The director of nursing is one of the pillars of every hospital and long term care facility. A Director of Nursing (DON) oversees the nursing services provided and coordinates between members of a nursing team, the medical team, and management.

While becoming a Director of Nursing requires a significant amount of education and training, it can well be worth it if you enjoy helping the vulnerable and are looking for a high salary. In this article, we will tell you what a DON does, how one becomes a DON, what to expect in terms of pay, and the potential career paths of acute care and long term care.

The Job Description of a Director of Nursing

A Director of Nursing is the head of the other nurses and is responsible for training and supporting the other nurses on the staff. That means he or she generally must have years of bedside clinical nursing experience as well as managerial skills and sufficient education.

A Director of Nursing facilitates the functioning of a system already in place at a hospital or nursing home. “You don’t run the building,” said Charles Oliver, a DON of ten years. “You manage systems, and then the building runs itself.” He referred to Director of Nursing as the “checks and balances” that keep the system in place.

What Does a Director of Nursing Do?

The responsibilities of Directors of Nursing include supervising nurses; overseeing the quality of care provided and improving upon it; acting as a liaison between the team at a hospital or other facility; keeping track of finances, medical records, and purchases; and maintaining good relations with the people whose loved ones are receiving care. These five categories of responsibilities along with examples are provided below:

Supervising nurses:

Managing and leading all nursing personnel operations
Reviewing the performances of nurses
Developing short and long-term goals for the nursing department

Elevating the standard of care:

Establishing a standard of high-quality care that complies with state and national laws and regulations
Enacting new policies and updating existing policies to improve the standard of care for patients or residents
Rewriting the objectives of the nursing service within a particular system
Consulting health staff members and outside agencies to gain insight into the areas of care that require the most attention
Receiving and addressing complaints

Coordinating between members of the team:

nurses looking at information — A director of nursing and physician review a patient’s chart

Acting as a point of contact between the nursing staff and the facility’s doctors and management by addressing problems or concerns and facilitating change when needed
Advising medical staff, department heads, and administrators in matters related to nursing service within the relevant care system
Reporting overall performance, progress, and concerns to high-level staff members

Administration:

Overseeing the hiring, firing, training, and development of nursing staffs
Monitoring expenses, finances, and accounting
Planning the direction of the facility as part of a business plan and assisting in its financial development
Providing insight to both help determine and balance department budgets
Overseeing inventory, order processing, and distribution of products and services
Keeping track of data and health records, which can now be done using an electronic health record system

Building relationships:

Deescalating issues as they arise from operations and requiring coordination with other departments
Serving as a resource for others within the community
Consistently engaging with physicians, patients, residents, and the family members of those at your facility to ensure that communication is at a high level and concerns are being addressed
Developing excellent rapport with the medical director and director of nursing services

How EHRs and long term care software systems are making the jobs of Directors of Nursing easier

While the tasks mentioned above may seem like a lot, there are now systems in place to facilitate these processes. Oliver, who has 31 years of overall nursing experience, found that electronic health records (EHRs), in this case long-term care software, revolutionized how he and his staffs were able to provide care. “In the paper world, I had this massive black box of my charts, and I had to keep my fingers crossed that everything was in there,” he said. “Then EHR comes along, and I can run a report that tells me every single thing that’s broken.” Oliver referred to the ease by which he could observe a resident’s information using point of care charting. POC charting allows for proper documentation of any care activity, including activities of daily living (ADLs), restorative nursing, therapy, and mood observation.

Of course, there is always an adjustment period when switching to such advanced long term care software. Oliver talked about how, initially, he was “overwhelmed” by the possibilities presented by EHRs. “You look at it, and you think, ‘Wow, look at all this stuff that needs to get done!’,” he remarked. “Previously, you knew, consciously or subconsciously, that there were a great number of tasks that you needed to perform, and you would get to the chart eventually,” he said. “But now I’ve got this report in front of me, and it’s like you’re drinking from a water hose instead of a glass.”

EHRs ultimately facilitate a Director of Nursing’s work and allow him or her to work more efficiently and effectively. “[An EHR] is a new set of eyes that allows me to see a lot further than I could if I were just making my rounds,” Oliver said. But EHRs do require a different sort of skill, namely, correlating data to be able to prioritize tasks. “The best advice I ever got about using EHRs came from a physician on a day in which I was having a meltdown,” he said. “He told me, ‘Well, as a doctor, you know that you can’t take care of 100 people at once, Charles, so you must decide who your sickest patients are.’ And so I had to learn how to use my EHR to tell me who was the sickest, so I could know where to insert myself or approach my staff accordingly, tell them to watch particular people.”

