Why Nurse Leaders Matter: DON Turnover Linked to Nursing Home Quality Declines

As frontline nurses, you know that consistent leadership matters. But what happens when the person responsible for overseeing nursing staff—the Director of Nursing (DON)—leaves?

It turns out, DON turnover has a significant impact on nursing home quality, with new evidence showing that frequent changes in this vital leadership role lead to lower star ratings and reduced consumer satisfaction scores.

Key Findings: DON Turnover and Quality Measures

A recent study published in the Journal of the American Medical Directors Association found that DON turnover is reliably linked to subpar outcomes. Researchers analyzed data from nursing homes across Ohio—merging staffing records, satisfaction surveys, and CMS star ratings—to explore how turnover among DONs compared to turnover among Nursing Home Administrators (NHAs) impacts care quality.

Key findings include:

• 5-star ratings dropped by 2.9% - 11.5% points in facilities experiencing DON turnover.
• Consumer satisfaction fell by 0.4% - 1.5%  points.
• While NHA turnover also affected quality, its impact was much diminished once DON turnover was taken into account.

In essence, DON turnover had a more pronounced and consistent negative effect on both objective quality metrics and resident and family experience.

Why DON Stability Matters

The DON not only sets the tone for clinical care and compliance but also drives the day-to-day culture and communication within the nursing team. Turnover in this position leads to instability and impacts resident care by:

• Decreasing staff engagement and the consistency of protocols.
• Disrupting resident-staff relationships, leading to lower satisfaction.
• Undermining regulatory compliance and increasing the risk of deficiencies.
• Creating communication gaps across the interdisciplinary care team.

These effects are amplified by studies showing that every increase in nursing turnover can result in more regulatory citations, poorer health outcomes, and reduced continuity of care.

Call for Change: Accountability Is Needed

Currently, the Centers for Medicare & Medicaid Services (CMS) only reports DON turnover as part of overall staff or registered nurse turnover rates. Researchers and advocates urge CMS to make DON turnover a standalone measure—not just a footnote in staffing data—so that nursing homes are held accountable for leadership stability and transparent performance tracking.

Takeaway for Nurses and Facilities

For bedside nurses, this study reinforces how leadership changes can ripple through the work environment, affecting care delivery and morale. For administrators and policymakers, the push for improved reporting and retention strategies is clear: stable DON leadership means better outcomes for residents, families, and staff.

Facility teams and nurse leaders can advocate for:

• Measuring DON turnover explicitly in quality metrics.
• Investing in development, well-being, and retention for DONs.
• Engaging nursing staff in leadership transitions to preserve team culture.

DON turnover isn’t just an administrative issue—it’s a clinical one. The departure of a DON is linked to measurable declines in quality ratings and resident satisfaction. As nurses, your voice matters: advocating for leadership stability is an act of advocacy not just for yourselves, but for every resident entrusted to your care.

By emphasizing DON retention—through recognition, support, and leadership development—we can help ensure continuity, safety, and dignity for residents—and make our workplaces stronger from the top down.

🤔 Nurses, what do you think about this new research? Share your thoughts in the discussion forum below.