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Make your DON your strongest link: getting the most from your DONs and charge nurses.

When owners or administrators spot exceptional nurses on their staffs, they typically ask those nurses to become the facility's directors of nursing (DON). However, those nurses receive no education in management and no guidance to do the job. The result an approximate 50% turnover rate for DONs in the country today.

Nursing home leaders straggle with DON recruitment and retention without addressing the cause at its root. Consider a change of attitude toward your facility's DON position. First of all, implement standards for your DON position. The position should be a privilege instead of a hardship.

To this end, here are some essential skills your nurse will need to attain before reaching the position of DON--so he or she is not set up for failure at the start:

1. A DON who can hire, fire, and be comfortable disciplining your staff

Set up outcomes for the DON position instead of just hiring someone you think is qualified or has been a DON before. For example, state that the person accepting the position must decrease the nurse staffing agency pool usage to 0% and increase the census by 5%. Also ask specific questions and give scenarios to ensure that the person can handle discipline.

Meet with the DON at the beginning of the week to set goals for the week. At the end of the week, meet again to see whether he or she met objectives. Discuss why or why not and strategies to improve.

2. A DON who knows the Minimum Data Set (MDS) and care plans front to back

Your DON must have a working knowledge of the MDS system as it generates all care and reimbursement. He or she should periodically review MDSs and should attend care plan meetings on a routine basis.

3. A DON who is fiscally responsible

A good DON will understand the relationship between the resident assessment instrument, Resource Utilization Groups, and reimbursement. That person should be able to provide input for the budget, such as how much money to set aside for restorative programs, etc.

4. A DON who understands risk management

As risk management is a key issue in any nursing home, the DON should set documentation guidelines for the facility, including those for Medicare Part A charting. Another key skill is the ability to explain to nurses the legal hazards and responsibilities related to their actions.

5. A DON who manages the nursing department

A good nurse manager knows the rule of the three Es: educate, evaluate, empower. He or she ensures a solid, working orientation and staff development program in facility. The DON must outline the objectives of halls/units to the charge nurses and allow them to take ownership of their areas, such as handling the schedule for certified nursing assistants for their units. They should offer resources to their nurses, including mentors and outside consultants.

6. A DON who can provide samples of a weekly job routine

A competent DON should learn to calculate reimbursement rates, look at census, and meet with the Medicare team. He or she needs to be comfortable auditing several medical records for compliance, including the MDS, and review all consultants' reports.

Other essential weekly activities include communicating with other departments regarding inservices needed, dietary concerns, activity needs, and more during the department head meeting. A good DON should review staffing and remember that it is important to be flexible when dealing with nurses who have families and other obligations. Delegation of evaluations and policies and procedures to be written can also be a weekly job duty.

DONs are also great at the clinical side, such as reviewing and evaluating pressure ulcers, infections, falls, and other areas from the quality measure/quality indicator report. He or she needs to prepare list of procedures to be reviewed by charge nurses, such as tube feedings and incontinence care, and delegate that task to them.

Finally, your DON will take charge of preparing goals for the week, meetings needed, and reports to file.

Managing savvy

In long-term care, being a successful DON not only requires clinical knowledge but also depends on the ability to manage people. That doesn't just encompass residents and charge nurses, but also the rest of the staff, residents' families, lawyers, clergy--everybody. It is a juggling act, and to succeed, there must be plans, goals, and the means of evaluating the process.

If the DON is successful, then the charge nurse will take charge. It is absolutely a trickle-down process.

As nurses, we learned a long time ago that if you did not chart it, you did not do it. That still applies; however, we need to chart using MDS language to put everyone on the same page. It is the responsibility of the DON to ensure that the charge nurses document for care and reimbursement and to provide training and evaluation. Role play helps if your staff can see it in action, they're more likely to remember how to do it.

If nurses state that they are overworked--and we don't disagree--then we suggest that the nurses keep a time-study log where they write down, in intervals of 15 minutes, everything they do during a week. For example, if they spend time going back to the nurse's station to answer the phone, then they need a portable phone. If they spend all day dispensing medications, the physician or pharmacist may need to take a closer look at unnecessary drugs and the possibility of other medication-related problems.

It is okay to have problems, but it is not okay not to fix them. Fix the problem, rather than pointing fingers, and assess what is not working and what possible solutions exist. One of the biggest complaints nurses have is that management simply does not listen. If your meetings have agendas and you don't let them turn into mere gripe and sounding board sessions, you can set goals and accomplish them.

Directing responsibility down the line

The dictionary defines "charge" as "to impose a task or responsibility on." This is exactly what the DON is doing with charge nurses. The charge nurse is directly responsible for evaluating, reporting and monitoring most of the facility's high-risk areas and then documenting the findings. Some nurses tend toward the model of the "medicine nurse"--that is, going down the hall with their carts and not always looking at the big picture as they go.

The DON and charge nurse can be your strongest links or your weakest. You can help them get to the former by providing a code of conduct to ensure the strongest link to quality care. A code of conduct might include the following:

1. Take responsibility for what you do

2. Be flexible, have fun, but stay focused on your job

3. Care enough to do your best and do more than is expected of you

4. Always be a team player

5. Put the resident's and the facility's interest before your own

6. Go out of your way to please the residents and their families

7. Make wise use of your time

8. Communicate effectively and only act on good and accurate information

9. Do your part in helping the facility to be profitable

10. Use common sense and your best judgment in all situations

11. Don't resist change

12. Manage your stress

13. Ask yourself whether you are doing all you can to maintain residents' health and whether you are documenting that care

RELATED ARTICLE: Are your charge nurses effective?

Ask yourself the following about these critical staff members:

* Do they observe and monitor the resident and the environment?

* How would you describe your relationship with your charge nurses?

* What feedback do you get from residents and families about your charge nurses?

* Do your charge nurses demonstrate an eagerness to learn and adapt?

* Are they facility leaders for quality care?

* Do your charge nurses give direction to certified nursing assistants and truly take charge?

* Are your charge nurses clinically competent?

* Do they have positive attitudes in stressful times?

--Bonnie Foster and Bette D. Rodman

A good charge nurse must be ...

* multitask-oriented

* focused on the resident, his or her condition, and the environment

* tuned into total resident care

* a problem solver

* a team leader and mentor a documentation expert

* proactive, with a good understanding of the links to other disciplines

Bonnie G. Foster, RN, BSN, MEd, is a national speaker on healthcare issues. She has worked in long-term care since 1969, as a charge nurse, in staff development, as a director of nursing, and as a state surveyor for CMS. She has written manuals and teaches on management, mock surveys, MDS and resident care plans, restorative nursing, documentation, survey survival and quality assurance. You can reach her at

Bette D. Rodman, LPN, NHA, has more than 37 years of healthcare experience and is presently the administrator of a 140-bed skilled nursing facility. She has worked as a charge nurse, a nurse manager, and a director of staff development. She is active in the Tennessee Health Care Association and has served on numerous boards to enhance quality care.
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Article Details
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Author:Rodman, Bette D.
Publication:Contemporary Long Term Care
Date:Jan 1, 2007
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