—Susan LupPlace, msn, rn

$30 for Non-members

“This is a first of its kind.”

—Susan LupPlace, msn, rnIndependent Healthcare Consultant

“I have been a DON for 30 years and this is the most comprehensive description of the skill set that a DON

needs that I have ever seen. It is outstanding!”

—Shelley Acus, rn, dns-ct, qcp Director of Nursing Services

AADNS’s Body of Knowledge for Director of Nursing Services in Long-Term Care

iCopyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Directors of Nursing Services. All Rights Reserved. AADNS-LTC.org

Introduction 1Background 1Table 1. Organizations Associated With SNF Competency Programs 1Methods 2

Summary of Domains and Tasks List 4

DNS Career Ladder—From Novice to Expert 5

Details of Domains and Tasks 6Domain #1: Principles of Leadership 6Domain #2: Individual Skills for Management and Supervision 9Domain #3: Organizational Oversight and Management 12Domain #4: Business Acumen for the DNS 14Domain #5: Quality Improvement in the Nursing Department 17Domain #6: Regulatory Compliance 19Domain #7: Professional Development 23

Contributors 25

Appendix 1: Second National Nurse Leadership Summit, Milwaukee, Wisconsin, July 2015: Results of Group Participants’ Domain and Task Word Sort 26Background Information and Keys 26Word Sort Results by Group 27Nurse Leadership Categories 29Consensus Domain: Business Acumen 30Consensus Domain: Clinical Practice (QoL, QoC, Care Delivery) 31Consensus Domain: Compliance (Regulatory, Ethics) 32Consensus Domain: Leadership 33Consensus Domain: Management and Supervision 34Consensus Domain: Professional 35Consensus Domain: Quality (QAPI, QIPI) 36Consensus Domains for Each Word 37

References 43


1Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Directors of Nursing Services. All Rights Reserved. AADNS-LTC.org

IntroductionDirectors of nursing services (DNSs) are responsible for driving the success of the nursing department within the long-term care facility in which they work. These individuals coordinate and oversee resident care delivery and heavily influence quality and outcomes.1,2 For example, research has linked DNS tenure with lower nurse-turnover rates.3–6 Leadership has been recognized as an important variable in improving quality in nursing homes.1,7

Considering the impact that the DNS has on staffing retention and, more importantly, on quality of care and positive outcomes, today’s DNS must have the skills to lead his or her team effectively. Through a structured certification program that focuses on the leadership skills needed to elevate the nursing department care delivery systems, the DNS can become better prepared to share the organizational mission, vision, and values and both lead and collaborate with teams.

The purpose of this report is twofold: (1) to describe the expert workgroup’s identification of the need for a new certification program for the DNS practicing in a skilled nursing facility (SNF); and (2) to describe the methods used to identify, define, and measure core competencies required of DNSs practicing in SNFs. The core competencies are being used to provide further structure and content to the process of updating the current version of the AADNS certification program and DNS Certification Test (DNS-CT).8

BackgroundDefinitions and measurements of competence. Three foundational publications have been available to nurses; they define and measure nursing competence regardless of the context or setting of practice. They have served as general standards, or the baseline, for definitions and measurement of nursing competence. For example, the American Nurses Association (ANA) published a position statement on professional role competence,9 and the ANA Leadership institute developed a Model of Professional Nursing Practice Regulation.10 Similarly, the National League for Nursing published Outcomes and Competencies for Graduates of Practical/Vocational, Diploma, Associate Degree, Baccalaureate, Master’s, Practice Doctorate and Research Doctorate Programs in Nursing.11 See Table 1 for a list of other competency-based programs and organizational sponsors.

The workgroup defined competence as the state of being competent in ways believed or demonstrated to be associated with the quality of a DNS’s performance. in other words, a competent DNS has the requisite knowledge, skill, and traits to perform his or her role while complying with accepted SNF

standards, whether of a regulatory or professional nature. Understanding the concept of competence and nursing competency, as they relate to the SNF practice environment, is essential for the DNS. The Centers for Medicare & Medicaid Services (CMS) 2016 Conditions of Participation mandated that “licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.”12 However, specific competencies were not defined, and methods used to measure them were not prescribed. This provides the DNS with an opportunity to demonstrate leadership in the development and implementation of a competency training program.13–17 While not the only factor affecting performance, the better a person’s competencies match the requirements of a role, the more likely the person’s performance will be effective.18

it is important to note that there is no gold-standard definition or measurement of the concept of competence. Rather, defining and measuring it have been approached in a variety of ways. These have included written tests, computerized tests,

Table 1. Organizations Associated With SNF Competency Programs

American Association of Homes and Services for the Aging (AHSA) (2009)

American Health Care Association (AHCA) (Radiating Excellence)

American Association of Colleges of Nursing (AACN)American Association of Nurse Assessment

Coordination (AANAC)American Association of Post-Acute Care Nursing

(AAPACN)American Nursing Association (ANA)American Nurses Credentialing Center–Gerontology

(ANCC)Association of Nurse Executives (AONE)Geriatric Nursing Leadership Academy Sigma Theta Tau

international’s Center for Nursing Excellence in Long-Term Care

Hartford instituteLong-Term Care (LTC) Nursing Leadership ToolkitLong Term Care Professional Leadership CouncilNational Association of Directors of Nursing

Administration in Long Term Care (NADONA)NurseLEAD Online Training Program



records of performance, simulations with anatomic models, other simulations, work sampling, and performance appraisals. Different methods have been found to have strengths and weaknesses associated with their validity, reliability, and feasibility.18

Framework. Workgroup contributors wanted to use a framework that could be understood and used by the DNS, all nursing staff, and other interdisciplinary SNF staff. They selected the American Association for Operations Management (APiCS) Operational Body of Knowledge Framework (BOK)19 because it had the capacity and potential to support all SNF staff in defining, measuring, and developing competency training programs.

Common characteristics of the DNS practice environment. in revising the certification program, the workgroup was committed to acknowledging those characteristics of the SNF industry that significantly impact the actual practice environment of the DNS and nursing staff. Researchers have reported that there is an association between characteristics of the SNF practice environment and resident outcomes.20 Some characteristics known to have an impact on the quality of SNF services, and thus on the potential for employing competent DNS staff, are described.

• The Medicare and Medicaid Conditions of Participation (COP) in the federal SNF programs provide the standards for facility compliance. individual states have regulatory standards that may differ to some degree from federal standards and regulations.21

• Types of SNF ownership include governmental (7%), for-profit (68%), and not-for-profit (24%), according to 2015 data.21

• Medicaid serves as the primary payer source for most SNF residents (62%), according to 2014 data.21

• Concerns remain among advocates, consumers, nurses, and researchers about the adequacy of the federal COPs for nursing staffing levels.22

• in comparison with acute care settings, SNFs have been slow in promoting nursing professionalism and evidence-based practices.23

• Historically, human resource practices have been based more on hierarchical principles and compliance than contemporary principles of human resource management and quality.20,24

• The nursing staff skill mix and basic education of nursing staff in SNFs differ significantly from the nursing staff skill mix and educational background that is common in acute care settings.25

• Nursing policy changes have resulted in increasing the

number of BSN-prepared nurses practicing within acute care settings; there is less professional emphasis on the educational advancement of non-BSN (i.e. associate degree, diploma graduate) staff working in SNFs.25

• Limited incentives are provided by SNF owners to encourage advanced DNS education, including AA-to-BSN programs or certification in topics relevant to DNS practice.6

• it is likely that significant turnover of DNS and nursing staff in SNFs will persist.3

• Relatively limited research evidence exists to support inclusion of DNS preparation at the bachelor’s degree level as a COP in SNFs.2

MethodsReview of evidence. The workgroup’s first step was to conduct a scoping literature review to find articles, including research and descriptive publications, related to the DNS role. The criteria for inclusion were that the articles be published in English between 2008 and 2016. Key words included directors of nursing services, registered nurse, competence, nursing professionalism, RN practice environment, and nursing homes. PubMed and Google Scholar were used as databases. The review contained a variety of articles related to the DNS and registered nurse (RN) roles, in addition to DNS competency. During the review process, numerous resources related to certification and nursing home competency, whether delivered online or in the traditional classroom, were identified. The goals of the review were to increase DNS awareness of the existing evidence base related to DNS competence, increase understanding of SNF systems from a complexity science perspective, and describe reported associations between DNS practice and clinical outcomes.