The 4 Steps to Becoming a Director of Nursing (DON)

A director of nursing must receive at least two years of college education in nursing. After that, an aspiring Director of Nursing must receive state licensing to become a registered nurse. One can then either begin gaining experience as an RN or pursue a graduate degree. The latter is highly recommended, though it is also possible to become a DON with just an undergraduate degree so long as it is accommodated by extensive experience. Next, one will need to get certified. Finally, a prospective Director of Nursing will need to serve as an administrator before he or she can be employed.

1. Get or have a college degree

If you want to become a Director of Nursing:

You will need to pursue a college degree, which can be one of the following:
- A two-year associate’s degree in nursing (ADN).
  - The prerequisites for an ADN include:
    - English Composition
    - Communications
    - Psychology
    - Sociology
    - Biology
    - Chemistry
    - Human Anatomy & Physiology
    - Statistics
  - And the coursework for an ADN will focus on nursing skills and practice, likely including classes on:
    - Microbiology and Immunology
    - Medical-Surgical Nursing
    - Introduction to the Nursing Profession
    - Nursing Health Assessments
    - Professional Issues in Nursing
    - Pediatric Nursing
    - Psychiatric Nursing
    - Maternal-Newborn Nursing
    - Community Health Nursing
- A four-year bachelor’s of science in nursing (BSN).
  - The core curriculum could include classes on:
    - Biology
    - Chemistry
    - Nutrition
    - Psychology
    - Statistics
    - Technology
    - Sociology
    - English composition
    - Ethics
  - Core nursing classes, meanwhile, include:
    - Professional nursing
    - Health assessment
    - Public health
    - Family nursing
    - Nursing management
    - Leadership
    - Medical and surgical care
    - Psychosocial nursing

While a BSN takes two more years than an ADN, it does increase your employment opportunities. For information about the BSN programs out there, including online options, click here. You can learn more about the coursework for a BSN by clicking here. And to learn about the available options for pursuing an ADN, click here. You can learn more about the coursework for an ADN by clicking here.

A graduate degree is not required for becoming a Director of Nursing, but it is strongly encouraged. Many facilities prefer that the DON that they hire have a master’s degree in nursing (MSN) or an administrative field, like public health administration or business administration.

One can also pursue a dual master’s degree and earn an MSN with a concentration in another field, like:

business (MSN/MBA)
public health (MSN/MPH)
health administration (MSN/MHA)
public administration (MSN/MPA).

These master’s degrees help prepare prospective Director of Nursing for the challenges they will face in healthcare administration, which include managing, training, and problem-solving.

One can go a step further and enroll in a doctor of nursing practice (DNP) program in Executive Nursing Administration to further refine their leadership skills. In addition to becoming a Director of Nursing, one with a DNP can also choose to work in advanced practice nursing (APRN), which would allow a nurse to work directly with patients as a:

Nurse Practitioner (NP)
Nurse Anesthetist (CRNA)
Nurse Midwife (CNM)
Women’s Health Nurse Practitioner
Pediatric Nurse Practitioner
Family Nurse Practitioner (FRNP)
Adult-Gerontology Nurse Practitioner
Neonatal Nurse Practitioner
Psychiatric-Mental Health Nurse Practitioner

You can learn more about pursuing an MSN here and about pursuing a DNP here.

2. State Licensure For Directors of Nursing

Directors of nursing must also hold state licensing as registered nurses by passing the National Council Licensure Examination-Registered Nurse, or, NCLEX-RN. This exam uses a five-step process, so the questions fall under the categories of assessment, diagnosis, planning, implementation, and evaluation.

