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Nursing home leadership styles and performance outcomes: A quantitative study about leader relationships

Dissertation
Author: Jean Lorraine Olinger
Abstract:
This quantitative multivariate correlational research study used data about nursing home quality from the Centers for Medicare and Medicaid Services and data collected with Multifactor Leadership Questionnaires to determine whether a relationship existed between nursing home care quality, and the leader team of nursing home administrators and nursing directors. Eleven skilled nursing facilities participated. Descriptive and inferential statistical data analyses were performed using SPSS software. Analysis results concluded that no statistical significance existed in the study between the nursing home administrator and nursing director leadership styles, and care quality. Further studies are warranted in this area with differing methodology and care quality measures to determine whether nursing home leader teams of nursing home administrators and nursing directors are somehow related to care quality delivered in the long-term care setting.

Table of Contents List of Tables ............................................................................................................ xi

List of Figures ......................................................................................................... xiii

Chapter 1: Introduction .............................................................................................. 1

Background of the Problem ....................................................................................... 2

Culture change efforts. ........................................................................................ 2

Organizational culture and subculture. ............................................................... 3

Statement of the Problem ........................................................................................... 4

Purpose of the Study .................................................................................................. 5

Significance of the Research ...................................................................................... 6

Significance of the study. ................................................................................... 7

Significance of the study to leadership. .............................................................. 7

Nature of the Study .................................................................................................... 8

Overview of the research method. ...................................................................... 9

Overview of the design appropriateness. ............................................................ 9

Research Question ................................................................................................... 10

Hypotheses ............................................................................................................... 10

Theoretical Framework ............................................................................................ 13

Systems theory. ................................................................................................. 14

Leadership. ........................................................................................................ 14

Systems leadership. ........................................................................................... 15

Definition of Terms.................................................................................................. 16

Assumptions ............................................................................................................. 18

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Scope and Limitations.............................................................................................. 18

Delimitations ............................................................................................................ 20

Summary .................................................................................................................. 21

Chapter 2: Review of the Literature ......................................................................... 23

Title Searches, Articles, Research Documents, and Journals .................................. 24

Literature Review..................................................................................................... 26

Nursing homes. ................................................................................................. 26

Corporate governance. ...................................................................................... 34

Organizational cultures. .................................................................................... 42

Leadership. ........................................................................................................ 46

Multifactor leadership questionnaire. ............................................................... 51

Teamwork. ........................................................................................................ 53

Conflict. ............................................................................................................ 61

Care quality. ...................................................................................................... 66

Conclusions .............................................................................................................. 72

Summary .................................................................................................................. 74

Chapter 3: Method ................................................................................................... 79

Research Method and Design Appropriateness ....................................................... 79

Quantitative as opposed to qualitative methods. .............................................. 80

Rationale. .......................................................................................................... 82

Research Question and Hypotheses ......................................................................... 83

Population .............................................................................................................. 845

Sampling Frame ....................................................................................................... 86

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Informed Consent..................................................................................................... 86

Confidentiality ......................................................................................................... 87

Geographic Location ................................................................................................ 88

Data Collection ........................................................................................................ 88

Instrumentation ........................................................................................................ 89

Validity and Reliability ............................................................................................ 91

Internal validity. ................................................................................................ 92

External validity. ............................................................................................... 92

Reliability. ........................................................................................................ 94

Data Analysis ........................................................................................................... 94

Summary .................................................................................................................. 96

Chapter 4: Results .................................................................................................... 98

Research Overview .................................................................................................. 98

Data compilation. .............................................................................................. 99

Participant responses. ..................................................................................... 100

Findings.................................................................................................................. 101

Descriptive statistics. ...................................................................................... 101

Inferential statistics. ........................................................................................ 110

Summary ................................................................................................................ 116

Chapter 5: Conclusions and Recommendations .................................................... 118

Research Study Overview ...................................................................................... 118

Study limitations. ............................................................................................ 120

Research findings. ........................................................................................... 122

