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.”
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.
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.