The content of the NCLEX-RN falls under four general groups related to client health needs:

Safe and effective care environment – These questions ask you about the appropriate safety measures for preventing injuries, how to prevent infections, isolation precautions, and other safety issues. This section makes up 26 to 38 percent of the exam and includes two categories: management of care (17-23%) and safety and infection control (9-15%).
Physiological integrity – This topic pertains to needs related to adult medical and surgical nursing care, pediatrics, and gerontology. This section is 38 to 62 percent of the exam and includes questions on: basic care (6-12%) and comfort; pharmacological and parenteral therapies (12-18%); reduction of risk potential (9-15%); and physiological adaption (11-17%).
Psychosocial integrity – These questions will ask about health care issues related to psychiatric problems. You will also need to know about coping mechanisms for exceptionally stressful situations, like life-threatening illness or trauma. This is 12 to 24 percent of the exam and includes questions on: coping and adaptation (6-12%) and psychosocial adaptation (6-12%)
Health promotion and maintenance needs – This section deals with matters related to reproduction – like pregnancy and delivery – early infant care, fetal development, and even birth control measures and contagious diseases, in particular sexually transmitted diseases. The topic makes up 12 to 24 percent of the exam and includes questions on life span growth and development (6-12%) and prevention and early detection of disease (6-12%).

To learn more about the components of the NCLEX-RN exam, read pages 205-225 of Joseph Catalano’s Nursing Now! Today’s Issues, Tomorrow’s Trends.

3. Director of Nursing Certification

After completing your degree and obtaining your RN license, you must receive certification to become a Director of Nursing through a qualified agency, such as:

The American Association of Post-Acute Care Nursing, which provides certification for those who look to be Director’s of Nursing in nursing homes. Before receiving this certification, you must gain two years of experience in long term care or post-acute care as well as one year or more of nursing leadership.

The National Association of Directors of Nursing Administration in Long Term Care, which offers the Certified Director of Nursing (CDONA) Exam. To be eligible to take this certification exam, you must first gain two years of experience as a director or assistant director of nursing (ADON).
The American Nurses Credentialing Center (ANCC), which provides board certification upon completion of the Nurse, Executive Certification (NE-BC) exam and the Nurse Executive, Advanced Certification (NEA-BC).

It should be added that certificates will require renewal and continued nurse education.

4. Experience. Experience. Experience.

Experience is the final component necessary to become a Director of Nursing. You will generally want to spend some time as a nurse manager, clinical leader, or department manager. You can also get administrative experience in the process of earning your doctor of nursing degree. This would place you in the category of “top executives,” which means, according to the U.S. Bureau of Labor Statistics (BLS), you could be expected to earn about $107,680 annually.

psychological help — A Director of Nursing reassures a resident at a nursing home.

What Makes One a Good Director of Nursing (DON)?

Like any profession, meeting the minimum requirements of being a Director of Nursing is no guarantee that you will be successful in your work. In addition to the extensive education and training described above, a Director of Nursing, like all other health care professionals, must have patience, perseverance, and a passion for providing care and demonstrating empathy. In addition to those qualities, though, a Director of Nursing must be a leader and manager.

A Director of Nursing must be present to provide both nurses and residents or patients with reassurance. For instance, Oliver mentions that he will insert himself in situations where a nurse may not be comfortable performing a task that is not often required, like inserting a nasogastric (NG) tube into a patient’s nose. “If a nurse hasn’t done it for a few years, they will be scared and hesitant,” he said. “And the patient picks up on that. So sometimes the Director of Nursing just has to be present to alleviate fear.”

It is also important for Directors of Nursing to remember to keep patients, residents, and the staff happy. “Don’t get trapped behind the desk,” said Oliver. “The most important thing is to be seen out on the floor.” He mentioned that, when he was a nurse aide, he thought that he was aware of all of the activities for the day. “When I became a DON, though,” he said, “I came to realize that it was hard for me to keep up with all the names of my staff members, let alone know exactly what they were doing each day.” Oliver would compensate for this by complimenting his staff, which would encourage nurses and make life better for residents and patients. “I would never say, ‘You set up those trays horribly’,” he recalled. “Instead, I’d say, ‘I want you to work on setting up that tray, as it’ll allow Ms. Smith to access her fork easier, and she will love you for that’.”

Some of the other essential traits of a Director of Nursing are:

extensive knowledge of the workings of one’s particular facility
the drive to continue to learn and adapt to improve one’s work environment and improve the quality of life of others
superb communication and conflict-resolution skills
the ability to balance positive reinforcement with constructive criticism

The Biggest Challenges That Directors of Nursing Face

One of the most difficult parts about being a Director of Nursing is holding your staff accountable, Oliver noted. “That is hard to maintain because they’re stressed and working hard,” he said. “You then have to come to them and tell them that they messed up.” He explained that one must find a tone that is encouraging and highlights the positive contributes one has made while also motivating them to improve upon their performance in other areas.

