Wanted: Qualified nurse leaders

Michael Bobbit has one of the most demanding jobs as the director of nursing (DON) at the busiest nursing home in the Dallas metropolis. His schedule is anything but typical: On average he manages to oversee staffing issues, budget concerns, clinical matters and sporadic complaints among the 75 admissions and 30 discharges that come in and out of the facility during his 50-hour work week.

It’s a jam-packed schedule that might drive many people crazy, but for Bobbit it’s simply what he loves.

“I worked for hospice shortly after becoming a nurse and then made my way into long-term care (LTC). That is where I found my true love,” said Bobbit, MSN, RN, who now works at Presbyterian Village North. “This really is a calling that sticks with you and is something that is in your gut.”

Those who surround Bobbit love him as well. It’s an admiration that extends beyond the residents, each of whom is personally given his cell phone number on the day they arrive.  Bobbit is also indispensable to the top tier decision makers within his community. In his role, Bobbit has helped lead Presbyterian Village North to receive numerous regional and national awards. The community has been recognized by U.S. News & World Report as one of the best senior-care communities for the past two years and recently Bobbit himself was named the Nurse Administrator of the year by the National Association of Directors of Nursing in Long Term Care (NADONA/LTC).

Bobbit’s awards are impressive, but his day-to-day accomplishments are not isolated. Increasingly, LTC nurses are becoming valued resources beyond passing medications and are being groomed by the communities that understand the rich resources they have in their nurses. They are being encouraged and educated for leadership—whether that be on the frontlines or in the boardroom. Nurses are no longer people who merely carry out orders, but are instead key participants who engage in collegial relationships with both clinicians and administrators.


Nurses comprise the largest proportion of LTC employees. Residents at senior care communities require nursing care more than any other service provided in these settings. However, nurses have not always had a strong voice in decision making or have been provided the opportunity to learn how to lead properly, said Robin Arnicar, RN, president of NADONA/LTC.

“When I first became a director of nursing 17 years ago, the role was more like that of the head nurse of the facility,” Arnicar said. “I became DON literally because I was the nurse in the building they liked and they thought had potential. So, they tapped me on the shoulder one day and said they would like me to be their director of nursing. I love to share the story about how one day I was a nurse like everyone else and the next people were coming up to me and asking me questions like somehow magically overnight I knew something more.”

Slipping into the DON role was daunting for Arnicar as a 27-year-old nurse. However, she was blessed that the role simply involved staffing. “The majority of my role was making sure there were enough nurses to help run the facility,” she said. “I had to figure out leadership skills on my own through trial and error.”

The DON position has drastically changed over time, along with the industry.The complexity of running an LTC community has increased to include new areas of focus such as regulatory demands, compliance issues, MDS and surveys. Likewise, a  DON’s responsibilities have expanded from just staffing concerns to include risk management, infection control, staff education, customer satisfaction and budget and finance.

Arnicar will quip that she isn’t the best clinician in her community called Charlestown, an Erickson Living Community in Maryland. However, she believes the DON’s expanded responsibilities have served the LTC community for the better. “You see the bigger picture,” she said. “You are no longer just looking at your department, but you are looking at how nursing impacts dining and rehab and programming and how nurses impact the bigger team. As a result, all the teams within the community are starting to work together more.”

In his role as DON, Bobbit has fostered significant change among the training of his nurses. The first thing he noticed when he arrived at his community three years ago was that training was not up to par for the level of acuity coming through the facility’s doors. His first initiative as DON was to increase training for nurses so that they could adequately handle these cases.

Bobbit has also helped foster communication between different areas of the community in order to increase resident satisfaction, said Dr. Mary Bean, associate executive director at Presbyterian Village North.

“Mealtime is very important for residents because it is not only a social time, but it’s also a time for them to maintain a certain level of health through the food they take in,” Bean said. “But from an operational standpoint, mealtime can also be challenging because the food service may set a time that doesn’t always work with the staff and residents. So, Michael worked very intimately with the dining director to establish a time that would work best for everyone.”


Strong nurse leaders are a growing need, but nurses need a framework in which they can learn how to do it—something that isn’t always provided in their academic settings. In 2013, Life Care Center of Sarasota won the nurse leadership award from the Florida Health Care Association. It was an honor that came on the heels of an intense focus to train and educate nurses.

The previous year, the community was a beneficiary of a $145,000 county grant, of which it decided to pour a significant amount into training its nurses. A large portion of that money was used to hire a career coach who came in every other week—at the cost of $1,500 a session—to train nurses. These nurses not only had the privilege of learning on the job, but getting paid their usual salary while doing it.

“They received conflict resolution training, teamwork training and they learned how to empower their staff and how to delegate,” said Nina Willingham, executive director at the community. “We did an assessment of their leadership skills before the training, after it and then six months later. What it showed is that they learned a great deal and were able to retain it.”

Life Care Center of Sarasota used additional money from the grant to pay 100 percent of the tuition for 10 of its nurse associates to further their degrees. It also paid for 40 hours of training for each nurse who would work in a new cardiac rehab unit, which was created to reduce readmission rates. Willingham believes her community’s keen focus on training is why it enjoys its 83 percent retention rate.

“I believe that as an administrator, my most important job function is to be a good leader,” she said. “And to be a good leader means that I am responsible to develop other leaders.”


Unfortunately, there is still significant room to grow in both how nurses are perceived in the LTC setting and what type of training they are receiving. Lori Guiterrez is the clinical development specialist for Chamberlain College of Nursing as well as an LTC consultant and clinical educator. Guiterrez said nurse participation in leadership at LTC facilities has increased over time, but still has a way to go.

“As I travel and work with LTC nurses, the pendulum is swinging in that direction, but very slowly,” she said. “LTC needs to recognize and increase the number of nurse leaders. Nurses need to come to the table and have a voice for what is right in the profession of nursing in LTC.”

Guiterrez said there is still a misperception that nurses in LTC settings are less knowledgeable as nurses working outside of LTC. This is something she has not only viewed in her work, but also experienced firsthand.

“I have had people say to me in the past, ‘You look like you’re smart and you have been a nurse for a long time. Why are you working in long-term care and not in a hospital?’” she said. “We need to change the landscape of LTC by encouraging young nurses to look at this area as a specialty.”

Guiterrez said nurses need to be encouraged to achieve higher education as well as completing American Nurses Credentialing Center (ANCC) certifications. She said LTC needs to utilize more evidence-based practices and give nurses more tools to be successful.

“LTC nurses are working with a vulnerable population with many comorbidities and diseases processes,” she said. “The nurse needs to have the critical thinking, financial and leadership skills to meet the needs of the changing landscape of LTC.”

Julie Thompson is a freelance writer based in Dayton, Ohio.

Topics: Alzheimer's/Dementia , Articles , Clinical , Executive Leadership , Leadership