Preparing today's DON: the ideal education.

Here is the training you should have had (and are probably picking up the hard way)

Imagine that you are the DON of a 250-bed skilled nursing facility (if this is not already the case). On Monday morning - the day before your state survey - you arrive in your office to find that six of your nursing staff have called in ill for the day, two more of your nurse aides have quit and your charge nurse on the subacute unit has just had "words" with a resident's daughter who now wants to remove her mother from your facility.

On your way to the administrator's office to discuss staffing problems (he's always given you good advice), you're called into a meeting and informed that Friday was the administrator's last day - his replacement will begin tomorrow (the day of your survey).

If any of this sounds painfully familiar, you're not alone. The feelings of frustration and helplessness that can arise from the events of a day like the one described above seem to be part of the DONs' lot in life. And is it any wonder? The DON's position is one of the most - if not the most - critical to the quality of care and day-to-day operation of the nursing home. The DON is expected to be an expert on everything from patient care to budgets, regulations, staffing, purchasing, training, management and interpersonal relationships. Indeed, the DON is often placed in the position of needing to be "all things to all people."

Do you feel as if you've been adequately prepared for this awesome responsibility? If, like most DONs, you're in that 40-something age group, you went through a two or three-year education program in the 1970s that didn't even begin to cover budgets, regulations, management skills, or the "how to's" of functioning within a turbulent health care system. There is no question that you've gained a working knowledge of these issues throughout your career, but most of that learning has been by trial and error, and that can be one of the toughest ways to learn.

The person who directs the nursing care in a nursing home needs to be prepared both educationally and experientially, on both a clinical and an administrative level. The good news is that gerontological content appears to be increasing in all levels of nursing education. While this is a tremendous step forward in terms of clinical education, the teaching of management skills - specifically those required in the nursing home setting - is still sorely lacking from many nursing school curricula. The result is that many DONs are essentially thrown into management positions, ready or not.

What's needed is a multi-pronged approach to nursing education, especially for those who intend to manage staff during their career. The core components of an ideal curriculum for the would-be nursing home DON would, of course, include the clinical/gerontological education required to care for the increasingly medically complex nursing home resident. But beyond the purely clinical, DONs should be knowledgeable in the following areas as well:

Nursing home management. This is a broad area involving a number of key components including, but not limited to, the following:

Leadership skills. This would include knowledge about managing groups of professional staff as well as working with multidisciplinary teams to optimize resident outcomes. Other needed leadership skills include things such as policy making and maintaining, conflict management, organizational problem solving and decisionmaking and strategic planning.

Organizational culture and climate. How do you assess these, and what effect do they have on nursing care? How can these factors, whether positive or negative, be used effectively?

Managing quality. This should include not only quality of the residents' medical care, but quality of the residents' life as well.

Communication skills. A basic, of course. The best managers can - and probably will - fail if they are unable to communicate effectively with staff.

Creating a satisfying work environment. Turnover is still a major problem in many nursing homes, and the key to creating a satisfying work environment in this situation is to focus on those aspects of the turnover problem that can be changed or controlled. For example, DONs and nurse managers should provide staff with a variety of challenging work assignments. This will stimulate staff and help them grow. No doubt, this takes time, which is in precious short supply. But anything one can do to reduce turnover will have a positive effect on every aspect of the facility's nursing care.

Advanced nursing knowledge. The nursing profession is changing. Greater reliance is now placed on research findings to guide nursing practice. Familiarity with nursing theories and use of computer systems can also help improve nursing outcomes.

Financial management. Economics, budgeting and accounting specifically for long-term care.

Politics and negotiation. Today's nursing homes are dealing with an increasing variety of outside influences, ranging from government agencies to other providers (e.g., networks) to managed care. There has never before been such a demand placed upon DONs to understand the politics, both internal and external, of decisionmaking.

No doubt, if you are the typical DON - i.e., two- or three-year- prepared - then what has been described in this article is the curricula you have picked up in on-the-job training. This is a difficult way to go. The fact is, it is only when you get to the four-year programs and beyond that formal education includes these types of issues. Even at the four-year level, these areas are dealt with only briefly, and it's really at the master's level that management skills are given the emphasis they are due. Hence a somewhat controversial recommendation: that DONs be prepared with, at the very least, a four-year degree, and, preferably, a master's degree.

The idea is not new. This recommendation was made by the author of a large national study (Lodge, Mary P., Professional Practice for Nurse Administrators/Directors of Nursing in Long-Term Care Facilities,) as long ago as 1985, when long-term care nursing wasn't nearly the complex, multifaceted profession it is today. Also, in the January/February 1984 issue of Nursing Homes ("Exploration of Roles in Nursing Homes"), Ann Butler, GNP, called for "adequate preparation of nurse executives to fill these complex roles in nursing homes..." Twelve years later, Butler's words are more relevant than ever.

As for yourself, there are formal education programs that offer the management training discussed in this article - it's just a matter of being selective in your choice of schools. Moreover, this kind of preparation can be had from a number of informal sources. There are, for example, a number of continuing education programs, including wonderful seminars dealing exclusively with managing human resources and organizational behavior, and geared specifically to the LTC nurse. Professional organizations, such as NADONA, provide invaluable information about such courses. Continuing professional contacts and familiarity with the literature are also essential.

Pursuing any or all of these avenues will help ensure your success as a DON, today and for the foreseeable future. More specificially, it will help you to prepare to deal effectively with scenarios like the one described at the beginning of this article - and to come through them unscathed.

Connie J. Rowles, RN, DSN, is an assistant professor at the School of Nursing, Ball State University, Muncie, IN.