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Leadership in Nursing Homes Directors of Nursing Aligning Practice With Regulations Elena O. Siegel, PhD, RN; Kristen Bettega; Debra Bakerjian, PhD, APRN, FAAN, FAANP; and Suzanne Sikma, PhD, RN

ABOUT THE AUTHORS Dr. Siegel is Associate Professor, Ms. Bettega is Project Manager, Dr. Bakerjian is Associ-

ate Adjunct Professor, Betty Irene Moore School of Nursing, University of California, Davis, California; and Dr. Sikma is Professor Emeritus, School of Nursing and Health Studies, University of Washington Bothell, Bothell, Washington.

Th e authors have disclosed no potential confl icts of interest, fi nancial or otherwise. Th is project was funded by a grant from National Council of State Boards of Nursing Center for Regulatory Excellence (R80005). Th e authors are grateful to the study participants for their time and support for this project and the Advisory Panel for sharing their expertise: Cynthia Gustafson, PhD, RN; Shirley Brekken, MS, RN; Karen Lyon, PhD, RN, ACNS, NEA; Paula Meyer, MSN, RN, FRE; and Pamela Zickafoose, EdD, RN, NE-BC, CNE.

Address correspondence to Elena O. Siegel, PhD, RN, Associate Professor, Betty Irene Moore School of Nursing, University of California, Davis, 2450 48th Street #2600, Sacramento, CA 95817; e-mail: [email protected].

doi:10.3928/00989134-20180322-03

ABSTRACT

Nursing homes use team nursing, with minimal RN presence, leaving the majority of direct care to licensed practical/vocational nurses (LPNs/ LVNs) and unlicensed assistive person- nel (UAP), including medication aides. The current article describes challenges faced by nursing home directors of nurs- ing (DONs) leading and managing a team nursing approach, including consider- ation of scope of practice, delegation and supervision regulations, and related policy implications. A secondary data analysis was performed of qualitative data from a study to develop and test DON guidelines for delegation in nursing home practice. A convenience sample (N = 29) of current or previous DONs and other nursing home leaders with knowl- edge and expertise in the DON role par- ticipated in in-depth, guided interviews. The fi ndings highlight a core concern to nursing licensure policy and regulation: knowledge and practice gaps related to scope of practice and delegation and su- pervision among DONs, RNs, and LPNs/ LVNs, as well as administrators, and the role of nursing leaders in supporting appropriate delegation practices. The fi ndings off er directions for research and practice in addressing challenges in aligning team nursing practices with regulatory standards as well as the relat- ed gaps in knowledge among DONs, ad- ministrators, and nursing staff . [Journal of Gerontological Nursing, 44(6), 10-14.]

Eff orts to improve the quality and safety of nursing home care include a breadth of research in staffi ng practices focused on staffi ng levels, mix, and turnover (Dellefi eld,

Castle, McGilton, & Spilsbury, 2015; Trinkoff et al., 2013). Although suf- fi cient staffi ng is critical, it is equally important to understand how staff function within the nursing home,

particularly when there is minimal RN presence, leaving the majority of direct care to licensed practical/ vocational nurses (LPNs/LVNs) and unlicensed assistive personnel (UAP), including medication aides. Of the nursing staff in nursing homes, 57% are UAP, followed by 21% LPNs/ LVNs, 8% staff RNs, and 13% ad- ministrative RNs (American Health Care Association, 2012).

Centers for Medicare & Med- icaid Services (CMS) regulations (§483.30 42 CFR Ch. IV) require only one RN in facilities with ≤60 beds and that a RN may be the director of nursing (DON). Th e DON is responsible for overseeing and organizing the nursing staff to deliver high-quality and eff ective care. Given the nursing home staff licensure/skill mix, a team nursing approach is the only viable delivery model option; however, team nursing is complex and aff ected by a variety of contextual factors. RN and LPN/ LVN practices are set forth by state agency/board of nursing practice standards, consistent with their licensure, including provisions for delegation and supervision. Yet, the literature suggests discrepancies in ways some RNs and LPNs/LVNs en- gage in team nursing (i.e., enact their scope of practice and/or delegation and supervision), with implications for a variety of care practices and quality outcomes (Corazzini, Muel- ler, et al., 2013; Mueller, Anderson, McConnell, & Corazzini, 2012).