Over the past decade, the DNS role and its relationship to quality have been the focus of numerous studies. in 2008, literature reviews on domains of DNS practice were published. Briefly, reviews focused on staffing characteristics and turnover;26 geriatric RN nurse competencies;27 use of advanced practice nurses for care of SNF residents;28 nursing leadership;29 best practices related to supervision, management, and human resource practices;24 best practices in implementing findings of the quality improvement literature;30 and development of RN professionalism in the practice environment.31

From 2010 to 2016, a series of research studies using qualitative methods was published. The actual roles and responsibilities of the DNS were described using self-report of the DNS and administrator.32 A series of studies



conducted by RN health services researchers and social scientists contributed significantly to providing empirical support for components of the revised curriculum, including conceptualizing the SNF as a healthcare system,33 RN delegation of care,34 interchangeability and connections between RNs and licensed vocational nurses (LVNs), and differences between RN and LPN scopes of practice.35 Of note, these studies and others used complexity science as the framework for studying the dynamic practice context of the DNS.36–39 Other researchers examined dimensions of DNS competence and its relationship to DNS tenure, education, certification, and clinical outcomes.6 A comprehensive overview of evidence-based practice and management skills relevant to the DNS emphasized the importance of relationship-oriented management practices among staff, residents, and family.39

in summary, over the past decade, the number of research studies with findings relevant to the DNS, his or her competency, and related management practices has increased substantially. The scoping literature review served to provide empirical evidence to support the content included in the revised curriculum. Ultimately, the domains included leadership, skills in management and supervision, conceptualizing the SNF as a system, business acumen, quality improvement, regulatory compliance, and professional development.

First National Nurse Leadership Summit. invited experts had the opportunity to attend a Nurse Leadership Summit held in New Orleans in May 2015. The attendees included clinical, managerial, leadership, academic, and research experts with knowledge of the DNS role and the extant SNF-industry practice environment. (The workgroup members and their affiliations are listed at the end of this document.)

AANAC, the sponsor of the event, used McKinley Advisors to summarize the findings of the summit.40 One of the recommendations made to enhance DNS professionalism was the development of a new certification program. Given the rapid pace of change and the dynamic character of the practice environment, DNSs could benefit from a revised curriculum program that was developed with greater rigor, systems and implementation oriented, evidence based, and framed as a means of advancing professional nursing leadership and management practices. The revised certification program would continue to target RNs with at

least one year’s experience either as a DNS or in another leadership role.

After the first leadership summit, concepts related to DNS competence that were culled from the literature review were listed alphabetically. Duplicates and synonyms were eliminated, resulting in 90 concepts related to DNS competence. A recognized limitation of this process was that no comparison of each concept, as it was defined in the original materials, was made. See Appendix 1.

Second National Nurse Leadership Summit, July 2015. invited participants included experts in SNF operations, clinical practice, regulation, research, and education, including some who attended the first summit. Attendees were divided into four groups, based on their primary area of expertise (e.g., clinical practice and research, education, operations and leadership, oversight role in a region/group of facilities). Each group was given an identical set of 90 index cards, along with instructions for conducting a card-sorting exercise. The method of card-sorting was used to achieve consensus in categorizing concepts or constructs to identify core domains of professional competencies.41–43 This method was also used because it was relatively low-tech, inexpensive, and feasible as compared to the Delphi method. Following the card-sorting exercise, each group reported on the domain under which it had categorized concepts. A few concepts were categorized under two domains. After group discussion, consensus was reached. The domains included business acumen, clinical practice, compliance, leadership, management/supervision, professionalism, and quality.

After the second summit, the consensus that was achieved regarding domains was further discussed and analyzed. Detailed analysis of the work of each group was done at AANAC, using Venn diagrams to display the word overlap of each group. (See Appendix 1.) The final list of standards and competency domains included leadership, risk management, quality, human resources, survey, business acumen, and administrative oversight of clinical care systems. See the Summary of Domains and Tasks List used to develop the Body of Knowledge framework, in which tasks, knowledge, skill, and attitudes were categorized. The reference list includes articles that provide empirical support for the need for DNS certification programs that are consistent with the related literature.



Summary of Domains and Tasks ListDomain #1: Principles of Leadership

Task 1: Promotes organizational vision, mission, and values Task 2: Applies the principles of leadership and management skills in the nursing departmentTask 3: Effectively uses different types of leadership styles to impact team functionTask 4: Applies principles of leadership as a role model Task 5: Develops and fosters activities and functions of the nursing management team Task 6: Leads the nursing department in interdisciplinary team collaboration

Domain #2: Individual Skills for Management and SupervisionTask 1: Promotes the role of the manager in the nursing departmentTask 2: Ensures team compliance with laws governing the organization, residents, employees, and the environmentTask 3: Employs effective interpersonal communication skills Task 4: implements effective human resource management

Domain #3: Organizational Oversight and ManagementTask 1: Applies principles of systems thinking for quality outcomes in the nursing departmentTask 2: implements principles of staff competenciesTask 3: Describes principles and processes for clinical surveillance of nursing systemsTask 4: Utilizes nursing knowledge for oversight of the nursing department in specific resident care areas

Domain #4: Business Acumen for the DNSTask 1: Understands the DNS’s role in horizontal and vertical organizational hierarchiesTask 2: implements effective strategic planning processesTask 3: Applies principles of fiscal managementTask 4: Describes the current healthcare environment impacting post-acute careTask 5: Applies principles of informatics and technology management to long-term care (LTC)Task 6: Engages marketing and public relations for the nursing department

Domain #5: Quality Improvement in the Nursing DepartmentTask 1: Applies the components of quality assurance and performance improvement (QAPi)Task 2: Describes how Quality Measures are used as outcome measuresTask 3: Understands the Five-Star Quality Rating System and can evaluate nursing department performance

based on the findings

Domain #6: Regulatory ComplianceTask 1: Demonstrates skills for continuous regulatory survey readinessTask 2: Applies principles of regulatory survey managementTask 3: Ensures the system for ongoing compliance and ethics is implemented in the nursing departmentTask 4: implements principles of resident rights and safetyTask 5: Creates systems to address risk management

Domain #7: Professional Development Task 1: Applies knowledge of nursing staff scope of practice in the organization of care deliveryTask 2: Engages in the development of one’s personal and professional competencies Task 3: Engages in advocacy to enhance the profession of nursing and resident care



DNS Career Ladder—From Novice to Expert

Registered Nurse

Licensed Practical/Vocational Nurse

Certified Nursing Assistant

entry level

Case Manager

House/Shift Supervisor

Infection Control & Prevention Specialist

Unit Manager/Resident Care Coordinator

Nursing Informaticist

QAPI Nurse

Restorative Nurse

Safety Specialist

Staff Development Nurse

Compliance Nurse

Liability Mitigation Nurse

Adverse Event Investigator

Nurse Assessment Coordinator

Medicare Nurse

mid level

Director of Nursing

Assistant Director of Nursing

Certified Infection Control & Prevention Specialist

Certified Gerontological Nurse

Certified Wound Care Nurse

Certified Rehabilitation Nurse

Certified Restorative Nurse

Certified Staff Development Nurse

Certified Quality Specialist

QAPI Certified Specialist

Certified Risk Manager Certified Nurse Assessment Coordinator

advanced level

Certified Director of Nursing Services

Clinical Quality Compliance Reimbursement

nursing domains

mastery level

Long-term care offers an array of job opportunities for nurses. From entry level to advanced skill levels, long-term care nurses can broaden their career by crossing a spectrum of nursing domains. Use this career map to discover where long-term care can take you!



Details of Domains and TasksDomain #1: Principles of LeadershipOverviewTask 1: Promotes organizational vision, mission, and values Task 2: Applies the principles of leadership and management skills in the nursing departmentTask 3: Effectively uses different types of leadership styles to impact team function Task 4: Applies principles of leadership as a role model Task 5: Develops and fosters activities and functions of the nursing management team Task 6: Leads the nursing department in interdisciplinary team collaboration

DetailsDomain #1—Task 1: Promotes organizational vision, mission, and values

Knowledge Skills Attitudes

Defines organizational vision, mission, and values

Applies the organization’s vision, mission, and values to operational structures

inspires others to embrace the organization’s vision, mission, and values

identifies the role of the leader in creating a vision, a mission, and values

Communicates the organization’s vision, mission, and values

Commits to transparency of the organization’s vision, mission, and values

Domain #1—Task 2: Applies the principles of leadership and management skills in the nursing department


Defines leadership • Continuously develops own leadership• Employs motivation/accountability/

effective communication/empowerment/mentoring

• Uses leadership skills to help nursing services align with organizational goals

• Assesses own leadership abilities• Acknowledges own and others’

leadership skills and challenges• Demonstrates consistency in

decision-making that aligns with the organizational culture

• Models behaviors reflective of a leader • Recognizes leadership abilities of staff

Differentiates principles of leadership and management

• Uses principles of leadership to effectively delegate managerial tasks

• Values individual team members’ input• Commits to honesty and integrity

Describes strategies that influence others to reach organizational goals and high-quality nursing care

• Shapes the organization’s culture through communication, transparency, and high-quality standards

• Engages with others and shares future possibilities

• Perseveres through difficult times to reach goals



Domain #1—Task 3: Effectively uses different types of leadership styles to impact team function


Defines leadership theories (for example, but not limited to, trait theory, behavioral theory, transactional leadership theory, contingency theory, transformational leadership theory)

identifies own leadership style (for example, but not limited to, autocratic, democratic, team strategic, transformational, service)

• Demonstrates understanding of own leadership strengths and limitations

• Appropriately applies leadership theories to situations

• Operates from a framework of high integrity and character

Describes the components of emotional intelligence

• Understands own internal traits and leadership behaviors and applies them in situations

