Journal of Gerontological Nursing

Feature Article 

RNs’ Transitions into Director of Nursing Positions in Nursing Homes: Hiring Practices and Role Development

Elena O. Siegel, PhD, RN; Suzanne Sikma, PhD, RN

Abstract

The current paper discusses RNs’ transitions into their first nursing home director of nursing (DON) position, including hiring practice and role development. A convenience sample of 29 current and previous DONs and nursing home administrators completed semistructured interviews for the current qualitative, descriptive study. Using thematic analysis, the finding revealed three primary themes: (a) DON hiring criteria are not necessarily matched to role demands; (b) various pathways to developing DON expertise suggest an undervaluing of the competencies needed to effectively enact this nursing leadership position; and (c) although limited formal training for the DON position was well-acknowledged, concerns or reports of the consequences varied, and there is no consensus as to the optimal route to preparation. Overall, the current study findings highlight gaps across practice, policy, and research, emphasizing the consequences of limited attention to gathering evidence of the breadth and depth of DON role demands and related role qualifications. [Journal of Gerontological Nursing, 41(6), 32–38.]

Dr. Siegel is Assistant Professor, Robert Wood Johnson Foundation Nurse Faculty Scholar Alumna, and JAHF/Atlantic Philanthropies Claire M. Fagin Fellow Alumna, UC Davis Health System, Betty Irene Moore School of Nursing at UC Davis, Sacramento, California; and Dr. Sikma is Professor, Nursing and Health Studies, University of Washington Bothell, Bothell, Washington.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The current study was supported by a 2009 American Nurses Foundation Grant (#2009-083, Margretta Madden Styles Award) and a 2007–09 JAHF/Atlantic Philanthropies Claire M. Fagin Fellowship. The authors thank Heather M. Young and Barbara Bowers for their mentorship, Vanessa Santillan and Kristen Bettega for their support as research assistants, and the research participants for contributing their time and perspectives.

Address correspondence to Elena O. Siegel, PhD, RN, Assistant Professor, Robert Wood Johnson Foundation Nurse Faculty Scholar Alumna, and JAHF/Atlantic Philanthropies Claire M. Fagin Fellow Alumna, UC Davis Health System, Betty Irene Moore School of Nursing at UC Davis, 4610 X Street, Suite 4202, Sacramento, CA 95817; e-mail: elena.siegel@ucdmc.ucdavis.edu.

Received: November 29, 2014
Accepted: December 18, 2014
Posted Online: March 16, 2015

Abstract

The current paper discusses RNs’ transitions into their first nursing home director of nursing (DON) position, including hiring practice and role development. A convenience sample of 29 current and previous DONs and nursing home administrators completed semistructured interviews for the current qualitative, descriptive study. Using thematic analysis, the finding revealed three primary themes: (a) DON hiring criteria are not necessarily matched to role demands; (b) various pathways to developing DON expertise suggest an undervaluing of the competencies needed to effectively enact this nursing leadership position; and (c) although limited formal training for the DON position was well-acknowledged, concerns or reports of the consequences varied, and there is no consensus as to the optimal route to preparation. Overall, the current study findings highlight gaps across practice, policy, and research, emphasizing the consequences of limited attention to gathering evidence of the breadth and depth of DON role demands and related role qualifications. [Journal of Gerontological Nursing, 41(6), 32–38.]

Dr. Siegel is Assistant Professor, Robert Wood Johnson Foundation Nurse Faculty Scholar Alumna, and JAHF/Atlantic Philanthropies Claire M. Fagin Fellow Alumna, UC Davis Health System, Betty Irene Moore School of Nursing at UC Davis, Sacramento, California; and Dr. Sikma is Professor, Nursing and Health Studies, University of Washington Bothell, Bothell, Washington.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The current study was supported by a 2009 American Nurses Foundation Grant (#2009-083, Margretta Madden Styles Award) and a 2007–09 JAHF/Atlantic Philanthropies Claire M. Fagin Fellowship. The authors thank Heather M. Young and Barbara Bowers for their mentorship, Vanessa Santillan and Kristen Bettega for their support as research assistants, and the research participants for contributing their time and perspectives.

