Strengthening Nurse Leadership in Long-term Care : A Case Study

The purpose of this case study is to share an innovative program developed for Registered Nurses (RNs) working in long-term care settings in the Midwest region of the United States and outcomes of the Geriatric Nurse Leadership Academy for Long-Term Care (Leadership Academy). In the United States, the growth of the population over the age of 65 and the need to quality and competent care in long term care has grown exponentially. The Leadership Academy was developed as one component of a research grant aimed at improving the competency of RNs in long-term care (nursing home) settings. The goals of the grant, which also included two on-line educational programs along with the Leadership Academy, were to improve Gerontological nurse competency, enhance leadership skills, and impact job satisfaction and intent to remain in current practice. These are metrics that are evaluated annually by the American Health Care Association and found to continually be a concern for long term care facilities [1]. The Leadership Academy provided a venue for peer networking, mentoring and resources for the RN members who had completed at least one of the two online educational offering: Gerontological Nurse or Nurse Leader. These courses prepared the RNs to sit for national certification exams in these specific areas. In this community based participatory approach, the volunteer Leadership Academy Board and members actively participated in the process, helping to develop a business plan that lead to sustainability of the group and a Best Practices in Long Term care document that was accepted by the five-community based long term care partners in the project. Valuable lessons from both the successes and challenges encountered during the program were learned that could help improve the success of future programs to support nurses working in nursing homes.


Introduction
The demand for high quality skilled nursing care in the United States (U.S.) has grown rapidly over the past decade.Skilled nursing care in the U.S. is provided in long-term care facilities, or what traditionally has been referred to as nursing homes.This increased demand has been fueled by two key factors.First, there has been a significant increase in the number of aging "baby boomers" (i.e., those born between 1946 and 1964) who have entered or are soon entering their retirement years.There are slightly less than 77 million baby boomers in the U.S., and many are living with multiple co-morbidities [2].Indeed, more than 15 million older Americans will have some form of disability by 2050 [3].American baby boomers are more highly educated than previous generations, and through sheer numbers this generation has dominated and altered the U.S. culture through every major phase of life [4].During their working years, American baby boomers grew to expect high quality healthcare that met their needs, and it is certain they will continue to drive the demand for excellence in health care as they age.Secondly, regulatory changes by the U.S. Centers for Medicare and Medicaid (CMS) have indirectly driven many nursing homes to become the "new hospital".As recently as a decade ago, most nursing home residents were low level acuity residents who required only minimal nursing care.However, U.S. trends in medical intensity level for patients from 2001 to 2010 show that patient acuity measures increased dramatically in nursing homes, while at the same time decreasing for hospital based settings [5].This shift in patient acuity has created a need for nursing homes to employ a more highly skilled staff to care for and re-

CaSE REpoRT
Check for updates to address a regional health care issue of concern: Nursing home care quality.Together the academic-community partners raised $250,000 and applied to the Robert Wood Johnson/Northwest Health Foundation for the match grant, Partners Investing in Nursing.The partners collaborated on designing specific elements of the project (i.e., on-line education, Nursing Home Leadership), which were implemented in for-profit and not-for-profit nursing homes located in three Midwestern states.The participating nursing homes were under the ownership of five different organizations that were community partners on the project.
The study participants were RNs employed and selected for the program by leadership in the five longterm care partners.Of the N = 167 RNs invited to participate there were N = 144 who completed one of two online educational courses and N = 114 who accepted the invitation to join the Leadership Academy.In order for RN participants to join the project's new Geriatric Nurse Leadership Academy for Long Term Care, each was required to first matriculate in one of two on-line courses that would prepare them for successfully attaining national board certifications in 1) The clinical specialty (i.e., Gerontological Nurse through the American Nurses Credentialing Center [ANCC]) and 2) Nurse leadership (i.e., Nurse Leader through ANCC, Director of Nursing in Long Term Care Certification through the American Association for Long Term Care Nursing (AALTCN).The institutional review board of the academic medical center approved the project and study.

