The director of nursing and the administrator must understand their differences in order for their working relationship–and facility–to flourish.

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n any nursing home, the two most potentially influential positions are that of the administrator and director of nursing (DON). Administrators come from a wide range of backgrounds that influence their level of understanding of the function of the nursing home and the needs of those living in their settings, while DONs primarily have a strong clinical background. Lack of understanding caused by differences in preparation of these leaders has the potential to negatively impact operations.
       There are three actions a DON can take to foster a positive working relationship with an administrator:
       1) Understand the administrator’s specific background and clinical knowledge base
       2) Identify and discuss the home’s status related to five key topics
       3) Prepare in advance for discussion of the topics so the information is understood and valued by the administrator.

Commonalities and Contrasts of Administrators and DONs

       Administrators have widely varying professional backgrounds in addition to differing management styles and knowledge bases. In order to understand the perspective his or her administrator brings to the facility, a DON will benefit from first examining DON commonalities. No matter which career track a DON has traveled, there is one strong foundation that all DONs have in common: they are all registered nurses (RNs). They speak a common clinical language and have been trained to focus primarily on the health and well-being of their patients or residents.
       Whether a DON has a background of critical care, pediatrics, psychiatric nursing, orthopedics, emergency nursing, or long-term care nursing, he or she shares the commonality with other DONs of completing nursing school and achieving licensure as an RN. Regardless the depth of the individual’s education—from an associate’s degree, a diploma, or a bachelor of science in nursing (BSN)-foundational preparation—each DON is imprinted with a similar clinical language and patient focus.
       In contrast, administrators come from a wide range of career preparation and specialty backgrounds. Each state board of nursing home administrators determines the content of the Administrator in Training (AIT) Program and the preparation required before an individual can take the Administrator Licensure Exam in his or her particular state. State entry-level requirements for an AIT Program vary widely, from a minimum of a high school diploma with prescribed work experience at the department-head level to a bachelor’s degree with specific relevant course content. Despite these differences, they all completed a prescribed AIT Program, with the length and content varying by state. During his or her AIT Program, each individual worked under the supervision of a licensed administrator for a state-prescribed period of time. This method of training may result in the trainee incorporating the strengths as well as the biases and weaknesses of the trainer into his or her practice habits.
       The strongest

Table 1

commonality of facility administrators is that they all have passed state and/or national boards and are licensed by their respective states. (See Table 1 for a comparison of the commonalities and contrasts of administrators and DONs). Review of the professional paths an individual may have traveled to become an administrator will assist the DON in understanding how best to relate to and work with his or her specific administrator.
       Administrators can be separated by background into two distinct groupings: those with clinical experience and those with non-clinical experience. DONs will need to adjust their explanations of nursing department activities, depending on the background of their administrator.
       Administrators with clinical experience. For the purpose of this comparison, clinical experience is defined as having experience in a department in which the individual had direct patient or resident contact. Examples of clinical nursing home experience include administrators who previously worked in a nursing home in nursing, activities, social work, physical/occupational/speech therapy, respiratory therapy, or food and nutrition services or another department requiring direct resident contact and related education. Also included in this clinical experience category is an individual with previous clinical experience outside of a nursing home setting.
       Administrators with non-clinical experience. A second segment of nursing home administrators includes those individuals with a non-clinical background in which they had no significant direct contact with patients or residents. These individuals may have previously worked in a nursing home business office, a maintenance department, environmental services, community development or marketing, or another department whose function was not of a direct patient/resident contact nature. Included in the non-clinical group are those administrators with no previous nursing home experience of any type other than during their AIT period.
       Because of the variations within the categories of clinical or non-clinical experience prior to achieving the role of administrator, each individual brings a differing level of preparation and understanding to that key position. It is vitally important for DONs to understand their specific administrators’ backgrounds in order to promote meaningful communication on significant operational issues. The DONs must also understand that administrators may not realize how little they know about clinical topics. Likewise, DONs may lack understanding of the business side of the operation of a nursing home and should be open to explanations by the administrator.

