Transforming the DON: still managers, but clinicians, too.

Directors of nursing are no strangers to challenge, and there's no shortage of challenges on the horizon for nursing home DONs. In fact, the next few years will likely be risky, and even a bit scary, for them with respect to managed care. DONs will need to hone their clinical skills as never before.

No question, the DON's role is principally a managerial one. But this will not suffice to relieve them of the clinical challenge. Competition for managed care patients will require that DONs make thorough, accurate admissions assessments with unprecedented speed, working closely with the admissions director, administration and the nursing staff. Under a managed care contract, it is crucial to know who you're taking on as patients, and what sorts of treatment you're agreeing to. It is not beyond the realm of possibility in this market that a very young person admitted to the facility for a 30-day stay could develop some other problem and end up being a very long-term resident on Medicaid - a potential financial surprise for the facility for which the DON may be held responsible.

Making these rapid assessments - and making them accurately - will require sharpened clinical skills, the ability to assess not only the presenting diagnosis, but also its ramifications: what extra care or equipment might possibly be needed, what additional staff might be involved? The DON must be able to make these determinations or else have ready access to a clinician/practitioner who can.

Some DONs already possess this degree of clinical skill, such as those who began their nursing careers in areas such as critical care. In general, though, for many DONs, improving clinical skills has taken a back seat to issues related to reimbursement, Medicare/Medicaid rules and regulations and so on. These topics are certainly important, but they are only part of what DONs need to learn in order to survive the coming changes in long-term care.

Re-education

Where will the added clinical expertise come from? For most DONs, getting a degree from the local college simply isn't feasible. There are, however, other ways to fill in some of those educational gaps. One of the most effective is to join and actively participate in professional organizations, both at the local and national level. Through the courses they provide, DONs can receive education that is low-cost and suited to their needs.

NADONA, for example, now sponsors clinical symposia at each of our conferences, conducted by experts in various fields. At our forthcoming conference in June, a "nurse staffing forum" will provide DONs with various staffing models from which to choose, and will teach them how to negotiate and submit staffing proposals.

The aim is to help DONs become proactive as well as educated - to become adept at meeting the challenges ahead and to step up and have a say about what goes on in their nursing homes and in the LTC nursing field.

To this end, in addition to honing their clinical skills, DONs need to become expert negotiators. They need to learn how to submit recommendations and proposals to their administrators, to do time studies enabling them to go to their administrators and say, "It takes 157 minutes per shift to care for this type of patient. Here, documented, are my staffing needs for these patients."

The Staffing "Controversy"

One thing is certain: the staffing issue will not go away. NADONA recently adopted a position statement on minimum staffing which caused a good deal of controversy in the industry. Nevertheless, of the large number of our members who responded via ballot, 80% indicated that they had no alternative but to accept minimum staffing, since it would give them "something to go by."

The comments of one of our members, a DON from Alabama, stand out in my mind. Her facility had recently admitted a post-mastectomy patient. Her staff was totally unprepared to deliver this type of care, and she wasn't permitted to increase her staff accordingly. She viewed the NADONA position statement as a "godsend," noting that it would provide her with "needed ammunition" for the required staffing increases. Many other respondents echoed these remarks.

This call for minimum staffing does not, in any way, advocate over-staffing which, as research indicates, does not equate with quality care. Rather, it makes a case for reasonable numbers of staff to meet the increased clinical needs of the residents and patients we're already taking on today and will be even more so in the future. This is not "controversial" - it is simply a fact of life.

Staffing is a qualitative, as well as a quantitative, issue. Just as do DONs, nursing staff need ongoing, continuing education, and the tools to prepare them to meet the clinical needs of today and tomorrow. This is one area in which the role of the DON is not changing. DONs have always been dedicated to educating and maintaining high-quality nursing staff, but simply haven't had sufficient control of this very critical component of quality care.

As I've said more than a few times over the years, an overworked, under-rewarded staff is going to move on to where the grass appears greener. The take-home message for facility management is that staffing appropriately and rewarding that staff for their efforts is cost-effective and simply good business. Perhaps part of the solution lies in redirecting more of the funds we're getting from Medicaid toward nursing care and staffing.

Even in the area of subacute care, I believe there's a happy medium to be found that will enable us to increase and educate our staffs, reward them appropriately, and provide the highest quality care - and, in the process, offer some stiff competition to other institutions looking to grab up the subacute dollar.

The ideal situation - and one which I believe will come to be - is one of LTC facilities admitting and specializing in the care of specific types of patients: head injury patients, AIDS patients, pediatric patients, and so on. This way, the staff becomes adept with those situations, and the specialized environment, supplies, training and methodologies for these are all in place. This only emphasizes the need for clinical expertise on the part of the DON.

A Hint of Optimism

My hope for the future is that DON turnover won't continue at the present rate. Unfortunately, with the prospect of increased competition, dealing with managed care, and the potential for mistakes during rapid assessments, I do worry about the proverbial "rolling of heads" (i.e., the DON's) after a bad survey. I would hope that there will still be a good team in place after the smoke settles.

I find cause for optimism, though, in that I see DONs taking a proactive stance, recognizing the need for assistance, seeking out continuing education, anticipating clinical needs and, specifically, advocating for a nurse clinician on staff to help with these rapid assessments. Yes, the dollar will rule, initially, but as will happen throughout health care, long-term care will ultimately be consumer-driven on the basis of quality.

The evolution of long-term care over the next few years is going to force these issues. In that respect, the challenges ahead can be seen as positive. DONs will accept them as such. They're nurses, after all, and this is what they do.

Joan Warden, RN, BSN, CDONA, is Executive Director, National Association of Directors of Nursing in Long-Term Care (NADONA/LTC).