Clint Maun, CSP
There is no question that the jobs, tasks and functions associated with long term care facilities are different today than they were a decade ago, and that the changes occurring in Medicare affects them.
In this new era, the Director of Nursing (DON) remains a major leader; but instead of being the superstar of the organization who both manages and gets involved with the minutiae of care giving, the DON must become a champion of teaming.
To ensure a team-centered program’s success, administrators must develop an orientation program for the DON that will help define and teach the team leadership skills needed for this critical position including time management, coaching and development, communication, and budgetary fiscal skills.
Team leadership is a process by which all members of the organization, beginning with the top leadership in the facility, are tied to common team targets, including the budget, customer satisfaction, quality assurance, staff turnover, and revenue. Setting goals at the top allows individual staff members to focus on what it takes to be successful as a team. Goal setting promotes the concept of involvement, cross-functional interaction, communication and a sense of common focus.
This process breaks the "fragmentation of efforts," mold where departments follow their own agenda which often leads to interdepartmental turf and territory conflicts. Since nursing is the largest department in the facility, it is important to ensure that staff are playing team ball and not relying on the DON to make decisions that staff should make at lower levels. The stress of putting out fires and burnout from handling issues leaves the DON little time to actually manage, which ultimately leads to turnover.
Most organizations do not have a team-based leadership process in place. However, it is possible to initiate a teaming concept with the arrival of a new DON.
The first step the administrator should take to prepare for a successful DON orientation is to set goals. Acclimate the DON to the facility through meetings with all staff, thus developing a sense of "team" to assist the DON in determining barriers to successful realization of the daily operations calendar.
The calendar is particularly important since DONs are responsible for critical daily functions such as specific reports, quality checks, budgetary reviews, staffing issues, federal and state guideline checks and other corporate reporting requirements. A calendar should outline exactly what the DON needs to accomplish within certain time frames - daily, weekly and monthly. The orientation should allow enough time for the DON, in conjunction with the administrator and any corporate resources such as a nurse consultant or regional manager, to develop a comprehensive calendar.
Once the goals of the orientation have been established, the administrator or other designated manager must develop the elements of the program and assign staff to implement them. Orientation/Mentoring program elements should include:
- A description of and theory behind the role the new employee will be expected to assume.
- A sequenced checklist to be completed by the DON as each component of the orientation program is accomplished.
- A schedule based on the sequenced checklist for the administrator, corporate support staff, and any other people assigned to the mentoring program.
- An assessment of the current strengths and weaknesses of team leadership in the organization, including how charge nurses and unit managers are functioning in their role as team leaders. Being involved in this process will enable the DON to determine the best way to delegate responsibility. A review of past practices and incidents can give the DON insight into the capabilities of staff such as charge nurses and unit managers.
- An organized set of interdepartmental meetings to address the effects of team leadership from each department’s perspective.
- A series of readings, tapes and other sources that emphasize the daily requirements of the position and educational assignments for the DON to complete during the orientation program.
- Introduction of the DON to any clinical guidelines and critical practices the facility uses.
- An opportunity for the DON to observe the team leadership concept in action. If a facility does not currently operate under a team-based leadership process but plans to begin, it is helpful to send the DON to another facility that does have the process in place to receive peer coaching. The administrator should choose a cooperative entity such as a sister facility, another noncompetitive facility, or a peer facility in a health care association .
Allow Enough Time
If the DON is moving to the position from a similar position, the overall program may take about a week, not including other corporate or facility-specific orientations. If the person is taking a DON position for the first time, the process could take two weeks to allow for identifying areas of deficiency. The DON should be given the necessary time to:
- Meet and spend time with all key leadership individuals.
- Observe and participate in a best-practices process at another facility.
- Learn to know the members of the nursing team.
- Review, watch and be involved in critical functions such as care planning, meals, medication management, leadership group meetings, shift reports, and active time with customers including therapy, admissions process, discharge planning, residency and family counseling.
- Master critical areas in which he/she may be deficient. These areas should be identified early in the process and mutually defined by the administrator and the DON.
(They could include the prospective payment system, electronic transmission of the minimum data set, budget responsibilities, completion of forms, or documents specific to the organization.)
- Spend time in coaching or mentoring sessions with various individuals (particularly in areas of deficiency).
By allowing these components to take shape in a step-by-step orientation plan, the facility is helping the DON accomplish the objectives of the program. It also will give the DON a well-rounded understanding of the functions of the facility. The orientation schedule should also allow time for the DON to review critical forms, documents, and completion processes associated with this paperwork. Simply throwing the DON into a pile of paper will not ensure success. The DON must have time to spend with individuals who can explain how the paperwork is completed.
The DON should not be expected in the first week or two to make major organizational decisions or changes that affect the functioning of the facility. Certainly it may become necessary for the new DON to make weighty decisions if an immediate need arises. Examples include concerns with a specific resident or an immediate issue surrounding a survey or compliant investigation. However, in such cases, the DON should be instructed to consult first with experienced nursing team members. It is strongly recommended that the DON be allowed to learn the job and its responsibilities before beginning to effect major change.
It is important throughout the orientation and beyond for facility staff to start communicating in terms such as. "We need to do this," or "This is something our organization needs to accomplish." When staff members are in the habit of making statements - particularly to a new DON - such as, "You need to see to it that Mrs. Smith’s fluid intake is monitored," the facility is reinforcing a model of decision-making that is not team-based.
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