Why Skilled Nursing Providers Must Embrace the DON of Tomorrow

The director of nursing (DON) role has picked up dozens of additional responsibilities during the pandemic, clinical leaders say, as the nursing home sector continues to work through a historic staffing shortage.

The result can amount to, at times, an “extremely stressful” position, according to North Shore Healthcare Chief Clinical Officer Tina Belongia.

DONs across the country have not only taken on responsibility for the overall clinical product at a facility, but have picked up shifts as a nurse, a certified nursing assistant (CNA), or even cooked meals for residents, Belongia said.

“It has put an absolute heavy burden on their shoulders, and many of them have, quite frankly, left nursing or left our industry because of it,” she explained. “It has forced us in turn to take a step back and look at how we can better support our directors of nursing.”

Added responsibility bleeds into staff training too, especially with nurses that got the majority of their training during the pandemic. Pre-Covid procedures feel foreign to graduates, leading to on-the-job training often left to directors of nursing.

North Shore works with medical directorship companies like GAPS Health to refocus or redesign the care delivery system and positions within it, she said, effectively “stabilizing” leadership to avoid a domino effect in turnover.

A lingering impact of Covid on the nursing workforce as a whole and the idea of role instability is echoed in analyses. A McKinsey & Company report found 29% of responding registered nurses in the country plan to leave their role in direct patient care, many specifying they want to leave the workforce entirely.

“Buildings that have turnover in directors of nursing, those are the ones that start having all the quality issues,” Belongia said. “Outcomes are starting to change, they are starting to drop because there’s not that leadership stability, there’s not that culture in the building.

By 2025, facilities across the care continuum may see a 200,000 to 450,000 gap in available nurses – nursing home recruiters and DONs will have their work cut out for them, competing against hospitals and other more lucrative RN positions.

DON as an educator

On top of high turnover for the role, those in the field say they’re seeing a “very different” workforce coming out of nursing school, with less clinical experience than they would have seen pre-pandemic.

That means more on-the-job education falls to a director of nursing according to Cascadia Healthcare’s DON Amie Barrio.

“That’s a big piece – workforces don’t have practical experience because most everything they got was confined to these little, controlled environments in a classroom,” added Zendi Meharry, director of clinical operations for Cascadia.

The Eagle, Idaho operator has always done skills fairs and competency evaluations, Meharry said, but the additional education needed for direct care staff is on a “brand new level.”

“It definitely is a big hurdle we’re having to overcome right now as far as that education and making sure your staff feels supported through it,” noted Barrio. “I’m constantly educating my managers and constantly educating families, making sure I’m just as knowledgeable as infection preventionists.”

It’s been a struggle to pave a way back to normalcy for staff – nurses fresh out of school or those working at a facility in the last three years have only known Covid, said Barrio. That has left DONs with the task of retraining staff to what skilled nursing should look like on a normal basis.

Basic practices like tray passing in a dining hall is new to incoming staff, said Meharry, as pandemic staff have only known strict Covid protocols.

“Managing these processes is kind of interesting, just making sure everybody gets up to speed. It’s a whole new norm,” Meharry said.

Expanding recruiting, retention involvement

DONs have a part to play in internal, ongoing training programs too, both as educators and a target for recruiting and retention programs.

Lisa Chubb, chief clinical officer for Brickyard Healthcare, said the Indiana operator’s in-house mentor preceptor program, which teaches staff how to teach others, extends to the assistant DON role.

Registered nurses (RNs) in particular are acting as “resource nurses” on the floor, and they’re going in to serve in this assistant role too, Chubb added.

The program has fostered a 91.3% retention rate so far.

Belongia told Skilled Nursing News the North Shore team is working hard to build recruitment programs for nurses and directors of nursing – and involving them as educators.

North Shore’s efforts are still in their infancy, Belongia added, starting with hiring a new director of education, along with regional educators to help coordinate general orientation.

“What are the needs of our buildings? What are the needs of our residents? We’re going to be building out more competencies and more training, which then, of course, pulls people away from the direct care side … there’s always that balance,” said Belongia.

DON role outside of Covid

It’s important to take a look at the shifting role of the DON outside the context of Covid too, Belongia said, especially if SNF staff are looking to take on a more holistic approach to care and operations.

That translates to less siloes, she added, and more transparency between medical directors, direct care staff, residents and their family.

“We are literally building a small community within our centers, right? It’s a little town in and of itself. We’re trying to get them all involved in letting them know, here’s what we’re doing good, here’s what we need to do a little bit better,” Belongia said.

The DON’s role in this more transparent community is to be a point person in redesigning the care delivery team and general workflow in the building. When designed right each nurse, each CNA would be practicing to the full extent of their license, according to Belongia.

A lot of those changes determined by the DON would make sure nurses are not scheduling appointments or transportation, she noted, reassigning duties so that nurses can instead be by the bedside delivering care.

“The DON of tomorrow that is trying to move past Covid really needs to take a step back and take a look at work practices … not being afraid to take a risk every now and then, an intelligent risk – trying something new to provide that better care,” Belongia said.