· Web viewInterviews will be transcribed and data coded using Microsoft word ... to 12...

1Running head: EXAMINING THE ROLE OF DIRECTOR OF NURSING

Examining the Role of Director of Nursing in Long-term Care

Stacey Johnson

Master of Science in Nursing Program

Bethel College

2Examining the Role of Director of Nursing

Abstract

The DON position within a long-term care nursing facility is a key factor in providing a

quality environment for staff and residents. Research is needed to comprehend the perceptions

of DONs regarding their role in the LTC environment. The research design for this study will be

phenomenology. Phenomenological study will allow the researcher to understand the

experiences of those working in this position. Twelve to 15 DONs working in facilities in the

Midwest will be interviewed. Interviews will be transcribed and data coded using Microsoft

word and excel. Major themes and concepts will be identified in an attempt to begin to build a

theoretical framework. The study will add to the body of knowledge needed to understand how

DONs perceive their roles in the long-term care environment.


Examining the Role of Director of Nursing in Long-term Care

Due to the baby boom generation, it is expected that the number of individuals needing

long-term care will increase to 12 million by 2020 and peak in 2030 when many of the baby

boomers turn 85 ( Redfoot & Pandya, 2002). Industry leaders must be prepared to offer high

quality services to meet increasing demands. Directors of nursing (DON) in the long-term care

environment are in a unique position to influence the quality of services provided in this setting.

DONs serve as the key nursing leader within a facility. ‘The Institute of Medicine

report on improving quality in long-term care identified nursing management and leadership as a

central factor in the provision of high quality care, especially in light of residents’ complex

nursing needs” (Siegel, Mueller, Anderson, & Dellefield, 2010, p. 111). Research supports the

importance of the DON role. Longer tenure and experience was shown to improve resident

outcomes (Anderson, Issel, & McDaniel, 2003). Staff retention including RN’s and certified

nursing assistants (CNA) was improved with stable DON leadership (McKinney & Roberdeau,

2010, Brannon, Zinn, Mor, & Davis, 2002).

“The DON job is commonly referenced as ‘impossible’ or ‘the most difficult in the

nursing home setting’” (Siegel, et al 2010, p118). DONs must manage complex regulatory and

reimbursement requirements. They must have advanced clinical skills and understand human

resource management. The Long Term Care Professional Leadership Council (2007) identified

core functions of DONs. These include knowledge of geriatric care, skills in leadership,

management, and development of nursing systems, knowledge of state and federal regulations,

and professional development.

Demographical studies of DONs indicated that the majority of registered nurses in this

key role are prepared at only a diploma or associate degree level (Mueller, 1998, Olson &


Zwygart-Stuaffacher, 2008). These programs emphasize clinical skills and do not develop

management abilities. Tellis-Nayak (2005) studied surveys done in collaboration with the

Virginia Health Care Association and MyInnerview, Inc. and found that the majority of DONs

surveyed would not choose to be a DON again or recommend the role to others. Staffing

problems were the leading cause of frustration for directors of nursing followed by burdensome

regulatory requirements and liability concerns. National turnover rates for DONs in 2007 were

as high as 38% (American Health Care Association).

DONs reported being most satisfied providing resident care and making a difference in

the lives of others (Tellis-Nayak, 2005). In a study by Thomas and Campbell (1999), 88.8% of

Dons surveyed saw their work as having a greater purpose.

Research Problem

It is clear that the DON position within a long-term care nursing facility is a key factor in

providing a quality environment for staff and residents. While there have been efforts to

improve the quality of care in the nursing home environment, the importance of the DON role

needs further evaluation. There is a need to understand the experiences, educational needs,

frustrations, and job characteristics that support nurses in this role. Research is needed to

comprehend the perceptions of DONs regarding their role in the LTC environment.

Research Purpose

The objective of the research will be to examine how DONs view their roles,

competencies, job satisfaction, and factors that support success in the role. To understand the

role from the viewpoint of nurses who are the leaders in LTC facilities will add a unique

perspective to research on the topic. The goal is to determine perception of DONs regarding

their positions.


Literature Review

The literature review will examine empirical research that has been done since 2000

regarding the role of DONs in LTC and the relationships between tenure, education, leadership,

and quality of care. A discussion of theoretical literature related to nursing leadership and

expertise will be included. Databases searched were CINAHL, EBSCOhost, and Google Scholar.

Keywords used were; director of nursing, long-term care administration, long-term care

leadership, and nursing home administration.