Address correspondence to Elena O. Siegel, PhD, RN, Assistant Professor, Robert Wood Johnson Foundation Nurse Faculty Scholar Alumna, and JAHF/Atlantic Philanthropies Claire M. Fagin Fellow Alumna, UC Davis Health System, Betty Irene Moore School of Nursing at UC Davis, 4610 X Street, Suite 4202, Sacramento, CA 95817; e-mail: elena.siegel@ucdmc.ucdavis.edu.

Received: November 29, 2014
Accepted: December 18, 2014
Posted Online: March 16, 2015

The director of nursing (DON) is expected to lead and manage all nursing services in the nursing home (American Association of Long-Term Care Nursing, 2009; American Health Care Association, 2007), and is considered central to the design and provision of quality care (Wunderlich & Kohler, 2001; Wunderlich, Sloan, & Davis, 1996). The Institute of Medicine (IOM; 2011) report identified barriers that prevent nurses from responding effectively to rapidly changing health care settings and an evolving health care system. These barriers need to be overcome to ensure nurses are well-positioned to lead change and advance health in nursing homes of the future. Two recommendations of the report are particularly germane to the DON role in nursing homes: (a) ensure nurses can perform to the full extent of their education and training; and (b) nurses should achieve higher levels of education and training through an education system that promotes seamless academic progression.

Preparation for the DON position is of high interest, given ongoing reports of low quality in nursing homes (U.S. Department of Health and Human Services, 2014). DONs require competencies in areas including leadership, health policy, system improvement, research/evidence-based practice, teamwork, and collaboration, as well as competency in specific content areas, including geriatrics (IOM, 2011). DONs are uniquely positioned at the intersection of (a) professional accountability to their state board of nursing, (b) organizational accountability to their employer (i.e., fiscal/quality demands), and (c) regulatory accountability to federal/state nursing home agencies. Yet, many DONs are underprepared to effectively navigate the nuances of this nursing leadership role, with an associate’s degree (Corazzini, Anderson, Mueller, Thorpe, & McConnell, 2012) representing a clinically focused education that does not include preparation for the advanced competencies necessary to be successful in the DON role. As such, associate’s degree–prepared DONs reflect a group of nurses who have been used to fill positions that require knowledge and skills beyond their level of preparation. Corazzini et al. (2012) developed a typology of professional nursing jurisdiction (i.e., authority and autonomy over nursing practice using specialized knowledge and judgment) in nursing homes and categorized facilities with high, mixed, or low capacity for professional nursing jurisdiction. Having a DON prepared at the bachelor’s level and specialty certification of the DON were two of seven staffing characteristics found to predict high capacity for professional nursing jurisdiction. Of serious concern was the low probability of DONs and RNs prepared for managing and leading care delivery in many low-capacity facilities.

Gaps between the preparation of and expectations for DONs confirm the IOM (2011) recommendation that nurses advance their education and that facilities/institutions support academic progression for nurses. As advancements are made to enact the IOM recommendations, the contexts must be better understood in which RNs take on DON roles and develop the needed competencies. The current article describes RNs’ transitions into their first nursing home DON positions, including hiring practices and role development.

Method

Design and Sample

The current report describes a third analysis of data resulting from a qualitative, descriptive study (Sandelowski, 2000). Previous reports described DON roles and responsibilities (Siegel, Young, Leo, & Santillan, 2012) and tactics related to resources (Siegel, Young, Zysberg, & Santillan, 2014). The purposeful, geographically cross-sectional, convenience sample recruited through networking included 29 participants with current or previous experience as a nursing home DON or administrator. Detailed participant characteristics are available in the study by Siegel et al. (2012). Oregon Health & Science University and University of California, Davis Institutional Review Boards provided human subjects’ approval.