Another major challenge is filling out a staff. “It’s really hard, especially now, because there aren’t enough nurses out there to begin with,” said Oliver. “And in long term care, it’s even harder, since there is a smaller pool of people who really love caring for the elderly.” What a Director of Nursing should not do, he warned, is find “temporary fixes” and hire anyone available.

It may even be possible to hire two nurses for the same amount it would cost to pay one nurse who is a good fit, Oliver mentioned. But that is a mistake he learned not to make. “You’re tempted to hire for pulses and warm bodies because you know that your staff’s getting tired and you just need to get somebody on the floor,” he said. “But if you can avoid that at all, you’ll save yourself a lot of headaches, as nurses will usually cause more pain and injury by being in your building if they’re not the right fit.”

It is also important to determine the standard of care you expect at your facility. “Set your bar in the road,” said Oliver, “and keep nurses to it, whether they have experience, are just out of school, or took a nurse aide class.” The Director of Nursing then raises the bar by staying on top of the quality of care and coaching up the handful of nurses who fall behind.

How Much Money Do Directors of Nursing Make?

Directors of Nursing make far more than the average nursing salary, which the BLS lists as $75,330 for 2020. The BLS lists the average salary of medical and health services managers as $104,280 for 2020. What is even better is that the job outlook for 2019-2029 is 32%, which is much higher than average. And while Directors of Nursing do not always make as much as the average medical and health service manager, they do see their salary approach that with experience.

According to Nurse.org, the median annual salary for Director of Nursing is:

$81,815 per year when they have one to four years of experience
$83,296 annually with five to nine years of experience
$91,995 annually with 10 to 19 years of experience
$96,303 annually with 20 or more years of experience

A director of nursing with extensive experience can make even more by becoming a Chief Nursing Officer (CNO). For more, read here.

Where Does a Director of Nursing work?

Wherever you find nurses, directors of nursing will be there. That is because there must always be a supervisor to ensure a high standard of care, and who more qualified than a trained expert on nursing? Nurses, of course, can be found not only in hospitals but also in long term care facilities and places where large populations gather consistently.

Some of the potential job environments for Directors of Nursing are:

Hospitals
Physicians’ clinics
Private practices
Outpatient care centers
Long term care facilities
Insurance companies
Health care corporations
Government agencies
Colleges and universities

Being a Director of Nursing in Acute Care

A Director of Nursing that works in a hospital will help supervise the nursing staff in treating critical care, preparing patients for surgery, and making sure they receive the attention they require afterward. DONs in acute care will heavily engage with the medical staff and will see a high turnover of patients, meaning, they will not build the same sort of long-term relationships with those they treat as DONs in long-term care. DONs in acute care will be asked to care for cardiac patients, surgical patients, neurosurgery patients, and all others that can be found in a hospital setting.

Being a Director of Nursing (DON) in Long Term Care

A Director of Nursing that works in a nursing home or assisted living facility will play a somewhat different role. A DON in LTC must develop a relationship with his or her residents and ensure that his or her staff does the same. That means the DON must teach his or her nurses to recognize the specific needs and preferences of the elderly in their care.

nurse assisting senior woman at nursing home

Hiring nurses at an LTC facility

As noted above, filling out a qualified staff can be difficult. It is even more of a challenge in long-term care, where a nurse’s ability to empathize with seniors must be established before they are offered a place on your staff. Oliver suggests that, in the interview process, Directors of Nursing:

Ask empathy questions – These are simple ways of determining how a potential hire will respond to various scenarios. “You ask them questions, situational questions, like, ‘What would you do in this situation? What do you think the family or the patient felt at that moment?’,” Oliver said. “If they can’t answer that empathy question, they’re probably not going to be a good fit in long term care, because you’re dealing with patients and families who are in highly emotional states.

Do not focus on skills that can be taught – A nurse may not have all the tools he or she will need to provide care in nursing homes. That does not mean the particular candidate will not be a good fit. Rather, what is important, Oliver opines, is that they have the necessary people skills for the job. “I avoid functional questions because I can always teach [nurses] the skills they need,” Oliver said. “My questions were more about who could add empathy.” He mentioned how he would ask nurses who would be put in leadership positions, like assistant directors of nursing (ADONs) about the first time they provided counsel, how they would handle workplace conflict, or what they would do if too many nurses showed up for work.