Discussion of Theoretical Literature

Experience and leadership ability of the DON in LTC has been shown to be a factor in

staff turnover (Brannon, Zinn, Mor, & Davis, 200; Donoghue, 2010; McKinney & Roberdeau,

2010) and resident outcomes (Anderson, Issel, & McDaniel, 2003; Krause, 2012). With

experience, DONs may develop leadership and clinical expertise that promote success in the

role.

Benner (1984) identified the stages of professional experience. She suggested that with

experience nurses transition through five levels of expertise. The novice is a beginner with no

experience and focuses on taught rules to complete tasks. The advanced beginner is the nurse

who begins to recognize recurrent experiences and uses these experiences to start to guide her

practice. The competent nurse becomes more aware of long-term goals and develops analytical

thinking. Nurses who are at the stage of proficient understand experiences in a more holistic

fashion and have learned what to expect in certain situations. Finally, expert nurses have

reached a level in which they have an intuitive understanding of the situation. They have a great

level of experience and are highly proficient in their roles.


In addition to experience, DONs need leadership abilities. Leadership can be defined by

the ability to inspire and motivate others. Characteristics of nurse leaders include

thoughtfulness, responsiveness, commitment, creativity, resilience, scholarship, courage, and

innovation (McBride et al., 2006).

The American Association of Home Services for the Aging (aahsa) (2006) developed a

framework for development of leadership skills for nurses in LTC. The 2006 report identified

the lack of adequate education in management as a reason many nurses are uncomfortable in the

leadership role. “To support, lead, and execute organizational change initiatives, nurses need to

acquire management and leadership knowledge and skills” (aahsa, p. 3). More knowledge is

needed to understand how DONs feel about their own leadership abilities and what competencies

would support their role in LTC.

Discussion of Empirical Literature

Empirical research done since 2000 regarding DONs in LTC has focused on DON

education level, tenure, quality of care, workforce retention, nursing home culture, and roles and

responsibilities. Studies done by Carroll (2001), Tellis-Nayak (2005), and Resnick, Manard,

Stone, and Castle (2009) looked at education, skills, and job tenure of DONs.

Carroll (2001) surveyed 175 senior leaders in LTC in Florida using the health care

leadership survey. The study found that leaders in LTC need similar skills to health care leaders

in other healthcare settings. The LTC leaders surveyed ranked knowledge related to clinical

practices, reimbursement, and quality management as important. Skills such as decision-making,

communication, project leadership, and human resource management were also ranked as

important. The author felt that leaders in LTC need comparable education, training, and


mentorship as leaders in other healthcare settings and that a bachelor’s degree should be the

minimum requisite.

Tellis-Nayak (2005) studied surveys of 103 DONs in Virginia. Forty percent of

respondents had associate degrees, 21% were diploma nurses, 28% had bachelor’s degrees, and

six percent had master’s degrees in nursing. About half of the DONs had been in the role for

five years or less. Only 52 % of respondents reported they would recommend the DON role to

others. Two out of three agree or strongly agree that they are frustrated with their job. DONs in

this study considered their clinical skills strong, but did not feel prepared for nonclinical

responsibilities such as managing regulatory inspections, human resource issues, liability, and

budgeting.

Resnick, et al. (2009) studied data from the 2004 nursing home survey, which included a

sample of 1500 nursing homes across the US. This study showed that only 25 % of DONs had

ten or more years of experience in the role. Thirty percent had less than one year experience at

their current facility. Only nine percent of DONs had been at their current facility for 10 or more

years. The authors identified the need to understand how variation in leadership skills affects

quality of care and work life outcomes.

Aroian, Patsdaughter, and Wyszynki (2000) and Olson and Zwygart-Stauffacher (2008)

examined DONs perceptions of their roles and responsibilities. Aroian et al. used a mail survey

of 247 DONs in New England. Activities that participants reported being most involved in

included maintaining nursing standards, implementing regulatory requirements, and promoting a

high quality work environment. DONs reported being least involved in working with the

community, influencing public policy, and assisting staff to develop career paths.


Olson and Zwygart-Stauffacher (2008) collected surveys of 460 DONs in Minnesota and

Wisconsin. In this study, 60 % of DONs had a diploma or associate degree in nursing. From

qualitative responses several themes developed. DONs reported an interest in enhanced

leadership roles, the need to be more involved with resident and family relations, and human

resource skills. The authors express the need for additional empirical studies of leadership roles

in nursing homes.