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Important findings and inferences. ................................................................. 122

Conclusions ............................................................................................................ 125

Lessons learned. .............................................................................................. 128

Ethical considerations. .................................................................................... 128

Study Significance ................................................................................................. 129

Implications............................................................................................................ 130

Recommendations .................................................................................................. 131

Recommendation 1: Nursing home leadership as teams. ............................... 132

Recommendation 2: Future research endeavors about nursing home leaders and transformational leadership. ..................................................................... 132

Recommendation 3: Stakeholder perception, care quality measures and process redesign. ............................................................................................. 133

Summary ................................................................................................................ 134

References .............................................................................................................. 136

Appendix A: Letter of Introduction for Research Study ....................................... 164

Appendix B: Informed Consent Form ................................................................... 166

Appendix C: Individual Informed Consent Form .................................................. 167

Appendix D: Instruction Letter to Individual Participant ...................................... 168

Appendix E: Multifactor Leadership Questionnaire .............................................. 170

Appendix F: MLQ Rater Form .............................................................................. 170

Appendix G: Demographic Questionnaire............................................................. 172

Appendix H: Follow Up Letter .............................................................................. 173

Appendix I: Permission to Use an Existing Survey ............................................... 174

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List of Tables Table 1 Administrator and Nursing Director Background Variables

................... 102 Table 2 Administrator Experience Levels

.............................................................. 103 Table 3 Nursing Director Experience Levels

......................................................... 104 Table 4 Combined Descriptive Statistics (N = 22)

................................................ 104 Table 5 Descriptive Statistics about Administrator Leadership Styles and DON Perceptions of Counterpart

.................................................................................... 107 Table 6 Descriptive Statistics about Nursing Director Leadership and Administrator Perceptions of Counterpart

............................................................ 108 Table 7 Department of Aging and Disability Services Facility Quality Measurements

........................................................................................................ 109 Table 8 Spearman’s Rank Correlation Analysis for Leadership Style and Quality Service Rating

........................................................................................................ 111 Table 9 Chi-Square Analysis for the Relationship of Leadership Styles and Quality Measurements

........................................................................................... 111 Table 10 Spearman’s Rank Correlation Analysis for Shared Transformational Leadership Style and Quality Service Rating

........................................................ 112 Table 11 Chi-Square Analysis for the Relationship of Leadership Styles and Quality Measurements

........................................................................................... 113 Table 12 Spearman’s Rank Correlation Analysis for Similar Leadership Style and Quality Service Rating

.................................................................................... 114 Table 13 Chi-Square Analysis for the relationship of Similar Leadership Styles and Quality Measurements

.................................................................................... 114

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Table 14 Leadership Styles of Administrators and Nursing Directors for each Nursing Home

........................................................................................................ 115

xiii

List of Figures Figure 1. Leader team member education level by gender.

................................. 105 Figure 2. Leader team members’ professional experience compared to tenure.

.. 106

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Chapter 1: Introduction Poised to reorganize nursing homes, leaders confront relentless dissatisfaction, limited funds, and an industry history of few successful attempts at changing nursing home cultures (Weiner & Ronch, 2006). Long-term care regulators mandate culture changes, encouraging staff to embrace residents with humanistic values, person-centered care, and home-like settings (Sullivan-Marx & Gray-Miceli, 2008; Weiner & Ronch, 2006). Differences in focus adversely influence leadership change in organizational cultures and team member direction (Choi & Pak, 2006; McCallin, 2006). A literature search generated more than 182,000 articles featuring topics for change and improved care by long-term care nursing staff or doctors. Search terms long- term care, nursing home, teamwork, and teams resulted in more than 60 years of interest represented in more than 80,000 peer-reviewed articles. Castle, Ferguson, and Hughes (2009) explored leadership influences on humanistic care in a descriptive, qualitative study of nursing home leaders who encouraged humanistic care as a result of an effective culture change. The management team of leaders composed of the administrator and nursing director implement and direct nursing home policies and procedures (Yeo, 2006). Comparing leaders’ identified leadership styles with nursing home quality signals may determine whether a relationship exists between leader teams and care quality. Research findings expanded nursing home literature and theories on leader teamwork. Nursing home culture changes do not address the combination of nursing home administrator and nursing director leadership styles used in nursing home settings in leader teams. The next sections include the background of the quantitative multivariate correlational study, problem identification, purpose, and study approach (Simon, 2005).