Gauge how potential hires handle stress – Another difference between acute care and long term care is that, in the latter, nurses must learn to deal with the stress of assisting residents with psychological challenges. “I would ask [potential hires], ‘How do you deescalate this kind of situation?’,” Oliver said. “And sometimes you have to know the resident really well to figure that out.”

Training a team of nurses for elderly care

The next step for a Director of Nursing is training the staff that he or she puts together. Today, Oliver says, that involves more than simply teaching protocol. Rather, it includes helping nurses make the transition to using electronic health records, which means getting them to buy into this new form of technology. “A lot of nurses are good at providing care but not necessarily good at using computers,” he said. “They often don’t see the computer as a replacement for paper.” He mentioned that training nurses in using an EHR is a major component of onboarding today, though it rarely receives sufficient attention.

Staying on top of QAPIs

EHRs help care providers in LTC keep up with the rising standards of care. That means having an organized method of staying in compliance with federal regulations and statutes, such as a QAPI, or, Quality Assurance and Performance Improvement system. This is a data-driven approach to assuring that care meets acceptable standards as well as the continuous study of processes with the intent of improving outcomes.

The Centers for Medicare & Medicaid Services (CMS) list five elements that every QAPI must have, and those are:

Design and scope – This means that a QAPI must deal with the full range of activities at an LTC facility, including systems of care, management practices, clinical care, quality of life, and resident choice. It should also emphasize both safety and the autonomy of residents.
Governance and leadership – The governing body of any nursing home is responsible for developing a culture that ensures that: there are adequate resources for QAPI efforts; safety and quality standards are met; and responsibility for QAPI is effectively designated to one or more persons. While the body should assume leadership, it should also consult the other members of the facility, including staff, residents, and their families or representatives.
Feedback, data systems, and monitoring – Data should be drawn from staff, residents, and families. And adverse events are to be tracked and monitored. These findings must then be measured according to the performance indicators of the facility. As Oliver says, “The number one thing to successfully implementing a QAPI is including nurse aides in the conversation. You need to hear the voices of the people who are actually out there day after day, as they will be able to pick up on things from their first-hand experience that you might not notice yourself.”
Performance improvement projects (PIPs) – This is a concentrated effort in one area of the facility or a specific issue that runs facility-wide.
Systematic analysis and systematic action – A facility will use a systematic analytical approach to better understand how to address a particular problem. Once the matter is identified, the facility’s leadership can determine if the organization or delivery of care and services are to blame. This procedure requires proficiency in root cause analysis (RCA).

A Director of Nursing at an LTC facility may wonder how to address so many critical issues at once. Oliver says the key is to focus on one problem at a time. “You can’t decide that you’re QAPI-ing one thing today, and then tomorrow say that something else is the problem,” Oliver said. “You shouldn’t have more than four true QAPI projects [at any given time], because you will become overloaded, and nothing gets done.”

EHRs are a great way of meeting the standards of your QAPI, staying on top of the most recent federal regulations, and meeting the high expectations of residents and their families. They represent a big step forward in terms of the amount of attention that is paid to seniors in the care of a facility. “When I was a nurse aide, I had about five things on my nurse aide flow sheet that I had to answer: What did you eat for breakfast, lunch, and dinner?; Did you have a bowel movement?; Did anything unusual happen today? That was it.” Now, though, he notes, nurse aides must keep track of a much great number of activities of daily living (ADLs). “For instance,” he says, “now they have to include whether there was weight-bearing assistance, meaning, you received help putting on your socks and shoes, or if it was just queuing as opposed to having a nurse set you up.” Staying on top of ADLs by using EHRs is now easier than ever.

Summary

If you are considering becoming a Director of Nursing, be prepared to assume heavy responsibility but also to receive great rewards in terms of job satisfaction; not only does it pay well, but you will be responsible for improving the lives of the sick and elderly on a daily basis. The two paths outlined here, acute care and post-acute care (or long-term care), share a lot in common, though the nature of engagement with patients or residents differs. Meanwhile, there are a number of options in terms of education and training. While a lengthier education will create better job prospects, it is still possible to suffice with a two-year degree (ADN). In short, each individual must select the path most appropriate based on his or her disposition and particular situation.

For more about the most recent developments in long term care, read our blogs on Experience Care. And you can gain insight from some of the leaders in the industry by listening to the LTC Heroes podcast. Click here to subscribe.

The 5 Steps to Becoming a Director of Nursing