Fleming and Kayser-Jones (2008) used an ethnographic approach to study the reasons

DONs assume the leadership role. Data was obtained using interviews and extensive participant

observation. Three themes emerged from this study. First, the DONs identify themselves as

leaders. Second, that professional mentorship and administrative support affect the style of DON

leadership. Third, factors that constrain DON autonomy restrict DONs effectiveness.

Five studies focused on quality outcomes in relationship to the DON role. Zimmerman,

et al. (2002) looked at the relationship between nursing home process and resident infection and

hospitalization for infection. RN turnover was related to both the rate of infection and

hospitalization for infections. The authors identified the importance of nursing leadership in

reducing RN turnover and resident infections.

Anderson et al. (2003) studied 164 nursing homes in Texas to assess the relationship

between management practices and resident outcomes. Data was obtained for the Minimum

Data Set instrument required of all federally funded nursing homes. Primary data collection

involved a survey done by nursing home staff. The results of the study supported the hypotheses

that management practices of communication, openness, decision-making, relationship-oriented

leadership, and formalization were related to improved resident outcomes. Complexity science


was used to explain the results, which suggest that DON leadership abilities affect resident

outcomes.

Scott-Cawiezell et al. (2004) studied staff perceptions of communication and leadership

in 995 participants in three states. Respondents reported communication was the top

consideration in providing quality care. Frustrations with communication between staff and

leadership were the most frequently cited weakness. The study supported the need for strategies

to improve leadership in nursing homes.

Decker and Castle (2011) studied the relationship of job tenure of DONs and their

relationship to rates of pressure ulcers, pain, and physical restraint use. Data was obtained from

the 2004 nursing home survey. The study found that increased DON tenure was significantly

related to decreased percentages of pressure ulcers and reports of moderate to severe pain. No

correlation was found with DON tenure and restraint use. The authors discussed the need for

initiatives that focus on DON retention in LTC facilities.

Krause (2012) utilized data from the 2004 nursing home survey and quality measure from

CMS’s publically reported ratings. The study determined that longer current DON job tenure,

but not past career experience, was associated with higher quality ratings. This supports the idea

that more understanding is needed to determine what factors contribute to job satisfaction in the

DON role. When DONs stay at the same facility longer, the quality of care in that facility is

positively affected.

Only one study by Castle and Linn (2010) reported a correlation between DON turnover

and improvement in three quality indicators: depression, delirium in short-stay residents, and

pain in short stay residents. These findings were contrary to previous research finding. The


authors theorized that DONs are often replaced when quality is poor within a facility, and new

leadership may lead to a focus on improved quality.

Several studies examined how the DON role is related to the nursing home culture. Tyler

and Parker (2011) studied teamwork in 20 LTC facilities. The authors concluded that managers

of high teamwork facilities modeled positive values and attitudes through their own behaviors.

They recommended further study to determine the impact of training for leaders in LTC on

developing team-building skills.

A study by Hall, McGilton, Krejci, and Pringle (2005) used 12 focus groups and

grounded theory techniques to generate themes related to supportive supervisory behaviors in

LTC facilities. Two common themes emerged. One, that communication such as considerate

listening, praise, and role modeling were considered supportive supervisory skills. Two, that

knowledge, experience, and expertise were important factors in supportive supervisory skills.

Castle, Ferguson, and Hughes (2009) reviewed the current literature on the humanistic

component of care in nursing homes. They found that there are very few studies examining this

approach. While, they feel that managers play a key role in creating a humanistic culture in LTC

facilities, they identify a need for more research to support this theory.

Summary

Studies of DONs have shown that the role requires leadership abilities and expertise.

Although quality outcomes have been shown to be related to DON job tenure and leadership

abilities, the majority of DONs have only an associate degree or diploma school education level.

Experience in the role is lacking with a 2009 study reporting only 25 % of DONs have 10 or

more years’ experience with thirty percent have less than one year experience. It is not


surprising that two out of three report frustration with the role. Several authors have identified

the need for further research to understand strategies to support the DON in the role.

Research Question

The research question is what will nurses report about their experiences as DONs in LTC

facilities.

Research Method

Design

The research design for this study will be phenomenology. Phenomenological inquiry is

a holistic perspective that studies the phenomena or the appearance of things as experienced

(Speziale & Carpenter, 2003). Phenomenology seeks to understand phenomena from the

perspective of those who experience it. Husserl is acknowledged as the founder of

phenomenology. Cohen (1987) reported that Husserl proposed that phenomenon could not be

separated from the experience of those that live it and that the way to understand the phenomena

was through reflective descriptions in the subjects own words.

