Today’s Administrator and DON

In your opinion, what is the administrator's biggest challenge?
Rowe: I think a lot of that depends on the area that you're from. In some areas, it's obviously going to be staff shortages. But generally speaking, the biggest challenge is getting a compassionate staff to care for the residents the way that you want them to, at the level and standard of care you want. That is achieved through being able to provide them with the amount of education and training they need. However, administrators may not be allowed to have as much staffing and training resources as they'd like. That makes the challenge more difficult. These resources can be limited by census, regulations, reimbursement, and other external forces that are sometimes difficult to control.

Do you look back and see that things are different in nursing homes today as opposed to when you started working in them?
Rowe: I do. I've worked in a lot of different areas-a mountainous area, the inner city, affluent areas, and now in a small town-and changing cultures play a big part in things. But I'm one of those people who won't take no for an answer. You can't just tell me that the nurses aren't out there. If you aren't getting the staff you need from simply placing a newspaper ad, it means you aren't working hard enough. You need to go to the nursing schools and offer scholarships and get creative in other ways. You can offer volunteer programs and reach potential staff members in high schools.

How have you personally managed to adapt to these changes so successfully?
Rowe: I think you always have to be willing to change. You have to know that you're never going to stop growing, and your job on earth is never done until the good Lord calls you home. Never accept defeat and never lose your creativity. Sometimes, I'm not the one who has the answer-many times, my staff has it. I feel that I'm as strong as my worst CNA, but I've managed to hire the best people out there. They know what makes a great environment and what attracts people to our facility.

How is your facility affected by staffing issues?
Rowe: As I said earlier, I think this differs from place to place. In our facility, therapists are very hard to attract because we are in a small town, whereas I have no problem attracting CNAs and, in fact, at times I have a waiting list for them to come and work for us. In a big city, I likely couldn't find a CNA to save my life, but I'd have all the therapists I need. Everybody has their own set of challenges that are affected by culture and geography. You need to stay creative to solve them. I know an administrator in Colorado who went to Texas to recruit CNAs and paid their moving expenses to relocate. Life Care as an organization is bringing in a lot of nurses from other countries. You just have to stay ahead of the game!

What are some of the things that you do to maintain staff and keep them positive and motivated?
Rowe: In our facility, if any CNA wants to go to nursing school, we'll pay for it if she stays employed here at least part-time and agrees to work for us for a year after she graduates. The program at our local school, which is about a ten-minute drive from here, takes 18 months to complete and costs us about $2,000-that's less than it would cost to pay for a nurse from an agency. It's a wonderful investment, and if you want to maintain a quality staff, you have to invest in them. You can invest through education and through making a work environment that appeals to them. Staff need the recognition-they work for praise, not a raise necessarily. I have an open-door policy here, and they know that they can go to me as easily as they can go to a supervisor if they have issues.

What skills or personal attributes does it take to be an effective administrator?
Rowe: You have to listen and keep an open mind and an open heart. You have to be willing to give more than you receive. I used to think that this whole career was only about the residents, but it is not. The residents are certainly in the center of the big picture, but staff is this huge vehicle that you use to get to the residents to deliver quality care. If you don't have that core group of staff that you need, you aren't going to make it as an administrator. And to get it and keep it, you need to have camaraderie and open communication with your staff.

How do you balance the various responsibilities of being an administrator on a day-to-day basis?
Rowe: Certainly you don't sit behind your desk-you have to get out on the floor. I don't really come from a clinical background, so to compensate I tend to focus on the clinical reporting systems we use at our facility. Although it may be a time-consuming process, I do it so I can stay involved in direct resident care. It allows me to chart progress, make sure the systems are working properly, and watch for trends and potential safety and regulatory issues.

I find that it's better to be involved, not just to sit back and look at reports once a month. You need to get in there and ask questions, attend meetings, and see things firsthand. If you don't do that, you're going to miss the boat completely. You also have to be out there on the floor, answering those call lights and making beds with the CNAs and, if staff is short, even passing meals or filling water pitchers. Some days go really smoothly and others don't, but you have to stay involved in all facets because only then can you decide what is most important. In our facility, we don't live by the phrase, "It's not my job," and that has to start with me.

If you could change one thing about your job, what would it be?
Rowe: You know, I don't think I would change anything. It has its ups and downs, but it is rewarding. I feel like I'm really doing something. I get my energy from my staff and my residents, and some days I feel guilty that I get more from them than they get from me. But I feel like we are all one big wheel working together, and that is why we have been successful.