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Background of the Problem Federal and state data show administrative leaders control care quality and services in nursing homes (Allen, 2008). Regulators recommend nursing home culture changes that encourage staff to embrace residents with humanistic values and person- centered care in home-like settings (Weiner & Ronch, 2006). Nursing home professionals follow traditional care models; regulators address issues in long-term care environments (McCulloch & Turban, 2007; Sullivan-Marx & Gray-Miceli, 2008; Vladeck, 2006). Nursing home care success relies on team performance inspired by skillfully guided leader vision (Rader & Semradek, 2006). Rader and Semradek posited culture changes occur when leaders support resident decision-making and decrease staff doubts about new approaches. Leaders manage the nursing home culture to avoid increasing staff doubt or irregular levels of care while complying with new standards. Culture change efforts. With common goals for improved services, the long- term care industry has undergone years of varied culture change efforts (Weiner & Ronch, 2006). Weiner and Ronch reported diverse change efforts resulting in shared values becoming interwoven in nursing home models of care. Gibson and Barsade (2006) posited that shared values, respect, and integrity form foundational philosophies underlying organizational cultural patterns. Dixon (2006) recommended nursing home paradigm shifts with creative campaigns to preserve long-term care industry changes. Theories challenging care delivery models, patterns of belief, and values result in shifts in behavior that form new organizational cultures. Gibson and Barsade (2006) asserted that individual informal mental, emotional, and social responses shape cultures and subcultures in an organization. Bass (1985) posited a leadership theory applicable to the success of a nursing home culture in which

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the nursing home leader team of administrator and nursing director and the organizational culture influence one another and develop together. Leader team communication and teamwork combine to manage change efforts, conflicts, and staff doubts. Speaking about nursing homes, Deutschman (2005) stated, “From a communication perspective, there is substantial evidence that existing systems are not working well” (p. 274). Deutschman questioned whether leader team communication affected care quality in nursing homes. Future change efforts will need strong leaders who understand how to create successful teamwork and who can develop a healthy and united organizational culture (Deutschman, 2005). Organizational culture and subculture. Researchers believe organizations have multiple cultures and subcultures, and underlying beliefs and values that strengthen organizational cultures (Gibson & Barsade, 2006; Schein, 1996). Organizational subcultures draw meaning from values set in occupations, professions, departments, and ethnicities (Gibson & Barsade, 2006). Kanter, Stein, and Jick (1992) compared managing the organizational culture to driving a car; leaders decide the direction by tuning into the internal and external environments. Researchers find that leaders steer the organizational culture by strategically selecting people who fit the environment and future vision (Gibson & Barsade, 2006; Ronch, 2006; Schein, 1996). Leaders dictate the nursing home care quality by selecting individuals who positively contribute to the organizational cultures. An organizational culture includes three layers: (a) the visible artifacts; (b) behaviors; and (c) underlying values, beliefs, and assumptions (O’Reilly, Chatman, & Caldwell, 1991). Organizations employ many well-known models for culture advances. Traditional change models are based on the assumption that a need exists for disrupting organizational stability to make way for future improvements (Lewin, 1997). Kanter et

