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Assuming the

Mantle of Leadership
Issues and Challenges for Directors of Nursing
Abstract Background
This ethnographic study investigated leadership from the perspective of directors Call for DON Leadership
Ethnographies have long report-
of nursing (DONs) in proprietary nursing homes. Data from interviews and extensive
ed that nursing leadership is needed
participant observation with 10 DONs were analyzed using open coding and content to improve staff attention to the
analysis. The study drew on a priori concepts from transformational leadership the- human conditions of older adults
ory to describe the role, DON approaches to leadership, and factors that facilitate or in nursing homes (Foner, 1995; Gu-
brium, 1975; Kayser-Jones, 1981).
impede leadership in nursing homes. This article reports findings from a larger study
Many studies that report poor resi-
related to conditions existing when participants entered the DON position. Anteced- dent outcomes suggest that good
ent conditions influenced organizational expectations of incoming DONs and shaped DON leadership would improve
participants’ leadership experiences. DONs filling long-standing vacancies had to re- cost-effective quality care (Ballard,
1995; Cherry, 1991; Kayser-Jones,
establish the influence and authority of the role. Those replacing unsuccessful DONs
1997; Kayser-Jones et al., 2003;
confronted serious regulatory, care, and morale issues. In contrast, DONs with success- Lodge, 1985; Mueller et al., 2006;
ful predecessors experienced organizational support and had confidence in their abili- Rantz et al., 2003; Schnelle, 1990).
ties to lead. Others that describe inadequate
staffing, turnover, and organiza-
tional failure to adopt and sustain

T
he director of nursing (DON) home problems, yet relatively few clinical interventions also call for
holds one of the most crucial studies have examined the role, and more research on management and
organizational positions to fewer still have explicated DON leadership (Anderson, Corazzini, &
affect the quality of care and daily leadership. This study aimed to de- McDaniel, 2004; Castle, 2005; Har-
operations in nursing homes (Row- scribe and analyze the phenomenon rington, 1990; Institute of Medicine,
les, 1995). More than a quarter of a of leadership from the perspective of Committee on Improving Quality
century has passed since Eliopoulos DONs. We were specifically inter- in Long-Term Care, 2001). Despite
(1982) proffered the notion that well- ested in learning how DONs assume these compelling arguments, DON
prepared DONs could lead focal ef- the mantle of leadership and what leadership remains an understudied
forts to address intransigent nursing factors influence their leadership. phenomenon.

Mary Louise Fleming, PhD, RN; and Jeanie Kayser-Jones, PhD, RN, FAAN

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DON Position Requirements DON Tenure and Turnover suggest a critical need to shed new
Federal law stipulates that The 2002 American Health Care light on the influence and challenges
skilled nursing homes must em- Association survey reported the na- of the DON role.
ploy an RN as the designated tional DON vacancy rate at 4.8%;
DON (“Rules and Regulations,” two states had more than 100% turn- DON Studies
1998). Although a 1998 national over, and all but three had turnover Research on nursing home DONs
survey confirmed compliance with rates greater than 25% (Decker et al., is limited; however, a full review of
this mandate, most states allow 2003). Longer DON tenure has been studies is beyond the scope of this
nursing homes with fewer than 60 correlated with better resident out- article. Key studies conducted dur-
beds to use DONs to meet mini- comes (Anderson, Issel, & McDan- ing the past decade have extended
mum requirements for hours per iel, 2003) and with staff retention the seminal work of Lodge (1985)
resident day (HPRD), and facili- and satisfaction (Castle, 2005). Stable to explicate DON roles and char-
ties with between 60 and 100 beds leadership is at the core of maintain- acteristics (Aroian, Patsdaughter,
to use DONs as charge nurses ing quality, whereas DON turnover & Wyszynski, 2000; Byers, 2001),
(Harrington, 2005). Thus, DONs creates a downward spiral of dissat- educational needs and programs for
are often the only RN on site or isfaction, poor morale, and caregiver advanced training (Mueller, 1998;
on call, and they have little time to turnover, which leads to inadequate Ross, Carswell, Dalziel, & Aminza-
provide basic supervision or en- care and performance on state sur- deh, 2001), DON use of standards in
gage in leadership activities. veys (Castle, 2005). These factors practice (Bottrell, O’Sullivan, Rob-
bins, Mitty, & Mezey, 2001; Resn-
ick, Quinn, & Baxter, 2004), and the
influence of DON performance on
resident and workforce outcomes
(Anderson et al., 2003, 2004; Tellis-
Nayak, 2005).
In general, prior studies have been
descriptive and atheoretical, have
relied on self-report, have had small
samples or poor survey response
rates, and have stopped short of de-
scribing how DONs conceptualize
and enact leadership. Studies that
included face-to-face inquiry or used
survey methods with open-ended or
in-depth strategies provided rich-
er descriptions of the DON role,
expectations, and actual practice
(Fleming, 2007). Limited accounts of
leadership leave a gap in the knowl-
edge about this important aspect of
the DON role.

