High turnover in LTAC's?

Kasandra · Aug 3, 2012

Are you new to nursing? If so, I would recommend against starting out in LTC. This is why: I have been a nurse for two years. I spent most of that time on the floor in the hospital setting before switching things up with LTC. This is what I have seen:

I have encountered the predominant majority of RNs and LPNs in LTC not to be critical thinkers. They do not know the vitals for their residents before administering b/p meds, do not assess, and even give meds they have no idea about because "they are too busy". The month that I did LTC, I had within one week two people that I had to send out when I assumed my shift at 2200: One which was hypotensive with a 80s systolic with frequent liquid diarrhea and emesis and another g.i. bleeder with three large, tarry stools that showed the classic presenting s/s of a g.i. bleeder. For the exception of my assessments, no one had assessed these two. On the former, no one had taken vitals on her since January of this year. I, however, took vitals on those people who did not appear well or who were on any cardiac meds because that is a safe standard of care. For the latter, while getting report on my 36 residents, the LPN happened to mention one tarry stool. No mention of an assessment of the resident. She said she had called the PCP, informed him of the one bm, and was told to do a H&H on the resident the following day. When I spoke with the CNAs from the LPN's offgoing shift, I was told that the resident had three large, tarry bm's. I always assess first, and noted all the textbook s/s of a g/i. bleeder. Regardless, I was sending both residents out.

Lack of supplies is another issue. You will run out of things important for the nursing care you provide.

No training. In the hospital, you will receive never ending training. In LTC (at least where I was), training was non-existent. There was a high turnover. A RN was usually there from a couple days to 2 weeks at the most because of the bad care environment. I was an overachiever: I was there for a month, and am going back to the hospital to stay with a new job.

Another thing that I detested: Paper charting. Too much paperwork! Double, quadruple charting for the same thing. Just ridiculous.

To their credit, I did work with a couple good RNs and LPNs. However, out of the entire staff, I could only say this of 3 of my colleagues who were on point with their nursing care. The rest: not so much.

In a hospital, you will see muliple pathophysiologies. You will grow so much as a nurse. In LTC, you take care of the same people every day who, for the most part, take the same meds every day. You do not develop your critical thinking as well as what you would in a hosptial.

For those nurses in LTC: I do not mean to insult your profession. After a month of full time experience in a LTC, this is what I saw and what I know. If you can provide another point of view, please do. I, however, would not recommend any new nurse to go to LTC. However, if the new nurse really wants LTC, at least get some hospital experience so that you know your abnormal assessments so that you can get the residents help when they need it. :twocents:

BrandonLPN, LPN · Aug 3, 2012

LTAC is completely different from LTC. I would imagine LTACs have a high turnover because they deal with almost ICU level acuities mixed with med surg level ratios. And WAY less support. Many pts go straight from the ICU to a LTAC simply because their insurance ran out. Not because they are any less sick.

Kasandra · Aug 3, 2012

@Brandon: Thanks for the clarification! I totally thought this post was about LTC. Oh well. Anyone who was wondering about LTC: Maybe my post will be of some help to them. Who knows! :rolleyes:

Esme12, ASN, BSN, RN · Aug 3, 2012

Kassandra.....The contribution is always appreciated.

The LTAC has a big turn over rate for a lot of the same reasons but these facilities have an extremely high acuity. They are the sickest of the sick population in acute care that have failed to wean from vents or have had very complicated medically complex recoveries. These patients are too sick for LTC and home and have run out of hospital days/funding. Patients can be transferred from INtensive care units with vents, lines and drips. But the staffing is not as plentiful as acute care even though these patients are acute care patients.

Marginal staffing for acuity and adequate pay. These forprofit companies usually have marginal supplies as well.

There have been a few threads about this......... Google Search Results for LTAC esme12

https://allnurses.com/massachusetts-nursing/new-rn-grad-747659.html

BrandonLPN, LPN · Aug 4, 2012

@Brandon: Thanks for the clarification! I totally thought this post was about LTC. Oh well. Anyone who was wondering about LTC: Maybe my post will be of some help to them. Who knows!

Don't worry about it. Very similar acronyms. The pluses of working in a LTAC are that they readily hire new grads, you would learn a lot and the pay is better than the hospitals. (from my research, I've never actually worked in one). I also think it will be a wave of the future. Hospitals just don't keep inpatients as long as they used to. I'd be interested to see LTAC get it's own page here. It doesn't really fit with LTC or ICU pages.....

serenidad2004 · Aug 4, 2012

I spent the first 9yrs of my nursing career in LTC/skilled... I cant speak for all LTC facilities obviously but I can tell you that I used my critical thinking skills everyday. I imagine it is up to the individual nurse how they practice. I learned more about prioritizing care and time management than I ever could of in a hospital setting.

My props to you for actually trying out LTC to see how hard it actually is. Every time I sent one of my patients to acute I was talked to as if I was incompetent. I dont think acute care nurses actually know what goes on in LTC.

I now work in dialysis, having left LTC because I was growing tired of the "do more with less" attitude . I wish more acute care nurses would come work in LTC, and see exactly what we do.

nursingilove · Aug 4, 2012

Thank you for your replies, the feedback I'm getting is that you can't go wrong with the experience you get.

Esme12, ASN, BSN, RN · Aug 4, 2012

Are you asking from becoming a DON/ADON? or staff?

CapeCodMermaid, RN · Aug 4, 2012

Wow...I got NO orientation or mentoring or anything else when I was a new nurse working in the hospital. And there wasn't much need for most nurses there to think at all since the place was crawling with doctors. In LTC, it's you and your fellow nurses, and most of us have highly developed critical thinking skills.

Esme12, ASN, BSN, RN · Aug 4, 2012

Just to clarify......this is Long Term Acute Care. These are hospital patients that have "run out of days". The are vented, have complex ACTIVE medical problems. You will see HALO traction, vents, complex wounds, chest tubes, feed tubes, drain tubes. The hospitals that have BUs will have vents, multiple lines, including invasive monitoring PA lines (Swan Ganz) art lines with active interventions. They have telemetry floors that will have post open heart patients that have complicated post op courses. As a supervisor, I have seen some amazing stuff get transferred through the LTAC door. LTACS are licensed as acute care facilities and usually will perform same day surgery stuff like GOD's, Tube feeding insertion and trachea.

These patients will be actively treated with staff MD's that are in house (most of the time) The goal is to wean and discharge to LTC/Skilled or home with services.

The problem with LTAC is the acuity. These facilities get all these medically complex patients from several facilities and house them in one place. They are not reimbursed as acute care and there has been some progress towards a middle tier reimbursement that is higher than LTC/skilled but lower than acute care. These patients have labs and can receive transfusions. They will have insulin gtts.......but you will have several because they are now all under one roof from the multiple facilities.

They will train new grads. Their training is usually longer than usual, for a new grad, they will invest time and money on training. But.....staffing is not all that great. Burn out is very high. They historically run a very tight ship supplies wise and have very frugal budgets. This burns nurses out quickly.

Working at a a LTAC will give any nurse experience beyond belief. Unfortunately.....Hospitals still view them as "nursing homes" due to their lack of understanding of what an LTAC is....even though they send the patients they failed to get home. So a nurse who has worked at an LTAC has more selling to do about her experience than other nurses in acute care.

It is worth the effort and training ....IMHO

Kasandra · Aug 4, 2012

@CapeCodMermaid: I understand why what I wrote must have put you in a "defensive" mode. What I wrote was not meant to be hurtful towards any of the nurses that do LTC. It is, however, my objective experience. Although I apologize for offending you, or any other proud LTC nurses, it is my experience.

As far as what you said:

"And there wasn't much need for most nurses there (at the hospital) to think at all since the place was crawling with doctors. In LTC, it's you and your fellow nurses, and most of us have highly developed critical thinking skills."

If you had invested any significant amount of time in a hospital on the floor, you would realize that it is the bedside nurse, not so much the doctors, that know about the patients. The nurse is asked by the physician specific questions about the patients under her care in order for the best care to be given. Doctors are simply not there enough. They may spend a couple minutes (if that) with the patient while the nurse is there the whole 12 hours. Hospital nurses deal with unstable patients: that is why they are in the hospital in the first place: for both monitoring and treatment. If they were not predisposed to a decline in health status, they would not be inpatients in the first place. The hospital nurse collaborates with the physicians to address any aspect of the patient's care. In a nutshell, hospital nurses always "have a need to think" because people's lives can depend on it.

In contrast, LTC nurses can help or harm with their nursing practice as well. However, as we both know, LTC is not at all like the hospital. I already summed up most of my thoughts on my experience in LTC. I still stand by my position that a new grad needs to develop critical thinking which is achieved by learning what "normals" and "abnormals" are regarding their assessments. Yes, in LTC, a nurse cares for more people. This is the residents' home. They are stable. However, when their health status changes for the worse, it is the nurse's job to assess, and inform, the PCP of these changes. This was not happening at that facility.

I cared for all of the residents under my charge with the standards of care learned in the hospital setting. Also: They do not orient in the LTC like they do in the hospital. A new grad gets two weeks. An experienced nurse may get a day up to one week of orientation. In the hospital, a new grad gets up to 3 months training on the floor in addition to class training. An experienced nurse orients for a month.

I can only speak according to my experience. It was quite the eye opener. I shall leave it at that in an effort to keep what I am writing classy and not disrespectful.

What you said in your post was not objective: it was (is) your subjective opinion on hospital nurses. In contrast, my post was an objective post about LTC nursing. I did not even delve into half of what I saw (or heard) which was incongruent with safe nursing practice. With unsafe nursing practices, I stopped care at the bedside to protect the resident. With those many instances that were brought to my attention by another nurse, I told them to follow up first with the nurse and then management if necessary; otherwise, they would be just as guilty as the nurse who put their residents at risk by not following established nursing protocols (example: a nurse suctioning a trach with a dirty suction kit which had been stored in the resident's night stand or allowing the new grad to open the red container with sputum from the lower respiratory tract (from suctioning), emptying it at a sink or commode, because another LTC nurse told her that this was acceptable: putting herself and other people at risk of inhaling the contents). I can keep going but believe that I have made my point.

Like you, I am entitled to my opinion. I have respectfully stated it. I stand by my position. I respect your opinion even though I may not agree with you.