.130

12.3

0.010

0.115

Any certicationa
(yes vs. no)

0.024

2.3

0.623

0.124

11.7

0.121

0.207

18.7

0.018

0.097

Both higher education

and any certicationa
(both vs. all othersb)

0.010

0.9

0.907

0.743

7.2

0.728

0.252

22.3

0.009

0.121

Higher education
(bachelors vs.
associates)

0.100

10.4

<0.001

0.106

11.2

<0.001

0.058

5.7

0.020

Any certicationc
(yes vs. no)

0.071

6.9

0.012

0.123

13.1

0.240

0.058

5.6

Both higher education

and any certicationc
(both vs. all othersd)

0.087

9.1

0.031

0.062

6.4

0.535

0.180

16.5

* Coefcient.
One or more certication from CNHA or ANCC-unspecied.
Reference group = Masters  any certication (no), Bachelors  any certication (yes or no).
c
One or more certication among NADONA, ANCC-gerontological, AANAC, ANCC-other, CRRN, APIC, or other not listed.
d
Reference group = Bachelors  any certication (no), Associates  Any certication (yes or no).
a

p Value

Urinary tract infections

% Change

10.8

p Value

b*

% Change

p Value

0.004

0.053

5.1

0.002

0.005

0.011

1.1

0.760

11.4

0.717

0.014

1.4

0.770

0.017

1.7

0.654

0.041

4.1

0.510

0.512

0.184

16.8

<0.001

0.03

2.9

0.358

0.020

0.103

9.8

0.004

0.040

3.9

0.500

9.250

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

Nursing home
administrator
(NHA)
Education
Model 1

High risk pressure ulcer

* Coefcient.
CNHA = certied nursing home administratorAmerican College of Health Care Administrators; ANCC = American Nurses Credentialing Center; NADONA = National Association of Directors of Nursing
Administration in Long term Care; AANAC = American Association of Nurse Assessment Coordination; ANCC-other = other non-gerontological ANCC certications; CRRN = Certied Rehabilitation Registered Nurse;
APIC = Association for Professionals in Infection Control and Epidemiology.

0.052
7.0
0.072
0.029
11.1
0.118
1.2
2.4
0.024

0.554

0.009

0.9

0.947

0.013

0.916

0.760
0.9
0.009
0.003
14.7
0.159
0.252
8.7
0.083
<0.0001
41.9
0.350
4.9
0.048

0.381

0.394
0.397
3.3
4.0
0.032
0.039
0.012
0.131
14.9
6.8
0.161
0.070
0.880
0.238
1.6
10.8
0.016
0.114
0.992
0.008
0.1
32.9
0.001
0.285
0.043
0.001
6.3
13.8
0.065
0.149

Director of nursing (DON)

Model 1 NADONA (yes vs. no)
Model 2 ANCC-gerontological
(yes vs. no)
Model 3 AANAC, ANCC-other, CRRN,
or APIC (yes vs. no)
Model 4 Other (not listed above)
(yes vs. no)

0.804
0.430
0.9
6.7
0.009
0.069
0.002
0.493
10.3
8.0
0.108
0.077
0.022
0.067
17.3
23.1
0.190
0.263
0.178
0.053
10.7
14.6
0.113
0.158
0.717
0.965

p Value
% Change
p Value
% Change

2.1
0.6
0.022
0.006
Nursing home administrator (NHA)
Model 1 CNHA (yes vs. no)
Model 2 ANCC-unspecied
(yes vs. no)

b*
% Change

b*
p Value
% Change

b*

Pain (moderate-severe)

b*
b*

% Change

Low risk pressure ulcer

High risk pressure ulcer
NH resident outcomes: continuous

Table A2
Unadjusted estimates of specic certications in relation to nursing home (NH) resident outcomes.