Phenomenology has become an important research method in nursing. The

philosophical underpinnings are consistent with the holistic values of nursing (Earle, 2010). This

type of research provides an opportunity for rich, descriptive data. The researcher tries to

understand phenomena from the perspective of those who experience it. The researcher must

look at the experience with an open mind, without preconceived ideas or theories (Jasper, 1994).

The phenomenological method requires the researcher to draw conclusions from the data

collected and not from judgments made by the researcher.

This study seeks to understand the experiences of DONs in the LTC environment.

Phenomenological study will allow the researcher to understand the experiences of those


working in this position. Previous researchers have mainly utilized questionnaires to understand

factors related to the DON position. A few studies have utilized focus groups to examine LTC

leadership. Using a phenomenological approach will allow us to understand more about the real

life experience of DONs from their own viewpoint.

Setting

Interview of DONs will take place in the Midwest. Interviews will take place at an

agreed upon location, near or at the facility in which the DON works. The decision on where the

setting for the study should occur should be a reciprocal process. Both the researcher and the

participant should participate in the decision (Speziale & Carpenter, 2003). The participant and

the researcher will agree on a location and time for the interview.

Sample Size

In qualitative research, the sample size is determined by the saturation point in data

collection. This is based on field notes, interview transcripts, and data analysis (Brod, Tesler, &

Christiansen, 2009). Research has shown that after 12 interviews, between 88 and 92% of

themes have been identified (Brod et al., 2009).

The sample will consist of DONs working in LTC settings in the Midwest. This will

include only skilled nursing facilities that are licensed and receive reimbursement through

Medicare and Medicaid. Directors of assisted living facilities will not be included.

Several methods will be used to find participants for the study. I will e-mail DONs

involved in Leading Age, the trade association in LTC, and the St. Joseph County Collaborative

of LTC leaders. I can also make phone calls to facilities asking the DON if there is interest in

participating in the study.


Ethical Considerations

In preparation for this study the researcher completed the National Institutes of Health

Web-based training course, “Protecting research participants” and received a certificate (see

Appendix A). IRB review will be done at Bethel College. DONs participating in the study will

take part voluntarily. Essential information regarding the study will be given to participants and

consent obtained (see Appendix B).

Data Collection

Interviews will be scheduled at the consideration of the DONs and researchers schedule.

We will allow for about two hours total for the initial interview and follow up interview.

Interviews will be recorded. Open-ended questions will be utilized as a guide for the interview

process (see Appendix C). Phenomenology requires the participants to describe the phenomena

as fully and deeply as possible (Jasper, 1993). Participants will be invited to a lunch at the end

of the study to discuss results.

A pilot interview will be conducted to assess the interview questions and allow the

researcher to practice interview skills. Interviews will be transcribed verbatim after each

interview using Microsoft word. The transcriptions and recorded interviews will be reviewed

and field notes made to record observations. Coding of data will be done using Microsoft excel

and word programs using processes described by Hahn (2008). All data collected for this

research will be given to Bethel College Department of Nursing for safekeeping and digital

storage for a period of three years.

Summary

In order to analyze the data in qualitative research, the researcher must immerse

themselves in the data. “The goal of data analysis is to illuminate the experiences of those who


have lived them by sharing the richness of lived experience and culture” (Speziale & Carpenter,

2003, p. 37). Time must be spent listening to the tapes, transcribing the tapes, and reading,

rereading, and re-listening. Through this process, the researcher will find themes and significant

statements. Major themes and concepts will be identified in an attempt to begin to build a

theoretical framework. Similar ideas will be clustered into themes. Second interviews will be

scheduled to probe ideas that need further development after the first interview. At the

completion of the study, DONs involved will be invited to lunch to discuss findings.

Discussion

The study will add to the body of knowledge needed to understand how DONs perceive

their roles in the LTC environment. Understanding factors that support nurses in this role is

important to the quality of care provided in LTC facilities. Limitations to the study are the

inexperience of the researcher related to qualitative research methods. In addition, since the

researcher is a member of the group being studied there is the possibility of bias. The

opportunity for a deeper understanding of the role is also possible.


References

American Association of Home and Services for the Aging. (2006). Scanning the field: Nursing

leadership in long-term care. Washington, DC: Institute for the Future of Aging Services.