DONs’ role in ensuring safe and eff ective team nursing entails direct and indirect involvement in all aspects of nursing services, such as ensuring suffi cient resources for adequate nurse staffi ng (levels/mix/ expertise); staff training/professional development; hiring practices and performance evaluations; job descriptions/role responsibilities; and in some settings, nursing bud- gets (Siegel, Young, Leo, & Santil- lan, 2012). In addition, DONs must ensure a strong team-based approach

to care that involves appropriate supervision and delegation of tasks within the team. Although studies suggest gaps in elements of team nursing, such as delegation and supervision (Corazzini et al., 2010), few studies focus specifi cally on the role of the DON to ensure team nursing is performed safely, eff ec- tively, and in accordance with state nursing licensure regulations. Th e current article describes challenges faced by nursing home DONs lead- ing and managing a team nursing approach, including consideration of scope of practice, delegation and supervision regulations, and related policy implications.

METHOD A secondary data analysis

(Heaton, 2004) was performed of qualitative data from a study to de- velop and test DON Guidelines for delegation in nursing home practice. Th e study protocol was approved by the University of California Davis Institutional Review Board. For the parent study, qualitative data were collected in two sequential phases. Participants were recruited via networking with colleagues, e-mail invitations to professional/trade as- sociations, and in-person invitations at a professional association’s national conference. For Phase 1, 19 in-depth, audiorecorded telephone interviews were conducted to develop items for the Guidelines. Questions and follow-up prompts focused on the DON’s role in managing and leading nurse delegation; work factors that facilitate or impede eff ective delega- tion; and strategies to overcome environmental barriers. For Phase 2, 10 in-depth, audiorecorded inter- views were used to review the Guide- lines for clarity, usability, importance, and relevance. During initial review of the data to develop the Guidelines, a general theme was identifi ed refl ect- ing challenges and gaps in knowledge and/or practices to support team nursing among personnel situated

across the organizational chart, with implications for the DON’s role, thus prompting the current second- ary analysis.

Th e interview recordings were transcribed by a professional transcrip- tionist, verifi ed by a team member, and uploaded to a qualitative data management software (NVivo 10). Th e entire dataset from the parent study was used for this secondary analysis. Coding began with text pur- posively selected for statements related to DON preparation or knowledge, including references to preparation/ knowledge for their position in gen- eral and specifi c to their knowledge of scope of practice, delegation, and/ or supervision. Th e coding was then expanded to include references to DONs’ interface with others in the organization around their knowledge of scope of practice, delegation, or supervision. Th is interface was sub- coded for diff erent stakeholder groups (i.e., administration, LPN/LVN, UAP). Data were sampled until rep- etition in key concepts and variations within concepts occurred, meaning saturation was achieved (Corbin & Strauss, 2008). Coding practices and decisions were reviewed with members of the research team, and an audit trail was developed to document the cod- ing process.

RESULTS Th e convenience sample (N = 29)

comprised current or previous DONs and other nursing home leaders with knowledge of and expertise in the DON role. Most participants (n = 26) were DONs with an average tenure of 10.8 years (range = <1 to 25 years) in the role. Others (n = 3) included a Minimum Data Set coordinator, Assistant DON, and nursing home Vice President. Highest education was associate degree (n = 4); baccalaure- ate degree (n = 9); master’s degree (n = 12); and doctorate (n = 4).

Th e fi ndings of this analysis describe challenges faced by nursing home DONs in leading and man-

11JOURNAL OF GERONTOLOGICAL NURSING • VOL. 44, NO. 6, 2018

aging a team nursing approach in consideration of scope of practice, delegation, and supervision regula- tions. Results are organized into three sections: (a) DON role preparation and knowledge; (b) working with administration to assure an adequate team; and (c) nursing staff knowl- edge and practices that support team nursing.

DON Role Preparation and

Knowledge

Many participants suggested DONs do not commonly receive for- mal training or preparation for their nursing leadership position:

Th e…[DON] gets fi red or quits, and they…look around and go, “Hey, you could be the DON. Oh, that one over there…do you want to go into… this training program?” Which turns out really not to be a training program. You just end up in a building.

Some DONs lack knowledge about scope of practice diff erences between RNs and LPNs/LVNs, as stated by two participants:

I can’t believe the deer in headlights looks that I sometimes get when I talk about scope of practice and what LPNs can’t do…or what kind of supervision a nursing assistant needs. [For]…some of these directors of nursing, this is the fi rst time they’ve heard this.”

…It’s very interesting how… [DONs] are unaware of scope of prac- tice.… A very large number of DONs tend…not [to] appreciate…that the LPN…by scope of practice should not be the person doing an assessment.… Th ey often don’t know…where… the scope of practice for various posi- tions…is located.