• Values self-assessment of leadership qualities

Describes the various leadership styles/types (for example, but not limited to, democratic, laissez-faire, bureaucratic, transactional, transformational, servant leader)

• Applies the appropriate leadership style/type

• Recognizes the need to apply the appropriate leadership style in various situations

Domain #1—Task 4: Applies principles of leadership as a role model


Describes effective leader communication styles; can determine appropriate communication style

Describes the importance of articulating expectations to influence organizational culture

Understands when to delegate

Values effective and precise communication

• Demonstrates the ability to effectively communicate expectations

• Demonstrates exceptional listening skills

• Demonstrates the ability to delegate effectively to others when necessary

• Acknowledges own limitations in effective communication

• Remains open to learning new ways of communication

• Recognizes the importance of good listening skills

Defines the benefits of shared governance and shared decision-making

• integrates a team approach to decision-making

• Appreciates and recognizes input from those closest to the work

is knowledgeable of communication styles that inspire others

• Applies communication styles that influence and inspire others

• Values effective and transparent communication

Describes the role of critical thinking in decision-making

• Demonstrates the ability to ask the right questions and use objective analysis to evaluate an issue and form a sound judgment

• Documents the outcomes of critical thinking

• Applies the art of thinking to determine which mode of thinking is being used, in order to improve the quality of own critical thinking skills

• Applies the art of reflecting about thinking

• Values critical thinking as a critical component of effective leadership and problem solving



Domain #1—Task 5: Develops and fosters activities and functions of the nursing management team


Understands the role of the leader to set up the management team for success

• Establishes the nursing department’s organizational structure to benefit resident outcomes

• Commits to the individual role of a leader and manager in the organization

• Recognizes the value of allowing managers to manage

Defines what sufficient and competent staff means for the organization to deliver quality resident care

• integrates strategies to ensure sufficient and competent staffing to maintain resident safety and high-quality care

• Supports and advocates for a safe environment and culture for staff and residents

Understands the principles of delegation • Applies communication techniques necessary for delegation of tasks

• Effectively delegates managerial tasks to managers

• Accepts the limitations of others• Supports the enhancement of staff

competencies

Comprehends the principles of change management and creates the environment for change to happen

• Applies change management principles to implement sustainable change

• Designs, implements, and evaluates change

• Values leadership behaviors in effecting necessary change

identifies ways to engage staff • Uses leader rounding and other techniques to facilitate staff engagement

• Values input from individuals closest to the work being done

Explains the importance of mentoring to support succession planning

• Demonstrates mentoring skills to enhance future leaders

• Commits to creating an environment where team members are supported in their professional growth and development

Domain #1—Task 6: Leads the nursing department in interdisciplinary team collaboration


Understands the significance of interdepartmental communication and collaboration

Understands what it means to be on a team and what it takes to be in a team

• Regularly seeks input from a team of health professionals to ensure quality resident care delivery

• Values input from the interdisciplinary team

Evaluates the functions of the nursing department for efficiency, fiscal responsibility, and positive resident outcomes

• Works with the interdisciplinary team to set and use quality improvement strategies to achieve the best outcomes

• Demonstrates a commitment to team-based quality improvement strategies

Evaluates the QAPi program for the nursing department

• identifies measures that can be improved upon

• implements process-improvement projects

• Demonstrates behavior that aligns with high-quality care delivery

Defines systems thinking • Applies principles of systems thinking to improve quality within the nursing department

• Commits to reducing unintended consequences and unintended outcomes

Describes the importance of an organizational learning environment

• Promotes educational opportunities to ensure staff competency

• Promotes education for professional development

• Recognizes the value of organizational learning




Describes problem-solving strategies • Applies problem-solving skills to effectively address issues within the nursing department

• is open to new approaches to problem solving

Domain #2: Individual Skills for Management and SupervisionOverviewTask 1: Promotes the role of the manager in the nursing departmentTask 2: Ensures team compliance with laws governing the organization, residents, employees, and the environmentTask 3: Employs effective interpersonal communication skills Task 4: implements effective human resource management

DetailsDomain #2—Task 1: Promotes the role of the manager in the nursing department


Defines manager • Uses nurse managers, supervisors, and other nurse leaders to accomplish organizational goals

• Values the input and insight of other nurses

Understands the manager’s role within the nursing department

• Creates a practice environment that empowers decision-making and accountability for nurse managers

• Appreciates the contributions of nurse managers

Domain #2—Task 2: Ensures team compliance with laws governing the organization, residents, employees, and the environment


Defines the role of governmental regulations in governing LTC facilities

• Prioritizes quality activities that align with regulatory requirements

• Develops policies and procedures that align with regulatory requirements, research evidence, and professional standards of practice

• Respects that regulatory requirements provide a framework for quality resident care

Understands strategies to ensure team members understand the laws and regulations that govern long-term care

• Communicates regulatory requirements to the healthcare team and ensures understanding for use in practice

• Values working in an interactive manner with others

Understands federal, state, and facility regulations comprehensively

• Uses the State Operations Manual as the minimum standard of care delivery

• Facilitates the monitoring of nursing care in accordance with established professional, regulatory, and facility standards

• Recognizes that regulations are the minimum requirements for care delivery

Domain #2—Task 3: Employs effective interpersonal communication skills


identifies effective communication strategies to promote high-quality resident outcomes

• Uses effective communication skills to collaborate with others to enhance resident outcomes

• Values standardization of nursing processes




Synthesizes critical information and uses critical thinking strategies to identify root causes

• Allows self and others the appropriate amount of time to effectively problem-solve

• Appreciates the time constraints involved to effectively problem-solve

Understands the concept of conflict management

• integrates strategies to address and resolve conflict

• Demonstrates leadership abilities to effectively resolve conflict

Understands the impact on cultural competency and its effect on individuals

• Uses communication methods that consider unique cultural differences among staff and residents

• Values cultural differences among staff and residents

Describes how mutual support, collaboration, and creativity improve interprofessional communication

• Creates an environment where mutual support, collaboration, and creativity can be expressed and are used to improve processes that lead to improved resident outcomes and staff effectiveness

• Encourages an environment where mutual support, collaboration, and creativity are openly expressed to improve resident outcomes

identifies the need for ongoing problem-solving discussions to improve processes

• Uses problem-solving discussions to improve care delivery

• Recognizes problems as opportunities to improve a process

identifies processes used to effectively communicate causes of unintended consequences and unintended outcomes

• integrates effective communication strategies to promote the safe practices in place to mitigate harm

• Commits to open, honest communication with residents and families regarding unintended consequences and unintended outcomes

Domain #2—Task 4: Implements effective human resource management


Defines delegation • Appropriately delegates tasks to others to improve efficiencies

• Applies the National Council of State Boards of Nursing Five Rights of Delegation

• Values the abilities of others • Recognizes that growth results from

increased responsibility

Evaluates staff competencies prior to delegating tasks

• Communicates delegated tasks concisely

• Provides support to staff regarding delegated tasks

• Monitors for successful completion of delegated tasks with favorable outcomes

• Recognizes the limitations of others

Differentiates between accountability and responsibility

• Delegates responsibility while remaining accountable for outcomes

• Provides prompt, open feedback to staff

• Values clearly set goals

Defines scope of practice and standards of care

Knows the relevant state practice laws and regulations related to scope of practice

• Ensures nursing staff members function within their scope of practice

• implements care delivery processes within acceptable standards of care

• Respects professional standards and scope of practice of nursing staff




Differentiates between coaching (supporting the professional in his/her current role) and mentoring (recognizing leadership potential and supporting future growth opportunities)

• identifies when to use coaching versus mentoring skills with staff

• Values a climate that promotes professional development

Describes strategies for hiring competent staff

• Understands and applies hiring practices that align with current laws related to hiring new staff

• Ensures that job descriptions exist for each position within the nursing department

• Oversees the nursing department for compliance with human resource management standards

• Appreciates the time required to hire successfully

Describes the importance of providing a safe workplace environment for staff to perform their roles and responsibilities comprehensively

• Understands the elements of a safe work environment for staff to perform their roles and responsibilities comprehensively

• Values a safe work environment

Describes methods to determine sufficient and safe staffing

is knowledgeable about any state regulations related to staffing

• Analyzes staffing needs based on acuity, competency, and physical attributes of the facility

• Applies strategies to implement consistent assignment of staff members

• identifies and monitors staff limitations to aid in preventing resident abuse

• Advocates for competent, sufficient staffing

Analyzes current staffing patterns • Monitors for sufficient staffing based on the resident assessment, care plan, and quality outcomes

• Effectively organizes the staffing structure and patterns to meet the residents’ needs

• Understands that staffing is not based solely on federal and state minimum staffing requirements but also based on the needs and desired outcomes of the residents

• Offers innovative solutions to staffing patterns

Describes how the facility’s culture and staff engagement efforts impact staff retention, turnover, and hostility in the workplace

• implements a culture that encourages staff engagement that supports staff retention

• Values input from staff and actively seeks staff’s perceptions of engagement efforts

Defines union-related activities • Functions competently and within the confines of the law

• Understands and establishes professional working relationships with the union steward

