DAY IN THE LIFE OF A DON.

Whether the title is Director of Nursing, Director of Nursing Services, or something else, the person behind the badge carries responsibility for the facility's quality of care--and often exerts enormous influence over quality of life for residents, patients and staff. What does it take to do the job--and do it well--in today's challenging environment? Find out by following one through a typical ...

7:30 a.m.

Director of Nursing (DON) Sharon Kowalczyk, RN, C, arrives at Fort Collins [Colorado] Good Samaritan with a packed briefcase, box of dog biscuits, and mismatched footwear.

The briefcase contains paperwork completed at home, the biscuits are for the facility's dog, and the sandal attempts to match, and minimize, the walking cast on her other foot.

Last year, she shepherded the 56-bed skilled facility, (part of the 120-resident skilled, assisted living, and apartment facility) through JCAHO accreditation. It was the first Western region nursing facility to earn an OSHA "SHARP" award for standards compliance, and got a near-perfect survey, too. Now she's helping to open its therapy center, and working on phase two of a more "Edenized" environment. (See "Alternative lifestyle," July 2000 CLTC, page 38.) This is merely a glimpse into a typical day.

It begins with a 5:30 am. phone call to the night nurse who expressed interest last year in working days. Kowalczyk finally has an opening: her daytime charge nurse is switching to special care and relief. Kowalczyk calls to see if the night nurse is still interested. She'll also post the job, but usually knows if any of her 44-member staff want changes. Her biggest question is whether she'll advertise a night or day position.

After calling, she awakens her husband, son, and grandson, and prepares for work. Now, she drops briefcase and biscuits in her shared office, checks her calendar, affixes her name tag, and grabs paperwork for multiple meetings.

7:35 a.m.

"I like to perch," says Kowalczyk, rolling in a feeding stool, rather than crowding another chair into the social services office, which barely accommodates the weekly Medicare meeting team: the MDS nurse, physical therapist, PT assistant, occupational therapist, rehabilitation coordinator, and restorative aide.

They comment on sticky notes papering Kowalczyk's calendar. "I can't operate without them," she confesses. Most list meetings to attend, but at least one is a quote: "Creativity is the ability to look at the ordinary and see the extraordinary." It's from last week's inservice video. "I loved it," she says. Staff members murmur in agreement, then begin review. They're covering seven residents, and at least one dilemma.

After intensive therapy, the resident hopes to go home with 24-hour care, reports the PT, despite complex physical and psychological problems.

"I'm hearing what he says," says Kowalczyk. "What does his wife say? Have we asked her?" Caring for families, as she often says, is a lot of work, but as much a part of the job as resident care.

The rehabilitation medical director arrives, and this time, when the PT outlines the problem, she expresses concerns that the huge emotional burden of providing care may put the wife at risk. Kowalczyk murmurs, "oh, yes" in fervent support.

She asks the doctor's opinion about the resident's inappropriate behaviors, dementia, and emotional status. Decreasing medications has increased his disability.

"What about treating the depression component?" Kowalczyk asks. "This is hard for us, too. We've known him since he was coming here to care for his family."

As other residents are covered, Kowalczyk often comments on their status: "She's been looking pretty blank," she says about one; "She isn't doing well with her scooter," about another. Last session, she expressed doubts about one resident's test results and status. "Sharon's gut was right on that one," says the PT. "Kudos to you."

It's more than gut. Kowalczyk, a certified gerontological nurse who specialized in geropsychiatry, has been a director of nursing services for nursing homes and home care, provided direct care and hospice services, and managed a home care agency. She was a DON for a psychiatric hospital, and worked med-surg. "My father knew nursing offered life-long security," she says. "By example, my mother taught me to appreciate elders."

Staff members intermittently open and fan the door to bring air into the windowless room, which is getting hot and stuffy. Confidential meetings are held here to give residents full access to common areas and community rooms, although the forthcoming expansion includes a conference room. Despite crowding, Kowalczyk is grateful for the size of the team. "When I started in nursing, I did all the rehabilitation, scheduling, and staff development myself, and with a social worker I did the MDS," she says.

Since the inception of PPS, they must complete three to four times as many MDS forms. "That's tremendously increased the workload for all staff," Kowalczyk says. "We have to keep adding upper layers to do paperwork, rather than people to give care."

8:25 a.m.

When the case load is finished, most members bolt. Kowalczyk remains as the restraint reduction committee arrives. Since the facility is restraint-free, members focus on reducing falls by eliminating hazards and stabilizing or strengthening residents. "We've got it down to a science," says Kowalczyk, who also attends monthly meetings to reduce psychoactive medications. Today, they address the five residents who use partial side-rails, three who wear self-releasing seatbelts, and several falls.

One resident declined placement of skid strips in her room. "What's going on with her?" asks Kowalczyk "She was doing well, Is her daughter on vacation? Or is it Parkinson's cycles?" She explains them briefly.

Another family declined to pay for the recommended bed alarm, and since the resident is frightened by alternative measures, Kowalczyk received facility permission to waive the cost. She's suggested a new bed alarm system for consideration in the August budget.

9:05 a.m.

During pauses, Kowalczyk huddles with some staff members. "Lots of little subcommittees go on during committees," she says. "There's just not enough time for everything." Her broken foot temporarily suspends strategy sessions she formerly combined with lunchtime walks.

A resident's non-slip floor pad is missing. "Let's see who's cleaning there," suggests Kowalczyk. "If people think picking it up is a favor, let's write on it, 'Please keep on floor."'

When she volunteers to move equipment for the therapy center's opening, the group choruses, "You're supposed to stay off your foot," then threatens her with medical orders. "I can lean on the cart," she protests.

9:15 a.m.

Kowalczyk leads the next committee, reviewing Quality Indicators.