p Value

Catheter use

p Value

Urinary tract infections

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

343

References
Abt Associates Inc., 2004. National Nursing Home Quality Measures:
Users Manual. Abt Associates Inc., Cambridge, MA. http://www.cms.
gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/
NursingHome-QualityInits/downloads/NHQIQMUsersManual.pdf
(Accessed September 26, 2013).
Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., Silber, J.H., 2003.
Educational levels of hospital nurses and surgical patient mortality.
J. Am. Med. Assoc. 290 (12), 16171623.
American Nurses Credentialing Center (ANCC), 2013. Pathway to Excellence in Long Term Care. American Nurses Credentialing Center
(ANCC) http://www.nursecredentialing.org/Pathway/PathwayPages/
PTE-LTC (Accessed September 26, 2013).
Anderson, R.A., Issel, L.M., McDaniel, R.R., 2003. DON or NHA with
additional leadership training. Nurs. Res. 52 (1), 1221.
Barry, T.T., Kemper, P., Brannon, S.D., 2008. Measuring worker turnover in
long-term care: lessons from the better jobs better care demonstration. Gerontologist 48 (3), 394400.
Bostick, J.E., Rantz, M.J., Flesner, M.K., Riggs, C.J., 2006. Systematic review
of studies of stafng and quality in nursing homes. J. Am. Med.
Directors Assoc. 7 (6), 366376.
Carayon, P., Schoofs Hundt, A., Karsh, B.T., et al., 2006. Work system
design for patient safety: the SEIPS model. Qual. Saf. Health Care 15
(Suppl 1), i50i58.
Castle, N.G., Engberg, J., 2006. Organizational characteristics associated
with staff turnover in nursing homes. Gerontologist 46 (1), 6273.
Castle, N.G., Fogel, B.S., 2002. Professional association membership by
nursing facility administrators and quality of care. Health Care
Manage. Rev. 27 (2), 717.
Castle, N.G., 2006. Measuring staff turnover in nursing homes. Gerontologist 46 (2), 210219.
Centers for Medicare and Medicaid Services (CMS), 2008. CMS Manual
System. Centers for Medicare and Medicaid Services (CMS). https://
www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/
downloads/R37SOMA.pdf (Accessed September 11, 2014).
Center for Medicare & Medicaid Services (CMS), 2012. MDS Quality
Measure/Indicator Report. Center for Medicare & Medicaid Services
(CMS) http://www.cms.gov/Research-Statistics-Data-and-Systems/
Computer-Data-and-Systems/MDSPubQIandResRep/qmreport.html
(Accessed September 15, 2014).
Center for Medicare & Medicaid Services (CMS), 2013. Medicare.gov:
Nursing Home Compare. Center for Medicare & Medicaid Services
(CMS)
https://data.medicare.gov/data/nursing-home-compare
(Accessed September 26, 2013).
Collier, E., Harrington, C., 2008. Stafng characteristics, turnover rates,
and quality of resident care in nursing facilities. Res. Gerontol. Nurs. 1
(3), 157170, http://dx.doi.org/10.3928/00220124-20091301-03.
Decker, F.H., Castle, N.G., 2011. Relationship of the job tenure of nursing
home top management to the prevalence of pressure ulcers, pain, and
physical restraint use. J. Appl. Gerontol. 30 (5), 539561, http://
dx.doi.org/10.1177/0733464810375801.
DeMaris, A., 2004. Regression with Social Data: Modeling Continuous and
Limited Response Variables. John Wiley, New York, NY.
Donabedian, A., 1972. Models for organizing the delivery of health
services and criteria for evaluating them. Milbank Meml. Fund Q.
50 (4), 103154, http://www.jstor.org/stable/3349436 (Accessed
September 26, 2013).
Dwyer, D., 2011. Experiences of registered nurses as managers and
leaders in residential aged care facilities: a systematic review. Int.
J. Evidence Based Healthc. 9 (4), 388402, http://dx.doi.org/10.1111/
j.1744-1609.2011.00239.x.
Horn, S.D., Sharkey, S.S., Hudak, S., Smout, R.J., Quinn, C.C., Yody, B., 2010.
Beyond CMS quality measure adjustments: identifying key resident
and nursing home facility factors associated with quality measures.
J. Am. Med. Directors Assoc. 11 (7), 500505, http://dx.doi.org/10.
1016/j.jamda.2009.10.008.
Kendall-Gallagher, D., Blegen, M.A., 2009. Competence and certication of
registered nurses and safety of patients in intensive care units. Am. J.
Crit. Care 18 (2), 106116, http://dx.doi.org/10.4037/ajcc2009487.
Kendall-Gallagher, D., Aiken, L.H., Sloane, D.M., Cimiotti, J.P., 2011. Nurse
specialty certication, inpatient mortality, and failure to rescue. J.
Nurs. Scholarship 43 (2), 188194, http://dx.doi.org/10.1111/j.15475069.2011.01391.x.
Krause, M.R., 2012. Director of nursing current job tenure and past experience and quality of care in nursing homes. Health Care Manage. Rev.
37 (1), 98108, http://dx.doi.org/10.1097/HMR.0b013e318222429a.
Lerner, N.B., Trinkoff, A., Storr, C.L., Johantgen, M., Han, K., Gartrell, K.,
2014. Nursing home leadership tenure and resident care outcomes.
J. Nurs. Regul. 5 (3), 4852.

