Why DONs drop out.

Today's director of nursing grapples with high expectations and limited resources

Like many others in health Care, the role of director of nursing (DON) in a long term care facility has changed almost beyond recognition. "I've been a director for over 20 years and it just isn't fun anymore," laments one nurse. 'When I started we had time to spend with the residents. That has changed. Now I spend it on paperwork, compliance, and staffing."

One doesn't need to go back 20 years to see the many changes in responsibilities. Try 10 years--implementation of OBRA, MDS, criminal background checks, staffing shortages, reimbursement changes, higher acuity levels. Or how about five years--PPS, acute staffing crisis, regulatory changes.

The changing health care environment is having a tremendous impact on the role and responsibilities of the director of nursing in long term care. Today's director must know how political, social, and economic trends are affecting long term care. A DON must also have strong management skills and clinical expertise. She must understand concepts of marketing, outcome achievement, finance, and quality improvement.

Dr. V. Tellis-Nayak, a private consultant from Alexandria, Va., who has researched DON turnover in more than 500 facilities located in more than 30 states, puts it more simply. "The director of nursing is the architect of quality," he says. "She juggles many worlds and is the mother for all seasons. She is part Mother Theresa and part soccer mom."

But this "part Mother Theresa and part soccer mom" is vacating the position with increasing frequency. Turnover rates range as high as 60 percent. [1] One study conducted in a Midwestern state found that more than one-fourth of facilities had a DON in the position for a year or less, and fewer than 50 percent of facilities had just one director over the previous five-year period. Furthermore, almost 56 percent of DONs said they'd leave the position if they could and 89 percent would not take another DON position. [2]

This scenario is occurring within an environment where the RN workforce is aging, more RNs are leaving the profession than entering it, and most wouldn't recommend the profession to a child or friend.

Morale busters 

Three main themes emerged when Dr. Rita Winters, formerly an assistant director of nursing at a Midwestern nursing home, did a graduate school survey in 1994 and a follow-up doctoral study in 1999 and 2000. She surveyed 230 rural facilities in a Midwestern state.

Staffing shortages, lack of administrative support, and increasing regulations were the themes, according to Winters. "These comments showed up so frequently there was no doubt that they were the big issues," she says. "Remember that I first got the comments about staffing back in 1994 when it was tough but nothing like it is now. It has become an even greater problem during the past several years."

Also of concern in 1994 was the increasingly tough regulatory environment. "Directors began to hear about fines being levied by the health department for certain deficiencies," says Winters. "At first, they thought, 'It's happening to the poor facilities, so it won't happen here,' but soon they noticed perceived good facilities being fined. It started happening closer to home, and many became fearful that no matter how hard they worked it wasn't good enough."

A long-time urban director of nursing who recently left her position for a non-administrative one said that Winters' reasons for the turnover in the rural environment are just as relevant in the urban environment. But she adds another: the stress of decreased reimbursement and its complicated systems. "There is less money under the complex PPS system," she says. (See "Profitability under PPS," September 2001 CLTC, page 38.)

Staffing issues are of particular concern, especially since decreased reimbursement results in staff cuts. "Fewer staff members means the potential for decreased quality of care at a time when the regulations are getting tougher. We are expected to provide perfect care with an imperfect system," Winters continues.

Others might envy this director who left a stressful position behind. "Many DONs said they would leave their positions if they could but there aren't as many options in the rural areas," said Winters.

The mean tenure rate she identified was 6.3 years (range of one month to 28 years), considerably more than the 2.2 years that a study of urban and rural nursing homes in that same state had identified five years earlier. Winters, whose mean rate was influenced by a large number of older tenured nurses approaching retirement, said that the reason for the longer tenure was limited job mobility in rural areas. "The nearest nursing home may be many miles away in contrast to a metro area where there might be several facilities close by," she said. She believes rural nursing administrators, predominantly women, are tied to an area because of family commitments.

Tellis-Nayak has another opinion as to why there may be longer tenures in rural areas. In a small community, they know one another, he says. They are familiar with residents and families from contacts outside the facility, so it creates a different environment.

Diane Vaughn, immediate past president of Minnesota Directors of Nursing Administration, has several suggestions. The DON needs a balanced life with time off and normal workdays, she says. The Minnesota organization feels so strongly about balance that it awarded a $500 scholarship to a member for personal wellness use. The recipient could choose how it was used--perhaps a massage or a day at the spa.

A professional networking system is important too, Vaughn continues. Getting together with colleagues to share ideas and encouragement can provide a new perspective. Reading professional journals and attending training workshops keeps one updated on new trends.