Method
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This ethnographic study used


in-depth interviews and participant
observation to investigate DON
leadership in nursing homes. Central
to ethnographic descriptions are the
beliefs, values, norms, and practices
of people within a community, or-
ganization, or institution (Field &
Morse, 1985). DONs across nursing

Journal of Gerontological Nursing • Vol. 34, No. 11, 2008 19


interviews, 23 hours of informal
Table 1 conversations, and 164 hours of par-
Characteristics of the Study Sample (N = 10) ticipant observation.
DON Characteristics Range Mean (SD)
Data Analysis
Age 33 to 62 45.6 (9.2) Data were simultaneously col-
Years as an RN 8 to 40 20.8 (8.12) lected, compiled, interpreted, and
Years in nursing home practice 4 to 34 12.6 (9.6) analyzed. Audiorecorded interviews
were transcribed verbatim, and de-
Years as a DON 1 to 14 4.90 (4.35)
tailed field notes were written dur-
Years in other settings 0 to 22 8.3 (7.57) ing and at the end of each session.
Memos were written and analyzed
Note. DON = director of nursing.
throughout the study. Preliminary
themes, patterns, and relationships
among data guided subsequent inter-
Table 2
views and observations. Field notes
Educational Preparation of the Study Sample (N = 10) and transcripts were read multiple
Initial times to modify themes and deter-
Nursing Degree n (%) Location Additional Education mine common ideas. These fell into
Diploma 1 (10) 1 United States natural groupings that were further
examined for themes that typified
Associate degree 3 (30) 2 United States 1 bachelor of arts degree
participant accounts and experiences.
1 Caribbean 1 master’s degree in public Themes were analyzed and woven
administration
together to form a comprehensive
Bachelor’s degree 6 (60) 1 United States 1 master’s degree in public picture of the collective DON expe-
administration rience. As fieldwork concluded, data
5 Philippines were reviewed with a priori concepts
set forth in transformational lead-
ership theory (Bass, 1985; Burns,
home settings represent a cultural sian (n = 3), Black (n = 1), and East 1978). Saturation was achieved when
group, as they are connected by the Indian (n = 1). Sample characteristics no new themes or relationships were
systems, regulations, and popula- (Table 1) and educational prepara- found in the data and a rich descrip-
tions they serve. Participants with tion (Table 2) were self-reported on tion of the DON role was developed
at least 1 year of combined experi- a demographic questionnaire. fully. ATLAS.ti, version 5.2 was used
ence as a DON or assistant DON for data management.
(ADON) were recruited using pur- Data Collection
posive and snowballing strategies. Fieldwork consisted of system- Findings
The study was approved by the atic observations and interviews to All participants identified them-
University’s Committee on Human learn about DONs’ daily routines, selves as leaders, and the DON posi-
Research. Pseudonyms are used to patterns of interacting, concerns, be- tion as a leadership role. When asked
ensure confidentiality of individuals liefs, and perceptions. An interview to describe their role, 5 (50%) began
and study sites. guide was used initially to organize with a statement about being the
and frame grand tour questions nurse leader. One responded, “My
Sample about the DON role. Participants role? It’s to be the leader for nursing
Ten DONs from four corporate spoke freely, and general probes were and nursing care. I represent all of us
multifacility nursing homes (i.e., used to seek clarification or deeper and the work we do.”
chains) located in five West Coast explanation. DONs conducted an
urban counties were interviewed initial facility tour with the principal Antecedent Conditions
and observed over 6 months in 2007. investigator (M.L.F.) to provide an Participants entered DON posi-
Proprietary nursing homes were orientation to the setting and a view tions to (Figure):
used as study sites as they comprise of the organization through their l Fill long-standing vacancies.

