In dedicating 30 years of my life to long-term care skilled nursing, with 17 of those as a director of nursing (DON), I have had some amazing successes mixed with a few disasters along the way. The most important lesson that I have learned: If you and your administrator are not attached at the hip and heading in the same direction, the goal of providing outstanding care and service to your residents will never be reached. It is a fact of life—the two of you need to be walking and talking the same walk and talk, having the freedom to disagree privately and a keep tabs on each other to take your jobs seriously and if not yourselves.
       You and your administrator will not survive the challenges of clinical, operational, and regulatory operations in your facility if the two of you do not have an open, honest respectful relationship. Does the relationship just happen, or do you have to take steps to ensure that it happens? Many times, a DON and administrator believe that they are operating on the same page only to discover at the end that they were reading from two different books.
       Communication is key to the relationship, and so whether you have juststarted to work together or have worked side by side for the last 10 years, I would recommend that you start with a conversation consisting of the following ten questions.

1. What are our current roles and responsibilities, and how do we make this work together?
       In our work, we ask the questions, make an assessment, and develop an action plan. Job descriptions are reviewed when we are interviewed, scanned on the day of hire, and forgotten in a personnel file. As we absorb more responsibilities, we jokingly say, “Is this under any and all other duties that are assigned?” The administrator and the DON need to review their job descriptions annually to make sure that both key leaders understand clearly what each other is responsible and accountable for. Review and revise your job descriptions based on your current level of responsibility.

2. What is the mission and/or vision of our organization?
       If the mission is to serve the poor and the sick, how many poor and how many sick are you suppose to care for in your facility? If your mission is to service skilled-care clients, do you have clinically competent staff trained to provide care and service based on the current clinical standard of practice? And what type of financial outcome is needed in order to bring results for your organization and the esidents and staff that you serve? As the DON, it is your duty to ensure that the services that are being marketed in your facility are the services that you can provide, not only with clinically competent staff but within the current budget that has been developed for your organization. Review each potential admission from a clinical, financial, and regulatory category before accepting an admission.

3. Is there a facility commitment to a professional organization, and at what level may I participate?
       Your organization may be committed to a state or national organization that you may not have been affiliated with in a previous position. You should discuss whether you can volunteer to serve on a committee or hold an office. These additional duties will take time away from facility duties. If you are an active member of an organization, who covers for your duties when you are away from the facility, and how will that be communicated in your organization?

4. What is the expected number of hours that you will put in weekly?
       According to regulations, the DON must work 35 hours weekly. But the reality is, you will more than likely put in 50 hours a week. What happens if a night nurse calls in sick? Is there an expectation that the DON will cover? And if you do, are you expected to be around for the day shift the next day. You might chuckle with reading this dilemma, but believe it or not many DONs face this. But few have the honest discussion with their administrators on how to take back some of those hours so that they are not exhausting themselves at work.

5. What are the on-call duties for the two of us?
       Do you remember the feeling you had when you carried a beeper at your first job? You were important. You could solve problems and be at the staff’s beck and call. But after the first week, this importance wore off and beck and call had you questioning if your staff members could do anything on their own. As they say, be careful what you wish for. Your staff members are just trying to make sure that they notify all the right people when they have to. It is up to the two of you to put together an operational, clinical, and environmental call list for your staff with contact numbers and protocols for contact. Then determine who in the facility takes call and how it is rotated.

6. How will we tell each other that you or I need a time out?
       As the two of you develop a professional relationship, there will be days or times that you disagree, and there may be an occasion that you see your partner go down the wrong leadership path. The obligation of this professional partnership is to be open, honest, and respectful. Communicate your concern in private, and let your partner know that you can cover for him/her to take an unexpected day off or go home and rest.

7. What are the important events outside of work that you need to attend?
       I believe that family comes first and that we must not miss family events. Remember that childrens’ school plays and sporting events cannot be replayed. The two of you are expected to create a home-like environment for your residents. The two of you need to honor your own home lives and support each other in maintaining the balance of being a leader and having a personal life.