• Understands the processes and details of the union contract

• Demonstrates the ability to manage unionized workers within the confines and directives of the union contract

• Respects the individual employees’ rights and desires




Analyzes team functions for optimization of task completion with positive outcomes

• is able to work collaboratively with others on organizational goals, using team members’ individual strengths

• Values the unique contributions of others

• Recognizes own limitations and seeks input from those closest to the work

Domain #3: Organizational Oversight and ManagementOverview Task 1: Applies principles of systems thinking for quality outcomes in the nursing departmentTask 2: implements principles of staff competenciesTask 3: Describes principles and processes for clinical surveillance of nursing systemsTask 4: Utilizes nursing knowledge for oversight of the nursing department in specific resident care areas

DetailsDomain #3—Task 1: Applies principles of systems thinking for quality outcomes in the nursing department


Defines systems thinking • Applies systems thinking in order to problem-solve

• Values a systems approach to solving problems

Understands how micro- and macro-systems impact care delivery

• Analyzes how micro- and macro-level system changes impact resident outcomes

• Recognizes the significant role played by micro- and macro-level system changes in influencing resident outcomes

Describes the role of policies and procedures within the nursing department

Understands the rationale for policy reviews and revisions

• Uses policies and procedures to provide safe, consistent nursing care without unexplained variances related to changes in caregivers

• Recognizes that policy development is essential to quality care delivery

Describes the process for ensuring that policies and procedures and clinical decision supports are based on current research

• Develops policies and procedures using current research

• Values evidence-based practice as the basis for determining best clinical practice

Describes how data is measured in various quality domains

• Measures areas of quality such as structural, process, outcome indicators, and Quality Measures

• Demonstrates a commitment to quality improvement initiatives

Defines benchmarking and describes how benchmarking is used to improve quality outcomes

• Uses performance improvement tools to improve care delivery systems

• Recognizes technology as a tool to extract nursing care information for analysis and improvement in care delivery systems

Defines resident-centered care • Uses a resident-centered approach to develop and implement care delivery systems

• Values care delivery systems designed with the resident as the locus of control

• Honors the resident’s choice and voice



Domain #3—Task 2: Implements principles of staff competencies


Differentiates between competency-based education and knowledge-based in-services

• Monitors the competencies within the nursing department

• Ensures methods for improving competencies are present and are based on the facility assessment findings

• Recognizes staff education and training as an important element in improving resident outcomes

Describes the benefits of providing staff education that allows demonstration of competencies

• implements ongoing staff education that improves care delivery and outcomes

• Recognizes and advocates for staff education to improve care delivery

Understands the role of organizational performance improvement in developing competent staff

• Develops performance improvement processes and consistently identifies and addresses performance-related challenges

• Values consistent application of the performance improvement process

Domain #3—Task 3: Describes principles and processes for clinical surveillance of nursing systems


Defines clinical surveillance of nursing systems

• Applies a systems approach of oversight related to quality care delivery and standards of care

• Demonstrates a commitment to quality

Describes the significance of clinical assessment and oversight of care delivery systems

• Uses various sources of data to review outcomes of care and care delivery systems

• Commits to ensuring the use of the highest-quality care delivery systems possible

Details the interactions between various systems

• Participates in a team approach to quality oversight of systems

• Values the role of other departments in quality care delivery systems

Understands the actions the nurse leader performs to ensure clinical surveillance activities

• Uses surveillance strategies to ensure quality care delivery

• Commits to clinical oversight and delegation of tasks

Domain #3—Task 4: Utilizes nursing knowledge for oversight of the nursing department in specific resident care areas


identifies specific nursing systems that require clinical surveillance

• Provides clinical oversight to multiple clinical systems to ensure quality resident outcomes

• Commits to improving care delivery systems that lead to positive resident outcomes

Understands the required expertise for management of clinical systems

• Appropriately delegates oversight and management of clinical systems

• Values delegation and respects others’ scope of practice




Understands the following clinical areas:

Safety • Falls• Pressure injuries • Abuse• High-risk medications• infection control & prevention• Emergency preparedness/disaster

planning• Transitions of care & readmissions • Antibiotic stewardship

Body Systems Oversight• integumentary• Genitourinary• Gastrointestinal• Musculoskeletal• Neurological• Respiratory• Cardiovascular• Metabolic• Psychiatric/Mood• Sensory • Disease states (cancer, infection)

Care Coordination (Case Management)• Admissions & discharges • Hospice• insurance• Accountable care organizations,

bundled payment programs, and other contract entities

• Develops oversight, processes, and operational strategies to manage the clinical areas

• Ensures the care system provides expert assessment and person-centered care planning to achieve the desired outcomes

• Recognizes that regulatory requirements are the minimum criteria and commits to care delivery that achieves the highest-quality outcomes

Domain #4: Business Acumen for the DNSOverviewTask 1: Understands the DNS’s role in horizontal and vertical organizational hierarchiesTask 2: implements effective strategic planning processesTask 3: Applies principles of fiscal managementTask 4: Describes the current healthcare environment impacting post-acute careTask 5: Applies principles of informatics and technology management to LTCTask 6: Engages marketing and public relations for the nursing department

DetailsDomain #4—Task 1: Understands the DNS’s role in horizontal and vertical organizational hierarchies


Understands the importance of a strong relationship with the administrator

• Applies the skills necessary to foster a positive functional relationship with the administrator and achievement of organizational goals

• Commits to a cohesive relationship with the administrator




Understands the importance of a collaborative team approach to care delivery with the interdisciplinary team (iDT) and medical director

Has knowledge of the competencies needed for team-based care (for example, interprofessional Education Collaborative [iPEC] competencies)

• Demonstrates the skills necessary to forming a collaborative team approach to care delivery

• Ensures staff is knowledgeable about principles of team-based care

• Commits to a team approach to care delivery

Understands the DNS’s role in the organizational hierarchy

• Promotes the executive team’s organizational goals and aligns the nursing department to achieve organizational goals

• Advocates for the nursing department in order to achieve quality outcomes

• Demonstrates a commitment to the organizational hierarchy through one’s own actions

Domain #4—Task 2: Implements effective strategic planning processes


Defines strategic planning process • Uses strategic planning to attain organizational goals

• Recognizes the value of strategic planning in implementing change

Describes two approaches to strategic planning

• Develops strategic plans using approaches outlined

• implements the strategic plan• integrates the strategic plan into

organizational practices

• Appreciates the structured strategic planning process to attain goals

Domain #4—Task 3: Applies principles of fiscal management


Defines the principles of fiscal management (for example, but not limited to, forecasting, budgeting, reporting, controls, reading profit/loss statements)

• Applies the principles of fiscal management to the nursing department

• Values the budgetary process• Values fiscal prudence

Defines key budgetary terms • Demonstrates the ability to develop, monitor, and evaluate a budget for the nursing department

• Develops business cases to show the return on investment for high-cost expenditures and strategic initiatives

• Demonstrates a commitment to fiscal responsibility

Understands the financial impact of nursing department expenditures (for example, but not limited to, ancillary costs, supplies, scheduling, agencies, rentals)

• Demonstrates fiscal responsibility in the nursing department

• Commits to establishing budgetary systems and sound fiscal practices

Describes the need to look for unwarranted waste of healthcare resources

• Responds to unwarranted healthcare waste and implements plans to reduce waste

• Recognizes the need to address healthcare waste



Domain #4—Task 4: Describes the current healthcare environment impacting post-acute care


Understands the various payment initiatives and systems (for example, but not limited to, Medicare, Medicaid, accountable care organizations, bundled payments)

Describes the concept of care management

• Analyzes the impact of payment initiatives and systems on daily operations

• Manages the cost of care while maintaining quality service delivery

• Recognizes the importance of high-quality, cost-effective care delivery

Describes and understands the Resident Assessment instrument (RAi)/Minimum Data Set (MDS) process

• Collaborates with the iDT to ensure accurate resident assessment for care planning and reimbursement

• Values the contribution of the nurse assessment coordinator and recognizes this position as integral to operations

Domain #4—Task 5: Apply principles of nursing informatics and technology management to LTC


Defines nursing informatics

Describes the role of Health insurance Portability and Accountability Act (HiPAA) security

• Applies principles of nursing informatics to manage data and information in order to support effective decision-making

• Values nursing informatics as a nursing science

Describes an informational system • Analyzes how computer systems and software programs function as tools for managing information and generating knowledge

• Recognizes the need to embrace technology and information systems to improve care delivery

Understands that information technology has a system life-cycle that requires planning, analysis, and implementation

• Directs the nursing teams to effectively participate in the nursing informatics system life-cycle in order to impact models of care delivery

• Applies change-management theories to the technology system life-cycle

• Embraces technological advancement for the betterment of resident outcomes

Has a working knowledge of key technology applications (for example, but not limited to, electronic health record, computerized physician order entry, data management, telehealth)

• Applies nursing informatics applications to care delivery systems to provide efficient resident care

• Uses technology to enhance the use of evidence-based care

• Values the role of technology applications in enhancing care delivery

Understands the risk of medical errors when using information technology

• Proactively establishes systems to monitor and evaluate potential and actual medical errors resulting from information technology use