the major sector of the U.S. nursing eyes. The relationship with each par- l Replace unsuccessful DONs

home industry (Harrington, Carril- ticipant was the cornerstone of the removed from their positions.
lo, & Mercado-Scott, 2005). Partici- research endeavor. Thus, multiple l Replace successful DONs who

pants were Filipina (n = 5), Cauca- visits included 44 hours of in-depth had retired or were promoted.

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Each unique situation shaped or-
ganizational expectations, as well
as DON entry and ongoing leader-
ship experiences. Those filling long-
standing vacancies had to re-estab-
lish the influence and authority of
the role. Participants replacing un- Fill
successful DONs confronted seri- long-standing
Replace vacancies
ous problems related to regulatory successful DONs
compliance, poor care, and low staff
morale. In contrast, DONs follow- 50 % 20%
ing successful predecessors felt
prepared, had confidence in their
leadership abilities, and had support
to make improvements in staff and Replace
resident programs. unsuccessful DONs
Fill Long-Standing Vacancies.
Two participants accepted positions
30%
that had been vacant between 11 and
14 months. The extended absence
of a DON resulted in operational
and resident care problems Ellen Figure. Antecedent conditions of entry to the director of nursing (DON) role.
and Carol needed to “tackle right
away.” Both struggled to re-estab- nated staff breaks during resident tive feedback from families: “Fami-
lish the influence and authority of mealtimes. She insisted that dietary lies know the DON makes the dif-
the DON role in clinical and opera- and therapy staff attend key meet- ference. If staff is happy and well
tional domains. ings and family conferences. Each trained, the residents are going to get
Ellen, an experienced clinician change was met with resistance and better care and be happier too.” As
and administrator, was new to nurs- resentment: “They felt I was taking the study concluded, Ellen resigned
ing home practice. Previously, DON over, not because of residents’ needs, to join a “more progressive” nursing
duties had been assigned to a staff but for making nursing’s job easier. home.
RN who mainly covered sick calls To this day, they think they’re doing Carol took a position that had been
on all three shifts. The non-nurse nursing’s job.” vacant or filled by a series of short-
administrator assumed other respon- An exchange during a administra- term DONs for 14 months. Unlike
sibilities, including staff scheduling tive meeting exemplifies the ongoing Ellen, Carol had worked exclusively
and making clinical decisions. Ellen nature of Ellen’s struggle. The envi- in nursing homes and was reluctant
had difficultly establishing her role ronmental service director demanded to challenge existing norms. The ad-
in clinical and operational decision the administrator “make those nurs- ministrator maintained oversight of
making. Even gaining entry into es clean up resident ‘accidents’ in the many nursing operational and clinical
routine meetings was a challenge. halls.” The administrator turned to areas, such as staffing and admission
She was expected to cover shifts as Ellen and asked, “Why don’t staff do decisions. Carol said, “Basically I
the RN had done previously. She their jobs?” Ellen explained her view was just doing my old job…. I didn’t
considered her biggest challenge to of the situation: “Nurses are on the even realize it until we are talking…I
be “competing with the administra- bottom of the ladder here…. They was like the assistant.” When the ad-
tor who wanted ultimate control and had no one to stand up for them for ministrator was promoted, Carol felt
[to] continue speaking on behalf of so long…. I’ve worked out some alone and unsupported: “The district
nursing.” of the compromises with depart- boss has his certificate hanging in the
For the first year, Ellen had to ments…at least we have decisions I front office, but he is never here….
“fight for every little decision, no can use to stand my ground.” I am learning everything now and
matter how small.” After months Ellen was exhausted and believed running the whole show at the same
of discord, she increased staffing to their problems were “basically un- time.” Throughout the 6-month
3.46 HPRD for 96 beds (which is solvable.” Progress was incremental study period, the administrator posi-
slightly above the state minimum and painstaking. She found strength tion remained vacant.
requirement of 3.2 HPRD), initiated in the “little wins” of improving With expanded responsibility,
a change of shift report, and elimi- staffing and care plans and in posi- Carol discovered she could make

