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Training needs of the DON.

Statistically, staff turnover is astronomic in long-term care. Based on independent surveys, licensed staff turnover in long-term care stems from nurses not feeling needed. Survey participants rated workload, career advancement, and getting along with peers/management as more important than salary, availability of personal time and decreased weekend duty. The licensed nurses surveyed felt that knowledge and/or dependability was the most important factor that they wanted a co-worker to have.

One approach offered to deal with this combines the concepts of a Career Ladder System and a Director of Nursing College for Long-term Care.

The core components of a career ladder concept for long-term care include:

* A system of nursing management, providing opportunities for professional growth and recognition for long-term care commitment.

* A system whereby licensed nurses share in the decision-making process, thereby increasing involvement and ability to make independent judgments.

* A system whereby incentives are given for nurses to achieve professional and personal growth by rewarding positive achievers.

A career ladder program meets the following needs:

1. It recognizes the importance of nursing in the overall "care plan," which reduces turnover, increases tenure, and decreases the need to use temporary or pool nurses.

2. By defining the needs of residents in compiling a nursing skill inventory, the quality of resident care increases.

3. The program allows nurses to progress or stabilize at their own rates and proficiency levels.

4. It offers nurses the opportunity to make career choices and thereby promotes increased self-esteem.

5. Facilities can develop clear standards for attendance, merit increases, promotions, and educational expectations.

As managers, a long-term care career ladder can "cut your losses" and provide the following benefits:

1. The improvement of communication, quality of care, and the overall environment for residents.

2. Foster self-esteem, professional development and education, and independent thinking or decision-making for licensed staff nurses.

3. Facilitate administrative support, team spirit and actions, and positive resident outcomes.

Although guidelines should be followed for the planning, in-service and organization of a long-term care career ladder, the concept can easily be individualized to meet the needs of the facility's residents and staff. The criteria for "moving up the ladder" and the incentive awards system are two examples of where facilities can adapt the career ladder to their own particular situations.

DON Skills

Along with the concept of a long-term care career ladder, Directors of Nursing in long-term care must possess skills necessary to survive in today's changing health arena.

We must focus on the DON because he or she supervises over two-thirds of the staff and sets the stage for the facility's operations as it directly relates to resident care. Because DONs are leaders, we must first discuss characteristics which are common to all leaders. The following traits are especially important for an effective DON:

1. They do not blow up or sulk, but possess a high frustration tolerance.

2. They do not insist on the acceptance of just their own ideas, but encourage participation by others.

3. They look for mistakes in their own methods and continually question themselves.

4. They are clearly competitive and realize that competition is part of the job, but do not give in to feelings of hostility.

5. They let others know when they "step out of line," but keep the impulse to "get even" under control.

6. They feel good about reaching goals, but do not let themselves get carried away, i.e., they can win without exulting.

7. A setback does not cause them to give up on other goals, i.e., they can lose without moping.

8. They have realistic goals which are both high and achievable.

In addition, we all know that communication is the key to every effective organization. A DON's entire job depends on the ability to communicate. Some typical criteria (offered in an article by Getbette):

1. Think before communicating - communication usually fails without proper planning.

2. Check the true purpose of the communication. Decide what must be achieved.

3. Consider the situation. Timing is very important. Take into account the circumstances under which announcements are made.

4. Consult with those who are excellent communicators.

5. Be aware of overtones. Tones of voice, expression, and apparent receptiveness to the response of others.

6. Convey something of value.

7. Follow-up. Feedback is important to ensure complete understanding.

8. Communicate for tomorrow. The message needs to be consistent with long-term goals.

9. Support the communication you give with actions.

10. Listen and look. A good communicator should be tuned into the reactions and attitudes of others.

Coupled with these characteristics, an effective DON must possess essential skills in which to provide leadership and guidance to the staff. These necessary skills can be divided into four distinct categories:

Quality Assessment

Whether called QA, Total Quality Management, Total Quality Leadership, or Continuous Quality Improvement, the DON must assess and improve quality through effective monitoring and evaluation. The DON's monitoring and evaluation must be applied to activity programs, dietetic care, drug usage, medical care, restorative nursing care, and social services.

Management Issues

The Director of Nursing must identify, classify, and deal effectively with staff motivation; recruitment and retention; human relation areas, such as interviewing, disciplining, hiring and firing; communication and leadership; and administrative issues, such as Medicare Part B reimbursement.

Resident Care

Directors of Nursing must assist in assessing the health status of the elderly resident in regards to medications, special care units, restorative programs, resident care plans, staff patterns, and infection control. We are seeing an increased acuity level of residents which is necessitating acute care skills in intravenous therapy, both peripheral and central line care. Many facilities are developing sub-acute units for residents who require these services. We are also seeing residents in our facilities with implanted ports who require epidural pain management, chemotherapy, and TPN. These high technical skills require proficiency by the DON for adequate performance and monitoring.


Service delivery is not complete, particularly these days, without documentation of the service. It is crucial that the DON have a working system for documenting communications for resident care in a consistent, meaningful, and relevant manner, including individualized care plans, development of policies and procedures, and legal recordkeeping and charting.

DON Support

Just as infants without touch, attention, and communication in their first year will not thrive, DONs will not thrive in their roles if not supported, guided, and given the tools to do the job of directing the nursing department--a department which has become more multidisciplinary since OBRA. Whereas DONs used to have clearly delineated roles, in today's facility department lines cross over in addressing the "holistic" concept of resident care. For evidence of the need for this increased support, just look at the DON turnover rate across the country and the types of citations on state and federal surveys for either lack of knowledge of regulations or how to enforce them through sound and effective management practices.

All of this underlies the concept of what we call a DON College of Long-term Care. It is, after all, up to the leaders in long-term care to recognize and meet these needs, if they are to survive in today's long-term care arena.

Bonnie G. Foster is Professional Staff Consultant with Holistic Education & Consultation, Inc., Rock Hill, SC, which offers management services, nursing consultation, quality assurance assistance and staff development programs. It has published a Long-Term Career Ladder Manual and offers a two-week intensive Director of Nursing College. The firm is based in Rock Hill, South Carolina (803-329-6501).
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Title Annotation:directors of nursing
Author:Foster, Bonnie G.
Publication:Nursing Homes
Date:Apr 1, 1993
Previous Article:How administrator characteristics correlate with licensure exam performance: test results show a changing picture in nursing home administration.
Next Article:Teaching staff how to budget.

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