American Health Care Association. (2008). Report of findings 2007 AHCA survey. Nursing staff

vacancy and turnover in nursing facilities. Author. Retrieved from

http://www.ahcancal.org/research-data/staffing/documents/vacancy-

turnoversurvey2007.pdf

Anderson, R.A.,Issel, M.L., & McDaniel, R.R., Jr. (2003). Nursing homes as complex adaptive

systems. Nursing Research, 52(1), 12-21.

Aroian, J.F., Patsdaughter, C.A., & Wyszynski, M.E. (2000). DONs in long-term care facilities:

Contemporary roles, current credentials, and educational needs. Nursing Economics,

18(3), 149-156.

Benner, P. (1984). From novice to expert: Excellence and power in clinical practice. Menlo

Park, CA: Addison-Wesley.

Brannon, D., Zinn, J.S., Mor, V., & Davis, J. (2002). An exploration of job, organizational, and

environmental factors associated with high and low nursing assistant turnover. The

Gerontologist, 42(2), 159-168.

Brod, M., Tesler, L., & Christensen, T.L. (2009). Qualitative research and content validity:

Developing best practices based on science and experience. Quality of Life Research, 18,

1263-1278. doi: 10.1007/s11136-009-9540-9.

Carroll, T.L. (2001). Long-term care providers’ perceptions regarding senior leadership roles.

Nursing Administration Quarterly,26(1), 83-86.

http://www.ahcancal.org/research-data/staffing/documents/vacancy-


Castle, N.G., Ferguson, J.C., & Hughes, K. (2009). Humanism in nursing homes: The impact of

top management. Journal of Health and Human Services Administration, 483-508.

Castle, N.G., & Lin, M. (2010). Top management turnover and quality in nursing homes. Health

Care Management Review, 35(2), 161-174.

Cohen, M.Z. (1987). A historical overview of the phenomenologic movement. Journal of

Nursing Scholarship, 19(1), 31-34.

Decker, F.H., & Castle, N.G. (2011). Relationship of the job tenure of nursing home top

management to the prevalence of pressure ulcers, pain, and physical restraint use. Journal

of Applied Gerontology, 30(5), 539-561. doi: 10.1177/073346481375801.

Donoghue, C. (2010). Nursing home staff turnover and retention. An analysis of national level

data. Journal of Applied Gerontology, 29(1), 89-106. doi: 10.1177/0733464809334899.

Earle, V. (2010). Phenomenology as research method or substantive metaphysics? An overview

of phenomenology’s uses in nursing. Nursing Philosophy, 11,286-296.

Fleming, M.L., & Kayser-Jones, J. (2008). Assuming the mantle of leadership. Issues and

challenges for directors of nursing. Journal of Gerontological Nursing, 34(11), 18-25.

Hahn, C. (2008). Doing qualitative research using your computer. London, England: SAGE.

Hall, L.M., McGilton, K.S., Krejci, J., Pringle, D.,Johnston, E., Fairley, L., & Brown, M. (2005).

Enhancing the quality of supportive supervisory behavior in long-term care facilities.

Journal of Nursing Administration, 35(4), 181-187.

Jasper, M.A. (1994). Issues in phenomenology for researchers of nursing. Journal of Advanced

Nursing,19, 309-314.

Krause, M.R. (2012). Director of nursing current job tenure and past experience and quality of

care in nursing homes. Health Care Management Review,37(1), 98-108.


Long Term Care Professional Leadership Council. (2007). Essential core functions: A guide for

the consultant pharmacist, director of nursing, medical director and nursing home

administrator in long term care organizations. Author. Retrieved from

http://www.nadona.org/pdfs/LTCPLC-Core.pdf

McBride, A.B., Fagin, C.M., Franklin, P.D., Huba, G.J., & Quach, L. (2006). Developing

geriatric nursing leaders via an annual leadership conference. Nursing Outlook, 54, 226-

230.

McKinney, H., & Roberdeau, S. (2010). Factors related to registered nurse retention in nursing

homes: A national perspective. ( Unpublished doctoral dissertation). University of South

Carolina, Columbia.

Mueller, C.H. (1998). LTC directors of nursing define educational needs. Nursing

Management, 29(11), 39-42.

Olson, D., & Zwygart-Stauffacher, M. ( 2008). The organizational quality frontier and essential

role of the director of nursing. Journal of Nursing Care Quality, 23(1), 11-13.

