LTC 101: What To Expect

**VivaLasViejas**, ASN, RN

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 door frames 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.