• Commits to actively participate in solving potential and actual information technology medical errors

Domain #4—Task 6: Engages marketing and public relations for the nursing department


Describes the DNS’s role in marketing and public relations

• Analyzes data that impacts the public’s view of the quality of care delivered within the facility

• Respects transparency related to the public-reporting process




Understands the importance of maintaining positive relationships with care partners

• Builds and maintains relationships with care partners that aid in the delivery of quality care

• Recognizes that the care continuum extends beyond the resident’s stay at the facility

• Models exemplary customer service behaviors

Describes how cultural diversity influences resident care delivery

• Demonstrates culturally competent behaviors when dealing with others

• Respects the cultural diversity of others

Understands the impact of patient- and family-satisfaction surveys

• Models positive customer service behaviors

• Values input from patients and their families to improve care delivery processes

Domain #5: Quality Improvement in the Nursing DepartmentOverviewTask 1: Applies the components of quality assurance and performance improvement (QAPi)Task 2: Describes how Quality Measures are used as outcome measuresTask 3: Understands the Five-Star Quality Rating System and can evaluate nursing department performance based on the findings

DetailsDomain #5—Task 1: Applies the components of quality assurance and performance improvement (QAPI)


Describes the five elements of the QAPi program

• Applies the components of the QAPi program to improve and monitor quality care

• Values quality improvement efforts

Understands the DNS’s role on the Quality Assessment and Assurance (QAA) committee

• Uses the QAA committee as the foundation for quality improvement activities

• Embraces the DNS’s leadership role on the QAA committee

Examines how quality and safety can be improved through QAPi activities

• Participates in designing, monitoring, implementing, and evaluating quality and safety improvement efforts

• Embeds QAPi principles into daily care delivery systems

• Uses all types of data to drive quality activities

• Commits to high-quality outcomes

Understands that quality improvement is a team activity

• Actively incorporates various team members into QAPi, particularly Performance improvement Projects (PiPs)

• Ensures high-level communication and coordination between PiP teams and leadership

• Recognizes the value of including all levels of staff in QAPi efforts

Understands the importance of communicating QAPi activities to all members of the organization

• Engages iDT members in QAPi initiatives

• inspires others to participate in quality improvement efforts




identifies areas that influence quality care delivery

• Analyzes areas that impact quality care delivery

• Addresses gaps in systems and processes

• intervenes and corrects inappropriate care processes to improve quality

• Appreciates the role of identifying quality concerns in improvement efforts

• Values a proactive approach to improvements in care delivery

identifies the role each staff member plays in proactively preventing and identifying care system–related issues

• Prevents and identifies quality concerns by seeking information from staff

• Trains staff to become proficient in process improvement

• Values input from all staff members

Understands the need to monitor care and services, drawing from a wide range of resources to direct QAPi efforts

• Monitors performance indicators and reviews them against facility-set benchmarks

• Facilitates team efforts toward QAPi

• Values data measurement and monitoring as methods for quality improvement

Describes the purpose of performance improvement plans

• Prioritizes PiPs based on high-priority, problem-prone areas

• Demonstrates commitment to high-quality care delivery

Domain #5—Task 2: Describes how Quality Measures are used as outcome measures


Understands the role and objectives of Quality Measures (QMs)

• Communicates to staff the role and objectives of QMs

• Appreciates transparency of high-quality care through published QMs

Describes how data is collected and calculated for QMs

• identifies how QM information is collected and calculated to formulate facility percentiles

• Values measurement as a determinant of quality

Describes the impact of MDS accuracy on QMs

• Uses current coding regulations to ensure the accuracy of MDS assessments

• Appreciates the importance of accurate, valid data used to determine QMs

Describes strategies to monitor QM reports for trends or changes requiring root-cause analysis

• Uses QM reports to identify trends that require in-depth analysis to determine the root cause of the issue

• Commits to monitoring trends and analyzing changes requiring root-cause analysis

identifies potential problems with QMs • implements corrective action plans to address issues with QMs

• Commits to continuously monitoring for improvement opportunities

Domain #5—Task 3: Understands the Five-Star Quality Rating System and can evaluate nursing department performance based on the findings


Describes the elements that constitute the Five-Star Quality Rating System (FSQRS)

• identifies the components that make up FSQRS

• Values the transparency of FSQRS

Understands the systems processes that impact FSQRS

• Evaluates systems and processes for improvements that impact FSQRS

• Acknowledges that system processes allow for continuity of care through established practices

Describes how proactive practices decrease the likelihood of processes that could threaten the Five-Star rating

• implements improvement efforts proactively for areas that threaten the Five-Star rating

• Appreciates input from staff related to quality improvements that impact the Five-Star rating




Describes the importance of staff education related to FSQRS

• Provides education to nursing and other staff regarding the components and impact of FSQRS

• Values the role of education related to improving FSQRS

Understands the importance of investigating resident and resident representative concerns and how complaint investigations can impact the Five-Star rating

• investigates concerns from residents and resident representatives to identify the root cause of problems

• implements interventions to mitigate future issues related to resident/resident representative concerns

• Values input from residents and resident representatives

Domain #6: Regulatory ComplianceOverviewTask 1: Demonstrates skills for continuous regulatory survey readinessTask 2: Applies principles of regulatory survey managementTask 3: Ensures the system for ongoing compliance and ethics is implemented in the nursing departmentTask 4: implements principles of resident rights and safetyTask 5: Creates systems to address risk management

Details Domain #6—Task 1: Demonstrates skills for continuous regulatory survey readiness


Understands the federal regulations that govern the facility and that federal regulations are the minimum standard of care

• Uses the federal regulations as a guide to meet the minimum standard of care

• Respects that the federal regulations are the minimum standard of care

Understands the survey protocol and the forms required throughout the survey process

• Demonstrates effective use of the forms required during the survey process

• Navigates through the required survey process steps

• Teaches staff to be ready 24/7 for the survey process

• Supports the federal regulatory processes

Explains the rationale for having a survey readiness system such as a binder as part of the survey preparedness plan

• Participates in the development of a survey readiness system such as a binder to be prepared for survey at all times

• Supports the development of a 24/7 survey readiness culture

Describes the role that policies and procedures play within the survey process

• Ensures that policies and procedures are realistic and consistent with current standards of practice and, at a minimum, meet survey expectations

• Develops resident care systems based on up-to-date policies and procedures

• Commits to high-quality care delivery practices

Understands how survey-identified risks can translate into litigation risks

• Uses the survey readiness process to look at systems, procedures, and processes of care to identify and minimize survey risks

• Values being survey ready at all times • Values survey readiness as a risk-

management approach




identifies areas where quality improvement plans are required to meet the minimum federal requirements

• implements quality improvement plans to improve care delivery and outcomes that meet the minimum federal requirements

• Appreciates continuous quality improvement

• Appreciates the QAPi process

Understands the importance of staff education related to the survey process

• Educates staff about the purpose of the survey and the areas that will be evaluated by surveyors

• Respects the role of education to ensure staff members are competent in patient care systems

Describes methods of monitoring care processes to ensure care delivery that is consistent with regulatory compliance and facility policies and procedures

• Monitors care delivery processes to ensure compliance with regulations, professional standards of care, and facility policies and procedures

• Corrects issues that are discovered through monitoring care processes

• Avoids and manages immediate jeopardy situations

• Values the discovery of ways to improve care delivery through monitoring current processes

Understands the importance of a documentation system that supports accurate, concise, and consistent resident-specific information

• implements, and ensures that staff sustain, a documentation system that supports accurate, concise, and consistent resident-specific information

• Values documentation that supports accurate resident-specific information

Describes how past survey reports and citations impact future surveys

• Reviews past survey deficiencies to ensure past citations have been addressed, and uses past deficiencies as teaching tools

• Addresses barriers and creates a path to improving future care delivery

Understands how networking, communicating with other nurse leaders, and keeping up with the literature enable one to stay abreast of current practices and trends that impact the clinical practice setting

• Uses networking and communication skills to stay current with changes impacting nursing practices

• Values networking and staying current with the literature as means to staying abreast of current changes in the nursing practice

Understands the financial impact on the overall budget of high scope and severity citations via denial of payment for new admissions, loss of community referral sources, and high-dollar civil money penalties

• implements system oversight of high-risk, problem-prone areas, to avoid the financial burdens of high scope and severity citations

• Values oversight of systems to identify areas that need improvement before financial penalties accumulate

Domain #6—Task 2: Applies principles of regulatory survey management


Explains how regulations are applied throughout the survey process

• Demonstrates knowledge of regulations and communicates with surveyors to address survey-related concerns

• Commits to keeping abreast of regulatory changes and their impact on LTC

Understands how to conduct a root-cause analysis related to survey deficiencies

• Demonstrates the ability to conduct a root-cause analysis to identify the cause of survey deficiencies

• Respects the process of finding the root cause of problems

Understands the components of the plan of correction to address survey deficiencies

• is able to write an effective plan of correction with the required components

• Supports the corrective action process




Describes methods of presenting investigative findings and subsequent resolutions to the QAA committee

• Applies the knowledge from investigative findings to implement and monitor sustainable action plans to correct survey issues

• Commits to monitoring improvement action plans to ensure sustainability

Understands the surveyor revisit process • is able to prepare for surveyor revisits and demonstrate how compliance has been achieved and maintained

• Prepares and gathers sufficient evidence to support that past survey deficiencies have been corrected

• Presents information to surveyors in an organized fashion

• Demonstrates a calm demeanor during surveyor revisits

Describes the factors that interfere with ongoing regulatory compliance

• identifies unique factors that impede regulatory compliance

• Advocates for the needs of the staff and residents in order to improve quality

Domain #6—Task 3: Ensures the system for ongoing compliance and ethics is implemented in the nursing department


Defines code of conduct • Demonstrates exemplary standards of conduct

• Commits to treating others with trust, respect, and integrity

Describes the principle of ethics • Navigates through difficult ethical dilemmas by applying ethical principles

• Contributes to the resolution of ethical dilemmas using ethical principles

Describes the role of the nursing department in the compliance and ethics program

• Works with team members to help improve their understanding of compliance and ethics

• is open to risk identification and improvement strategies to mitigate risks

Understands the role of the compliance and ethics program in the day-to-day facility operation

• Takes steps to integrate compliance and ethics standards into daily operations

• Values transparency and reporting of compliance- and ethics-related concerns

Domain #6—Task 4: Implements principles of resident rights and safety


Understands the process of investigating complaints, incidents, accidents, and other unusual events

• Develops a process to acknowledge, investigate, and follow up on complaints, incidents, accidents, and other unusual events

• Commits to the process of investigating complaints, incidents, accidents, and other unusual events

Describes a just culture

Understands the need to have processes in place that get to the root cause of errors

• identifies adverse events and reviews them as potential process issues rather than individual performance-related issues

• implements processes that help identify and correct system errors

• Recognizes adverse events as opportunities to learn and improve

• Values honesty when mistakes are made

• Fosters a just culture

Understands the balance between resident rights and safety

• Develops processes to ensure resident rights and safety are maintained

• Values residents’ voice and choice in their plans of care

Describes the fundamental concepts related to HiPAA and privacy

• Demonstrates actions that support ongoing protection of patient privacy

• Values protecting patient privacy information

Understands the importance of creating a care delivery system that encompasses resident choice

• Ensures that patient choices are being heard and adhered to, including those based on culture, religion, and preferences

• Respects and values differences among individuals and their choice of lifestyle



Domain #6—Task 5: Creates systems to address risk management


Understands the importance of systems for risk reduction and risk management

• Ensures the presence of and adherence to a system for risk reduction and management

• Participates in the development of policies and procedures related to risk management

• Participates in communicating risk-management policies and procedures and plans to staff members

• Values a systems approach to risk management

• Commits to prevention of unintended outcomes

Understands the procedures, systems, and work processes related to identifying risk though errors or incidents

• Analyzes procedures, systems, and work processes in order to improve them and minimize the potential for errors and incidents

• Supports a safe work and safe resident care environment

Understands the role of systematic methods in risk identification

• Establishes and supports systematic methods to ensure shared understanding of risks, priorities, and action plans

• implements a risk-management program to prevent and reduce nursing errors

• Values a team approach to reducing risks

Defines adverse events

Understands which adverse events require reporting and reports them accordingly

Understands the reporting requirements related to abuse, neglect, exploitation, and misappropriation

• Ensures staff education on identification of and response to adverse events

• Oversees investigation of reportable incidents

• implements a process to report adverse events as required by regulations

• Commits to solving safety-related concerns

Describes methods for tracking risk-management indicators

• implements and oversees tracking methods and uses this information to learn from collected data and information

• Promotes learning from mistakes to improve systems

Understands how processes can decrease risks

• Develops processes for decreasing risks and avoiding or minimizing them

• Commits to correcting flawed processes

Understands appropriate responses to mitigate risk

Describes ways to rank the severity of risk-related issues

• implements appropriate responses to minimize or correct risk-related issues based on their severity ranking

• Commits to providing the resources necessary to decrease or correct risk-related concerns

Understands the appropriate use of equipment and the risks associated with improper use

• Oversees implementation of appropriate action steps to ensure that equipment is used as intended

• Commits to ensuring safe equipment use by staff members



Domain #7: Professional DevelopmentOverview Task 1: Applies knowledge of nursing staff scope of practice in the organization of care deliveryTask 2: Engages in the development of one’s personal and professional competencies Task 3: Engages in advocacy to enhance the profession of nursing and resident care

DetailsDomain #7—Task 1: Applies knowledge of nursing staff scope of practice in the organization of care delivery

Knowledge Skills Attitude

Understands the significance of ongoing education to maintaining competence in nursing

• is able to seek new information to stay abreast of changes in nursing practice

• Applies current evidence-based research to current nursing practice

• Commits to being a lifelong learner

Understands nursing scope of practice regulation

• Ethically applies nursing scope of practice to day-to-day operations

• Responds effectively to pressure to practice outside the scope of practice

• Develops, maintains, and implements professional standard of practice

• Commits to working within the scope of practice

• Values and respects other individuals’ scope of practice

• Empowers staff to work within their scope of practice

Understands the importance of staying abreast of regulatory and scope of nursing practice changes

• Uses new information and applies it to daily practice

• Provides ongoing education to nursing staff on regulatory and professional practice changes

• Values education of nursing staff to stay current with regulatory and practice changes

Domain #7—Task 2: Engages in the development of one’s personal and professional competencies


Describes the importance of professional development

• Evaluates the professional development

• Develops and implements a professional development program for the development and implementation of clinical, educational, and administrative standards

• Demonstrates ongoing personal professional development

• Seeks out professional opportunities for growth, such as attending workshops/conferences, networking with other professionals, participating in committees, and mentoring

• Supports professional development opportunities for staff

• Values professional development of staff

• Advocates for professional development to improve quality outcomes

Describes nursing professionalism • Demonstrates ongoing professionalism during day-to-day interactions with others

• Requires professional standards from staff

• Commits to and values professionalism




Describes the importance of self-care that supports one’s role as an effective DNS

• Engages in self-care• identifies the signs of burnout among

staff and supports self-care for others • Applies principles of emotional

intelligence to support physical, mental, and emotional health in others

• Promotes and fosters a self-care environment

Domain #7—Task 3: Engages in advocacy to enhance the profession of nursing and resident care


Understands the importance of nursing advocacy

Describes the impact of nursing advocacy efforts related to post-acute care and services

• Uses opportunities to advocate for the resident, staff, facility, and profession

• Advocates for policy changes for the nursing profession and post-acute care

• Communicates with local, state, and federal legislators to improve post-acute care and the nursing profession

• Communicates with local, state, and national professional organizations that improve post-acute care

• Respects the role of legislators and their impact on post-acute care nursing

• Respects the role that the organization plays in advocating for professional development in the nursing profession



ContributorsShelley Acus, RN, DNS-CT, QCPDirector of Nursing ServicesMaple Knoll VillageJudith Bagby, BSN, RAC-CT, DSN-CT, LNHANurse ConsultantJA Bagby Consulting LLCDebra Bakerjian, PhD, APRN, FAAN, FAANP, FGSAAssociate Adjunct ProfessorBetty irene Moore School of Nursing UC Davis Health SystemBarbara Bates, MSN, RN, DNS-MT, RAC-CT, QCP-MTNurse ConsultantSandy Biggi, BSN, RN, SNT, RAC-MT, DNS-MT, QCP-MTNurse Consultant, RetiredPriscilla Bragg, RN, MSN, MSEd, RAC-CTManager, Clinical ServicesGood Samaritan SocietySophie A. Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC Director, Clinical Advisory ServicesBaker Tilly Virchow Krause, LLPDiane Carter, MSN, RN, RAC-CT, DNS-CT, FAANSusan Davis, MS, RN, CRRNSenior Vice President of OperationsSMV Management Company, LLCMary Ellen Dellefield, PhD, RNResearch Nurse ScientistVA San Diego Healthcare SystemClinical ProfessorUniversity of San Diego Hahn School of Nursing and

Health ScienceCharlotte Eliopoulos, MPH, PhD, RN Author, Consultant in Holistic Long Term and Chronic Care

NursingJeanne Gerstenkorn, BSN, RN, MSN, DNS-CT, RAC-CT, QCPSenior Vice President of Health and WellnessPresbyterian Manors of Mid-AmericaBetsy Hardy, BSN, RN, DNS-MTVice President of Business DevelopmentAAPACNGail Harris, BSN, RN, DNS-CTClinical Risk Manager and Quality Assurance ConsultantLong-Term Care Nursing Education Foundation Board of

Directors, Secretary

Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DNS-CTVice President of Curriculum DevelopmentAAPACNSusan LupPlace, MSN, RNindependent Healthcare ConsultantSoutheast Asia Healthcare Partners, Board of DirectorsLynn Milligan, MSN/ED, RN, DNS-CT, RAC-CTDirector of Education/Employee HealthLeahi HospitalRuth Minnema, RN, MA, NHA, RAC-CTDirector of Nursing ServicesShalom ParkChristine Mueller, PhD, RN, FGSA, FAANProfessorAssociate Dean for Academic ProgramsLong-Term Care Professorship in NursingUniversity of Minnesota, School of NursingLinda Shell, DNP, MA, RN, DNS-CTPrincipal and PartnerLindaShell.comCarol Smith, RN, BSN, RAC-CTManaging Consultant BKD CPAs & AdvisorsJill Snow, MBA, BSN, RN-C, CHCVice President of Compliance and QualityCHSGaAmy Stewart, RN, DNS-MT, QCP-MT, RAC-MTCurriculum Development SpecialistAADNSLisa Thomson, BA, NHA, RMT, CIMTChief Marketing and Strategy OfficerPathway HealthDiane Vaughn, RN, C-DONA/LTC, LNHAVice President of Clinical ServicesVolunteers of AmericaLinda Winston, RN, MSN, BS, DNS-MT, QCP-MT, RAC-CTNurse Consultant

The contributors gratefully acknowledge the VA San Diego Healthcare System and the opportunity to contribute to DNS staff working in state veterans’ and community-contract SNFs, two components of the VHA Nursing Home Program.