Beyond regulatory knowledge about scope of practice, delegation, and supervision, participants spoke about other knowledge/skill gaps that potentially challenge DONs when working with administration and staff to implement team nurs- ing, including: budgeting/fi nancial considerations, staffi ng model calcu- lations based on resident acuity/care needs, and leadership skills.

Working With Administration to

Assure an Adequate Team

DONs face the challenges of administrator knowledge about scope and procuring adequate staffi ng budgets to comply with regulations. Some administrators lack knowledge of the diff erence in scope of practice for RNs and LPNs/LVNs and risks of interchangeably using LPNs/LVNs for RNs:

…[Th e DON] can try to ask ad- ministration…[to] increase your RNs in-house, but…the cost diff erence is pretty great and a lot of administra- tions are going to try to get you to keep the LPNs when they don’t fully understand how critical the RN role is.

Th e DON’s role to assure an adequate team focuses largely on working with administration to obtain budget allocations for staffi ng to support nursing services in terms of numbers as well as mix (i.e., RNs, LPNs/LVNs, UAP). Participants described a variety of ways DONs approach administration to making the case for additional nursing staff :

…You can’t just say, “Oh, I need more staff .” You really have to look at what is the staff doing? How are they doing it?… Come up with “Okay, I need this position to do this.” And then go to your administrator…. Yeah, you’re the director of nursing. You’re not some minion. “We need this be- cause, boom-boom-boom-boom.” And the administrator should say, “Yes.”

Getting a “yes” is not guaranteed, as one participant described: “You say to your Administrator, ‘We need another RN in the building on the evening shift.’ And then the Admin- istrator usually says, ‘Well, I guess it’s you then as the DON because we’re not paying for another one.’”

Participants spoke about this demoralizing expectation that the DON be the “stopgap” for fi lling actual or desired RN positions as further compromising the DON’s capacity to provide adequate facility- level leadership.

Participants off ered diff erent ap-

proaches to presenting the issue to administration based on goals and values of individual settings, includ- ing fi nancial, legal, and regulatory perspectives, as well as quality of care and staff satisfaction:

Th e administrators tend to be pretty sensitive…to be[ing] compli- ant with regulation, laws…. And just hearing that something is a good practice…contributes to good quality alone is not gonna do it.... But if the DON can locate where these docu- ments are, where the evidence of the diff erent scope of practice…the facts are…that person can then be an advo- cate and understand how to articulate that to the owners and administra- tors.… So it’s fi nding it, knowing how to communicate it, and in a manner that’s gonna resonate with the people who are concerned with regulatory compliance and fi scal responsibility.

Nursing Staff Knowledge and

Practices That Support Team

Nursing

Lack of understanding about scope of practice undermines enactment of team nursing. Some participants voiced concern about DONs working with nursing staff to enact scope of practice, delegation, and supervision regulations appro- priately within the team nursing model. Challenges included LPNs/ LVNs working beyond their scope of practice or a lack of understanding by RNs and/or LPNs/LVNs of their own or others’ scope of practice. For example, “I think the challenges are the LPNs do not see themselves any diff erent than an RN. Th ey did not understand delegation, assessment in care planning because they, as LPNs, cannot assess—they can only gather data,” and “…most RNs…don’t understand the scope of practice for their own licenses.”

Some participants spoke about the inherent tension between experienced LPNs/LVNs and less experienced RNs:

…and sometimes you have the RN who really ought to be an LPN be-

cause that’s where they function. And sometimes you have an LPN who re- ally ought to be an RN because that’s where they function…. But you can’t just willy-nilly change their job de- scription…so what do you do with that piece?

Others spoke about RNs working below their scope of practice and/or having limited interest in supervis- ing LPNs/LVNs or UAP: “…I have RNs—they pass meds…and they don’t want to oversee the aides and you’re trying to get them to do that oversight.… Everybody’s really tun- nel vision on what they’re doing.”

DISCUSSION DONs are responsible for ensur-

ing nursing staff provide high-quality and safe nursing care, which in- cludes staff functioning within their scope of practice in accordance with regulations/provisions for delega- tion and supervision and working collaboratively. Th e current study highlights some challenges DONs face in ensuring team nursing is performed safely, eff ectively, and in accordance with state nursing licensure regulations at three junc- tures: administration, nursing staff practices/knowledge, and the DON professional role (i.e., preparation and knowledge). Although each is important, it is DONs’ lack of formal preparation and the result- ing lack of knowledge that is most problematic, with direct impact on the other areas.