Procedures

A previous report (Siegel et al., 2012) described the method for interview-guide development and the approach to audiorecorded, 1-hour semi-structured telephone interviews. Broad, open-ended questions and prompts were used to elicit descriptive responses (e.g., “Tell me about your first DON position and how you came into that position” [for a participant with current/previous DON experience] or “What types of professional development opportunities are available to DONs from their employer?”). Follow-up questions and prompts were used to seek clarification, confirmation, and further explanation (e.g., in response to a participant’s description of DONs’ work, follow-up prompts may have included, “Where do they develop those competencies? How did you learn to do that?” or “Thinking about that new DON, what are your thoughts about best ways to prepare them for the position?”).

Analysis

Verbatim transcriptions of the interviews were verified and transferred to a qualitative data management program (NVivo 9). Siegel et al. (2012) previously reported procedures for data coding and trustworthiness of data collection and analysis procedures. For the current analysis, the authors selected the following codes and sub-codes from the larger data set: (a) challenges/positive factors related to performing the DON position; (b) education; (c) hiring practices; (d) job expectations; (e) professional development/acquisition of expertise; (f) training, preparation, and apprenticeship; and (g) recommendations. Using thematic analysis (Morse & Field, 1995), the authors examined the text by code and sub-codes to first identify major categories of responses related to RNs’ transitions into their first nursing home DON positions. Finally, the authors reviewed the content within and across each category to identify major themes.

Results

Two major themes emerged from the study findings. First, hiring practices, role preparedness, and limited formal training opportunities suggest an undervaluing of the competencies needed to effectively enact the DON position. Second, perspectives regarding best ways to prepare for the DON position varied, with no consensus regarding an optimal route or clear pathway.

Hiring Practices, Role Preparedness, and Training

Hiring Practices. Criteria for hiring a DON were described along a continuum. At one end, hiring practices focused on the need for specific expertise to address a facility’s immediate and pressing concerns (e.g., regulatory compliance, fiscal issues), or more broadly, general leadership and management capabilities, as described by one nursing home administrator: “System/process thinkers [who] can delegate, establish programs, monitor quality and outcomes, and collaborate with hospital customers.” At the other end of the continuum, participants referred not to practices for hiring based on expertise, but instead an organization’s pressure to simply place an RN in the role. Although not explicitly stated, this pressure presumably stems from regulatory requirements for a DON. A DON with 18 years of experience in nursing homes stated, “For directors—I mean, places are just desperate to have somebody.... Basically, if you are an RN and you are good to go, they will make you the Director just because they have to have one.” A participant with 6 years of experience as a DON recounted, “They [thought] I could figure it out on my own. I hear…[they] just [hire] to fill up the position because they don’t have anybody else.”

Prior to attaining the DON position, some participants described limited recognition of the expertise needed. One DON spoke about her hiring process and “baptism by fire” when she transitioned from a weekend per diem supervisor, stating:

[The DON] walked out one day and I get a call from the Administrator [saying], “You’re a great weekend supervisor, wouldn’t you like to be a Director?” I was like, “Oh okay, cool, I’ll try this.” I walked in, he handed me the keys and the beeper, and said, “There’s your office over there. Here’s my number if you need anything.”

Role Preparedness. Insufficient leadership skills were commonly cited as a gap in DON prepared-ness, along with various concerns regarding their working knowledge of regulations, quality improvement, systems, finance/budgeting, administration, human resources, across-department coordination and, more generally, not knowing the questions to ask, and overall ill-preparedness. Although some participants spoke of little or no DON training matter-of-factly, one administrator described challenges associated with inadequate DON preparedness, noting:

You’re really doing yourself a disservice, as well as [a disservice to] your staff because if the person who’s looking over the department doesn’t know the basic regs and doesn’t have the basic tools to do the job…it’s like tying their hands behind their back and throw[ing] them in the water and say[ing], “Swim.” Yeah, they can dog paddle for a while, but they’re really not going to flourish until their hands are free.

Other participants mentioned the implications of limited or no training, including staff concerns (i.e., “I didn’t know how to advocate for myself or my staff”), gaps in quality/safety, and negative consequences to the DON. A participant with 38 years of experience working in nursing homes explained:

It’s really amazing to me how little education is provided to them with these roles and how difficult it is for them to assess themselves in these areas and they don’t know where to go. Once they’ve figured out, “Oh gee whiz I need this information,” they don’t know where to go and quite frankly there isn’t a lot out there for them. Specifically for them. That’s really a big barrier.

