High turnover in LTAC's? - page 4
by nursingilove 15,150 Views | 43 Comments
I was wondering if there is a high turnover in long term actue care and if so why?... Read More
- 3Dec 12, '12 by RNikkiFQuote from KasandraSounds like you work in Long Term Care (read: Nursing Home). Long Term Acute Care (LTAC)is very very different from that. LTACs handle the same diagnoses as "standard" acute care hospitals, but for longer amounts of time. Pts at LTACs generally would be ICU/SICU/MICU/IMCU pts at traditional hospitals, but d/t CMS, they no longer qualify for care in that setting, or they continue to need intense care, but are generally stable so they no longer qualify for an ICU type setting in a traditional hospital.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.
We see dialysis, vents (a LOT), complex wounds (a LOT), peritoneal dialysis, continuous bladder irrigation, TBI/ABI, cardiac issues, uncontrolled DM, bariatric care, post S/P pts, post CABG, cancer and end of life patients just to name a few. These patients are VERY VERY sick for the most part. We provide nursing care in the same manner as nurses in standard hospitals.
The facility where I work seems to have ebbs and flows of high turn-over. Mostly it is because of management practices. All of the nurses that I have spoken to (including myself) love the level of care and the types of patients and challenges that we see.
I started my first nursing job at a prison (ACK!) and when I moved, I went to LTAC, so I had never been in a traditional hospital setting. 6 months ago, I decided to give it a try on an Oncology ward... 3 months is all it took for me to know it wasn't for me, and I am now back at LTAC. In LTACs, you get to KNOW your patients... not just their diagnoses. It gives you a more complete picture of their true needs and you're able to more quickly spot any changes.
You have FAR fewer resources. No RRT on standby, MDs not in house 24/7 (although my facility will be hiring 4 in house hospitalists as of Jan 1... we will see how it goes). You have to be able to think on your feet and rely heavily on the experience of those around you as well. You can't operate in a vacuum.
LTAC is not for everyone, but I feel that in LTAC, even though the pace gets HECTIC, I feel that I have the opportunity to provide better overall, person-centered care.
The politics are infuriating, and the governing boards are CHEAP, and yes, there's even some backstabbing among staff, but those things are everywhere. You have to be on your toes at all times.
Bottom line... LTAC is okay for newer nurses IF you find a mentor and ask a lot of questions. Don't assume you know everything. That's a quick way to get yourself or a patient in trouble in LTAC.
- 0Dec 12, '12 by bioniclewomanI don't feel like there is a high turn over in my LTAC. With night nurses maybe, seems like we hire alot of night nureses. Turn over for day nurses is pretty low. The ones that do leave are new grads that get experince, and then move on to something else. We have our group of CNAs that have been around for a long time, and a handful that keep coming and going, but I think that is pretty normal. RTs have had zero turn over since I've been around. Charge nurses and administration has a very low turnover too. Unit secretary is a revolving door, and so is case management.
- 0Wow; that many patients in LTAC the poster that said ten to fifteen? No way in world would I receive a patient load every day I work as such in LTAC.
When I worked LTAC, our ratio was 1:4 with charge not taking an assignment. The thing that made we walk away was one night many call ins and we had nine or ten apiece. Prayed my way through that entire shift and never looked back. I was PRN, but worked full time hours, so never gave anymore days and went on to full time management in LTC.
No, LTC and LATC are not actually the same but let me tell you that the residents in LTC are more sicker than ever too. Many come straight from the hospital, needing to go to ICU let alone LTAC but are put in the nursing homes and less than a few minutes on their way back to the hospital.
There are complex patients in the nursing home. Vents, IV and not peripheral IVs either, extensive wound care with multiple system failures that circle the drain even though chronic and becomes acutely quickly. Vent patients are accepted that can be weaned but many aren't.
It is, in lots of LTC, hard to be the nurse on any level but as house supervisor especially due to several can go bad at once and usually that house is the only RN in the building, needs to know the LPN she works with, critically thinking is a must to see the most needing patient first. Have the LPN, within scope of practice, do those things and calling the MD and nine one one and so forth.
Remember, LTC gets those patients time has run out on funds, and just need to be removed to needing that bed in the acute setting and not that they are "well" enough to go home or nursing home. Some Admin and some DONs and some Admission nurse accept patients in nursing home to fill the house knowing quite well that their facility and some of their staff is not capable of helping those patients.
As long as nurse settle for what someone other than a nurse, usually, think we can and cannot handle, we will remain in the same state of our profession.
- 1Glad to hear I was not the "only" nurse who took vitals, when I ended up on a cart when the LPN called in, before cardiac meds or did not seem right to me. I took them myself.
In some LTC, LPNs aren't allowed to call the MD. There are many variable to any setting of work and no matter where you work, some, cna, LPN, RN, will do great nursing and some will not. Period.
- 0Nov 23, '13 by SE_BSN_RNQuote from KasandraI have no experience in LTAC.....but I DO in LTC. I started there as a new grad LPN 8 years ago, because that's the only job I could find as a new nurse. And, now that I look back, I think ALL new grads should start in LTC....if they can't develop critical thinking skills there, perhaps they should find a new line of work! Critical thinking develops over time, and since most of these patients are stable, the nurse should be able to spot something abnormal, ask questions, and learn...I suppose you could do the same in acute care, but with a less sick patient, it should be easier to do. Or maybe my logic is flawed... If you can't learn to prioritize THERE....then definitely find a new line of work! If you can't manage meds for 20-30 people, along with charting, docs, families, other staff, management....seriously. I got a week of orientation, and learned to swim on my own. After that week, I had coworkers willing to help, and a DON who encouraged me, and didn't write me up for being late with meds, treatments, etc, etc. LTC has a bad reputation.....don't you wonder why?@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.
In my experience, it has been the CNA's in LTC that don't know the parameters of BP's....
LTC is one of the best places to build assessment skills! Those little old ladies would love to sit and talk for as long as you could sit and talk!
Golly gee....look at that.....I hated LTC....but I have positive things to say....Last edit by SE_BSN_RN on Nov 23, '13