Amy StewartThe relationship between the administrator and director of nursing services (DNS) has never been more important. Pandemic stress, coupled with increased regulatory scrutiny, has further strained what was already fraught; often, these stressors lead to turnover in one or both positions.

This critical relationship, often compared to a marriage, drives many aspects of care delivery. It affects facility culture because staff want to work on a cohesive team. It eases certification or complaint surveys by providing support. It generates financial benefits when these two collaborate on budget and census goals. And it improves the environment for residents and staff alike when communication between the two is transparent and truthful.

Achieving these results takes focus on the DNS-administrator relationship itself. When time and skill are invested in cultivating the relationship, it can withstand adversity, but if neglected, there can be far-reaching consequences.

Improvement on Both Sides

Consider this scenario: Joe, who recently started as the administrator, just told Nancy, the long-time DNS, she will need to cut her nursing budget this month. Nancy immediately became defensive, assuming he was saying she must make staffing changes. But, while Joe said she had to lower expenses, he hadn’t said to cut staff. In fact, Joe had wanted to review options with Nancy, but she jumped to conclusions.

Clearly, this does not create a cohesive team. If Nancy had listened carefully before responding, she would have known Joe wasn’t referring specifically to staffing. If Joe had built trust and established clear expectations, or communicated his wish to weigh options together, he could have avoided Nancy’s overreaction.

This scenario is far too common. When such conflicts occur frequently, they create irreparable damage. Below are five ways to improve the DNS-administrator relationship, regardless of tenure in each role.

1. Teamwork Makes the Dream Work

A solid foundation is necessary for a long-lasting, trusting relationship. Commit to working together as a team. Although each role has different responsibilities, the two must work together to meet patient outcomes and budgetary goals.

Yet teamwork goes both ways. Connect daily to discuss challenges, successes, and expectations. Start meetings by sharing what was done well before exploring what needs attention. Use reflective listening to understand what the other is saying before responding.

This takes practice. It is easy to let emotions take over, but reflection on the words used is more productive than reaction. Take time to learn each other’s strengths and weaknesses; use those strengths to improve care delivery and the work environment. A foundation of commitment and collaboration between the administrator and DNS will also reinforce teamwork within other departments and their staff.

• Case in Point

When Liz joined a small facility as the new DNS, tensions were high: The facility had recent survey issues, and census was low. Renee, the administrator, met with Liz daily. Renee discussed expectations and reviewed budget and census goals while Liz shared clinical improvements and concerns. By working to understand one another, Liz and Renee built trust and respected each others’ roles.

2. Healthy Communication Every Time

Learn each other’s preferred communication style and use it when possible. Some people prefer face-to-face communication, while others are perfectly happy with email. Whatever the style, remember that words are very powerful, so choose them wisely. Communicate frequently and honestly. Don’t hide issues to keep the conversations “nice and polite.”

Prioritizing communication requires a safe space to discuss tough situations that inevitably arise. Candid conversations are often necessary to improve care. Being truthful and having respect for each other avoids a negative work environment and supports the other’s efforts.

• Case in Point

When Mrs. Smith’s daughter arrived angry and demanded to speak to the administrator about care delivery concerns, Jen, the administrator, was already aware of the situation. She explained measures that had been initiated to improve care, and Mrs. Smith’s daughter felt reassured about how it was being handled. This confrontation could have gone differently if the DNS and administrator didn’t communicate regularly and transparently.

3. Conflict Resolution that Works

It is unrealistic to think that two people will always agree. Be prepared with a plan to overcome conflicts that will arise. It is best to disagree behind closed doors and work together toward resolution. Brainstorm options and discuss them until an agreement is reached. Sometimes, there isn’t a resolution; when that occurs, agree to disagree and move on.

Because the administrator and DNS are the two top leaders in a facility, staff watch the relationship closely. If staff observe disagreements, they may feel compelled to take sides. Don’t let conflict interfere with the facility’s mission and goals.

• Case in Point

Brenda, the administrator, and Amy, the DNS, discussed changing the uniform policy. Brenda wants nurses to wear one color uniform and nurse assistants another so patients know if the person entering the room is a nurse or assistant. Amy doesn’t agree.

Unhappy staff later question Amy about the change. Although Amy doesn’t like it, she explains the rationale fairly. Staff don’t need to know she disagreed, because it won’t change the policy, but could harm the work environment.

4. Support Each Other

There will be days when the stress level is so high that each person cannot be their normal self. Long term care has many stressful challenges, such as surveys, staffing, census, and regulatory change. When stakes are high, be a support system. Recognize when stressors are taking a toll.
Many of these challenges are unique to long term care, and no one can understand like the administrator or DNS. When things get tough, lean on each other. Occasionally, share a small token of gratitude to show you value one another.

• Case in Point

Already stressed about staffing, DNS Mike has just been told the survey team has arrived. Soon after, a surveyor asks Mike about an incident, and the conversation goes poorly. Administrator Tom recognizes that Mike’s stress level is increasing and checks on him, bringing a favorite coffee, moral support, and a sympathetic ear. This leaves Mike feeling heard, valued, and appreciated.

5. Be Goal-Getters

It’s easy to set goals, but the DNS and administrator must collaborate to achieve them. Being goal-getters requires a cohesive team. Offer to help one another with individual and mutual goals. When goals are not aligned, attainment becomes more difficult, and both parties become frustrated. However, when the two work together, goals are more easily achieved. And don’t forget to recognize and celebrate successes.

• Case in Point

Kathy, the DNS, proposes an annual goal of being deficiency-free with no complaint surveys. Bob, the administrator, recognizes that this is an ambitious goal and asks Kathy if she might want to consider a more realistic goal, such as fewer complaint surveys and two fewer deficiencies than last year.

Bob shares his census and budget goals and discusses how Kathy could help meet them. He asks her to include goals that increase the staff’s ability to care for medically complex patients, to help meet budget and census goals.

Cohesiveness in the administrator-DNS relationship has many benefits for a facility. Studies have shown that tenure of the two roles is associated with less staff turnover and lower survey deficiencies. It also enables better patient outcomes, as expectations, goals, and communication remain central to the working relationship. When both parties work together to provide the best care in a transparent manner, they can improve this critical relationship.

Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, is vice president of education and certification strategy at the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at