Redfoot, D.L., & Pandya, S.M. (2002). Before the boom: Trends in long-term supportive

services for older Americans with disabilities. Washington, DC: AARP.

Resnick, H.E., Manard, B., Stone, R.I., & Castle, N.G. (2009). Tenure, certification, and

education of nursing home administrators, medical directors, and directors of nursing in

for-profit and not-for-profit nursing homes: United States 2004. Journal of the American

Medical Directors Association, 10, 423-430.

Scott-Cawiezell, J., Schenkman, M., Moore, L., Vojir, C., Connolly, R., Pratt, M., & Palmer, L.

(2004). Exploring nursing home staff’s perceptions of communication and leadership to

facilitate quality improvement. Journal of Nursing Care Quality, 19(4), 242-252.

http://www.nadona.org/pdfs/LTCPLC-Core.pdf


Siegel, E.O., Mueller, C., Anderson, K.L., & Dellefield, M.E. ( 2010). The pivotal role of the

director of nursing in nursing homes. Nursing Administration Quarterly, 34(2), 110-121.

Speziale, H.J., & Carpenter, D.R. (2003). Qualitative research in nursing (3rd ed). Philadelphia,

PA: Lippincott Williams & Wilkins.

Tellis-Nayak, V. (2005, Nov/Dec). Who will care for the caregivers. Health Progress, 37-43.

Thomas, C.M., & Campbell, J.L. (1999). Issues of Concern for directors of nursing in long term

care (Master’s thesis). Retrieved from Cardinal Scholar. (LD2489.Z78 1999.T49)

Tyler, D.A., & Parker, V.A. (2011). Nursing home culture, teamwork, and culture change.

Journal of Research in Nursing, 16(1), 37-49. doi: 10.1177/1744987110366187.

Zimmerman, S., Gruber-Baldini, A.L., Hebel, J.R., Sloane, P.D., & Magaziner, J. (2002).

Nursing home facility risk factors for infection and hospitalization: importance of

registered nurse turnover, administration, and social factors. Journal of the American

Geriatric Society, 50(12), 1987-1995.


Appendix A

National Institutes of Health Certificate


Appendix B

Consent Form

Study Name: Examining the Role of Director of Nursing in Long Term Care

Investigator: Stacey Johnson R.N.Bethel CollegeSchool of Nursing1001 Bethel CircleMishawaka, IN 46556

Mrs. Johnson is a registered nurse in the MSN program at Bethel College. She is studying the perceptions of directors of nursing in long-term care regarding their roles. Although the study may not benefit you directly, it will provide information that might help regulatory bodies, corporations, and governmental agencies understand the needs of directors of nursing.

The study and its procedures have been approved by the appropriate people and institutional review board at Bethel College in Mishawaka, IN. The study may cause a minor inconvenience to you related to the time involved in the interview process. The procedure includes three interviews. The first interview will take approximately one hour. The second interview could take up to an hour. The third meeting will be a lunch meeting to discuss results of the study. You are free to ask any question about the study or about being a subject and you may call Mrs. Johnson at 574-229-3354 or email [email protected] if you have any further questions. You may also contact Dr. Karon Schwartz PhD MS RN CNE Graduate Nursing Program Director and Research mentor at 574-257-3382 or email [email protected].

Your participation in the study is voluntary; you are under no obligation to participate. You have the right to withdraw at any time. At the end of the study, you will be asked to attend a lunch meeting to discuss results of the study. You will not receive any other payment or compensation for participating in the study.

The study data will be coded so that it will not be linked to your name. Your identity will not be revealed while the study is being conducted or when the study is reported or published. All study data will be collected by Mrs. Johnson, stored at a secure place, and not shared with any other person without your permission.

mailto:[email protected]


I have read this consent form and voluntarily consent to participate in this study.

Participant’s Signature Date

I have explained this study to the above subject and to have sought his/her understanding for informed consent.

Investigator’s Signature Date

I have received a copy of the consent form.

Participant’s Signature Date


Appendix C

Potential Questions to Guide the Interview Process

1. Share with me your experience of being a DON.

2. In retrospect, what would you have liked to have known before you accepted the position?

3. What thing were the most helpful in your socialization into the role?

4. Share with me your motivation for continuing in the role.

· Web viewInterviews will be transcribed and data coded using Microsoft word ... to 12...

Documents

Transcript of · Web viewInterviews will be transcribed and data coded using Microsoft word ... to 12...