Gerontological and nurse leadership education:
The academic-community partners collaborated on developing the project's two 10-week courses: Gerontological Nurse and Nurse Leadership.These courses incorporated all information necessary to meet competency standards established by the national certification exams offered through ANCC and AALTCN board.A unique feature of the project's courses was that all information included specific adaptations based on RN roles and knowledge required in the nursing home setting.
All RN participants first matriculated through either the 10-week Gerontological Nurse Course or the Nurse Leadership course.Upon completion, participants were required to take the ANCC national certification exam or the AALTCN exam, and their employers reimbursed them for exam costs for passing (this ranged from $150-$240 depending on the exam).There was a 98.5% pass rate (n = 82/83) for the Gerontological Nurse national exam and a 78.7% pass rate (n = 48/61) for the Nurse Leadership national exam.There were 30 nurses who chose to take both courses.At the completion of the course, the nurses were invited to join the Leadership Academy.
Geriatric nurse leadership academy for long-term habilitate increasingly complex patients who are either acutely ill or who are coping with multiple co-morbidities [6].
In the U.S., nursing homes employ Registered Nurses (RN) as supervisors and administrators.Most of the RNs hired to work in nursing homes (66%) have only a 2-year nursing degree (i.e., Associate Degree in Nursing [ADN]), which prepares them primarily for direct patient care [7].The ADN curriculum includes little formal coursework or training in management or leadership; Yet, the roles that RN supervisors perform in a nursing home involve delegation, mentoring, training, supervision, and evaluation of other direct care staff with lesser education (i.e., Licensed Practical Nurses (LPN) with 1-year of training and Certified Nursing Assistants (CNA) with a minimum of 75 hours of initial training).In addition, RN supervisors are charged with interpreting and applying a complex set of federal and state regulatory mandates that govern U.S. nursing homes.It is this lack of leadership preparation among RN supervisors that has been linked to the perniciously high staff turnover rates in American nursing homes.Indeed, there has been a high turnover rate for RN supervisors themselves who become overwhelmed with the high level of management skills required to perform in their roles [8,9].High staff turnover-especially among RN supervisors-is a significant concern for the nursing home industry because research has associated turnover with adverse patient outcomes and lower care quality [10][11][12].Some studies indicate that addressing the need for leadership development is a critical factor that can improve RN retention, reduce staff retention, improve staff satisfaction, and increase quality of care [13][14][15][16].
The purpose of this case study is to describe an innovative leadership development program for RN supervisors in nursing homes.Case studies are not intended to be representative, but rather to improve Verstehen (understanding) based on the particularities of a single case and as viewed from multiple perspectives [17].Thus, this article is designed to provide insights into how a multi-faceted leadership development project enhanced job satisfaction and retention for RN supervisors in Midwestern nursing homes.

Case Study Background
This project was developed and implemented using a Community-Based Participatory Research (CBPR) approach.CBPR has been recognized as an essential tool for bridging the gap between scientific discovery and clinical care because it partners academic researchers with community members to address priority clinical problems and test evidence-based solutions at the point of patient care [18].For this project, research faculty from a Midwestern academic medical center partnered with 13 Midwestern community business leaders the needs of the group and developed a business plan to create sustainability after the grant period ended.Events for the Leadership Academy were also planned through this group.

Discussion
Evaluating the project's success used data collection methodologies consistent with case studies and included naturally occurring sources of knowledge, such as people, documents, and observations of interactions that occurred in these real-life events [19,20].Results from these data sources are integrated and presented in terms of the challenges and opportunities experienced from this project.

Opportunities
Education: The evaluation of the educational component found that the nurses felt their work was meaningful and important, they were confident and self-assured, and had the skills to make an impact on the nursing unit.Workload, general job satisfaction, and intent to turnover were improved, but were not significantly impacted.An unintentional improvement for the nurses was increase in confidence in the use of technology throughout both courses.In the Nurse Leader course, there was an improvement in eight of eleven areas of competency, and in the Gerontological Nurse course, there were improvements in four of the seven subscales evaluated.The overall satisfaction with the courses was also high, with 94% very satisfied with the Gerontological Nurse Course, and 96% mostly or very satisfied with the Nurse Leader course.
Additional opportunities for the nurse participants included the fact that the distance education technology used offered a new format for many of the participants to learn and provide peer mentorship.This type of educational offering increased accessibility to nurses who otherwise may have had to travel long distances to attend educational opportunities.Several of the participants also went on for either a bachelor's degree or master's degree in nursing.Other feedback from both the participants and their supervisors included recognition of increased competence, confidence, and leadership in practice.

Leadership academy:
The participants in the Leadership Academy were surveyed to evaluate their perceptions of the impact of the Leadership Academy on nurse roles, satisfaction, recruitment, retention, and public image.A total of 52 out of 83 participants responded to the survey.Overall, the respondents felt that the Leadership Academy had a positive impact on practice.This included a positive impact on the role of the nurses in the nursing home (94.2%) and in improved nurse satisfaction (88.5%).Respondents also felt that the Leadership Academy helped with recruitment and retention, as well as enhancing public image of nursing home nurses.Several primary areas of impact on RN care: There were 114 RNs who participated in the Leadership Academy from 2009-2011.The academic-community partners collaborated with national experts in gerontological nursing to develop an innovative new Leadership Academy that was specifically designed for RNs employed in nursing homes.The primary purpose of the new Leadership Academy was to promote professionalism among members by providing 1) Peer mentoring in nursing home leadership; 2) Formal recognition and awards for leadership excellence, and 3) Resources for continuing education credits, which would be required for certification renewals.
The Leadership Academy featured its own website, which allowed RN members to access information on various project activities as well as links to clinically relevant websites in gerontology and leadership.The website provided an opportunity for members to network with one another and to blog on various topics of interest.The website was co-sponsored by the state's Health Care Association (HCA), which proved to be important because the HCA represented over 2,000 nursing home members, and most RNs were already familiar with the HCA.As a co-sponsor, the HCA developed special recognition events at their annual and semi-annual conventions.These recognition events included awards and monetary stipends for Leadership Academy members who exhibited clinical excellence (i.e., Outstanding Gerontological Nurse) or exemplary leadership (i.e., Outstanding Nurse Leader).The Leadership Academy members themselves developed the awards criteria and nominations procedures.The awards were presented to the honorees in front of the full HCA membership at their annual convention.Also, at the annual HCA conventions, the Leadership Academy hosted its own breakout sessions, which featured invited speakers who were recognized as national experts in nursing home leadership and/or clinical care.The Leadership Academy members set up a booth at the conventions to promote the Leadership Academy and encourage more RNs to become eligible for membership.
Throughout the project, the Leadership Academy officers and members were mentored by the faculty, each other, and national Gerontological Nurse experts.Mentoring continued after the on-line courses were completed through the Leadership Academy website, meetings, and the HCA conferences.The mentoring process assisted the members in continuing to grow as Gerontological nurses and in the development of a business plan.
A special project of the Leadership Academy focused on developing a document for Best Practices in Long-Term Care.The RN members conducted a literature review on nursing home leadership and consulted with nursing home executives and chief nursing officers to develop the document that was shared among partners.In addition, the Leadership Academy officers evaluated tered with the Leadership Academy included scheduling of meeting times, finding volunteers, and helping the members to make use of the website.This was accomplished using a web-based service.Meetings were held using both face to face, conference calls, and Adobe Connect.In addition, keeping momentum going throughout the group was a challenge.The ongoing involvement throughout the two-year program was a significant commitment for the long-term care partners, and positions changed for a couple of the organizations.Because of this, new team members had to be caught up with the project.

Members of the Leadership Academy Advisory
Board were from four different cities and five different long-term care organizations.Scheduling times when all could meet was a challenge.Use of an on-line scheduling website did help with this.However, monthly meetings that were planned in the beginning were not always possible.Suggestions for this would include making increased use of web-based meeting formats such as WebEx or Adobe Connect.
The leadership in the long-term care organizations recommended the first volunteer board members.However, some of the members found it difficult to carve out time for the group, and finding replacements took time.Once again, using a different format for meetings instead of face-to face could have helped with this.The meetings may have been more realistic for the members to attend.
The website for the members was tracked for usage throughout the project.Members were encouraged to subscribe to the RSS feeds and updates from the website.However, throughout the project, use of the website remained relatively low.It was thought that having blogs or discussion boards would increase peer interaction, but it did not.The website was designed by a team from the project, with no input from the participants.This could have limited what the participants were looking for from the website.Better investigation into what the Leadership Academy members were looking for in a website may have improved the usage of the site.