Journal of Gerontological Nursing • Vol. 34, No. 11, 2008 21


significant contributions. She re- was terminated. Frances believed her over how she could maintain ade-
flected on her lack of participation in transfer was a planned strategy to quate resident care with fewer staff at
a project to redesign the resident din- address concerns the corporate of- the bedside. Helen had also created a
ing room: “I never gave an opinion as fice anticipated from the surveyors: flexible work schedule to meet resi-
the DON. I thought it wasn’t about “[I came] on a Monday. Tuesday, the dent care and staff needs. She feared
resident care, but it is.” As acting ad- State came for a survey. Wednesday, that eliminating individualized
ministrator, Carol experienced the I was the DON.” schedules would reverse the gains
influence she could have on improv- Frances’ major responsibility made in staff retention. In less than a
ing resident care and workplace con- was to bring the facility into com- week, she issued 20 written warnings
ditions. Carol wanted to develop as a pliance. Her typical days were spent for lateness or absences. She hoped
DON but described a bleak picture auditing and correcting documen- staff would “hang in” until she could
of ongoing inattention to her orien- tation errors, filling in for RN va- reinstitute prior schedules: “I hate
tation and professional development: cancies, and giving inservice classes to say it, but if staff quit over this,
“What training? There is none. Bap- on all three shifts. After a success- that might speed up the process for
tism of fire, right? No one to this day ful first re-survey, she faced a series changing back. We just exchange one
has shown me how to be a supervi- of additional inspections. Her only problem for another. I just ride out
sor, or a nurse manger, or a DON. goal was “to keep everybody on a the cycle.” The assault on Helen’s
Actually when I took this job, I had survey mode” for the next year. She authority did not go unnoticed. A
a consultant come by, say ‘Welcome’ hired several foreign-educated RNs relatively new ADON asked Helen
and give me a bouquet of flowers, who were new to the United States if she should “come back to work,”
and that’s it! You’re on your own.” and to nursing practice, who spoke believing she would be fired for su-
In sum, DONs filling long-stand- limited English, and who had no pervising staff inadequately.
ing vacancies had to overcome orga- prior experience or training in ge- Irma accepted a DON position
nizational constraints to re-establish riatric care. Frances entered nursing knowing that an “unexpected bad
their influence. Despite Ellen’s skills home practice under similar circum- survey” prompted the dismissal of
and perseverance, lack of support stances and having had a successful the administrator and DON. She was
from the administrator and her peers career, she gave little thought to recruited by the newly hired admin-
allowed only incremental changes in potential problems or the effect her istrator with whom she had worked
the culture over time. Carol’s inex- decision would have on communi- previously. She had extensive admin-
perience, coupled with her desire to cation with residents and families, istrative and clinical experience in
maintain harmony and the admin- on actual care, or on staff morale: acute care and recent experience as
istrator’s control over key nursing “If the surveys are good, that’s how a nursing home director of staff de-
areas, constrained her initial partici- I know I’ve done a good job.” Her velopment. The former DON “had
pation in leadership activities. These approach was supported by the cor- really let things go,” resulting in low
factors limited Carol’s ability to de- porate nurse consultant. staff morale, many care and practice
velop leadership skills. Helen worked with a series of problems, and daily use of registry
Replace Unsuccessful DONs. short-term DONs, often filling in staff to meet minimum staffing re-
Three participants accepted DON when needed. She accepted the per- quirements. On some shifts, regis-
positions after their predecessors manent position after a new DON try staff outnumbered nursing home
were dismissed for poor perfor- was fired for falsifying pre-survey employees.
mance. Frances and Helen were pro- documents. After leading a success- Unlike Helen’s conditional auton-
moted from ADON positions with- ful survey, the administrator gave omy, Irma had full authority to facili-
in a nursing home chain. Irma was Helen “his full permission to do tate changes in operational and clini-
recruited to a different nursing home what I needed as long as our sur- cal areas: “He [administrator] never
chain by a former administrator. veys were good.” As long as facility said my job security was riding on
Each confronted serious problems benchmarks were met, Helen had passing the survey, but I know that’s
related to regulatory compliance, freedom to make and implement au- the way it is for a lot of DONs.” Irma
poor resident care, and low staff mo- tonomous decisions. This condition- was appointed to lead the survey pro-
rale. Their principal goal was to pass al autonomy lasted until a problem cess, which gave her formal authority
the regulatory annual survey. of timely staff responses to call lights to build peer relationships and facili-
Frances was transferred to a poor- arose during an annual survey. tate improvements. This support re-
ly performing facility in the nursing The administrator issued a direc- duced potential resistance from oth-
home chain to help with a re-survey tive to end flexible staffing and de- ers: “Everybody knew we’d worked
for substandard care but needed to manded that Helen assign staff to together before. That really gave me a
“step in” mid-survey when the DON “cover the desk.” She was distraught good start with the department heads

