News Analysis — LTC leaders need training, support

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Professors write ACHCA concept paper to detail long-term care leadership needs, possibilities.

Editor's note: The following is an excerpt of a wide-ranging position paper written for the American College of Health Care Administrators, "Effective Leadership in Long-term care: The Need and the Opportunity." The authors delve into both historical and theoretical perspective in the long-term care context.

Most long-term care leaders have both the heart and desire to achieve high levels of performance. Unfortunately, they often lack the training and support systems that will help them to escape from crisis management, develop a vision for excellence, and create the culture changes and disciplines needed for the vision to be realized.
While limited, research provides strong evidence that effective leadership and management practices have a significant influence on organizational performance in long-term care settings. The potential for developing additional empirical studies in these areas is growing as LTC organizations confront the fact that "business as usual" is no longer acceptable.
Uniqueness, complexity
A plethora of different types of senior services create potentially differing demands and opportunities for leadership and management. Service settings range from the more formal to informal types of services. Services of the traditional skilled nursing facility have increasingly become medically complex and specialized.
Assisted living has emerged as an alternative to the nursing home, offering care and services in a less institutional setting with an emphasis on greater privacy and flexibility. Senior housing services continue to serve a less frail population, but many are making health and support services more readily available to their tenants. Community-based services, including home care, are often the preferred choice of frail older adults who desire to stay in their own homes.
Without credible research, one can only conjecture what might be the impact on leadership of different long-term care settings. Educational programs for administrators are largely driven by licensure requirements, which have historically emphasized the differences rather than similarities across settings.
Practical observations and some limited research of the senior service field reveal some of the unique challenges that effective leaders are able to address:
• Nursing facility administrators and management staff should be able to proactively understand, plan and execute person-centered change. Administrators should learn to overcome the barriers that drive them to evaluate their effectiveness through a limited focus on regulatory compliance and personal control.
• Assisted living administrators and management staff should balance their focus on marketing and customer service with the need to develop and institutionalize effective quality management systems that consistently meet and exceed the expectations of the customers. This is essential to minimize the need for increased regulatory requirements. The current pattern reflects what happened to nursing homes more than 30 years ago because of ineffective leadership.
• Both senior housing and community-based service administrators should create and communicate a shared vision that is supported by effective systems and training. These are essential to effectively lead a complexity of services with more empowered staff in a community rather than a single building.
LTC leadership is affected by the leadership history, the established organizational culture, customer differences, and ultimately the distinct goals and market forces for the individual setting. Some of the more universal nuances of LTC that affect leadership approaches include:
• The importance of creating an organizational culture that portrays a sense of caring.
• The need to personally model a compassionate perspective for the needs of others.
• The high-touch, labor-intensive nature of providing long-term care and services.
• The highly "regulatory-driven" and reactive environment.
• The predominately nonprofessional labor force with high employee turnover rates.
• The fairly "flat" organizational structure that makes it desired and beneficial for management to build relationships with as many staff as possible.
• The frequent changes in administrator, director of nursing services and other key positions.
• The governing boards, owners, and corporate level managers who often lack an understanding or sensitivity to the complexity of daily operations and the changing environment.
Greenleaf's concept of servant leadership (Spears 1995) addresses many of the nuances of long-term care.
The servant-leadership model emphasizes the practices of vision (conceptualization, foresight, building community); change (persuasion, commitment to the growth of people); communication (listening); visible presence (empathy, awareness, healing) and technical (stewardship).
Block (1996) supports similar views in proposing "stewardship" as an alternative to leadership. Block contends that positive culture change is impaired when leadership becomes "the act of a few, in charge, defining the future, controlling the path, and knowing what is best for others" (1996, p. 22).
Stewardship is operating in service rather than control of others for the betterment of the entire organization. Block calls for everyone's participation in defining the organization's purpose and culture with an equitable distribution of rewards. These elements could be incorporated into the spirit of any program.
Effective LTC managers and leaders develop and align their quality management system with doing the right thing rather than with some extrinsic requirement or incentive. They have a passion for providing superior customer value that takes them well beyond the need to comply with regulations or their own internal standards.
They continuously learn and develop effective leadership traits and competencies. They communicate a quality-focused mission and influence positive change. They contribute to a culture of empowerment, innovation, agility, and results. Effective LTC leaders are never satisfied with just good quality.
The health and aging services field needs to identify the leadership and management skills that are common across all settings. For instance, the need for the organization to focus on understanding and meeting the needs and expectations of its customers should transcend settings. On the other hand, setting differences should influence the identification of unique leadership practices and requirements.
Developing effectively
LTC providers should allocate resources to develop a systematic and objective leadership development process. The best way to start is by identifying what skills are most needed by managers.
The importance of three basic types of skills will shift as a manager assumes greater responsibilities. Technical skills are important for the beginning manager, but less important for the senior manager.
The need for effective relational skills (human resource and communication) becomes more important as the manager has an increased span of control, negotiates for resources, and attempts to influence results.
Conceptual skills are essential for senior managers. Conceptual skills include good judgment, foresight, intuition, creativity, effective planning, problem solving and coordination of the various organizational functions (Yukl 2006, p. 198-199).
This developmental shift in management skills is a very important concept for LTC providers to understand as they look at the development of department, unit and shift supervisors.
Most long-term care facilities promote people to management from the ranks. They are often promoted because they are loyal, perform their job well and never cause any problems. As a result, many managers are ineffective because they have never received management or leadership training and cope by simply imitating what someone else did before them (Dana 2005).
On an academic level, this developmental approach is already being incorporated into the applied field coursework of some university-based educational programs (Olson, Decker, Johs-Artisensi 2006).
Basic management skills should be developed if not already present. Training for long-term care managers and supervisors should include work design, conflict resolution, performance evaluation, communication styles, problem-solving methodologies and coaching.
Leaders and managers also should learn to use idea-generating tools, consensus-building tools, effective meeting techniques, and quality improvement tools (Dana 2005).
While everyone may not be in a position to lead an organization, department or work unit, every willing member of the organization should have the opportunity to prepare to lead in a particular circumstance or at a particular time.
Some people have no idea that they can lead until they learn how and have the opportunity. Many individuals can develop the traits of effective leadership by: (1) developing new habits to guide their behavior; (2) learning the principles, skills and techniques related to leadership; and (3) translating new knowledge into meaningful activities and actions.

Bernie Dana is an assistant professor of business at Evangel University (EU) in Springfield, MO. Dr. Douglas M. Olson is an associate professor in the Health Care Administration program at the University of Wisconsin in Eau Claire.
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