Leadership academy sustainability plan
Near the end of the grant period, the volunteer board met and discussed sustainability plans.The board decided to partner with the local Heartland Gerontological Nurses Association (HGNA) in order to allow local involvement for the members.Members were invited to join this group at the end of the grant with annual dues of $25.A member of the Leadership Academy was also chosen to represent the group on the HGNA board.
On a national level, the Leadership Academy partnered with the National Gerontological Association (NGNA) to form a long-term care special interest group.
practice were recognized through the surveys that were completed.About 80% of the respondents thought that the Leadership Academy could impact the work environment by setting quality standards, providing a networking platform for improvement, and empowering nurses in practice.By empowering the nurses, 89% of the respondents also felt that the Leadership Academy had the potential to strengthen the ability to made evidenced-based practiced changes and improve the skills needed to improve effective management practices and inspire excellence in care.
Moving the group into the sustainability phase broadened the scope of the group into the community Gerontological nurses in the state and nationally.This move did have both positive and negative consequences.To date, many of the nurses involved have not remained active with either the local or national organizational partners.However, those who have remained involved have taken on leadership roles on the local board or remain members of the local and/or national organizations.Many of the RN participants have also found it difficult to maintain the certification that was earned after successfully completing the on-line course and joining the Leadership Academy.This has led to a request in the state of Nebraska for more opportunities for continuing education to help maintain certification.The Nebraska Healthcare Association has applied to be an accrediting body in order to help the RNs in nursing homes to maintain certification once it has been achieved.
Surveys of the membership found overall satisfaction, with a belief that the group had an overall positive impact on care being provided in their facilities.The most common comments from the participants included appreciation for the networking and sharing of information, the recognition that came with involvement, and the special sessions held at the Nebraska Healthcare Association meetings.

Challenges
Education: Challenges encountered during the educational component of the program centered mostly on technology.Laptops computers were supplied to each participant to use during the course.Delivery and retrieval of the computers proved to be a challenge.Also, availability of internet connections and the technological knowledge that allowed for participation in the live sessions with faculty was a problem for a few of the participants.In order to remedy this, on-line training was held with the assistance of the Instructional Technology team at the University at the start of each 10-week course.The other issue was attrition, which ranged from three to eight of each class of 25.This was primarily due to time constraints or the participant leaving the position with the employer.

Leadership academy:
The biggest barriers encoun-UNMC College of Nursing Class of 1960, and the UNMC College of Nursing Continuing Education department.In addition, the American Association of Long Term Care Nurses supported the nurses by offering the Director of Nursing in Long Term Care Certification exam at a reduced rate and a free one-year membership in the association.Thanks also go to the national experts that were willing to participate as advisors in the process: Dr. Charlotte Eliopoulos, Dr. Claudia Beverly, Dr. Neva Crogan-Pomilla, and Dr. Cornelia Beck for their input during the development phase of the Midwest Geriatric Nursing Quality Improvement project.
This group has since merged with the Advancing Excellence special interest group and has participated in national conversations with the Centers for Medicare and Medicaid regarding issues in long-term care.The special interest group has also presented pre-conference sessions and posters at the annual NGNA convention.
The Geriatric Nurse Leadership Academy was developed as a networking system for RNs participating in a continuing education program to connect and discuss current issues in long term care.The result of this Leadership Academy found that participants of the structured educational program experienced enhanced competency and leadership skills.In an article related to this same study, it was found that RN participants experienced significant changes over time in competency, empowerment and job satisfaction [21].Research has shown that nursing leadership competency can be enhanced by education and opportunities for peer interaction [22].There are two primary implications for future practice based on the outcomes of the Leadership Academy.First, the members of the group valued the networking and recognition of the Leadership Academy membership.Second, it is important to increase the involvement of the members in developing the programs being offered, either in an in-person or online format.Based on this, the recommendations to future similar groups would be active involvement of interested parties and members from the beginning development stages of the program.Also, sustainability plans to enhance the program and further develop the leadership skills of the nurses should be in an active working phase from the development of the program.The support of the funding partners, organizations, and national leaders in Gerontological nursing were paramount in the success of this Leadership Academy.
The evaluation of the Leadership Academy, along with the two online courses in Gerontological nursing and nurse leadership, did show improvement in competence and ability to care for older adults in the nursing homes.In addition to evaluating the outcomes of a leadership Academy for the nurse participants, future studies should also examine the outcomes for residents and patients in the facilities to further understand the quality outcomes related to this method of education and development of nurses.