22 JOGNonline.com
and especially my staff. I think some here to learn and then move on to 1985; Burns, 1978). Transformation-
would have left if I had any doubts their own buildings.” This inconsis- al leadership theory includes three
about him, or he about me.” tency coupled with “always filling leadership dimensions: laissez-faire,
In sum, participants who replaced in for them, then teaching someone transactional, and transformational.
unsuccessful DONs confronted seri- new what to do, and then letting Laissez-faire leadership is charac-
ous problems with regulatory com- them take over” was time consum- terized by avoidance, delays in de-
pliance, poor resident care, and low ing and stressful: “It took me away cisions, and short-range planning.
staff morale. The focus on passing from my real job with my residents Transactional leadership is based
the annual survey set the tone for and staff.” on principles of give and take and
how DON leadership was enacted After 1 year as a DON, Josie is distinguished by an exchange of
and valued by others. Satisfactory “lost my good administrator.” Two negotiated rewards between leaders
survey results were tied to financial others came and left within a year: and followers for meeting minimal
goals of the larger corporation. For “They had no experience in nursing standards. Transformational lead-
example, Frances’ goal to bring her homes or in clinical [care] and tried ers are change agents who recognize
facility into compliance was linked to run us like a business.” Staff and personal and intellectual needs, and
to reinstating resident admissions residents “did not suffer too badly engage and inspire followers to make
and “keeping the facility open.” For because we had long history of good contributions to the higher goals of
Frances, actual resident care and staff nursing care.” She remembered that an organization. When considering
morale were secondary concerns. In year, however, as the worst period of DON leadership, the significance of
Helen’s case, decisional autonomy her career. the DON-administrator relationship
and authority to direct her depart- In sum, participants who followed and the importance of professional
ment were conditionally linked to successful DONs felt welcomed and preparation are well articulated using
satisfactory survey results. Good mentored into the position, had con- transformational leadership theory
surveys and financial success were fidence in their leadership abilities, concepts.
also important to Irma; however, del- and experienced team support to
egation of unconditional authority facilitate improvements. Unstable DON-Administrator Relationship
lessened organizational resistance to relationships with administrators The relationship between DONs
change and established expectations affected DONs negatively. Con- and administrators influenced
for teamwork and better care. Thus, sequences were similar to those of DONs’ leadership style and ef-
Irma’s initial goals included building DONs who filled vacant positions fectiveness. Interestingly, across all
relationships and improving practice, or had unsuccessful predecessors. A three groups, strong relationships
not simply achieving survey success. key difference, exemplified by Josie’s supported the DONs efforts to
Replace Successful DONs. Five situation, was the ability of the latter sustain and initiate improvements,
participants followed successful group to sustain satisfactory care and mitigated organizational resistance
DONs who were promoted or re- workforce stability. to change, and set the tone for the
tired. Following a well-respected expectation for teamwork and adop-
DON let them “pick up” where pre- Discussion tion of changes to improve resi-
decessors left off: “I felt they wanted With growing expectations for dent care. DONs with administra-
my ideas, even if they were different. DONs to address and sustain needed tive support held a broader view of
Nobody questioned me about my change, the findings from this study their leadership role and focused on
right to make some changes here.” add to our understanding of factors building relationships with staff and
Gail identified ongoing mentor- that facilitate or impede DON lead- peers and initiating practice changes.
ship from the former DON and the ership. The purpose of this research DONs encouraged staff and col-
administrator’s support as reasons was to investigate DON leadership leagues to look beyond compliance
she had a smooth transition into the and contextual factors that encour- benchmarks to promote better care
role. Amy also identified mentorship age and impede performance. Ethno- and workforce satisfaction. These
from a strong DON as a key reason graphic methodology allowed obser- values are characteristic of transfor-
she decided to “step up as a DON.” vation of DONs in everyday practice mational leaders.
Two participants who followed and access to their perceptions, ideas, Conversely, turnover and poor or
successful predecessors felt prepared and self-critique; thus, we learned inconsistent support from adminis-
for the role but not for the instability firsthand how preexisting conditions trators led to hierarchical relation-
associated with the turnover of facil- influence DONs’ leadership. ships in which DONs were expected
ity administrators. Diana explained, Transformational leadership to monitor performance and main-
“We were a training ground for the theory provides a broad conceptual tain stability. This focus on regula-
company, so administrators came lens to frame this discussion (Bass, tory compliance constrained DONs’