344

A.M. Trinkoff et al. / International Journal of Nursing Studies 52 (2015) 334344

Long Term Care Professional Leadership Council, 2007. Essential core

functions: Responsibilities, Knowledge, Skill: A Guide for the Consultant Pharmacist, Director of Nursing, Medical Director, and Nursing
Home Administrator in Long Term Care Organizations. Long Term
Care Professional Leadership Council. http://nadona.org/pdfs/PR1LTCPLC-Final-Intro9-4-07.pdf (Accessed September, 11, 2014).
National Center for Health Statistics (NCHS), 2009. The National Nursing
Home Survey: 2004 overview. Vital Health Stat. 13 (167) , http://
www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf (Accessed September 26, 2013).
Research Data Center (RDC), 2012. Creating Your Analytic Data Set. Research Data Center (RDC) http://www.cdc.gov/rdc/B5AprovProj/
AP520.htm (updated March 15, 2012) (Accessed September 26, 2013).
Resnick, H.E., Manard, B., Stone, R.I., Castle, N.G., 2009. Tenure, certication, and education of nursing home administrators, medical directors, and directors of nursing in for-prot and not-for-prot nursing
homes: United States 2004. J. Am. Med. Director Assoc. 10 (6), 423
430, http://dx.doi.org/10.1016/j.jamda.2009.03.009.
Rowland, F.N., Cowles, M., Dickstein, C., Katz, P.R., 2009. Impact of medical
director certication on nursing home quality of care. J. Am. Med.
Directors Assoc. 10 (6), 431435, http://dx.doi.org/10.1016/j.jamda.
2009.05.012.
Siegel, E.O., Mueller, C., Anderson, K.L., Delleeld, M.E., 2010. The pivotal
role of the director of nursing in nursing homes. Nurs. Adm. Quart. 34
(2), 110121, http://dx.doi.org/10.1097/NAQ.0b013e3181d91813.

Siegel, E.O., Leo, M.C., Young, H.M., Castle, N.G., 2014. Nursing home
administrator self-assessed preparedness. Health Care Manage. Rev.
39 (3), 210222, http://dx.doi.org/10.1097/HMR.0b013e318294e5ce.
Squillace, M.R., Remsburg, R.E., Bercovitz, A., Rosenoff, E., Branden, L.,
2007. An introduction to the National Nursing Assistant Survey. Vital
Health Stat., 1 44, 154.
U.S. Department of Health and Human Services, 2009. Examining Competencies for the Long-Term Care Workforce: A Status Report and
Next Steps. U.S. Department of Health and Human Services http://
aspe.hhs.gov/daltcp/reports/2009/examcomp.htm (Accessed September, 15, 2014).
Van den Heede, K., Lesaffre, E., Diya, L., et al., 2009. The relationship
between inpatient cardiac surgery mortality and nurse numbers and
educational level: analysis of administrative data. Int. J. Nurs. Stud. 46
(6), 796803, http://dx.doi.org/10.1016/j.ijnurstu.2008.12.018.
White, H.K., Corazzini, K., Twersky, J., et al., 2012. Prioritizing culture
change in nursing homes: perspectives of residents, staff, and family
members. J. Am. Geriat. Soc. 60 (3), 525531, http://dx.doi.org/
10.1111/j.1532-5415.2011.03840.x, [Epub 2012 Feb 8].
Wunderlich, G.S., Sloan, F.A., Davis, C.K. (Eds.), 1996. Nursing Staff in
Hospitals and Nursing Homes: Is it Adequate? National Academy of
Sciences, United States.
Zimmerman, D.R., Karon, S.L., Arling, G., Clark, B.R., Collins, T., Ross, R.,
1995. Development and testing of nursing home quality indicators.
Health Care Financing Rev. 16 (4), 107127.