Many state nursing home associations provide support in the form of training and networking. After commissioning a study to identify factors contributing to turnover in member nursing homes, the Kansas Association of Homes and Services for the Aging (KAHSA) used the conclusions to formulate educational programming, according to Vice President Debra Zehr. Supervisory training, a key recommendation of the study, has been enhanced. KAHSA was at the forefront of developing The Learning Network ([less than]www.tlnpartners.com[greater than]), a computer-based training and communication program for nurses and other long term care staff. These interactive classes assist DONs and others to improve not only supervisory skills but also staff recruitment and retention strategies.

For the past 10 years the Indiana Association of Homes and Services for the Aging (IAHSA) has conducted a retreat for DONs, says Barb Pantos of that agency's office. The retreat, geared toward nursing leadership, covers human resources, management, clinical, and regulatory issues--with an emphasis on self-renewal and stress management. The association also publishes the Director of Nursing Digest, a synopsis of clinical articles and best practices. IAHSA does not offer an orientation course for new DONs, but the Indiana Health Care Association holds one at least annually for members of both organizations.

Life Services Network of Illinois offers an orientation resource guide for new DONs, according to Tess Kwiatkowski, executive vice president. A quarterly leadership group discusses topics such as workforce and regulatory issues. An annual retreat for DONs and other nursing managers focuses on relevant issues and stresses networking.

Professional nursing organizations are another good source of training and support. The National Association of Directors of Nursing in Long Term Care (NADONA) promotes professional relationships with other disciplines, establishes standards of practice, and sponsors a certification system for DONs. Other member services include educational materials, a quarterly journal, scholarships, and national conferences. A phone mentoring system provides assistance with topics ranging from care plans to nurse aide training to litigation preparation.

Back to school

The Institute of Medicine's 1996 Task Force on Adequacy of Nurse Staffing recommended that nursing facilities place greater weight on the educational preparation of their directors.

But several barriers exist. Currently, the majority of DONs in long term care have a diploma or associate degree in nursing. The industry has placed limited emphasis on DONs' educational preparation, while schools of nursing have been slow to develop curriculum content that would prepare nurses for long term care leadership positions. Nurses are interested in pursuing formal education but also desire flexible, nontraditional approaches.

One nontraditional approach is a series of online education programs for nurse leaders in long term care developed by the University of Minnesota School of Nursing. The Web-based programs ([less than]http://ltcnurseleader.umn.edu[greater than]) are available for continuing education credits but eventually may be used for academic credits. Topics include staff recruitment and retention, developing a comprehensive staffing program, developing and evaluating nursing care delivery models, using evidence-based practice to improve quality, and financial management.

St. Joseph's College of Maine ([less than]www.sjcme.edu/gps[greater than]) also offers a nontraditional approach, according to John Pratt, director of St. Joseph's Undergraduate Healthcare Programs and St. Joseph's Long Term Care Management Institute. An RN who wishes to obtain a bachelor's degree may do so by combining transfer credit, course challenges, faculty-directed independent study, and two summer residencies. A master's degree offering an administrative focus is also available.

Stability and quality

"A stable director of nursing reaps a golden harvest," concludes Tellis-Nayak from his turnover research. He assigned a percentile rank to each of more than 500 homes according to the director's length of stay (LOS), then divided the homes into three groups according to rank. He found that in any given year the group with the longest LOS had higher indicators in all categories: Staff and family satisfaction increased, staff turnover declined, liability costs dropped, workers' comp decreased, state survey results improved, occupancy rose, bills were paid on time, and revenues soared. Tellis-Nayak is convinced that the indicators would have been even higher if he had factored in education and motivation.

The DON's role in long term care faces major stressors that compromise stability. Unless this problem receives attention at the highest and broadest levels, these stressors may well continue and escalate to the serious detriment of quality care for the nursing home population.

Woodbury, Minn-based Janice K. Olson, RN, MS, MEd is a member of CLTC's advisory board.

References

(1.) Heine C. Crisis in long-term care nursing leadership. The Director. 1993;1(1): 17-19.

(2.) Chiabotti D. Current trends for Minnesota's directors of nursing in long-term care. Unpublished paper, 2000.

WHY DO DIRECTORS STAY?

At a meeting of a metropolitan-area subgroup of the Minnesota Directors of Nursing Administration in Long Term Care, directors were asked what kept them in their positions. These are representative of their responses:

Meeting challenges; successful outcomes: "I like a position which offers me challenges," says Mary Hafner, RN, director of quality assurance for Elim Care Inc., Eden Prairie, Minn. "And I like making a difference in the residents' quality of life and in long term care."

Supportive administrator, mentoring staff; sense of mission: "I appreciate the support of my administrator. We may not always agree on issues but we can discuss them in a respectful manner. And I have the freedom to make all decisions pertaining to the nursing department," says Janet Churchill, RN, director of health services at Lyngblomsten Care Center, St. Paul, Minn. "I also get tremendous satisfaction from seeing staff grow and reach their potential."