Reg's Blog

Senior and Post-Acute Healthcare News and Topics

Wisconsin Directors of Nursing Fall Conference

Last Friday, I was honored to speak at the Wisconsin Directors of Nursing Fall Conference.  The crowd was great and I had a lot of fun talking with the hardest working professionals in health care.  As promised to them, I have attached the presentation to this post and a bunch of tools and references that everyone can use.  All links (except the books) are free!

Thanks again to everyone that attended.  Questions?  Feel free to reach out to me at!  Looking forward to seeing you all again in the near future!

WI DON Council Presentation

QAPI Indicator Summary – blank




Tuck in Program

CVA pathway


Admission Audit

5 day post discharge

30 Day Post Discharge Questionnaire

3-RoP-Checklist-overview-FINAL.101416 (book with great survey tools)  (tools, etc. all pertaining to UTIs)


September 25, 2019 Posted by | Uncategorized | , , , , , , , , | Leave a comment

Holding onto Your D.O.N.

In our annual Healthcare Leadership Labor Market Report released in July, we presented some rather alarming trends regarding the long-term care and post-acute care industry’s retention of nursing executives.  For example, we noted that 71% of the Directors of Nursing in nursing homes leave their positions each year.  We also noted that the average tenure of a Director of Nursing is three years.  Within the report, we cited numerous reasons for the short-tenure and resultant turnover with the key take-away point being “job dissatisfaction”.  Of course some or a large amount of the job dissatisfaction within long-term care has to do less with the “job” and more with “what” the job has become as a result of what is going on in the industry today.

The purpose of this post is not to reiterate the informationin the report, rather to provide some key information to combat the trends presented; namely turnover of this incredibly key resource.  What is most important to note however, is why these positions turn and what an organization can and should do about keeping the right people working in the right positions.  The reality most apparent is that there are not enough good nursing executives to fill the voids that are created at the rapid pace at which they are occurring.  The depth of this labor pool is rather shallow, especially when skill and acumen are accounted for as key requirements over against the willingness of a registered nurse to put his or her life and license on the “line”.  To that end, the principal reasons “why” a nursing executive or as is commonly known,  a D.O.N. leaves his or her post are as follows.

  1. Job Dissatisfaction: To be specific, this means general feelings of an inability to adequately perform one’s job and to be recognized for the performance due to the role or positional requirements which are viewed as unreasonable.  In most cases, the demands and expectations are too great for any one person to consistently accomplish.
  2. Industry Dissatisfaction: This dissatisfaction is principally about the present state of the long-term care industry and often is categorized into regulatory and budgetary issues that impact the D.O.N.’s ability (real or perceived) to deliver care sufficient to meet organizational and professional standards.  Not too surprising, labor issues such as staffing are also a part of this factor (insufficient and inadequate staffing numbers).
  3. Hours and Working Conditions: The sheer time demands and the often physical and emotionally demanding role of a Director of Nursing simply takes a toll and lifestyles and personal health (emotional and physical) suffers to the extent that leaving a position is viewed as necessary.
  4. Organizational Dissatisfaction: Key components herein were dissatisfaction with immediate supervisors and dissatisfaction with perceived or real lack of organizational support and allocation of resources.  Important to note that for Directors of Nursing in nursing homes, dissatisfaction with the Administrator was frequently cited and generally, cited more often than overall dissatisfaction with the larger organization.
  5. Professional Needs Not Met (Compensation, Advancement, Autonomy): Somewhat lumped together but this catch-all is rarely the key reason (or reasons) alone for turn-over.  What is important to note however is that compensation in terms of straight salary and benefits in long-term care falls significantly below compensation levels in acute care settings and when viewed in light of the job demands is appallingly low compared to other executives in healthcare and out of healthcare, especially non-clinical executives in healthcare.

Taking the above into account, the key is to devise an overall program and plan that sufficiently reduces the dissatisfiers, where at all possible.  It may seem impractical to think that any organization can change the influence the industry has on a position however, there are strategies that can be used to significantly minimize the negative environmental factors that come to bear and produce turnover.  To be certain, the most important step to take is to create a list of factors that an organization controls directly and a corresponding list of the factors that an organization doesn’t directly control but can manage as a means of developing an overall retention strategy. 