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al. (1992) described a newer approach in which change is complex with constant movement and minimum stability during all change phases. Few successful models for culture change exist in the long-term care industry. The Eden Model and Pioneer Network represent models of culture change success in the nursing home industry (Gibson & Barsade, 2006). Although some successful changes exist, the role of nursing home leader teamwork is not clear, which constitutes a gap in knowledge in the field. When understanding and reading the organization’s cultural stability, leaders can perform as a team and implement strategies that drive wanted culture changes. Leader teams play key roles in successfully changing the nursing home culture. The current study was an examination of administrator and nursing director leadership styles compared to the care quality in participating nursing homes. Similar values create positive behaviors in team members when confronting important challenges in any workplace (Melnyk & Swink, 2005). Leaders are cautioned to remain aware of employee disconnects from organizational values, resulting in limited employee performance and organizational failures. Strong organizational cultures encourage cooperation and associations that strengthen supervisor confidence in employee performance (Melnyk & Swink, 2005). The current quantitative research study was an evaluation of differences in team member leadership styles and nursing home quality signs. Comparing leader teams and care quality in nursing homes provided insight into employee performances. Statement of the Problem In July 2008, the United States Census Bureau (2009) estimated 39 million U.S. citizens over age 65 were at a median age of 74.8 years, and 35.6 million U.S. citizens, age 5 and older, lived with a disability. Future forecasts for 2030 indicate these

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populations will overwhelm the long-term care industry (Greene, Cohen, Galambos, & Kropf, 2007; Redfoot, 2006). The general problem is the needs of aged and disabled residents might go unmet because of how care teams deliver services. The delivery of services is dependent on team performance and leader input (Castle, 2006). In 1978, Vladeck (1980) introduced culture change ideas that framed the future of nursing home care. Leaders at the Centers for Medicare & Medicaid Services (2009d) recommended changes centered on resident choices and creative service methods. The specific problem for creating long-term care culture changes is the potential for a lack of teamwork among nursing home administrators and nursing directors. A lack of teamwork skews the organizational culture, influencing staff behaviors, team effectiveness, and organizational costs (Gibson & Barsade, 2006; Schein, 1996). The current quantitative research study was designed to examine nursing home administrator and nursing director teamwork in long-term care settings. The goal for the study was to determine whether leadership differences or alignment shapes resident care in nursing homes. A concomitant goal was to expand team theory for the long-term care industry. Data collected from nursing home administrator and nursing director teams (independent variable), provided information about each member’s leadership style. Comparing and contrasting leadership styles within teams revealed existing differences and alignments that affected care quality (dependent variable). Correlating the study results with the Centers for Medicare & Medicaid Services quality signals provided data about the relationship between leader teamwork and nursing home direct care staff. Purpose of the Study The purpose of the current multivariate correlational quantitative study was to determine whether long-term care administrator and nursing director leadership styles

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(independent variable) influenced care quality (dependent variable) in nursing homes. Data collected from the Multifactor Leadership Questionnaires (MLQ 5X short) (see Appendix E) were used to explore the leadership skills of key leaders from participant nursing homes. The intent of the current study was to link nursing home Five Star Quality Ratings (Centers for Medicare & Medicaid Services, 2009a) and data from the MLQ 5X (short) and MLQ 5X Rater Forms to imply the relationships between administrator and nursing director leadership styles and care quality at selected research sites. The focus of existing literature is teams in various organizational settings (Burke, 2008). Long-term care leaders impose traditional medical care models (McCulloch & Turban, 2007) and ignore team-building procedures. Preserving existing models instead of team building suggests poor organizational communications, varying hierarchies, and ever-changing staff assignments that compound nursing home problems (Sullivan-Marx & Gray-Miceli, 2008). Sullivan-Marx and Gray-Miceli (2008) reported that recent nursing home change initiatives recognized the value of team building in nursing homes. The focus of other known political, consumer, and payer-driven initiatives are physical environments and staff assignments (Cheek, Nolan, & Larsen-Otra, 2008; Gilbert & Bridges, 2006; Thompson Publishing Group, 2010; Weiner & Ronch, 2006). The purpose of the current study was to examine whether a relationship exists between leader teamwork and the quality of nursing home care. Significance of the Research The long-term care industry faces staggering statistics that forecast future increasing care costs for the elderly and disabled in nursing homes (Greene et al., 2007; Nelson, 2007; Redfoot, 2006). Nelson warned that rapidly aging national populations