All morning, as staff members rotate through the crowded, stuffy room, Kowalczyk remains, offering small details, catching inconsistencies, and providing continuity in patient care and facility planning. She does this all week long: QA, ethics, therapy center, workplace violence, safety, administration, nutritional risk, restorative dining, falls, chemical restraints, Medicare, care conferences. "It's all interwoven. I help tie it together," she explains.

9:35 a.m.

Kowalczyk greets staff members at the nurses' station, asking about grandchild due dates and travel plans. She checks the 24-hour report and staffing (which she usually does on arrival). During their absences, she covers for MDS and social services. She always reads the whole report, looking for ways to improve care. Today, all is quiet.

9:42 a.m.

After taking report from the charge nurse, Kowalczyk provides care planning updates. Noting one man appears unusually pale, she requests a pulse oximetry reading.

"I like to at least eyeball everybody twice a day," she says. "It's amazing what you pick up when you see residents regularly, but don't work with them all day, like late afternoon edema."

She walks through the building greeting most residents by name, putting on slippers, adjusting an oxygen tube, answering a resident's request for water, soothing one with conversation and another with a shoulder caress.

She also reassures staff, discusses needs for time off, and asks about personal matters. She approves one nurse's request to switch her day off to accommodate other commitments.

10:10 a.m.

Kowalczyk reviews her weekly nursing staff newsletter, "Sharing by Sharon," which is two or three pages of staff changes, policy reviews, and esprit de corps. Stacked nearby are inspirational and educational books she gives CNAs and licensed nurses.

"Caregivers give lots of support, and don't get it back," she says. "If we don't support each other, we bum out and lose all effectiveness." She estimates 50 percent of her time is spent counseling staff and others. Some counseling is personal, some is professional. "Some of their lives are so hard," she murmurs. "They need caretaking themselves."

She's encouraging distance-learning opportunities and developing performance incentives. Kowalczyk has also started career ladders, training all CNAs first in restorative care, then in the disease process. "Not feeling important is a big issue," she says. "New opportunities are exciting, and raise the bar."

10:50 a.m.

Kowalczyk investigates an incident report, verifying notification to appropriate parties. She works on the seven-page LTC100 admission form begun yesterday, then pauses for a staffing update, expressing concern for a nurse injured off-duty. She helps resolve a thorny behavioral issue.

She relinquishes the chart to others, because "my time's more fluid," she says. Next, she works with the medical records staff, developing data coding categories for facility audits. She spent three hours at home reviewing them. "We do lots of audits for QA and to remain compliant," she says. "And lots of staff education to address needs."

She discusses special projects such as room reorganizations with several GNAs, gives documentation advice and answers numerous questions about who's where. "Sometimes I feel like a traffic cop or mediator," she sighs.

She begins a staff evaluation. Instead of doing the entire nursing department herself, she encourages charge nurses to evaluate CNAs because they can provide better feedback.

12:40 p.m.

After a 20-minute lunch, Kowalczyk carries charts to the sunny dayroom, auditing them for completeness and accuracy. She cheerfully responds to resident requests for a blanket, then a lighter blanket, and staffs technical questions. "I rarely get to use my clinical skills anymore, because my staff is so competent," she says.

12:55 p.m.

While reviewing documentation to verify coverage, a visiting Medicare claims representative asks, "Were you crippled last time I visited?"

"I'll be fine," assures Kowalczyk.

"You sound positive," says the rep.

"I'm a nurse. Of course I'm positive," answers Kowalczyk.

1:05 p.m.

During care planning, one young resident expresses frustration with call lights; Kowalczyk, unruffled, explains the new system's installation.

She then takes time to counsel a stressed couple, discussing their mother's decline.

2:30 p.m.

Kowalczyk greets incoming nursing staff. One nurse offers to swap days with another who is expecting family, as long as it doesn't include Friday night. "Thank you," says Kowalczyk gratefully. "If she can't work Friday, I'll cover." She'd rather cover than call pool.

3:30 p.m.

Kowalczyk scans catalogues for staff gifts; she's suggesting departments give CNAs a week of personal thank-yous: car washes, sundaes, hand massages. In the dayroom, she audits more charts, then assists a resident outdoors for fresh air.

4:20 p.m.

She escorts residents to early supper seating, takes meal orders, and helps feed: "It helps show staff nobody is too important to pitch in." Despite shifting recently to daylight savings time, she regrets schedule shifts. "Changing routines impacts residents considerably," she says.

5:05 p.m.

Charting done, she returns to the kitchen. Despite her broken foot, she sets volunteer banquet tables. After resting briefly while guests arrive, she helps serve. "I'll feel guilty if I don't," she says. "Events are an extra burden on my staff."

6:25 p.m.

Kowalczyk sits to eat--and discovers she's an honoree during the meal, an unexpected bonus of the job, she says.

7:25 p.m.

As usual, before leaving, she checks if the staff and residents have everything needed, including resident snacks and night shift meals: they do. She thanks a family for their regular visits, then buses tables.

7:45 p.m.

Kowalczyk leaves.

She's taken four quick breathers, served on three committees, served two meals, counseled staff, given directions, set examples, provided countless checks and balances, and spoken twice with nearly every resident and on-duty employee.

She hasn't lost her cool. She hasn't covered crises--there weren't any. There rarely are, says administrator Sherry Friesen, because Kowalczyk keeps problems from blowing up through prevention and personality. "Sharon remains calm, seeking staff input and buy-in for solutions," says Friesen. "She supports me, and accomplishes our facility vision methodically, by holding higher standards, thinking through processes, creating audits, and holding people accountable. She's one of the best DONs I've ever worked with."

Wendy L Bonifazi, RN, APR, is a freelance writer in Fort Collins, Colo..