High turnover in LTAC's? - page 2

by nursingilove

12,895 Visits | 43 Comments

I was wondering if there is a high turnover in long term actue care and if so why?... Read More


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    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
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    @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.
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    staff
    Esme12 likes this.
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    ESME12,
    Thank you for explaining that. I understand much better.
    Esme12 likes this.
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    This is still a thread about LTAC's Long Term Acute care. A TOTALLY different entity from LTC Long term care. These patients are sick. These nurses have a highly developed sense of critical thinking. These facilities have intensive care units, telemetry units, and have minor surgical procedures performed at these facilities as well.

    Nurses/hospitals in general need to become better informed about the LTAC culture/environment for this is a growing industry as healthcare moves forward. These are acute care patients with long term complications. These nurses care for acutely ill, multiple complication patients. These patients are considered "heavy patients" at the acute care hospital. Here you have an entire facility full of these "heavy patients". I took the job as a supervisor at an LTAC to help out a friend....besides how hard could a nursing home be?

    Boy was I wrong!!!!! I was schooled pretty quicly that I needed an education myself.

    OP......You will work very hard. You will learn a TON!!!! The turn over is so great becasue it's a tough job.....these patients are sick. They are short staffed. Burn out is high. But these facilities are willing to teach you and train you. Learn what you can from them.
    Last edit by Esme12 on Aug 5, '12
    BuckyBadgerRN likes this.
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    @Esme12: I was responding to a post from CapeCodMermaid. I realized a couple posts back that LTAC is totally different from LTC. I even said this as well a couple posts back. I do not see you "scolding" CapeCodMermaid about posting about LTC. I do not plan on posting anything else on this thread.
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    Quote from Kasandra
    @Esme12: I was responding to a post from Cape Cod Mermaid. I realized a couple posts back that LTAC is totally different from LTC. I even said this as well a couple posts back. I do not see you "scolding" Cape Cod Mermaid about posting about LTC. I do not plan on posting anything else on this thread.
    I am not scolding....I will remove quoting you for maybe that helped in your thinking I was scolding you. I am just clarifying for there is a misconception,by many, about the LTAC. I was one as well. I sincerely apologize if you felt I was scolding for that is Never my intention.

    I wish you the best.
    BuckyBadgerRN likes this.
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    @Esme12: No worries. I apologize if I came off snippity. I realize that what I have written in inappropriate, really, for this thread. However, I was stating my position on nursing which does differ somewhat from CapeCodMermaid's. I did not know what LTAC was until I read this thread. I am glad to have stumbled across it. I did not know that such places existed outside of the hospital. Ok: Now I will stop posting on this thread! I did not want to leave you hanging, Esme12!
    Esme12 likes this.
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    Quote from Kasandra
    @Esme12: No worries. I apologize if I came off snippity. I realize that what I have written in inappropriate, really, for this thread. However, I was stating my position on nursing which does differ somewhat from CapeCodMermaid's. I did not know what LTAC was until I read this thread. I am glad to have stumbled across it. I did not know that such places existed outside of the hospital. Ok: Now I will stop posting on this thread! I did not want to leave you hanging, Esme12!
    ...all good
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    I think Cape Cod Mermaid's point was that in LTC we have far less support than nurses in acute settings. As someone who worked in a hospital and now in a nursing home, I agree. We have to rely more on our assessments than hospital nurses do. A hospital nurse can get blood work, ABG, UA, xray, respiratory therapist or even a phys/PA assessment very quickly. In LTC not so much. All the "diagnostic" tools we have at our disposal are a vitals machine a glucometer and maybe a bladder scaner.

    We are actually much more independent in our practice than our hospital counterparts. Our jobs don't revolve as much around following the doctors orders. We have FAR more standing orders, based solely on nursing judgement. It amazes me that a hospital RN can't give Tylenol to a febrile pt w/o calling a dr first. Where I work a RN can even initiate IV fluids on a resident who's clearly dehydrated per standing order.


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