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and unique baby boomer consumer traits added challenges to the long-term care industry. The industry leaders must discover alternative models for building sustainable team approaches to complex elder care issues (Baldwin & Baldwin, 2007). The current study included data pertaining to the importance of leadership styles for the administrator and nursing director team to confront mounting costs associated with the long-term care industry. Significance of the study. The efforts of regulators to improve nursing home cultures can fail when long-term care industry leaders respond to payer source pressures (Gibson & Barsade, 2006). Health care leaders recognize teams as critical to clinical decision-making and complex problem solving (Greene et al., 2007; Speck, 2007). Teams can work together to deliver consumer choices and service diversification, provide self-directed care, and meet quality measures while increasing staff retention (Cheek et al., 2008). Cheek et al. stressed team building, culture, composition, and development as important in the organization. The goal of the current study was to offer insight about pairing administrator and nursing director leadership styles to generate high levels of care quality in nursing homes. Data and new knowledge from the current study apply to the long-term care and nursing home industry. Innovative ideas gained through the study may be relevant to other professional health care disciplines and organizations. With the more recent movement toward the use of transdisciplinary teams (Choi & Pak, 2007), the study findings might become an important addition to empirical literature. Knowledge gained from the study might prove useful to the nursing home industry for administrators, nurses, and educators. Significance of the study to leadership. Administrators and nursing directors must work together, building long-term care cultures that support team development

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(Abbey, Froggatt, Parker, & Abbey, 2006). Nursing home leaders receive limited leadership and team building preparation (Sullivan-Marx & Gray-Miceli, 2008). Administrators can adopt initiatives and work with nursing directors to build excellence in care delivery teams. Change begins when leaders manage old personal behaviors and adopt new ones (Dixon, 2006). The current study might lead to information about nursing home leadership and individual roles within leader teams. Changing requirements in long-term care education and licensing might improve the success of nursing home leaders. Nature of the Study The quantitative study was an exploration of the connections in nursing homes that link administrator and nursing director leadership styles (independent variable) with care quality (dependent variable). Quantitative study designs are appropriate to collect data about population trends and attitudes (Creswell, 2009). Creswell stated that generalizing the results of studies to larger populations is a means to test theories for specific populations. The goal of the current study was to determine whether a relationship exists between leadership style and care quality. A multivariate correlational quantitative research design provided data about potential links between the independent and dependent variables (Neuman, 2005). Of the 54 existing sampled, nursing homes (Centers for Medicare & Medicaid Services, 2009c), data came from nursing homes whose leaders elected to take part in the study. Twenty-two responses from 11 nursing home administrators and 11 nursing directors remained paired as teams to ensure both members of the leader team represented the facility. Leader information was derived from the completed demographic questionnaire and the MLQ 5X (short) and MLQ 5X Rater Form. The MLQ 5X (short) was used as a report of self-perceptions about individual leadership

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styles, and the MLQ 5X Rater Form was used as a report of team counterpart perceptions for leader team members. Information gained from the Centers for Medicare & Medicaid Services websites completed the research datasets about care quality. Overview of the research method. A quantitative research design was used as the most appropriate strategy to collect and test the current study hypotheses (Simon, 2005). A correlational design was used to determine whether and to what extent relationships existed between multiple variables (Neuman, 2005). Unlike qualitative and mixed-methods research designs, quantitative correlational research facilitates the statistical investigation of relationships between the independent and dependent variables (Leedy & Ormrod, 2010). Overview of the design appropriateness. A Spearman rank correlation and chi- square table developed for the study sample allowed multivariate correlations and analysis of multiple variables. Correlational analysis was suitable in the study to explore whether or how one variable changed another (Creswell, 2009). Quantitative designs allow independent and dependent variable correlations (Creswell, 2009). A quantitative design is more suitable than a qualitative or mixed-methods design for generalizing the study results from the samples to specific populations (Creswell, 2009). Data about participating nursing home administrator and nursing director leadership styles (independent variable) were used to identify one of three leadership styles for each professional within the leader team. An initial Spearman’s rank correlation of the leadership styles was tested for variable independence (Neuman, 2005). A chi-square test was used to further analyze whether and how leadership styles affected the particular nursing home’s care quality (dependent variable). Comparing the results of the Spearman’s rank correlation and chi-