Working with Administrators from Varying Backgrounds

       A DON can work more effectively with an administrator by understanding his or her individual background and educational preparation. Additionally, the following tips can facilitate communication and teamwork between these two key persons.
       Administrators with a clinical nursing background. These persons speak the same clinical language as the DON and have a comprehensive understanding of resident needs. If the individual has a long-term care work history, he or she will understand staffing, the Minimum Data Set (MDS), Quality Indicators (QIs) and Quality Measures (QMs), wound care needs, weight loss, and a host of other related topics. An administrator who is a long-term care nurse can collaborate and communication completely with the DON about resident issues. This seems an ideal match of the two roles unless the administrator has a tendency to micromanage the nursing department and consistently overrides the efforts of the DON. Awareness of this tendency will enable the administrator to step back, empower his or her DON, and focus equally on the management of all departments.
       Administrators with a non-nursing clinical background. These persons often have a basic understanding of the MDS; Medicare A, B, and D; and other clinical topics. They have experience interacting with residents and families regarding healthcare issues. They have a measure of clinical understanding and are prepared by their previous clinical roles to discuss a range of issues. They use a level of healthcare terminology, although the DON may need to discuss complex healthcare issues in less medical terms.
       Administrators from non-clinical, business-related backgrounds. These persons have a primary tendency to be bottom-line focused. When a DON is discussing issues with an administrator who comes from a business background, it is helpful to create a link in the discussion between quality and cost and to provide explanations from a simplified clinical perspective. Explanations that show clear connections between the budget and quality-of-care benefits and risks improve communication between the two leaders. Regardless of the background of a specific administrator, there are five key topics that a DON should master and discuss with him or her on a regular basis.

1. Quality Indicators (QIs) and Quality Measures (QMs)

       To have a meaningful discussion of the facility’s QIs and QMs, the DON s

Table 2

hould obtain three facility reports from the MDS coordinator on a monthly basis. These reports are comprised of data from submissions for the Comprehensive Resident Assessment Instrument or Minimum Data Set (MDS). They include the facility QI/QM report, the resident/facility level QI/QM report, and the Facility Characteristics report. These reports are extremely important because they supply the information posted on Nursing Home Compare and are reviewed by the state survey team prior to its annual inspection. Each of the reports presents valuable information that benchmarks the facility to other nursing homes in its state and nationally.
       The facility QI/QM report. This report displays data specific to the home’s residents under a variety of domains. Each of these domains is broken down into multiple indicators/measures. For example, under the “Accidents” domain, there are two measures: incidence of new fractures and prevalence of falls.
       The DON should review the facility’s state percentage and compare it to the national average and state average. Items that “flagged” under the state percentage are of concern either because the score indicates that many residents are affected or because the indicator/measure is one of three sentinel events (dehydration, fecal impaction, and pressure ulcer low risk) that are of immediate concern, even if only one resident is affected. The DON should note measures with a state percentage score of 75% or greater and develop a related action plan, as these items will come under state survey scrutiny. It is a recommended practice to review any state percentages that display on the report at or above 50% to assure they do not develop into problem areas. Once this information is understood, it should be professionally discussed with the administrator.
       The resident-level QI/QM report. This report lists information related to the status of each resident with an MDS submitted during the period under review. Careful inspection of the report by the DON should focus on identification of residents who trigger for development of an indicator despite low risk status, trigger for presence of a sentinel event, have an overall high number of triggers, or have no triggers. In researching these patterns, at times it is discovered that lack of documentation or incorrect documentation has skewed the reported data. By identifying residents within these categories of concern, the DON will be prepared to discuss the facts and an appropriate action plan with the administrator.
       The Facility Characteristics report. Review and related discussion with the administrator regarding this report should focus on any item with a percentage significantly above the state and/or national averages. High scores may simply represent a specialty population cared for in the facility, but they could also be the result of documentation discrepancies that need to be discovered and corrected.

2. Status of Past or Potential Survey Issues

       Another key topic involves the facility’s survey-ready status. All department heads should periodically investigate to determine that what the facility’s previous Plan of Correction (POC) report aimed for is being accomplished. The DON (and all department managers, for that matter) should keep the administrator apprised of the status of each area in order to avoid becoming one of the estimated 80% of facilities that fail to follow their POC as it was approved.¹ If the previously planned actions are not achieving the desired outcomes, the administrator and DON should work with the quality assurance (QA) committee to make adjustments for correction and monitor for positive outcomes. Helping the administrator to identify and correct potential quality or survey issues is vital.

