LTC 101: What To Expect
Here is a brief guide for new LTC nurses as to what they can expect from their jobs. Included are the good, the bad, and the ugly aspects of working in this specialty. I hope it will be helpful to both new grads and nurses who are changing fields. Welcome to LTC!
Not every long-term care nurse chooses LTC as a profession. Sometimes, it chooses us.
But no matter how you've arrived at your first job in a nursing facility, there are challenges awaiting you that you didn't anticipate, especially if you're coming from acute care or another environment where even chaotic conditions have some form of logic to them. Here are a few things you should expect as a new long-term care nurse:
Expect to chase after supplies.
I have never worked in a nursing home where they kept everything in one place. You'd think they would put all the catheter supplies together, but no---whenever I had to change a catheter, I had to go to three different storage areas to obtain the necessary items. Even house stock meds were kept in different cabinets: vitamins and supplements at the nurse's station, OTC pain relievers and bowel care meds in the medical records office. I never did understand the reasoning behind this, so I lobbied administration to change the layout of the supply closets so we didn't have to waste time running all over the facility. Of course, they never did.
Expect to become the nursing version of McGyver.
LTC nurses need to be creative in order to solve the problems that frequently arise in a facility which always seems to be short of supplies and slow to make necessary repairs. You'll use washcloths or foam pipe insulation to wrap around the arms of wheelchairs when the vinyl gets torn up and causes skin tears. You'll utilize foam tape to "Nerf" splintered doorframes and the sharp corners of nightstands to prevent injury. Sometimes you may even have to use a Foley catheters as a G-tube because nobody ever remembers to order the insertion kits.
Expect to be challenged by a wide variety of situations.
Contrary to popular opinion, LTC is NOT boring. Yes, you will have routine tasks such as med passes and fingersticks on your 17 diabetics, but no two days are the same, especially if you work on a skilled unit, which is like a hospital only without the staffing and the equipment. Unfortunately, SNF patients are sometimes transported from the hospital in unstable condition---in fact, I've sent patients right back to the hospital without allowing them to be transferred from the stretcher. But even on the custodial care unit, you'll deal with a host of problems: falls, dementia, hovercraft families, scabies outbreaks, diabetic crises, psychiatric issues, and fights between residents.....to name a few.
Expect to become a diplomat.
It is difficult to hold your tongue when a resident's family member chews you out for the umpteenth time today because "Mom" isn't drinking enough fluids or eating enough or getting out of bed every day or having her 20-minute dental routine followed to the letter. It is beyond tempting to tell them to take her home with them if they feel they can take better care of her. But as you become more experienced, you learn how to let their constant complaints and demands roll off your back, and how to de-escalate a crisis situation by "killing them with kindness".
Expect to be looked down upon by other healthcare professionals; but remember, you are the expert on your residents.
Regrettably, long-term care is still regarded as the bottom of the barrel by many nurses in other specialties, as well as administrators, doctors, therapists, and even EMTs. I can't count the number of times I called the ER to give report on a resident I was sending out and was asked if I'd taken vitals! It's as if they think LTC nurses don't have the sense to do the basics before calling in the cavalry. And if I had a dollar for every time I tangled with EMTs over their reluctance to transport a resident because of insurance issues or "she looks OK to me", I'd be a rich woman today. But there is no need to let the idiots get you down.....when it comes to your people, YOU know best.
Expect to be chronically understaffed.
This is an issue everywhere, even in the best facilities. Granted, you can have days when there could be 15 staff on the floor for 30 residents and it still wouldn't be enough, but even on a good 3-11 shift, 3 CNAs and one nurse for those same 30 residents is pathetic. And when you complain, the general response will more than likely be "Suck it up, Buttercup" and that you should be grateful because XYZ Nursing Home's staffing is better than what the state requires.
Expect to fall in love.
LTC nurses don't do what we do for the money (it's also one of the most poorly paid specialties). We do it because we find so much to love in the wizened faces of our elderly, the funny things they say, the way they hold our hands in a tender moment. No matter how demented or ill, they will provide you with wisdom gleaned from their eight or nine decades of life, as well as a million and one laughs! I'll never forget the resident who once asked me, when I knocked over a couple of Jevity cans in the next cubicle, if I was the cat. Knowing that despite her dementia she had a wicked sense of humor, I said, "Yes, Elaine. MEOW!" To which she replied, "Oh, OK, thanks for letting me know," and promptly went back to sleep.
The hardest part of these special relationships is that sooner or later, your residents will break your heart by leaving you.....and every loss will change you. Some deaths will hit you harder than others, but eventually you'll learn that good-byes are not always the worst thing that can happen.Last edit by Joe V on Nov 4, '16
About VivaLasViejas, ASN, RN Guide
Joined: Sep '02; Posts: 26,727; Likes: 43,504
RN and blogger extraordinaire; from OR , US
Specialty: 20 year(s) of experience in LTC, assisted living, geriatrics, psychJul 15, '14Excellent writing. From this side of the computer screen, at least, it looks like your residents are lucky to have such a smart and caring nurse. Thank you.Jul 16, '14May GOD continue to bless your patients with your presence. Just curious. Do LTC's ever accept volunteer nurse/EMT's?Jul 16, '14Many nurses will end up LTC by default-Some hospitals are downsizing and others require acute care experience, which we all know we can't get unless someone hires us. Nurse residencies, while a good idea, only offer a few slots for a select few. It is usually the person who knows someone who gets the few available slots. Unfortunately, LTC can be a dead end where nurses are stuck because even after all the work done in LTC, acute care hospitals can't see the parallel in work so people become stuck in LTC. Frankly, I'd rather deal with the elderly than a maternity patient at one of our "boutique" hospitals! I think that everyone should have to be exposed to LTC as a student. As for me, I went back to get my BSN but now I need acute care experience which I can't get ( even home care requires it) so I'll be lucky if I can find a job in LTC.Jul 16, '14Reading this well-written article was like having a popsicle on a hot summer day. Delicious!