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square test for confidence intervals provided strength to the research design and study results with estimated value differences. Using descriptive and inferential statistics as described by Leedy and Ormrod (2010), the multivariate correlational quantitative research study was a study of leadership style likenesses and differences for administrators and nursing directors. Adding weight to the study, information about each participating nursing home came from the Centers for Medicare & Medicaid Services. The data available represented five features of nursing home care. Researcher analysis of data helped in determining whether an association existed between leadership styles and nursing home care quality. Research Question The purpose of the study was to determine whether a relationship existed between the administrator and nursing director (leader team) leadership styles and care quality in nursing homes. A comparison of leader team member characteristics permitted inferences of how and if existing leadership styles contributed to nursing home care quality. Based on known leadership theory literature (Bass, 1985; Burns, 1978), organizational cultures and leaders influence one another. The study was an effort to answer the central research question: What is the relationship between leadership styles of nursing home administrators and nursing directors and is there a relationship with the care quality delivered in nursing homes? Generalizations of leadership styles derived from a Spearman’s rank correlation. A chi-square test was used to add care quality data for statistical analysis (Doane & Seward, 2009). The null hypotheses were neither confirmed or rejected as a result of the chi-square test. Hypotheses Based on the central research question, the following hypotheses were posed:

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H1 0 : There is no statistically significant relationship between the leader team of administrators and nursing directors’ leadership styles and the care quality delivered in nursing homes. H1 A : There is a statistically significant relationship between the leader team of administrators and nursing directors’ leadership styles and the care quality delivered in nursing homes. H2 0 : There is no statistically significant relationship between the leader team of administrators and nursing directors’ shared transformational leadership style and the care quality delivered in nursing homes. H2 A : There is a statistically significant relationship between the leader team of administrators and nursing directors’ shared transformational leadership style and the care quality delivered in nursing homes. H3 0 : There is no statistically significant relationship between the leader team of administrators and nursing directors’, that do not share a similar leadership style, and the care quality delivered in nursing homes. H3 A : There is a statistically significant relationship between the leader team of administrators and nursing directors’, that do not share a similar leadership style, and the care quality delivered in nursing homes. H4 0 : There is no statistically significant relationship between the leader team of administrators with transformational leadership styles, and nursing directors with transactional leadership styles, and the care quality delivered in nursing homes. H4 A : There is a statistically significant relationship between the leader team of administrators with transformational leadership styles, and nursing

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directors with transactional leadership styles, and the care quality delivered in nursing homes. H5 0 : There is no statistically significant relationship between the leader team of administrators and nursing directors with laissez-faire leadership styles, and the care quality delivered in nursing homes. H5 A : There is a statistically significant relationship between the leader team of administrators and nursing directors with laissez-faire leadership styles, and the care quality delivered in nursing homes. Nursing home operations are based on business and medical models, creating a need for administrators and nursing directors (Allen, 2008; Ronch, 2006; Townsend, Davis, & Haacker, 2007). The following questions arose from the models: 1. What happens when nursing home leaders’ theoretical backgrounds diverge? 2. What takes place when leader teams do not share basic leadership skills? 3. What happens when opposing leadership styles exist in the leadership team? 4. Is there a correlation between leadership styles and care quality? The influence of leader teams on nursing home culture is an important issue. Eaton (2000) linked staff management and nursing home care quality. Nursing directors sometimes enter a nursing home when an administrator is appointed. Administrators may decide to select nursing directors after interviews and background checks. More often, an existing leader team assumes control and manages the nursing home. When a nursing director remains, the administrator must begin with one member of the team already in place. In either case, named background and nursing board checks are necessary employment conditions in long-term care settings (Allen, 2008; Department of Aging and Disability Services, 2009; Deutschman, 2005). Recognized

