What's Ahead for DONs.

An interview with Robin Storey, RN, BSN, FACDONA, President, National Association of Directors of Nursing Administration/Long Term Care (NADONA/LTC)

One thing is for certain: No matter how one assesses the future of long-term care, the director of nursing will be in the thick of it. In fact, one of the offshoots of the struggles over the Medicare Prospective Payment System (PPS) has been the demonstration of just how central the DON is to nursing facility operations, combining clinical and financial responsibilities. The DON is the one who oversees the hands-on care of residents within strict, financial boundaries, who can truly cost-justify investments in resident-care personnel and equipment, and who sets the standards for that care. Last year--the first full year's implementation of PPS--also demonstrated how difficult and frustrating the position can be. The DON, who cuts across all boundaries in facility operations, sometimes ends up getting caught in the middle, or lacking sufficient clout in any area of responsibility. Will the new millennium bring new satisfaction? Recently Robin Storey, NADONA's newly elected president and a founding member of th at organization, as well as a 17-year veteran of long-term care and, most recently, director of program development and quality improvement for five facilities of BJC Health Systems of St. Louis, Missouri, responded to some future-oriented questions from Nursing Homes/Long Term Care Management Editor Richard L. Peck.

Peck: What do you see as the biggest challenge facing DONs, whether in the short term, the long term or both?

Storey: I think we should take things one year at a time. From the experience I've had with our five facilities, I'd say staffing will be the most critical issue this year. It's becoming more and more difficult to attract staff to long-term care and, once there, to keep them. It's not just money. Nursing assistants say that people don't know how to talk to them. LPNs--and RNs, too--lack management training. They're managing people, one of our most precious resources, and they don't know how--a big concern for NADONA. And then, to attract people in the first place, you have to get past all the negative publicity that nursing homes have received in recent years. Everyone knows all about the bad things, but nobody outside the industry knows about the good things because nobody talks about them.

Peck: Given these difficulties, how do you see nursing home staff evolving in coming years?

Storey: The nursing facilities that survive will be those that are serious about training people to manage staff and resources well. They are also reviewing new staffing models. For example, there is a New York State facility that gives nursing assistants direct responsibility for coordinating care; the facility maintains a good staffing ratio, and there are still stacks of applications from nursing assistants waiting to get in. Obviously, you can't give away the duties of professional nurses, but you can give away those that professional nurses don't have to do and train nursing assistants accordingly. There are even facilities in which the nursing assistants are doing their own scheduling. Other steps include career ladders, so that even if the person can't go on to nursing school for whatever reason, there are more challenging roles they can take, such as managing special resident-care projects:

Peck: And how will the DON's role evolve?

Storey: I hope to see DONs develop a more genuinely collaborative role in facility management, including developing budgets and staff ratios and having more control over resources. Part of the frustration DONs can face is a lack of control over their responsibilities, so that they end up burning out and leaving. Administrators have to know that we need to work together.

Peck: Do you think, as some have suggested, that PPS has hastened the process of DONs assuming more managerial control?

Storey: Some DONs have become very astute and very involved very quickly in the handling of budgeting and staff issues because of PPS.

Peck: What will it take to attract professional nurses to this field, particularly in view of the growing general nursing shortage?

Storey: The situation is very bad right now. I've talked with nurses who've had charge nurse positions open for three or four months. Admittedly, it is very difficult to attract someone to geriatric care who has not been trained in it. To love geriatric care, you have to be exposed to it, and that's just starting to happen.

By the same token, there's a trend going on now toward hiring nurses fresh Out of nursing school to be DONs, and they're just not prepared for this position. One of NADONA's main projects is to develop minimum standards for the DON position so that administrators will know what to look for. These should be completed sometime this year.

Peck: What would you most like to see happen in the foreseeable future?

Storey: There are several things. First, I'd like to see our focus remain on long-term care reimbursement. It's not good and, even with the additions to PPS last year, PPS still has a way to go.

Second, I'd like to see more consistency in the survey process. I work with five facilities in two states and sometimes it's like night and day from one facility to the next, even with the same survey team. I'd like to see more consistency in the application of regulations by the surveyors. I'd also like to see a more collaborative and less punitive survey approach, at least in those facilities that have had a consistently good record but might be having a particular problem. Once a facility starts on a downward spiral, it is very difficult for it to come back.

Third, I'd like to see the continued growth of NADONA. I'd like to see more participation in our annual conferences, which are highly educational and an extraordinary networking opportunity. With an organization the size of ours--5,600--there should be a good proportion of that in attendance.

Peck: And what would you least like to see?

Storey: The status quo. We need to constantly challenge ourselves to make the system better.