Faced with unprecedented competition for registered nurses, skilled nursing providers are pulling out all the stops to recruit, up-train and retain what is arguably the most important clinical worker in any nursing home: the director of nursing services.

Earlier this year, clinical leaders at the Evangelical Lutheran Good Samaritan Society, which is routinely seeing 12 to 15 vacant DON positions across 140 skilled facilities, launched a Director in Training program.

The model is based on the administrator-in-training concept practiced by so many for up-and-coming nursing home administrators.

But the challenges seen in attracting candidates for the new program — one with full benefits and room to grow in a supportive environment — shows just how difficult it has become to recruit in today’s nursing climate.

Rochelle Rindels/Credit: Good Samaritan Society

“The last three to four years, we’ve seen kind of a slow increase in the turnover percentage of that director of nursing position,” Rochelle Rindels, MSN, Good Sam’s vice president of nursing and clinical services, told McKnight’s last week. ”It’s a position with people management, clinical complexity, payment and reimbursement, really having to know a wide variety of factors that influence long-term care and how to be successful.”

Not every nurse who appears ready to move up is truly prepared or willing to do so. That’s despite DON pay rates that rose an average of 5.4% since 2021. The national median salary now sits at nearly $109,000 nationally.

Heavy needs for the job

New regulations, especially during COVID, added to the DON’s plate and required even more expertise. The focus has also been on having more people management skills to navigate lockdowns and other pandemic conditions. 

“DONs do leave their jobs because they’re hard. They’re really hard,” said Sally Cantwell, senior director of recruitment and retention for PACS, a management group supporting more than 150 facilities in seven states. “It’s a demanding job that requires high emotional intelligence.”

Cantwell noted that nurses in other sectors may have received instruction in delegation, leadership and advocacy as part of a formal, four-year education track. But in skilled nursing, many DONs historically have only completed a two-year degree program that is laser-focused on clinical tasks.

“How do you retain somebody that doesn’t have the appropriate training?” Cantwell asked. 

PACS is working to build a “quality pipeline” by identifying nurses with an interest in a BSN degree, promoting scholarships and recruiting veterans with known leadership and clinical skills. With veterans, Cantwell noted, a successful selling point can be that nurse leaders can rise faster in the skilled sector than in many other healthcare settings.

Building a pipeline

Rindels agreed that it’s critical for providers to find ways to equip the next generation of DONs with a broader skill set.

Good Sam’s DON training pathway already included a seven- to 11-week program for nurses moving up within skilled nursing. But Rindels’ team also wanted to attract RNs from other healthcare settings. That’s why they designed this longer and more comprehensive program to entice a wider range of candidates.

The first directors in training will fill two pilot positions in Minnesota and Nebraska, each getting a four- to six-month training program that “exposes them to all things related to the long-term care industry,” Rindels said.

They’ll shadow clinical learning specialists for training in MDS, QAPI, mock surveying, audits and regulatory compliance. They’ll also be paired with an established DON preceptor, working side-by-side in the same building.

Good Sam is offering top pay that exceeds the national hourly average for RNs, but Rindels said none of the candidates who have applied have been a perfect match yet. Some, she acknowledged, have not liked the possibility of having to move buildings after the training period ends.

“This is something that I think is maybe a newer concept to the nursing profession as a whole,” Rindels said. “Recruitment is really, really challenging, especially in some of our rural locations, and we’ve had to be really creative with recruitment for this position as well.”

Keeping the ones they have

Esther Shain is director of nursing home recruitment at Alvin Kahn & Associates, a New Jersey-based firm that hires for clients across the US. Shain sees about one decent DON candidate for every five buildings with vacancies, she said.

That means high pay, recruitment bonuses and other financial recruiting tactics must remain commonplace. But they aren’t the only way to win RNs over, Shain said.

DONs may be more willing to go to work for a facility that invests in the staff around them. That includes an assistant DON, a full-time infection preventionist and a wound care specialist. Those additional staff members take on specific responsibilities that can ease the DON’s workload.

Shain said companies also can support new DONs with regional team members or access to additional training on clinical competencies. But it’s critical that employers looking for stability find candidates with soft skills.

“If they have that, they can keep anyone else that’s good on their team, and find more good people,” Shain noted. “Some DONs can be really good clinically, but they may alienate staff. Those soft skills are as important as any RN degree.”

And when providers find that ideal person, they have to operate with the assumption that headhunters are out there looking for the first signs of unhappiness.

“You just have to keep checking in with the ones you have,” Shain said. “Even if you feel like you’re overdoing it, you’re not overdoing it.”

At Good Sam, DONs still have an average tenure of seven years across the system. But more are approaching retirement age, and Rindels and her colleagues recognize the cultural shift away from workplace loyalty and longevity.

Advertising continues for the Directors in Training program, with the ultimate goal of having two each year in each state where Good Sam operates. For now, Rindels is focused on promoting the concept and getting prospective DONs to think differently about on-the-job learning.

“I really see this DNS in training program as one more opportunity to bring new people into the organization and really start out with those solid relationships with their co-workers and their residents,” she said.