Participants spoke of DONs learning over time; however, a lack of preparation was attributed to DONs not performing well early on. A participant with corporate-level nursing home management experience stated:

I see some of the newer Directors and [think] they’re not going to make it a month, there is no way because they don’t know how to work the systems and they do not know that they may have to call [human resources] before you term[inate] so that you’re not being yelled at a month from now that you didn’t do it right.

Another participant, who was a nursing home administrator, added:

That’s why there is such a high rate of turnover because they’ve never been given adequate preparation to do the job effectively.... There is a large percentage of Directors who don’t do it well and, as a result, organizations term[inate] DONs.

Training. Participants described a variety of ways RNs develop the expertise needed for the DON position, with limited opportunities for formal training. Some participants emphasized the value of an assistant DON position to learn from a “good” DON, whereas others described learning from seasoned or departing DONs. One DON recounted:

[The] administrator asked me to consider being the DON. I said, “Oh no, I don’t know how to do that.” They said, “The current DON is leaving and she is willing to spend a month with you and show you how to do it. We think you can do it.” I said, “Okay fine. I’ll give it a try.”

Many DONs develop their competencies on the job, with primary reliance on peer mentorship, professional development opportunities sponsored by state trade associations and national professional associations, and, when available, facility-level support (i.e., in-house training programs and workshops, one-on-one support from the administrator, corporate consultants, regional directors, and other nurses within the larger organization). One participant described the value of corporate support, commenting:

One of the big things that helps a DON is my [regional director]…. When I took the position, she spent time with me on a one-to-one basis, in this building on a daily basis, helping me with issues that came up, and knowing that I could call her with a situation and that if I did not know what to do, she would be right here or she would give me the answer over the phone.

Another DON described her transition from a floor nurse (“just a charge nurse”) to a DON position and her decision based on her expectations for mentorship, stating:

I was told that there was a regional nurse who would spend a month to 2 months with me every day and groom me for the role and train me and mentor me, and then she would be there once a week after that. I could…save up any issues that I needed to talk to her about. I thought, well that’s a perfect opportunity to start. I’ll know what I’m doing. I’ll have this mentor. Two days after she started training me, [something happened in another building and] she left, and I think for the 6 months I was there, she was back twice for like 2 days. Like 2 days total.

In contrast to opportunities for support from larger organizations, one nurse executive with previous DON experience spoke of DONs’ isolation in smaller facilities, saying, “[In] a smaller nursing home, there might only be the DON [and] sometimes the only RN…[or] only one to two other RNs. You can have DONs who are basically feel[ing] like they’re out there floating along.”

Corporate/facility-level support to attend outside conferences and workshops varied, with some administrators placing high value on DON professional development. In contrast, one participant described less supportive administrators “who don’t want to send their DONs out to sharpen the saw.” Other barriers to professional development included limited travel budgets and DONs’ hesitation to leave the building in case surveys or other crises occurred in their absence. A nurse executive with prior DON experience cited DONs’ limited professional development activities as a reflection of their sense of professionalism, noting:

I still get very frustrated with my dear nurse colleagues. I still have some of these DONs who don’t even want to [pay] for a book out of their own pocket—if their facility won’t buy it, they won’t do it. It’s like, God, this is part of our professional development, part of our responsibilities as a professional. But I find nurses don’t feel that to the same extent that other professional disciplines do.

Pathways to Optimal Director of Nursing Preparation

Participants shared different perspectives regarding type of preparation that supports DONs’ success, ranging from general or specific types of past experience to formal education. Some participants emphasized long-term care/nursing home experience as essential for the DON. A participant currently working as a regional director explained, “[I] just think that if [you] have never had long-term care experience, you are not going to be successful.” For other participants, this emphasis on long-term care experience appears equally or more important than baccalaureate- or graduate-level preparation. In contrast, others identified the value of past managerial experiences. For example, a nursing home administrator stated:

My DON was in management in acute care and so she has already dealt with a lot of [human resource] issues. Being a DON myself prior to this position, I, too, have been in nursing management for a long time in acute care, so I was also very, very familiar with [human resource] policies, procedures, what you can do, what you can’t do. I imagine it would be very difficult for someone who does not have any background in that respect.

