Sandra Hoban

Today’s director of nursing needs to offer more than clinical leadership

In long-term and post-acute care (LTPAC) settings, the director of nursing (DON) is expected to be an experienced clinician and a strong team leader. But the impact of healthcare technology, new payment models and the regulatory environment have made the DON’s role one that is much more than clinical.

What qualities make the ideal DON? Obviously, the DON is the driving force of clinical efficacy across the organization and is expected to display excellence in coordinating and overseeing nursing care. But the changing business environments in LTPAC settings have brought additional challenges to the fore.

The DON Candidate Checklist:

• Comfort with technology, electronic health records, nurse documentation systems, Minimum Data Set and other specialized programs.
• As organizations branch out into specialty services, the ability to operate specialized equipment such as dialysis machines and ventilators.
• Deep knowledge of programs such as Quality Assurance and Performance Improvement (QAPI) and the Nursing Home Compare Five-Star ratings.
• Bilingualism, given the diversity of staff and residents that LTPAC providers serve.
• Excellent communication skills that resonate across the entire team, including administrators, nursing staff,  residents and their families, particularly with counseling and crucial life-decisions.
• An expert understanding of LTPAC regulations, federal initiatives and the survey process to ensure compliance with myriad regulatory requirements while still able to maintain delivery of care services when a surveyor is on-site.

Finding the Right Match

There are two approaches to finding the right DON. For some providers, years of service and experience are the most important variables, so they will seek out external candidates. Other organizations take the nontraditional approach and look for potential candidates on the existing nursing staff.

The Traditional Approach

In an executive search, organizations place emphasis on past performance and years of service. The candidate exhibits growth and success at various levels of management.

A 2012 National Center for Biotechnology Information study examined whether job tenure or past experience differed across levels of the Quality Measure (QM) ratings. The study found that LTPACs with directors of nursing who had longer job tenure tended to have higher QM ratings and several QM scores for individual measures that suggest higher quality. According to the authors, “Past experience did not differ across levels of the QM rating and was neither associated with QM ratings or QM scores.”

An analysis of another study by a team of researchers from the University of Maryland and the University Red Cross College of Nursing in Seoul, Korea, was in an article in Provider. They found “striking correlations between the tenure of nursing center administrators and directors of nursing and the number, and severity, of survey deficiencies.”

According to study results, LTPAC organizations with short-tenured DONs were nearly four times more likely to have severe deficiencies than those with long-tenured DONs.

“High turnover at all levels, but especially at the leadership level, makes it hard to operate at peak efficiency and effectiveness,” says David Gifford, MD, senior vice president of quality and regulatory affairs for the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) in the article.

The Nontraditional Search

The Lutheran Home in Wauwatosa, Wisconsin, shared its experience in finding a DON who embodies its ideals, goals and compassion to become part of the executive team. Originally, leaders interviewed veteran nurses with 10 to 20 years of experience. “We found that many seasoned candidates carried significant road blocks with them, including being resistant to change or being entrenched in their previous culture. Many of them also wanted to limit their roles to delegative management in the office rather than be a visible leader of a team,” explains Administrator and COO Kathy Cavers, in an article.

As a result of its disappointing search, The Lutheran Home took a nontraditional approach to filling the position—hire from within the organization.

Whichever strategy you choose, consider your organization size, staff and culture. Whether your organization takes the traditional or nontraditional approach, the right DON is waiting to be discovered.