Without going into a full-blown plan that may or may not be applicable to a particular situation, there are some very basic organization level steps that can and should be taken to improve the probability of  D.O.N. retention.

  1. Develop an organizational commitment to keeping goals and objectives extremely clear and focused, inclusive of the time expectations required to complete same.  Involve the D.O.N. directly in establishing these goals and objectives including gaining agreement on realistic time frames for completion and identification of resources required for completion.
  2. Make certain that no organizational expectations are formally or informally enforced regarding “time in office” versus performance.  Provide complete control to the D.O.N. to come and go and be present as necessary and judge performance strictly on agreed-upon goals and objectives – not on time in the office or on a set schedule.
  3. Reduce to a minimum the number of non-essential and often, counter-productive meetings and committees involving the D.O.N.  Meetings add busy work and create confusion and often, lead to endless additional tasks that should be handled elsewhere.  Help the D.O.N. process his/her schedule and assure that maximum time is provided to him or her to complete his/her objectives, not consumed by organizational meetings that are not relevant.
  4. Make abundantly clear to the Administrator that a key element of his/her performance requirements and ultimately, job retention is the retention of the D.O.N.  It may be necessary (and advisable) to have a qualified third-party work with both the Administrator and D.O.N. to forge a true partnership agreement and develop role expectations and a structured reporting relationship.  Long-term care tends to be backward here in so much that Administrators are presumed to be superior roles when in reality, the D.O.N. is often the de facto leader within the nursing home.  Good Administrators fully understand their role and how to complement this relationship and support the work of the D.O.N.
  5. Pay special attention to getting and receiving constant and consistent feedback from the D.O.N. regarding job and positional demands.  Encourage the D.O.N. to participate in external networking opportunities and to take advantage of continuing leadership and clinical educational opportunities.
  6. Provide external resources such as consultants to the D.O.N. pre and post-survey.  Most D.O.N.s don’t feel adequately supported in advance of a compliance survey and don’t have the resources necessary to dissect survey issues.  Surveys are horrendously stressful and are not a true reflection of the D.O.N.’s performance in many cases.  Organizations that are aware of how widely variable compliance surveys are and how inconsistent surveyor practices are understand that D.O.N.s have only so much control over the ultimate outcome.
  7. Increase the expectations of other clinical staff (and the accountability) including the Medical Director in terms of overall patient care and satisfaction.  Too much falls directly on the plate of the D.O.N. that belongs to other disciplines and most often, he/she is left “holding the bag” for what others should have done.  In a fully evolved organization, the D.O.N. and the Administrator should actually jointly oversee and partner in managing and planning the work, required performance outcomes and review of all other clinical/care disciplines.
  8. While financial resources are always tight in long-term care, the organization must make an overt commitment to providing the D.O.N. with sufficient dollars to build and reward an adequate staff and to have current clinical resources and support systems.  Make the D.O.N. aware of key financial issues and measurements but don’t place the onus on him or her to be accountable for other organizational financial matters beyond his/her scope of control.  Too often, D.O.N.s are brought into census and payer mix issues that are only sources of frustration and beyond the scope of what a D.O.N. should truly be concerned with.
  9. Create an overall organization compensation policy that allows for frequent recognition and reward, beyond the scope of standardized evaluation programs, bonus programs and wage increase programs.  These programs work best if they are totally person-centered, allowing for the compensation program of the D.O.N. to be personalized.  Rewards and recognition need to be frequent and not just monetary.  Programs that use paid time off as reward, gift certificates, movie passes, flowers, spa certificates, etc. are viewed by all staff as significant and personal and D.O.N.s need to be a part of these programs and have the programs at their disposal for use among their own staff.

There is a time worn saying that is appropriate: “Its cheaper to keep them than to lose them”.  In too many cases, a highly qualified D.O.N. leaves only to be replaced by someone lesser qualified, often at a higher cost and in all cases, at a higher organizational cost.  Rarely is the replacement of this position an “upgrade” and certainly, at the rate of turn-over (once every three years) nearly always at a strategic and financial disadvantage to the organization.

September 2, 2009 Posted by | Skilled Nursing | , , , , | Leave a comment