After striving and thriving for 10 years in a position with the highest turnover rate in nursing, Kathy Bertram, RN, joined the exodus in August and refocused her management career to assisted living.

Surprisingly, her position as health services director at the first assisted and independent living community in Omaha, Neb., allows her more patient contact than in all her years as a director of nursing in long-term care facilities.

"I started a wellness clinic that I hold once a month," in which residents of Remington Heights Retirement Community, a 142-unit facility-64 of them assisted living-can bring up medical concerns and live with the security that if they have a health issue, care is at hand.

"I've actually found quite a few who have significant health care problems that weren't being addressed, such as diabetes or hypertension that was extremely high, and they weren't even aware of it," Bertram said.

A 2002 American Health Care Association survey of 6,155 nursing homes found a 49.7 percent turnover rate among long-term care directors of nursing, up from 46.6 percent in 2001. The turnover rate was about 1 percent higher than for staff nurses, and was surpassed among health care providers only by certified nursing assistants, with a 71.1 percent turnover rate.

Bertram's experience in 10 years as a nurse manager is a window to the future for RNs with managerial aspirations, and it makes the turnover rate among long-term care directors of nursing comprehensible.

"You have to dedicate almost your entire life to your career, your staff, your residents," Bertram said. "You're basically on call 24 hours, seven days a week in long-term care. They don't care at 3 o'clock in the morning that you were sleeping. If they need you, they need you and they will call. It wasn't unusual for me to get 40 phone calls on a weekend," she said, to deal with resident and staffing issues.

She said that much of what she learned was by trial and error because nursing school-at least short of an advanced degree-prepares clinicians, not managers. By networking with other directors of nursing, Bertram said she came to appreciate the nonclinical aspects, such as staff morale and an open-door policy.

"You have to do little things for your staff all the time-little morale boosters, little rewards, pats on the back, praises," she said. "You have to show that you appreciate them because if you don't, they'll find someplace that will.

"There's always an opportunity for them," she said. "I've had people who have come to work for me who have taken less pay just because they didn't feel they were appreciated where they were before."

Directors of nursing and RNs with administrative duties are paid more than staff RNs, but salary is the wrong reason to aspire to management, Bertram said. "You have to have a big shoulder. At times, you feel like a counselor. You want to be the person that all of the nurses or nursing staff can come to. They will come to you with every problem from A to Z and if you don't want to listen to their personal problems as well as their work-related problems, then that is not for you."

Bertram said managers have to be secure that they are fulfilling a nursing role, even though they are not starting IVs, doing wound care and administering medication. "If you can't laugh and share funny times and good times with your residents and with your staff, then you're not what nursing is all about," she said.

In the assisted living environment, personnel matters are not as acute, Bertram said, but other responsibilities, such as ensuring compliance with state and federal regulations, are the same.

"You have to be there for someone if they are ill and you have to have the state regulations memorized from the beginning to the end of the book. You're responsible for all those nurses and their jobs and what they're doing," she said. "If they're not doing their job right, they're not going to be the one losing their job. It will be the management person."

With an aging population, Bertram said the trend is toward a continuum of care. "A lot of our people are starting to need more services just because they've been here for 10 or 14 years," she said. Residents who need to move beyond assisted living are referred to a nursing home in Omaha, often in Remington Heights' sister company, Life Care Centers of America, she said.

Among the things Bertram brought out of long-term care is an absolute commitment to dying patients. It goes back to her first week as a director of nursing and the first resident to die on her watch. Through the years, the experience has become the foundation for a final-moments-of-life book that Bertram has in the works.

The 90-year-old man didn't have family. "As I sat with him, I realized that nursing wasn't going to be just caring for those that are sick, helping bring babies into the world, or bandaging a wound. We need to step in if families cannot be there during their end-of-life process. As caregivers, we are also their extended families," Bertram said.

At the man's request, she was reading the Bible to him, she said, and with his last breath his eyes opened and "he looked right through me as if I were not even there. But he was looking at something wonderful, and he was at peace."

"I learned that although the nursing foundation can be placed by your college degree, it is the people you care for and the experiences and lessons that you learn that make the difference between an OK nurse and a great nurse."