It's not easy being the Rodney Dangerfield of healthcare while you're doing the work of an action hero. You get an "amen!" for what you said about hovercraft families and a heartfelt "thank you" for your words on the subject. You'll be helping me the next time I'm dealing with the wife who always puts her chair next to my knee when I'm positioning for a two-person transfer of her husband up in the bed or... Nope, not even going to list the ways families make my job 30 times more difficult, just going to focus on how I can kill them with kindness.
Thank you for helping your residents on the job and your colleagues on Allnurses. Stay strong, we need you!
Jul 16, '14I LOVE, LOVE this . I'm a LTC Nurse started out as an STNA for 19yrs, Nurse for 6yrs I could not have said it any better. Kudos to youJul 16, '14I have worked LTC for 29 years. A few times I have tried to get out of the LTC grind-house, by trying to get into Acute Care hospitals or Home Health. Each time you meet the same barrier - many do not see or accept the experience and years put in doing long term care. For a lot of the Nursing/Medical employment LTC is looked down upon.
A typical day/shift has the nurse coming into the building already *Drowning* lately. You either have work thrown on the next shift by the prior shift, or by the Nursing Managers, or simply because the day itself has been a mad house. Lately it is the 2nd shift ( 2-10pm or 3 -11pm) that can get hair pulling crazy. Yet - understand, this is only via my personal experience. On the evening shift you get Admissions which can come in any time during your shift - up to the time your shift ends, you have doctors/FNPs coming in during the evening and writing orders, you have family members underfoot. Then you also have the support leaving you after 5 -6pm ( ie; Managers, etc). Some will see their staff struggling and stay alittle longer to aid you if able. Sadly though many notice and just walk right out the door.
Toward family members many are actually very nice and caring toward the LTC staff. Still it is the one or two that come in, believing NOTHING you do is good enough, that can break the work day. And though you want to just tell them to take their family member home sometimes inside....you put on that warm caring smile, bite your tongue and again try to appease that family.
Then in the past several years you notice CNAs you are getting want the paycheck but try to do as little as possible, so you have to play Warden....having to chase them continually to get things done. Then you have Managers telling the nurse "You need to really stay on top of your aides," when you are already doing the best you can.
When you finally get done at the end of your shift, a day that was so busy you could not take a break, had to sign out for supper but had work through it to get done on time, you now have to wait on your relief nurse. It is now 30 minutes after your end time, no call or anything, and your relief saunters in late habitually. So you know the next day you will get called in to the office for working late because at your facility *There is NO excuse for working late accepted*.
And at least where I work LTC.....this is considered a GOOD day ( LOL).Jul 16, '14Yep, sounds familiar! I finally burned out last year and got out of clinical nursing entirely, took a job as a state surveyor and fell flat on my face. I'm not even looking for nursing jobs anymore.....it's all just too much for me now. I admire those who can stay in ANY type of nursing for as long as many of you have.Jul 16, '14These are spot on!!!!!!! I worked in LTC for 5 years and loved every bit of the craziness and fell in love with the residents. Just like every dept in nursing...you'll either love it, or hate it!Jul 16, '14I just started as a cna in a LTC even though I have graduated from an RN program this June. I need the money to pay for my last semester to be cleared to the the nclex and pay for my exam from working here so I'll be taking my nclex in September or October god willing. I'm really scared about working there because I don't know what to expect but I hope it's not like what I've been hearing from others. I appreciate your article because it gives me hope :-)
Thank you!!!Jul 17, '14Thank you for a very enlightening article! I am trying to re-enter the clinical workforce, after working non-clinical nursing jobs for nearly 18 years - and am having to really think about the type of clinical setting I want to be working in. I envision working with the elderly, but not sure if I have what it takes for LTC. Rehab, maybe?Jul 17, '14I hate to break it to you like this, but rehab/skilled nursing is MUCH more intense overall than LTC. In a skilled unit (SNF), you have a lot of really sick people who are basically sub-acute---fresh post-op CABGs, hip and knee surgeries, trachs/vents, people who need IVs, diabetic care and teaching, serious wounds, even some psych and a lot of dementia. You will never be bored if you go this route, but be aware that it's like the hospital, only with fewer staff and resources. It's not unusual for one nurse to be responsible for 30-35 SNF patients, and you might get 5 aides on day shift if you're lucky, plus a med/treatment nurse or med aide.
Personally, SNF is not the way I would choose to re-enter clinical nursing after so long away. If you do, though, just be prepared to be overwhelmed for awhile. I worked as a med nurse for a while and ran my rear end off, but I at least got breaks; the poor charge nurse never even sat down until the end of the shift, and that was only to chart and give report. I wouldn't have traded jobs with him for anything.
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