Appendix 1Second National Nurse Leadership Summit, Milwaukee, Wisconsin, July 2015: Results of Group Participants’ Domain and Task Word Sort

Background Information and KeysA list of 90 words, compiled from the First Nurse Leadership Summit and various certification programs, identified commonalities in concepts included in curriculums related to Nurse Leadership programs. Each group at the Second Nurse Leadership Summit was given a stack of cards created from this list and asked to sort them into appropriate domains and tasks for a Nurse Leadership program. The individual results are listed in the Word Sort Results by Group page.

Word Sort List

Blues Group 1

Greenish blues Group 2

Purples Group 3

Oranges Group 4

Bold font Domain title used by group

Regular font Task title used by group

Grey text Word brought in by group (not part of the original list)

Nurse Leadership CategoriesOnce the groups finished sorting, the domains were discussed and commonalities among the groups were identified. This discussion is outlined in the Nurse Leadership Categories page.

Venn Diagrams of Word OverlapThe domains shown in the following Venn diagrams are from the “Agreement” column of the Nurse Leadership Categories page. The words listed in the diagrams were pulled from each group’s interpretation of the categories and sorted under the consensus titles. The Venn diagrams attempt to show overlap based on how many groups selected the same words for each category.

No overlap* Overlap of 2 groups Overlap of 3 groups Overlap of 4 groups

*Note: Overlap is defined as multiple groups selecting the same “task” word for the defined “domain”

Consensus Domains for Each WordThe groups also had different definitions/interpretations of the words. The final chart listed (Consensus Domains for Each Word) shows how many consensus domains each word fit into based on the groups’ sorting. This chart attempts to show the overlapping definitions of each word, based on each group’s interpretation of the definition and domain.



Compliance and regulatoryCode of conduct

Compliance expert

Environmental health

Ethics

Five-Star Quality Rating System skills

Quality of care

Quality of life

Resident behavior and facility practices

Resident rights

Survey management and enforcement

Survey readiness

QualityCare quality assessment

Customer service

Education

Outcome identification

Practice-based learning and improvement

Quality improvement

Quality of practice

Support for patient safety

Systems

AdministrativeAdministrative

Care coordination

Care delivery system

Create system of care delivery

Marketing

Organization management

Oversight—MDS

Public relations

Supervision

Technical skills

LeadershipAdvocate

Collaboration

Create homelike environment

Cultural competence

Development

Ensure accountability

Facilitator

interdisciplinary team

Knowledge of healthcare environment

Leadership

Organization learning

Performance improvement catalyst

Risk management

Role model

Shared decision-making

Strategic management

Systems thinking

Team

Teamwork

EducationDevelopment

Education

Nursing knowledge


Profession

Professional practice evaluation

Technical skills

Quality of lifeCreate homelike environment

Customer service

Evaluate extent of person-centered care implementation

Physical environment

Quality of life

Quality of careCare quality assessment

Clinical

Evidence-based practice



Nurse-patient relationship

Nursing care delivery process

Nursing process




QAPi skills

Quality improvement

Quality of care

Quality of practice


Care transitionsAdvocate

Care coordination


Care transitions


Patient education

ComplianceCode of conduct

Compliance expert

Ethics


Resident rights


Survey readiness

OrphansCultural competence


Marketing

Population health

Public relations

Resources and finance

Science

LeadershipLeadership

Collaboration

Communication

Communication skills

Conflict management

Facilitator

interpersonal skills

interprofessional skills

Management skills

Mutual support


Relationship building

Role model


Succession planning

Supervision

Environment/physical plantCreate homelike environment




Human resourcesCultural competence

Delegation

Development

Education


Human resource management

Maintain consistent assignment

Personal development


Profession

Professionalism

Staffing

ClinicalBehavioral management

Care coordination


Care transitions

Clinical


Define scope of nursing practice



Nursing knowledge

Nursing process

Patient education

Quality of care


Science

AdministrativeAdministrative

Advocate

Contingency planning

ProfessionCreate system of care delivery

Cultural competence


Healthcare environment


Population health

Profession

LeadershipCode of conduct

Collaboration

Delegation

Development


implementation

Leadership

Non-punitive response to mistakes



Professionalism

Role model



SupervisionCommunication skills

Conflict management

Education

Facilitator




Management skills

Mutual support

Problem solving


Supervision

Team

Teamwork

QAPI skillsOutcome identification


QAPi skills

ComplianceCompliance expert


Ethics


Quality improvement

Risk management

Situation monitoring


Fiscal managementAdministrative

Fiscal management


Staffing

Word Sort Results by Group



ClinicalBehavioral management

Clinical



Nursing knowledge

Nursing process

Patient education

Population health

Science

ProfessionDefine scope of nursing practice

Networking


Profession


Professionalism

Management skillsBusiness acumen

Care transitions

Conflict management

Data management

Delegation


Event investigation

Fiscal management


implementation

information/technology management


Management skills



Problem solving

QAPi skills



Staffing

Supervision

CommunicationCommunication




Mutual support



LeadershipCommunication



Facilitator

Fiscal management

implementation



Leadership


Problem solving

Professionalism

Risk management

Strategic planning

Systems

Systems thinking

Organization managementCollaboration



Team

Teamwork

Nursing managementAdministrative

Behavioral management

Conflict management

Data management

Delegation



infection control




Management skills

Mutual support


Oversight—MDS


Role model


Staffing


Supervision

Customer service

Fiscal management

implementation



Marketing

Oversight—MDS

Population health

Public relations

Quality of life

Resident rights


Strategic planning

Team

Teamwork

Technical skills

EthicsCode of conduct

Compliance expert

Data management

Ethics


Risk management

PI/QICare quality assessment




infection control





Problem solving


QAPi skills

Quality improvement

Quality of practice



Survey readiness

Systems

Systems thinking

Customer serviceCommunication

Customer service


Marketing

Public relations

RegulatoryFive-Star Quality Rating System skills

infection control

Oversight—MDS


Quality of care

Quality of life

Quality of practice


Resident rights


Survey readiness

Systems

Systems thinking

Care deliveryCare coordination


Care transitions

Data management




Nursing knowledge

Nursing process



Science

Technical skills

Patient careAdvocate


Care quality assessment

Clinical

Create homelike environment



Patient education



Nurse Leadership CategoriesGroup 1 Group 2 Group 3 Group 4 Agreement

Environment/physical plant

Quality improvement/ Performance improvement (QiPi)

Quality QAPi skills Quality (QAPi, QiPi)

Human resources

Clinical Clinical

Leadership Leadership Leadership Leadership Leadership

Administration Ethics

Organizational management Nursing management Education Quality of life (QoL) Quality of care (QoC) Care transitions

Compliance Compliance and regulatory Compliance Compliance (regulatory, ethics)

Orphans

Administration Management skills Communication

Profession Profession Professional

Patient care Care delivery Regulatory Customer service Fiscal management Supervision

Clinical practice (QoL, QoC, care delivery)Business acumenManagement and supervision



No overlap Overlap of 2 groups Overlap of 3 groups Overlap of 4 groups

Consensus Domain: Business AcumenDomain titles used by groups:

• Administrative (Groups 1 and 3)

• Communication (Group 1)

• Human resources (Group 3)

• Customer service (Group 4)

• Fiscal management (Group 4)

AdvocateCare coordinationCare delivery systemCommunication skillsContingency planningCreate system of care

delivery Cultural competence DelegationDevelopment Education

Ensure accountabilityHuman resource

management implementation interdisciplinary team interpersonal skills interprofessional skills Knowledge of healthcare

environmentMutual supportNon-punitive response

to mistakes


Personal developmentPopulation healthPractice-based learning

and improvementProfession Professionalism Quality of life Relationship building

Resident rights Strategic planning SupervisionTeam Teamwork

Communication Customer service Fiscal managementMaintain consistent

assignment

Oversight—MDSResources and finance StaffingTechnical skills

Administrative Marketing

Public relations




Consensus Domain: Clinical Practice (QoL, QoC, Care Delivery)Domain titles used by groups:

• Clinical (Groups 1 and 3)

• Care transitions (Group 2)

• Quality of care (Group 2)

• Quality of life (Group 2)

• Environment/Physical plant (Group 3)

• Care delivery (Group 4)

• Patient care (Group 4)

• Fiscal management (Group 4)

Customer service Data managementDefine scope of nursing practice Environmental healthFive-Star Quality Rating

System skillsinformation/technology

managementinterdisciplinary teamOutcome identificationPerformance improvement

catalyst

Population healthPractice-based learning

and improvement QAPi skillsQuality improvement Quality of lifeQuality of practiceResident behavior and

facility practicesTechnical skills

AdvocateCare quality

assessmentCreate system of

care delivery


Organization learning Physical

environmentQuality of careSupport for

patient safety


Care coordination Care delivery system Care transitionsCreate homelike

environment



Nursing knowledgeScience

ClinicalNurse-patient relationship

Nursing processPatient education




Consensus Domain: Compliance (Regulatory, Ethics)Domain titles used by groups:

• Compliance and regulatory (Group 1)

• Compliance (Groups 2 and 4)

• Ethics (Group 3)

• Regulatory (Group 4)

Data managementHuman resource

management infection control information/technology

managementOversight—MDS

Physical environmentQuality improvement Quality of practice Situation monitoring Support for patient safety SystemsSystems thinking

Environmental healthFive-Star Quality Rating System skills

Quality of careQuality of life

Code of conductResident behavior and

facility practices Resident rights


Survey readiness

Compliance expertEthics




Consensus Domain: LeadershipDomain titles used by groups:

• Leadership (all groups)

AdvocateCode of conduct Conflict managementCreate homelike environment Cultural competenceDefine scope of nursing

practice DelegationFiscal management

interdisciplinary team interpersonal skills Management skills Mutual supportNon-punitive response to mistakes Organization learning Organization managementPerformance improvement catalystProblem solvingProfessional practice evaluation Relationship building

Strategic planning Succession planning Supervision SystemsTeam Teamwork

Communication Communication

skills Development

Ensure accountability implementation interprofessional skillsKnowledge of healthcare

environment Personal development Professionalism

Risk management Strategic

management Systems thinking

Collaboration Facilitator

Role modelShared decision-making

Leadership




Consensus Domain: Management and SupervisionDomain titles used by groups:

• Management skills (Group 1)

• Nursing management (Group 2)

• Organization management (Group 2)

• Supervision (Group 4)

Administrative Behavioral management Business acumenCare transitions Collaboration Communication skills EducationEnsure accountability


Event investigation FacilitatorFiscal management implementation infection control interdisciplinary team interprofessional skillsNon-punitive response to mistakes Nursing care delivery process


Oversight—MDSPhysical environment QAPi skillsResources and finance Role modelShared decision-makingStrategic management

Data management DelegationHuman resource

management


interpersonal skillsMaintain consistent

assignmentMutual support Problem solving

Relationship building Situation monitoring Staffing Supervision Team TeamworkConflict management

Management skills




Consensus Domain: ProfessionalDomain titles used by groups:

• Profession (Groups 1 and 4)

• Education (Group 2)


Cultural competence DevelopmentEducationHealthcare environment Networking

Nursing knowledge Organization managementPersonal developmentPractice-based learning and

improvement ProfessionalismTechnical skills

Define scope of nursing practice Professional practice evaluation

Profession




Consensus Domain: Quality (QAPI, QIPI)Domain titles used by groups:

• Quality (Group 1)

• Quality of care (Group 2)

• Pi/Qi (Group 3)

• QAPi skills (Group 4)

Clinical Customer serviceEducationEvaluate extent of person-

centered care implementationinfection control interdisciplinary team

Non-punitive response to mistakes Nurse-patient relationshipNursing care delivery processNursing processPractice-based learning and

improvement Problem solvingProfessional practice evaluation Quality of careSituation monitoring Survey management and

enforcement Survey readinessSystems thinking



Organization learningSupport for patient

safetySystems

Care quality assessment Performance improvement catalyst

QAPi skillsQuality improvement

Quality of practice




Consensus Domains for Each WordWord Consensus Domain Group 1 Group 2 Group 3 Group 4

AdministrativeBusiness Acumen X X X

Management X

Advocate Business Acumen X

Clinical X X

Leadership X

Behavioral managementClinical X X X

Management X

Business acumen Management X

Care coordinationBusiness Acumen X

Clinical X X X

Care delivery systemBusiness Acumen X

Clinical X X X

Care quality assessmentClinical X X

Quality X X X

Care transitionsClinical X X X

Management X

ClinicalClinical X X X X

Quality X

Code of conductCompliance X X X

Leadership X

CollaborationLeadership X X X

Management X

CommunicationBusiness Acumen X X

Leadership X X


Business Acumen X

Leadership X X

Management X

Compliance expert Compliance X X X X

Conflict managementLeadership X

Management X X X

Contingency planning Business Acumen X

Create homelike environmentClinical X X X

Leadership X


Business Acumen X

Clinical X X

Professional X

Cultural competence

Business Acumen X

Leadership X

Professional X



Word Consensus Domain Group 1 Group 2 Group 3 Group 4

Customer service

Business Acumen X X

Clinical X

Quality X

Data management

Clinical X

Compliance X

Management X X


Clinical X

Leadership X

Professional X X

Delegation

Business Acumen X

Leadership X

Management X X

Development

Business Acumen X

Leadership X X

Professional X

Education

Business Acumen X

Management X

Professional X

Quality X


Business Acumen X

Leadership X X

Management X


Clinical X

Compliance X X

Orphans X

Ethics Compliance X X X X


Clinical X X

Management X

Quality X

Event investigation Management X

Evidence-based practiceClinical X X X

Quality X X

FacilitatorLeadership X X X

Management X

Fiscal management

Business Acumen X X

Leadership X

Management X


Clinical and Quality X

Compliance X X

Quality X




Healthcare environment Professional X


Business Acumen X

Compliance X

Management X X

implementation

Business Acumen X

Leadership X X

Management X

infection control

Compliance X

Management X

Quality X


Clinical X

Compliance X

Management X X


Business Acumen X


Leadership X

Management X


Business Acumen X

Leadership X

Management X X


Business Acumen X

Leadership X X

Management X

Knowledge of healthcare environmentBusiness Acumen X

Leadership X X

Leadership Leadership X X X X

Maintain consistent assignmentBusiness Acumen X X

Management X X

Management skillsLeadership X

Management X X X

Marketing Business Acumen X X X

Mutual support

Business Acumen X

Leadership X

Management X X

Networking Professional X


Business Acumen X

Leadership X

Management X

Quality X

Nurse-patient relationshipClinical X X X X

Quality X





Clinical X X X

Quality X

Management X

Nursing knowledgeClinical X X X

Professional X

Nursing processClinical X X X X

Quality X


Clinical X X

Leadership X

Quality X X


Business Acumen X

Leadership X

Management X

Professional X

Outcome identificationClinical X

Quality X X X X

Oversight—MDS

Business Acumen X X

Compliance X

Management X

Patient education Clinical X X X X


Clinical X

Leadership X

Quality X X X


Business Acumen X

Leadership X X

Professional X


Clinical X X

Compliance X

Management X

Population health

Business Acumen X

Clinical X

Professional X


Business Acumen X

Clinical X

Professional X

Quality X

Problem solving

Leadership X

Management X X

Quality X

ProfessionBusiness Acumen X

Professional X X X





Leadership X

Professional X X

Quality X

Professionalism

Business Acumen X

Leadership X X

Professional X

Public relations Business Acumen X X X

QAPi skills


Management X

Quality X X

Quality improvement


Compliance X

Quality X X

Quality of care

Clinical X X

Compliance X X

Quality X

Quality of life

Business Acumen X

Clinical X

Compliance X X

Quality of practice

Clinical X

Compliance X

Quality X X X


Business Acumen X

Leadership X

Management X X

Resident behavior and facility practicesClinical X

Compliance X X X

Resident rightsBusiness Acumen X

Compliance X X X

Resources and financeBusiness Acumen X X

Management X

Risk managementCompliance X X

Leadership X X

Role modelLeadership X X X

Management X

Science Clinical X X X

Shared decision-makingLeadership X X X

Management X


Compliance X

Management X X

Quality X




StaffingBusiness Acumen X X

Management X X

Strategic managementLeadership X X

Management X

Strategic planningBusiness Acumen X

Leadership X

Succession planning Leadership X

Supervision

Business Acumen X

Leadership X

Management X X X


Clinical X X

Compliance X

Quality X X

Survey management and enforcementCompliance X X X

Quality X

Survey readinessCompliance X X X

Quality X

Systems

Compliance X

Leadership X

Quality X X

Systems thinking

Compliance X

Leadership X X

Quality X

Team

Business Acumen X

Leadership X

Management X X

Teamwork

Business Acumen X

Leadership X

Management X X

Technical skills

Business Acumen X X

Clinical X

Professional X



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