One participant emphasized the links between an RN’s pre-licensure education in an associate’s degree program and the industry-wide reputation of poor quality, commenting:

The media loves to put terrible things about nursing homes in the paper—and how horrible nursing homes are—okay, so you get a lot of documentation related to that—and you say, “Okay, you know why this is? It’s because 50% of the DONs are associate-degree prepared.” You can’t have that anymore.

A master’s degree-prepared DON described the knowledge gained with this degree, stating:

I just don’t understand how some people could do this job without having some of that knowledge and bigger picture view [of] the world of nursing and administration. One of the most beneficial…[courses] had to do with company structure and organizational theory. The whole point…was to give you a different way of looking at an organization and where different pieces may help or hurt a company or your own position.

Another participant reinforced the value of advanced education, emphasizing links to professional credibility, stating:

There really are skill sets and knowledge that come along with having exposure to more formal education. There is the huge argument to be made that we need to have prepared people in the nurse leader role and by doing that, you’re taken more seriously and you’re more unwilling to not be at the table for those conversations. It’s not just the formal meeting, it’s also how you are present in key conversations in the organization and what you say is taken seriously.

Discussion

The current article provides new insights into challenges associated with preparing and hiring RNs with the expertise needed for DON positions; it provides evidence of a longstanding problem in nursing home leadership. Solutions should incorporate strategies for recognizing and valuing needed DON competencies and the development and offering of optimal routes for DON education.

Strategies for Recognizing and Valuing Needed Director of Nursing Competencies

The current findings support the recommendation that large-scale efforts to establish job guidelines for the DON position are needed (Siegel, Mueller, Anderson, & Dellefield, 2010). Industry leaders, nursing professionals, and policy makers must collaborate to establish evidence-based policy that sets the standard for the DON’s role, competencies, and educational preparation. In the absence of such standards, nursing home operators and entry-level DON candidates have limited resources on which to develop a full understanding of the DON’s role demands and required competencies.

Standards for the DON role must be incorporated into hiring practices. The current findings confirm that regulatory urgency to fill a vacant DON position potentially supersedes a facility’s more time-intensive, careful search process based on job descriptions with specific, evidence-based role standards. Hiring criteria for the DON position must match the actual demands of the role. For DON candidates with limited nursing leadership expertise, underestimation of role requirements in job descriptions places new DONs in vulnerable positions as they navigate their role demands. Studies of this vulnerability are limited; yet, the findings from the current study point to the potential for poor job–person fit (Edwards, 1991) and may explain reports of DON role dissatisfaction (Tellis-Nayak, 2005) and DON annual turnover rates of 30% to 32% (Castle & Lin, 2010; Resnick, Ma-nard, Stone, & Castle, 2009).

Optimal Routes for Director of Nursing Preparation

The current findings suggest workforce economics have likely influenced DON hiring practices. The federal regulatory requirement for the DON (Centers for Medicare & Medicaid Services, 2011) is an RN license. The real-world reality is that associate’s degree–prepared RNs are in greatest supply and offer the most cost-saving approach to comply with current federal regulation for DON preparation. Thus, it is not surprising that the dominant approaches to DON development have been local and informal educational approaches to develop the competency of associate’s degree–prepared DONs through mentoring, continuing education classes, professional development opportunities through larger organizations, peer networking in the community, and professional/provider associations. Limitations associated with local and informal educational approaches include inconsistency in standards and the availability of local facility support for such DON development opportunities. Nursing homes cannot afford to keep DONs isolated and “in the dark” with limited preparation and support.