As new regulations and technology evolve, how do you see the administrator position changing in the future?
Rowe: I think administrators are going to have to continue to be creative and flexible. They are going to have to continue to get involved in the changing clinical systems. I remember that ten years ago, I would rarely leave my office-now, you can't manage a facility that way. Staying active and maintaining and updating your education are also key. I'm an advocate for ACHCA, and I really recommend that administrators get certified. You need to know your resources-state agencies, educational groups, etc.-and not be afraid to use them. Everyone is on the same side here; it isn't a "we versus they" thing between regulators and facilities. And, of course, laughter never hurts!

Marjorie Berleth, RNC, MSHA: For 22 years I have been the DON of the Masonic Home of New Jersey, a 527-bed facility in Burlington, New Jersey. I attribute part of my success and longevity to the strong management team that works with me. Medicare and Medicaid issues are divided between two ADONs. Day-shift nurse managers and evening- and night-shift nurse supervisors provide critical supervision and presence on the units.

Today's DON is generally degree-prepared for the position. Twenty-two years ago, I never had to take management or financial courses, or study the psychology of human resources. In fact, it never crossed my mind that I would ever need those skills to do my job. What I had was nursing knowledge and support from administration; the rest was a learn-as-you-go experience. Because the position has become more diversified and complicated by a growing body of regulations, staffing challenges, reimbursement issues, increased paperwork, and technologic challenges, nurses who aspire to become a DON need to acquire a solid background in these non-nursing areas.

Dealing effectively with the survey system is one of my greatest challenges. I believe that it could and should have a positive instead of adversarial impact on facilities. Every institution needs monitoring, especially when that institution involves the care of people who are sick and/or frail, but it should be a collaborative process. The stress of an impending survey should not wreak havoc and disrupt a facility's daily operation. As the system stands, surveyors display the attitude that every facility they inspect is suspect and essentially a bad place where they expect to find bad things. I don't think these preconceptions serve anyone well. If a facility has good outcomes, a few undotted i's or uncrossed t's shouldn't be such a big issue if no harm is done. I wholeheartedly agree with surveyors that bad care deserves punitive actions, but the industry would be better served through collaboration.

Surveyors also see many good outcomes in the field. What better way for all nursing homes to learn than by hearing about what these exemplary institutions have done through best-practice recommendations? For example, falls present a difficult problem because they place you between the regulatory devil and deep blue sea, so to speak. Regulations prohibit restraints-but you can't let your residents fall. It's a fact-older people do fall. Short of giving them all bungee cords, we need to collaborate with government and with each other to find solutions. The New Jersey Department of Health and Senior Services has taken a step in that direction by sending out a survey on falls. When the results are studied, it's possible that an effective protocol can be developed and implemented throughout the state. We need more of these initiatives from surveyors to providers of care to help us do our job.

What makes a good DON? First and foremost, she (or he) needs to be a people person-the DON not only advocates for residents but for staff, as well. Computer literacy is no longer just nice to have; it's a definite must. At the Masonic Home, we take our MDS directly from the Web. Computer skills are also needed to access other systems and software that are used daily in patient care, staff scheduling, preparing documents for CMS and other government agencies, and more. We have a savvy IT department that guides us along. When computers first started appearing here, I didn't have much patience with them, but now I can keep up with my grandchildren.

When I became a DON, I wasn't aware of any support groups that were available to me. Today, the National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC) and its state chapters are excellent resources for support, education, certification, and more. Professional networking is available online and in person at chapter meetings and at the annual conference. If you need to develop a policy or procedure right away, material is readily available from the state association or the national office. Through professional affiliation, you're not alone. So when a problem or question arises, it's not necessary to reinvent the wheel.

Along with NADONA affiliation, I think that a DON should cultivate relationships with other related associations such as the American Medical Directors Association, the American Society of Consultant Pharmacists, and administrators' associations, to name a few. They, too, address long-term care issues that affect you and can provide a wealth of information.

So that's how I see my role today. Future DONs will have less hands-on clinical opportunities because the position will continue to become increasingly administrative along with whatever new wrinkles the future adds to the job. But a DON will continue to have to demonstrate a strong grasp of clinical issues and the creative mind-set to address all the challenges ahead.

