DON 2000: back in control.

What will a director of nursing be like in the year, 2000? In four more years (assuming a "best case" scenario), most of the original and updated "OBRA mandates" should have been met. DONs can then evaluate to see exactly how their nursing departments have evolved. They should notice things beginning to swing back under nursing's control because, as we all know, the responsibility for virtually everything that happens concerning the facility (except maybe the landscaping) falls on the DON's license - and when your license is on the line, you had better have control.

Nursing will find itself more responsible for the costs of care. No one can begin to predict exactly what will happen with all the changes underway in health care, but there will definitely be a strong trend toward more controlled, managed care.

When you or your nurses request an order for a new medicine, test or hospital admission, is the cost ever considered? Could an earlier intervention have prevented what is now a more expensive need - and more importantly - could earlier holistic measures have kept the person healthier?

A deceased resident's daughter recently related to me the sad tale of her mother, who was very lonely and had a demanding personality. The staff in the nursing home where she lived, according to her daughter, avoided her, which exacerbated her demanding nature and made her frightened that her needs would not be met. The resident frequently related to her daughter that when she put on her call light, someone would come into her room, turn off her light and say that they would return - but never did. As this intelligent lady deteriorated and lost control of her bowel and bladder, she complained that she was left to, as her daughter said, "mess her bed, then lie in it until someone finally came to clean her up." She was eventually sent to a psychiatric ward for several weeks, from which she returned to the nursing home several pounds lighter (she was already thin and frail) and confused - but on medication that made her less demanding. This hospitalization cost Medicare, for the bed only, over $10,000.

Was this necessary? Was this resident a threat to herself or others? Could this incident have been avoided if she had been treated more like a person, without the "demanding" label attached?

A nurse consultant friend of mine was evaluating a facility for a restorative nursing program and the facility's therapist told her he had recommended three days a week of range-of-motion for a particular resident and was told, "We are not allowed to do ROM on this lady." Would you want your nursing license to be on the line in this situation?

Nursing lost control chiefly because entirely too many changes were mandated over a short period of time. Many DONs began allowing anyone who seemed remotely capable of taking some of the load off her/his shoulders to take it. It was a way to survive while still trying to cope with staffing problems, obstinate physicians, families' complaints, resident care basics, finding clothes lost in the laundry, and checking charts, meanwhile making sure that all medicines and treatments were given, that all prescriptions were delivered from the pharmacy and properly stored, that the narcotic count was always right, that care plans were completed and absentee staffers covered for - and watching out for fire, flood, earthquakes and tornadoes!

In resuming control, ask yourself: Are all departments pulling their weight and working as teammates with nursing? Are all residents receiving the physical, mental and social stimulation needed to keep them at their highest level of functioning? Is dietary monitoring its feeding procedures and food and fluid intake, or do the dietitians feel their responsibility stops with preparing the food? Does nursing help to encourage residents to attend activities, and willingly assist with their transportation? Do your physicians and therapists understand restorative nursing and the potentials your residents have for increased independence?

Only one person can be "ultimately in charge" of your health care team, or there will never be continuity of care and adequate communication. Again, it is the DON's job description, responsibility, and license at stake - so she will want to be in control, and staffs in the good facilities will acknowledge that.

The DON of the year 2000 will always think holistically - looking for underlying reasons for a problem, at the whole physical and emotional person, and stressing that person's dignity. She/he will be well educated - not necessarily with degrees, but with knowledge of wellness, of human potential. She will keep her staff focused on the "person" and not the "machinery", always trying to keep her facility from becoming overly technical instead of focusing on simple, basic human needs. Though she will work on special projects in a timely, progressive manner, she will always see that day-to-day care comes first.

Our colleagues in acute care may even find they have something to learn from us!