Academic progression for associate’s degree–prepared nurses is needed to prepare for the DON position—an associate’s degree–prepared nurse is not enough. Siegel et al. (2010) summarized recommendations for DON responsibilities and qualifications from five national groups: two were silent on recommended educational qualifications, and the three that addressed qualifications recommended a baccalaureate or master’s degree as the minimum formal educational requirement for the role. The positive impact of formal nursing education on nursing practice outcomes is clear (American Association of Colleges of Nursing [AACN], 2014b). The IOM (2011) report recommended that, to meet the needs of the U.S. population, 80% of RNs should have a bachelor’s degree by 2020. In light of a growing body of evidence and national trends, the authors believe that it is time to move beyond a focus on an associate’s degree–prepared RN as the minimum qualification.

Current changes in the nursing educational system may better facilitate formal preparation of current and future DONs at the baccalaureate or higher level. RN-to-baccalaureate degree completion programs are booming and are available in formats that are widely accessible, regardless of geography (AACN, 2014a). Recent evidence (Hooper, McEwen, & Mancinin, 2013; Kumm et al., 2014; McEwen, White, Pullis, & Krawtz, 2012) demonstrates common curricular emphasis in RN-to-baccalaureate programs that are consistent with needed DON competencies, including (a) leadership and management concepts and processes and theories; (b) evidence-based practice; and (c) health care policy, finance, and regulatory environments, and interprofessional collaboration and population health.

The AACN (2008, 2011) provides standards used in the accreditation of bachelor’s and master’s degree nursing programs and provides guidance for laddered competency development from bachelor’s to master’s degree level in leadership and management competencies needed for the DON role. These competencies address (a) systems thinking; (b) health care systems organization, regulation, and financing; (c) program development and management; (d) quality and outcomes monitoring; (e) interprofessional and interorganizational collaboration; (f) care coordination and care transitions; (g) advocacy; and (h) professional accountability and commitment to lifelong learning.

Formal DON preparation could be further enhanced by collaboration between nursing education programs and the nursing home industry to provide valuable learning experiences for potential DONs. All educational programs provide opportunities for elective courses. Collaborative development of elective 400- or 500-level courses focused on the DON role could be a valuable option for either undergraduate or graduate students, providing leadership and management training specific to the nursing home environment. Standards for both bachelor’s and master’s degree programs encourage coursework involving practice or fieldwork experiences. The industry could partner with nursing programs to provide clinical leadership or management practicum experiences so students can develop and apply their leadership and management skills in (a) developing and managing budgets; (b) hiring, supervising, and managing personnel; and (c) monitoring quality and outcomes within the specific financing and regulatory environment of the nursing home context.

Conclusion

With escalating growth of the aging population and increasing acuity of care needs in nursing homes, well-prepared DONs are now more important than ever. There can be no settling for “just any RN” and a “baptism by fire” for new DONs. The findings from the current study are not generalizable due to the limited sampling; however, they reflect multiple perspectives from current/previous DONs and administrators working in a variety of nursing home settings. Overall, the findings highlight gaps across practice and policy in defining DON role expectations/qualifications and suggest limitations of the current dominant approach of informal and inconsistent preparation for the DON role. Creative collaborations between practice and education to promote academic advancement of associate’s degree–prepared nurse employees to at least the bachelor’s level can provide a rich pool of competent, professional nurse leaders ready to enact the DON role and produce quality outcomes expected from nursing home residents, families, staff, and society.

References

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Keypoints

Siegel, E.O. & Sikma, S. (2015). RNs’ Transitions into Director of Nursing Positions in Nursing Homes: Hiring Practices and Role Development. Journal of Gerontological Nursing, 41(6), 32–38.

  1. Hiring practices, role preparedness, and limited formal training opportunities suggest an undervaluing of the competencies needed to effectively enact the director of nursing (DON) position.

  2. Perspectives regarding best ways to prepare for the DON position varied, with no consensus regarding an optimal route or clear pathway.

  3. The findings highlight gaps across practice and policy in defining DON role expectations/qualifications and suggest limitations of the current dominant approach of informal and inconsistent preparation for the DON role.

  4. Industry leaders, nursing professionals, and policy makers must collaborate to establish evidence-based policy that sets the standard for the DON role, competencies, and educational preparation.

10.3928/00989134-20150309-02

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