DONs must effi ciently and eff ec- tively lead and manage a multilevel nursing team, which requires in- depth knowledge of state and federal regulations. Th e current fi ndings suggest implementing this knowl- edge includes helping team members understand their own and others’ scopes of practice; structuring the team so staff can work within and to the full potential of their own scope of practice; and structuring delega- tion and supervisory roles consistent with regulatory parameters. Without this knowledge, DONs cannot work

eff ectively and collaboratively with administrators to ensure suffi cient nursing home staffi ng that is com- pliant with state and federal regula-

tions and incorporate an appropriate team-based delivery model to provide high-quality resident care.

A lack of formal role prepared- ness can have critical implications for DONs’ ability to attain adequate resources for nurse staffi ng, meaning the right number and right staff (i.e., RN, LPN/LVN, UAP) used in the right way. Th e DON is an important resource for administrators, who may lack understanding of the various roles and scopes of practice of nurs- ing staff . Th e fi ndings from the cur- rent study highlight the importance of providing administration with data-supported rationale for staffi ng requests and linking these requests to the goals valued by administration, a tactic used by DONs to secure re- sources that was also found in a study by Siegel, Young, Zysberg, and San- tillan (2015) of the DON position. In settings where nursing staff lack role clarity or consistent diff erentia- tion in RN and LPN/LVN scopes of practice (Corazzini, Anderson, et al., 2013; Corazzini, Mueller, et al., 2013) and adequate training/ preparation in delegation or supervi- sion (Corazzini et al., 2010), DONs’ lack of formal role preparedness can also be a challenge to ensuring high functioning team nursing. Consistent with the literature, current study par- ticipants described issues around role clarity for RNs and LPNs/LVNs that included blurring of diff erences be-

tween functional roles and licensure, particularly when each type of nurse functions above or below his/her scope of practice. Th e consequences

of a lack of role clarity can be further exacerbated by diff erences in experi- ence when new RNs are working with highly experienced LPNs/LVNs.

LIMITATIONS Th e fi ndings from the current

study are not generalizable and should be interpreted with caution. In addition to limitations associ- ated with the parent study sampling approach, secondary analysis of qualitative data precluded opportuni- ties for follow-up prompts during the interviews to delve into the emerging themes.

POLICY IMPLICATIONS Th e fi ndings from the current

study highlight the policy–practice gap in DON role requirements for this key nursing leadership posi- tion and implications for eff ective leadership and management of team nursing consistent with regulatory standards. Although CMS nurs- ing home regulations specify RN licensure as the sole requirement for DONs, these fi ndings build on existing literature, reinforcing the need to advance policy requirements for formal training and education of DONs—beyond this minimum— to eff ectively execute this nursing leadership position (Siegel, Mueller, Anderson, & Dellefi eld, 2010). DONs’ knowledge defi cits are often attributed to how and why many

Directors of nursing must effi ciently and

eff ectively lead and manage a multilevel nursing

team, which requires in-depth knowledge of state

and federal regulations.

13JOURNAL OF GERONTOLOGICAL NURSING • VOL. 44, NO. 6, 2018

DONs are fi rst hired—directly from a staff nurse role because they were strong clinicians—learning leadership and managerial roles as a “baptism... [by] fi re” (Fleming & Kayser-Jones, 2008, p. 22; Siegel et al., 2010; Siegel & Sikma, 2015). Fleming and Kayser-Jones (2008) found that even baccalaureate- and master’s- prepared DONs felt unprepared for the DON role, citing lack of knowl- edge in communication, teamwork, and systems, which was described as essential for the position. In fact, the DON role requires extensive knowl- edge in multiple areas of nursing home leadership, administration, fi nance, management, and regulatory policy interpretation and compliance as well as clinical geriatric care.

Th e study fi ndings also raise questions about the extent to which other licensed personnel in the nurs- ing home (i.e., administrators and nursing staff ) should have a working knowledge of scope of practice and delegation and supervision. Col- laboration with regulators of nursing home administrator licensing to pro- mote administrators’ core knowledge of nursing practice regulations may be benefi cial. Th e recurrent fi nd- ings of knowledge and practice gaps related to scope of practice and del- egation and supervision among RNs and LPNs/LVNs, as well as adminis- trators, are of core concern to nursing licensure policy and regulation. Th ese core concerns suggest the need to reexamine educational curricula,

minimum standards for preparation and hiring of DONs, and regulation of nursing and administrative prac- tice in the nursing home setting.

CONCLUSION Th e fi ndings from the current

study off er directions for research and practice in addressing challenges in aligning team nursing practices with regulatory standards as well as the related gaps in knowledge among DONs, administrators, and nursing staff .

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