UCSF

Nursing Home Leadership: Experience and Perceptions of Directors of Nursing By Mary Louise Fleming School of Nursing University of California, San Francisco

This ethnographic study investigated leadership from the perspective of directors of nursing (DON) in proprietary nursing homes. Data from semi-structured and in-depth interviews and extensive participant observation with ten DONs were analyzed using open coding and content analysis to understand the experience of nursing home DONs. Findings describe the DON role, their definition and approaches to leadership, and the factors that facilitate and impede leadership in the nursing home context.

Role-related findings include the reasons participants began working in nursing homes, conditions antecedent to entry into the position, and preparation for the role. Five role responsibilities were consistent across all sites: 1) leadership, 2) administration, 3) clinical, 4) personnel, and 5) staff development. Common challenges included blurred work-home boundaries, 24/7/365 responsibility, inadequate staffing, and working in a "marginalized setting." The unrelenting burdens led to feelings uncertainty, exhaustion, discouragement, and professional embarrassment.

Major leadership findings include: 1) DONs identify themselves as leaders and their position as a leadership role; 2) unique profiles of veteran, reflective, and beginning leaders had an effect on staff performance and resident care, and 3) the nursing home context influenced DON leadership in positive and constraining ways. Mentored preparation, strong DON-administrator partnerships, adequate nursing infrastructure, and professional connections beyond the nursing home setting promote DON confidence and competency. Conversely, lack of nursing infrastructure, over reliance on corporate standardization, and constraints on creativity and risk-taking fundamentally impede DON leadership. Findings were presented as a rich description constructed from the stories, thoughts, and observed actions of participants.

This study drew on transformational leadership theory to examine structural and interactional aspects of the DON role. This study extends the theoretical literature by contributing a conceptual description of contemporary DON leadership in the nursing home context. Findings offer direction to support and develop leadership capacity of DONs in practice, and provide a foundation for subsequent research.