Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Related Sciences

First Advisor

Thomas T. H. Wan


Objective: The primary objective of this research is to examine how changing levels of nursing home staffing adequacy and variations in rehabilitation orientation have affected facility deficiencies and the quality of patient care as facilities responded to the Balanced Budget Act of 1997.
Data Sources: Analyses were performed using data from the On-Line Survey Certification and Reporting System (OSCAR) data from years 1997, 1998, 1999, 2000 and 2001 and were merged with Area Resource File (ARF) data released in February 2001.
Study Design: Contingency strategic adaptation provides the theoretical framework for developing the effects of environmental characteristics, organizational characteristics and strategic change on nursing facilities’ performance. The study employed a non-experimental, longitudinal panel design focusing on the individual nursing home as the unit of analysis. Measurement models were proposed and validated for each of the research constructs. Structural equation modeling was used to specify the relationships between staffing adequacy, rehabilitation orientation and nursing home quality.
Principal Findings: Decreases in staffing adequacy and rehabilitation orientation, and also in nursing home quality occurred during the period of 1997 to 2001. Environmental and organizational characteristics have various direct effects on staffing, rehabilitation orientation and nursing facility performance. Staffing directly affects rehabilitation orientation; rehabilitation orientation directly affects quality. The variances accounted for in the final structural model are small.
Conclusion: Staffing and rehabilitation orientation are, respectively, structures and processes of care subject to strategic change within organizations in response to changing environmental conditions. Changes in staffing and rehabilitation that occurred during the period of implementation of the BBA of 1997 reduced nursing facility performance. The relatively small contribution of each to the measurement of nursing facility performance suggests that other structures and processes should be identified, and their impact on the quality of care evaluated.
Keywords: Staffing, rehabilitation, nursing home deficiencies, strategic adaptation, Balanced Budget Act of 1997.


Scanned, with permission from the author, from the original print version, which resides in University Archives.


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