Journal of Gerontological Nursing • Vol. 34, No. 11, 2008 23


only one kind of nursing home, and
the geographical location. DONs
keypoints selected the days and events for par-
Nursing Home Leadership ticipant observation; consequently, a
full range of role and leadership be-
Fleming, M.L., & Kayser-Jones, J. (2008). Assuming the Mantle of Leadership: Issues and haviors may not have been observed.
Challenges for Directors of Nursing. Journal of Gerontological Nursing, 34(11), 18-25.
Although data were derived from the

1 Directors of nursing (DONs) identify themselves as leaders, and


the DON position as a leadership role.
subjective views of participants, the
design included multiple periods of
participant observation to confirm
2 Professional mentorship and administrative support affect the
quality and style of DON leadership.
interpretations. This supported pre-
cision in representing DON views

3 Organizational factors that constrain autonomy restrict DONs’


effectiveness to improve care and workforce conditions.
and the analytic accuracy in de-
scribing leadership. Although these
findings cannot be generalized to
all nursing home DONs, they serve
as a foundation for the design and
authority and effectiveness, permit- ments needed to succeed as a DON. implementation of future leadership
ting only incremental changes in the Their concerns were bounded by or- studies.
overall culture of the facility and res- ganizational and regulatory knowl-
ident care. Under these conditions, edge, further creating a gap between Conclusion and
DONs were more likely to comply nursing home expectations and pro- Implications for Nursing
with corporate expectations, feel dis- fessional practice. Our findings demonstrate the
couraged when staff failed to meet It is widely accepted that leader need to support nurses when they
standards, and intervene personally behaviors differ between kinds of or- assume DON leadership positions
to “get it done right.” These con- ganizations. Nursing homes are iden- in nursing homes. Although there
straints on DON leadership encour- tified as mechanistic organizations is little debate that strong nursing
aged laissez-faire and transactional where transactional leadership style is leadership is critical, organizational
approaches, which led to unspoken considered necessary to achieve stabil- factors and professional prepara-
allowances for mistakes, marginal ity, harmony, and efficiency (Jacques, tion affect the quality of DON
performance, and ultimately, mini- 1996). Leaders are expected to man- leadership. Thus, the findings sug-
mal improvements in care. age routines or make incremental gest three related recommendations.
changes to ensure organizational sur- First, DON-administrator relation-
Professional Preparation vival. Transformational leadership, on ships must be further investigated.
Unlike prior studies, more than the other hand, which engages people Studies are needed to examine how
half (n = 6) of these study participants in their work, has been identified as RNs in both the DON and admin-
held bachelor of science in nursing a more effective leadership style to istrator positions might affect re-
degrees, and 2 had master’s degrees. promote meaningful and long-lasting cruitment and retention of nurses
Despite their education, they were change in organizations (Dunham & for these roles, influence caregiver
prepared primarily on the job and Klafehn, 1990; Yukl, 1997). Because performance, and improve resident
were not active in professional or- numerous studies of leaders across care. Professional programs for joint
ganizations. By surviving “baptism many settings report transformation- leadership development of DONs
by fire” and leading successful sur- al leadership as essential to moving and administrators are also needed.
veys, these DONs earned facility and organizations forward in the current These programs must address the
corporate recognition. Those with health care environment (Kleinman, gaps and conflicts that interfere
good mentors or experience outside 2004), this study brings to light the with communication, teamwork,
of nursing homes said knowledge of question of whether organizational and effective problem solving. Sec-
communication, teamwork, and sys- factors that endorse and promote ond, DONs must be recognized as
tems were key components for DON transactional leadership are effective leaders. To fully develop their po-
preparation. These values are consis- in advancing the changes needed in tential, they will need the support of
tent with transformational leadership. nursing homes. the larger nursing profession. Such
In contrast, those promoted though support will involve the develop-
the nursing home ranks believed that Limitations ment of strategies to include DONs
knowledge of regulations and the The findings are naturally bound- in leadership networks and formal
survey process were the essential ele- ed by the small sample, inclusion of mentorship programs. Lastly, more

24 JOGNonline.com
research is needed to investigate research: The application of qualitative sky, J., Holland, D., & Joy, A. (2006).
approaches. London, United Kingdom: Nursing home staffing standards: Their
specific nursing home structures
Croom Helm. relationship to nurse staffing levels. The
and conditions that affect DON Fleming, M.L. (2007). Nursing home lead- Gerontologist, 46, 74-80.
leadership and, thus, improve resi- ership: Experience and perceptions of di- Mueller, C.H. (1998). LTC directors of nurs-
dent care. rectors of nursing (Publication No. AAT ing define educational needs. Nursing
3289307). Retrieved July 1, 2008, from the Management, 29(11), 39-42.
University of California, San Francisco, Rantz, M.J., Grando, V., Conn, V., Zwygart-
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L. (2003). Results of the 2002 AHCA sur-
ment, inadequate staffing, and lack of su- edge the Robert Wood Johnson Founda-
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pervision. The Gerontologist, 43(Special tion Executive Nurse Fellows program
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the United States. Berkeley: University of was provided from a John A. Hartford
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Journal of Gerontological Nursing • Vol. 34, No. 11, 2008 25


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