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Developing today’s (and tomorrow’s) NHA leaders

July 31, 2014
by Jennifer Johs-Artisensi, PhD, MPH, and Douglas Olson, PhD, MBA, NHA, FACHCA
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Nursing home quality reflects significantly on the expertise and commitment of the administrators in charge (AITs) of person-centered organizations. The AIT or practicum experience serves as an essential educational component, facilitating the transition from student to leader.

Although a great deal of variability exists in nursing home administrator (NHA) licensure requirements across state lines, most states require specialized education—an applied field experience commonly referred to as an AIT program—and passing scores on federal and state licensure exams. The content, length and model for these experiences have been driven largely by the National Association of Long Term Care Administrator Boards (NAB), which recommendeds NHA requirements and organizational managerial/technical needs. Even with these recommendations, standards still vary widely from state to state. Educational requirements range from a high school education to a bachelor’s degree, and AIT requirements range from 0 hours in a handful of states to 2,000 hours and beyond in others. 

During a practicum experience, the AIT has an opportunity to rotate through each facility department, developing an understanding of frontline service staff roles, the responsibilities of the departmental managers and how each department integrates with the rest to provide both effective and efficient person-centered care. Students also spend significant time learning about several administrative functions, such as managing the survey process, human resources and financial and information systems. In many programs, they also develop their leadership skills by participating in projects that effect change and produce favorable results.


Long-term care (LTC) administration has an employment cliff: More people are leaving the field than are entering it. Couple that with NHAs being under increasing pressure to transform their communities. These two issues are occurring against a backdrop of increasing consumer demands and dwindling fiscal resources.

The AIT program is an essential educational component, serving as a career transition between student and employment status, and its completion is essential to the success of potential administrators. Contemporary research has found preliminary evidence that the AIT experience is critical to the effective development of administration competencies and leadership skills.

A recent NAB-funded study that we just completed in concert with coauthors from University of Pittsburgh, George Washington University and St. Joseph’s College of Maine has further linked the important educational component of the AIT experience with administrator competency and quality. Our initial analysis found that an optimal level of education and training positively affects the development of successful LTC administrators as well as facilities’ five-star ratings.

Using education and training stringency scores developed for each state based on its NHA licensing requirements and NAB licensing exam data from 2001 through 2009, we found that both higher degree requirements and longer AIT requirements were correlated with better exam scores. Although we believed that exam performance was a good proxy for measuring competency, we wanted to know whether that higher competency translated to better quality in practice. 

As such, we identified the five-star ratings of nursing homes in 17 states where these recent licensees were used. We found that NHAs who earned higher licensing exam scores were leading facilities with better overall five-star ratings and health inspection ratings and had fewer total enforcement actions counts in their current facilities. 

Although this is just a preliminary study, this research strongly suggests that an optimal level of education and field training leads to better-prepared NHAs, resulting in a higher level of quality care and service. It is clear that new administrators need quality practicum/AIT experiences to ensure that they are well prepared for their future careers.


Although, as educators, we have a subjective sense about which practicum sites are excellent, which are good and which are less-than-ideal, we wanted more information to aid in the selection of the best possible sites and preceptors with whom to partner. We also developed resources and practices to support these practitioner-educators to best develop future administrators. 

With funding from the Commonwealth Fund and the NAB Foundation, we conducted a study that helped us discern that the quality of the AIT or practicum experience is influenced by the environment in which the trainee learns. We determined that the experience of the trainee’s preceptor and the “spirit of learning” embodied by the practicum site are two of the most significant driving forces.

To best prepare future leaders, several training site characteristics offer the highest quality experiential learning: