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Pathway to Excellence® in long-term care organizations

By: Edna Cadmus, PhD, RN, NEA-BC, FAAN, and John R Mastrocola, BS

This framework can help improve the practice environment for nurses.


  • Now, during the pandemic, is the time to make revolutionary changes in long-term care facilities.
  • Pathway to Excellence® standards can provide the roadmap for change.
  • Directors of nursing and administrators must lead the way.

The COVID-19 pandemic has prompted nurses to examine the long-term care environment and some of the ongoing issues that plague these facilities. Gaps and disparities highlight the need to focus on these settings and provide strategies, such as the Pathway to Excellence in Long Term Care® Program (PTE-LTC) to address concerns aggravated by the pandemic. The PTE-LTC designation, created by the American Nurses Credentialing Center, recognizes organizations that create a positive work environment to empower and engage staff. Applying PTE-LTC’s standards (leadership, shared decision making, safety, quality, well-being, and professional development) builds engagement and resilience of staff (both nurses and unlicensed assistive personnel such as certified nurse assistants), resulting in improvements in quality and safety for residents.


Leadership buy-in is key to a successful PTE-LTC journey—a journey well worth committing to. By creating a positive work environment, PTE-LTC’s framework helps improve staff recruitment and retention and—ultimately—care quality. Leadership plays a part in that environment by supporting shared governance and facilitating collaborative decision making.

Directors of nursing in long-term care need to be supported in their leadership work, especially during the pandemic. As one director of nursing for a small facility described, “I’m … feeling the weight of the world on my shoulders now. Our nursing home has nursing assistants and housekeepers who work two and three jobs to pay their bills.” The director adds that many staff are afraid to come to work and frequently express their anxiety. Many nurse leaders are under similar stress to maintain care quality and reassure staff; PTE-LTC can help them address issues brought to the forefront as a result of the pandemic.

Administrators and owners of long-term care facilities should understand that PTE-LTC designation provides the return on investment facility administrators and owners may be looking for. The return on investment calculator can be downloaded at

Shared decision making

Shared governance gives everyone a voice in their practice. It builds on nurses’ and certified nursing assistants’ strengths and brings them together to provide input into their work environment. Unfortunately, few long-term care facilities have a shared governance structure. The director of nursing and other organization leaders can support staff by facilitating networking, collaboration, and idea sharing and by creating a structure that fits the organization’s size and focus.


This standard includes resident and staff safety and a workplace free of incivility, bullying, and violence. Safety also relates to protection of staff from infection. Infections are one of the leading causes of morbidity and mortality among nursing home residents and are frequently attributed to low staffing levels and inadequate resources. These issues have been exacerbated during the pandemic, when lack of resources limited facilities’ ability to contain the virus. Most long-term care facilities are unprepared for the threat of a widespread infection, and they don’t have a full-time nurse who serves as an infection control preventionist to ensure all staff are using proper infection control techniques. It’s important for nurse leaders to ensure access to personal protective equipment (PPE) and realignment of resident rooms to prevent infections.


All long-term care should be person-centered and evidence-based, and quality care indicators should show continual improvement. Castle and colleagues examined deficiency citations for infection control in nursing homes and found that staffing levels for all caregivers were associated with deficiency citations. This finding also may be applied to nursing homes that enforce consistent staffing and refrain from rotating staff through multiple facilities, which may have better outcomes with regard to reducing COVID-19 spread among residents and employees.

Director of nursing and staff turnover increases costs and decreases care quality. Evidence supports that a healthy work environment can improve care quality and staff retention. An integrative review by Rajamohan and colleagues suggests that job satisfaction increases nursing home care quality and residents’ quality of life. The researchers also found that organization leadership support and person-centered care correlates with improved care quality, staff satisfaction, and staff retention. Therefore, workforce skill mix and engagement should be considered.


The well-being standard, which supports staff physical and mental health, is one of the defining hallmarks of PTE-LTC. Staff working in long-term care facilities endure difficult situations and accompanying stress, making strategies to improve their well-being essential. A thematic analysis of databases by Embregts and colleagues identified the potential impact of infection outbreaks on the psychological state of long-term care staff. The researchers identified three themes: emotional responses (fears and concerns, tension, stress, confusion, and no additional challenges), ethical dilemmas, and reflections on work attendance. Identified suggestions to support and protect staff include education, information, housing, equipment, and infection control policies and guidelines. Organizations can use these suggestions to build a sense of well-being in their facilities and a positive work environment during the pandemic and beyond.

Professional development

Leaders must ensure that nursing staff are competent and provided with education beyond mandatory state or federal requirements. For example, many nurses felt unprepared at the beginning of the pandemic, so emergency preparedness should be incorporated into all long-term care facilities’ professional development programs. Another advantage of education as a tool for professional development is that it enhances staff engagement. (See Steps to excellence.)

Steps to excellence

Self-assessment: Start your Pathway to Excellence in Long Term Care® (PTE-LTC) journey with a workplace culture self-assessment to identify gaps between your organization’s actual and desired state. Engage staff and leaders in this process and create a roadmap to build on the organization’s strengths and discover strategies for improving the work environment. Appoint a PTE-LTC program director to ensure timelines are followed and stories are collected.

Documentation and standards: Register for a PTE-LTC application. This starts the clock for document submission.

Validation: After you’ve submitted the documentation, a survey is administered to organization nurses (RNs, advanced practice RNs, and licensed practical nurses) and certified nursing assistants to validate the enculturation of the standards into the work environment.

Many resources—including workshops, webinars, a pre-intent program, a learning community, an annual conference, and a dedicated staff—are available to guide organizations through this journey. Learn more about PTE-LTC at

Why now more than ever?

Nurses voices can help shape the future of long-term care. The care inequity experienced by residents in these facilities during the pandemic must never happen again. System facilitators and barriers must be addressed to ensure this vulnerable population’s healthcare needs are met. Directors of nursing can lead this initiative and gain buy-in from facility owners and administrators. Too frequently, however, directors of nursing don’t have a strong voice in shaping the organization, so top leadership must make a commitment to change.

We applaud the nurses and staff working in long-term care during this pandemic, but we can’t accept what happened and go back to business as usual. Investing in long-term care staff is a powerful way to change the course of healthcare and improve patient outcomes. Now is the time to make revolutionary changes and take the PTE-LTC journey.             AN

Edna Cadmus is executive director of the New Jersey Collaborating Center for Nursing and clinical professor and specialty director in leadership at Rutgers University in Newark, New Jersey. John R Mastrocola is director of regional operations – southern region at Generations Healthcare in Santa Ana, California.


American Nurses Credentialing Center. 2020 Pathway to Excellence & Pathway to Excellence in Long-Term Care Application Manual. Silver Spring, MD: American Nursing Credentialling Center; 2020.

Centers for Medicare and Medicaid COVID-19 nursing home data. October 18, 2020.

Manatt. Recommendations to Strengthen the Resilience of New Jersey’s Nursing homes in the Wake of COVID-19. June 2, 2020.

Castle NG, Wagner LM, Ferguson-Rome JC, Men A, Handler SM. Nursing home deficiency citations for infection control. Am J Infect Control. 2011;39(4):263-9.

Castle NG, Hyer K, Harris JA, Engberg J. Nurse aide retention in nursing homes. Gerontologist. 2020;60(5):885-95.

Castle NG, Engberg J. Further examination of the influence of caregiver staffing levels on nursing home quality. Gerontologist. 2008;48(4):464-76.

Embregts,P, van Oorsouw W, Nijs S. Impact of infection outbreak on long-term care staff: A rapid review on psychological well-being. J Long Term Care. 2020.

Moore M. Shared governance: Why you need to empower your workforce and get out of the way. McKnight’s Long-Term Care News. September 21, 2019.

Pabico C. Dispelling common myths about ANCC’s Pathway to Excellence®. Am Nurse J. 2020;15(5):34-37.

Rajamohan S, Porock D, Change Y-P. Understanding the relationship between staff and job satisfaction, stress, turnover, and staff outcomes in the person-centered care nursing home arena. J Nurs Scholarsh. 2019;51(5):560-8.

Specht J. Quality of nursing home environments. J Gerontol Nurs. 2015;41(3):3-4.

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