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hiring laws prevent interviewers from confirming information beyond employment data and rehire status, limiting the content and depth of background information. The administrator and nursing director relationship is important to leading nursing home teams. Although the two leader team professionals have similar goals, associations must be cultivated and nurtured. Considered the 21st century’s quintessential social service, nursing homes need consistent staff-to-resident contacts that need staff emotional support for residents (Eaton, 2000). Eaton refers to resident needs for social contact that remain unfulfilled by lifetime family or other social attachments. Tasked to ensure quality medical care in the nursing home, nursing directors uphold traditional medical models. Administrator backgrounds in business prepare them to safeguard nursing home fiscal and regulatory compliance (Allen, 2008). Medical care costs beyond daily care include laboratory tests, x-rays, medications, specialty equipment, hospital and doctor visits. Administrators and nursing directors have differing perspectives because of diverging roles in the facility. Theoretical Framework As a system, an organization conveys care or services based on influences from individuals who enforce guidelines in the form of mission, vision, policies, and procedures (Greene et al., 2007). Bass’ (1985) work on leadership highlighted leader styles and the resulting effects within the organizational system. Based on leadership style, leaders influence the systems, products, and services in the organization. Johnson, Kast, and Rosenzweig (1964) offered that systems theory dispels management complexities by identifying “the integrated nature of specific systems” (p. 367). The theoretical framework for the current study developed from the germinal works on systems theory and Bass and Avolio’s (2009) subsequent joint contributions to the field of leadership.

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Systems theory. von Bertalanffy (1969) depicted systems theory as a tool for analysis of problems “that are novel and partly far from solution” (p. 35). von Bertalanffy believed a systems approach to organizational problems demanded “new ways of mathematical thinking” (p. 35) that viewed wholeness in light of causal chains and processes. Simms (2009) reported a revolution in which customers are served by the business and social system for sustainable change. Nursing homes operate through a number of complex systems that serve the individual resident and the supporting personal system. Leadership. Boulding (1990) depicted integrative influences as necessary for organizational survival. Fairholm (2004) stated that leaders in public domains need a practical and intellectual understanding of leadership as well as consent to practice leading. Leaders and leader teams develop roles from member leadership styles, and a shared permission to lead. Gandossy and Sonnenfeld (2004) distinguished favorable leadership styles as charismatic and values-based. Leadership with distanced communication between leaders and followers can have negative results (Gandossy & Sonnenfeld, 2004). Shared values among leaders and followers positively influence team leadership. Applicable to nursing home leadership, Gandossy and Sonnenfeld (2004) believed that cross-cultural leaders, communication gaps, and shared values shape leaders and teams. Values, personality, and behavior produce follower attitudes and performance (Bass, 1985; Burns, 1978; Deluga, 1990). Nursing homes need strong leaders to integrate the influences that shape internal systems and organizational cultures. The U.S. Army launching a post-Cold War training and educational revolution that successfully changed the entire organization is an example of strong leadership (Yang & Vocke, 2007). Similar changes implemented in American education demonstrate attempts to teach

Full document contains 188 pages
Abstract: This quantitative multivariate correlational research study used data about nursing home quality from the Centers for Medicare and Medicaid Services and data collected with Multifactor Leadership Questionnaires to determine whether a relationship existed between nursing home care quality, and the leader team of nursing home administrators and nursing directors. Eleven skilled nursing facilities participated. Descriptive and inferential statistical data analyses were performed using SPSS software. Analysis results concluded that no statistical significance existed in the study between the nursing home administrator and nursing director leadership styles, and care quality. Further studies are warranted in this area with differing methodology and care quality measures to determine whether nursing home leader teams of nursing home administrators and nursing directors are somehow related to care quality delivered in the long-term care setting.