Suzanne Blanchet, RN, BS: Before transferring to New Mexico to assume the position of Corporate Clinical Services Director for Trans Health Management, Inc., I spent ten years as a DON in Louisiana. Currently, I supervise DONs at all but one of the company's long-term care facilities in New Mexico. I have experienced firsthand how the DON position has grown more complicated and demanding. When I became a DON in 1984, my position was focused exclusively on clinical care, managing the nursing department, and staffing for nursing employees. There was mention of a budget and terms like "payer source," but the DON's chief concern was resident care. My duties, in addition to staffing, included doing care plans, ordering nursing supplies, being exclusively in charge of medical records, performing medication reviews, and having sole responsibility for month-end turnover, which entailed preparing the next month's physician orders and all the medication and treatment sheets for the nurses, including MD orders, MARS, and TARS, to name a few. This simplicity is unheard of in today's DON position.

Because of significant changes in long-term care, the DON must face new challenges. For all the duties listed above, there is generally another management position to fulfill them. Therefore, today's DON must recognize the importance of staff empowerment and the necessity of delegation. To maximize this team approach, she must teach, mentor, and supervise staff in carrying out their duties. No longer can one person do it all.

Motivating staff is another task the DON must take on. She must find ways to care for staff and acknowledge their contributions. It is her challenge to set the tone for the facility. Staff should know that they make a difference. They should work in a dynamic learning environment, where they are challenged and have advancement opportunities.

In addition to encouraging a team approach, the DON is now involved in new concepts in staffing-understanding and managing the number of staffing hours and dollars allotted to the residents. Along with this, the DON is now more involved with the budgetary expectations of her department.

Another core quality of a DON is that she be able to meet the demands and pressures of a changing survey environment. The DON must deal with excessive pressure. Sometimes numerous complaint surveys, in addition to the annual process, are carried out in a less than supportive environment. Historically, the survey process was much more of a learning environment-one in which areas of improvement were identified, addressed, and resolved. It can be very challenging to keep staff motivated and focused on residents in an atmosphere that can be very draining and discouraging.

As important as it is to be self-directed and be able to prioritize the multiple tasks that fall under the job description, one of the most important things a DON must remember is to take time for self-care. Nurses are characteristically caregivers. We need to remember that we can't give what we don't have. If your battery is dead, find a way to recharge it. Have personal boundaries and a sense of balance in your life and profession. Encourage and support your staff in doing the same.

I can't emphasize enough the power of networking with other DONs. They are the only others who totally understand the job, its expectations, demands, and challenges. Don't rationalize that you don't have time to attend a day of in-services, to have lunch out of the facility, or to belong to a professional organization. Finding people and places that support and nurture you are critical. Keep personal and professional growth high on your list.

In supervising DONs, I face my own particular set of challenges. I must teach, direct, motivate, and support them so that they can relay the information to their staffs. I am their advocate, but I am also their challenger and the one who sets the bar for clinical excellence. My previous years as a DON have prepared me for this role.

Retaining DONs in their positions is another challenge I face. By no means am I the reason for their longevity, but I can have a direct effect on it. Too much care, support, time, and energy are put into develop-ing a DON to not feel frustrated when you find out that the process has to be repeated again within a few months or a year.

If we could increase the professional longevity of DONs in general, it would enable me to fine-tune and advance the systems and protocols we put in place, as well as help the DONs to mature and advance. I would love to have more time to dedicate to actual teaching and hands-on mentoring of new DONs. I truly believe that this process has a positive effect on job satisfaction and retention.

To make the DON's job easier, I think that administration should become aware of the complexity and high expectations inherent in this position and, if administration can't understand this, should at least provide support and respect. The DON and administration should have daily open communication. This is critical in the message it sends to staff and is fundamental to understanding the expectations of each day. To help with the new responsibilities that have been added to a DON's plate, administration should be willing to educate and include the DON in operational matters.

What will the DON face in the future? I believe that she must become knowledgeable about new technologies because that will become the standard. I also believe that there will be a continuing evolution in the professionalism of long-term care nurses. DONs will have to embrace the responsibility of not only knowing what long-term care is about, but being willing to educate others-families, communities, and governing agencies. We will all have to take positive steps in being advocates for ourselves and the amazing challenges we face on a daily basis. We cannot become victims of the misinformation and misunderstanding of the community at large about long-term care and the people who provide it.