3. Barriers to Success

       Communication about what keeps the nursing department or any other department from optimal performance will benefit the entire facility. When a DON approaches the administrator regarding barriers, he or she should bring facts and suggested solutions and seek comments and input. It is not simply enough to state the problem. Drilling down to the root cause by repeatedly asking “Why?” will reveal the true problem so that it can be corrected. The administrator cannot address what he or she does not know. A simple root-cause analysis will often provide insight that enables barrier removal and gets the department moving in the right direction. If more intervention is needed, the administrator who has been provided with the facts can intervene appropriately.

4. Staffing/Recruitment/ Retention Needs

       It is a rare facility that does not deal with staffing difficulties. The DON should explain to the administrator case-mix distribution and clustering and the related staffing needs. If the department is having difficulty meeting resident needs or regulatory requirements, discuss the true facts after performing a root-cause analysis. Include present staff turnover, vacancies, and what is being done to address identified problems. The administrator needs to have a clear picture of the facility’s status in order to help correct the problems.

5. Departmental Target Goals

       A DON will benefit from taking time to create a meaningful list of short- and long-term departmental goals. Staff members are a great resource for identifying topics and assisting with prioritization by level of importance. Including team members in the process builds loyalty and develops them professionally. The DON can delegate assignments that foster growth and job satisfaction to team members so they become the expert of a specific issue and the related goals.
       Feedback for a job well done or provision of further information that strengthens an individual’s performance builds a strong nursing department. Identified action plans should be assigned realistic time frames with periodic reassessment for progress. Awareness of goals and planned steps for achievement is valuable information for the administrator, who can support getting needed resources to assure success.

Presenting Information that is Valued and Understood

       Presentation style is a crucial element in having the DON’s message understood by the administrator. In order to effectively communicate the preceding key topics, the information must be professionally delivered. The following elements of that presentation will facilitate delivery and strengthen both the message and the messenger so that important topics are valued and understood.
       1. Know the Topic: Information will capture the attention of the administrator when it is presented in a confident manner. The greatest foundation of a confident delivery is first-hand knowledge of the facts rather than repeating what others have reported.
       2. Identify Areas of Concern: To prepare for meaningful discussion, the DON as the clinical expert should research the issue. It can be difficult to admit to and present significant problematic areas, but avoiding the discussion does not foster a strong working relationship between the DON and the administrator. Concerns should be presented truthfully, without exaggerating or downplaying the facts. This prevents the administrator from being caught off guard because issues were not identified or communicated.
       3. Analyze Each Issue: Presented topics need to be fact-based, bearing in mind that opinions and emotion are not facts. Nurses often function from an emotion-based focus because they are trained to be caregivers and nurturers. It is important to balance the emotional component with facts that connect to the administrator’s more bottom-line focus. Use a root-cause analysis approach to determine the true foundation of the issue that needs to be addressed.
       4. Develop, Implement, Monitor, and Communicate an Action Plan: The findings from the root-cause analysis form the basis for building an action plan. Starting from this foundation, the DON can create a prioritized list of desired outcomes for the identified problems and their related causes. The action plan should be goal-oriented, time-directed, and resident-centered. Progress, barriers, and adjustments should be documented and discussed with the administrator.
       5. Assess for Success, Adjust, and Discuss: Periodic reassessment of problematic areas will assure that the DON knows where each area stands. The use of measure-and-display graphs or other visual methods tracks progress and facilitates presentation. Periodic updates presented to the administrator help strengthen the partnership between him or her and the DON.

Conclusion

       The creation of a positive working partnership between the DON and the administrator is crucial. By understanding the differences in backgrounds and preparation of administrators, the DON can share key topics in a way that assures the information is understood and valued. In some cases, this may take significant effort, and at times it may seem impossible, but it is vital for success. Positive working partnerships between the DON and administrator are rewarding and worth all of the effort.