How to work with acute-minded nurses in LTC setting?

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Specializes in Med/Surg, LTC.

Maybe some of you can help me and some of my colleagues (RN) where I work.

I have been working a number of years in an LTC facility and things have generally run along well with other colleagues. We have had a very supportive team.

Recently two younger but experienced nurses were hired to work on my floor opposite me. I am not sure of their backgrounds, but both have worked fairly extensively in acute care prior to this, but I believe they both have come into their new positions with some LTC experience.

As the weeks and months go by I and a few of the other nurses have become alarmed at the aggressive nature that these nurses appear to display in the way they seem to manage the problems on the floor. There are always a bunch of residents on antibiotics at any one time, a reddened area under a breast or groin will have a request flying to the doctor for an antibiotic, a urine result that is contaminated will do the same, or any cloudy appearance. Lab results are scrutinised and faxed to doctors (who get the results anyway) with remarks and suggestions on what treatment options should be thought of, asking them to initiate certain treatments that we others feel are not necessary and not in the interests of our elderly residents, and are concerned that this approach can undermine our good relationships with our doctors.They do procedures which we others feel,are uncalled for, but get "its the only way to do it." kind of thing. I am not the only nurse that feels this way. I mean, this place where we work are these residents' home, its not a hospital. And its not that we do not want to work and learn new things, and support our colleagues. We generally have had a very supportive team. The problem is that when we have approached these two nurses with some of these issues they become quite aggressive and emphatic. Our nursing manager is very nice and helpful when we need her, but we are getting the idea that we think she doesn't quite know how to handle this, or maybe is unaware of how it is affecting things. We haven't had this as a problem before. The acuity is increasing, the workload is becoming unmanageable and I think its time for us older ones to nip this in the bud. How do you think we should tackle this and still keep the supportive culture in our facility intact??

maybe some of you can help me and some of my colleagues (rn) where i work.

i have been working a number of years in an ltc facility and things have generally run along well with other colleagues. we have had a very supportive team.

recently two younger but experienced nurses were hired to work on my floor opposite me. i am not sure of their backgrounds, but both have worked fairly extensively in acute care prior to this, but i believe they both have come into their new positions with some ltc experience.

as the weeks and months go by i and a few of the other nurses have become alarmed at the aggressive nature that these nurses appear to display in the way they seem to manage the problems on the floor. there are always a bunch of residents on antibiotics at any one time, a reddened area under a breast or groin will have a request flying to the doctor for an antibiotic, a urine result that is contaminated will do the same, or any cloudy appearance. lab results are scrutinised and faxed to doctors (who get the results anyway) with remarks and suggestions on what treatment options should be thought of, asking them to initiate certain treatments that we others feel are not necessary and not in the interests of our elderly residents, and are concerned that this approach can undermine our good relationships with our doctors.they do procedures which we others feel,are uncalled for, but get "its the only way to do it." kind of thing. i am not the only nurse that feels this way. i mean, this place where we work are these residents' home, its not a hospital. and its not that we do not want to work and learn new things, and support our colleagues. we generally have had a very supportive team. the problem is that when we have approached these two nurses with some of these issues they become quite aggressive and emphatic. our nursing manager is very nice and helpful when we need her, but we are getting the idea that we think she doesn't quite know how to handle this, or maybe is unaware of how it is affecting things. we haven't had this as a problem before. the acuity is increasing, the workload is becoming unmanageable and i think its time for us older ones to nip this in the bud. how do you think we should tackle this and still keep the supportive culture in our facility intact??

the answer to your concerns is education, specifically evidence based treatment modalities and considerations for the elderly population. from reading your post, i suspect that both "factions" will benefit from additional information which in turn should improve resident care.

perhaps you could involve your physicians and midlevel providers by asking them to speak about current research regarding asymptomatic colonization, antibiotic utililization, lab interpretation and other assessment data etc.

become active participants in the process. review the literature on your own for the answers to your concerns. perhaps a discussion of a relevent journal article regarding an aspect of elderly care at each monthly staff meeting might be helpful.

you and your new colleagues must shift the focus from how you have "always done it" (whether in ltc or acute care) to what the evidence suggests is the best way to do it.

I am an "acute" RN, and have worked LTC in the past, and feel that LTC residents absolutely need to have their healthcare concerns addressed, really no differently than any other human being. For example, if someone has a bad lab result, I advocate for the patient and call the MD, regardless of whether they're in the hospital or LTC.

If there is some tension or conflict over all of this, I think that the best approach is to sit down with the nurses and see if you can reach some sort of compromise.

I think its time for us older ones to nip this in the bud

This probably isn't the best way to get a positive working relationship started...

(For anyone who wishes to disagree or flame me over my opinion, I will be out of the country for a few days, so please save it for when I return. :))

Specializes in Home care, assisted living.

My boss comes from a hospital background and has tried to run things a bit like a hospital. The new company that took over our facility seems to be more aggressive as well. Now all of sudden the med techs are expected to do things like write in "Progress Notes" and "Alert Charting", and God forbid anything should happen with one of the residents. If they get a skin tear, the med tech in charge gets to call the doctor and ask for an antibiotic, then it's time to fax the pharmacy. And if a resident needs to go the hospital, God help the med tech. They'll be calling everyone from the director to Santa Claus, and will spend a good deal of time going blind on paperwork.

Whatever happened to the good old days when we had the 24-hour report book and the pocket worksheet? :o

Specializes in Nephrology, Cardiology, ER, ICU.

I guess I see this from some of the resident's view too. I am an ER Case Manager who regularly admits patients to NH from the ER. THese patients may have IV needs, new onset diabetes, poor social situation, wound care needs, not to mention more monitoring than has previously been provided in NH. So, I feel that as the acuity in the NH increases, so too must the nursing education. I don't want this to turn into a LTC versus hospital thread, but I do see that over the years, the line is blurring between NH and hospital. Many of our patients are short-term NH patients due to the need for rehab, IV drug needs, ventilator weaning.

I think I see where the OP is coming from. We have a 99 yo resident with dementia who gets frequent UTIs...of course she tries to get all positive urines treated (even if she is asymptomatic) and even recomended/ agreed with the doc for a bladder scope. What about keeping the resident comfortable? After talking with the family and doc...a maintance dose of ABTs was ordered.

I truely believe in giving the best care to all my residents, but what is best (sometimes aggressive) , might not always be in the residents best interest.

I see where you are coming from TramaRUS, but that just points to a bad nursing home and the poor care they are giving there.

Another point to consider is the family dynamics. Some families are very specific in what measures they want taken in certain situations, others aren't sure and they want to "talk it over" with other family, friends, doc...thus delaying treatments and when they do decide to treat a minor thing they are needing acute/ ER care.

We treat pretty aggressively at our facility too. That is how our current DON likes it. We don't usually treat UTI's unless the patient is having symptoms though. Every pink area under a breast gets trx at my facility as well. LOL

Maybe some of you can help me and some of my colleagues (RN) where I work.

I have been working a number of years in an LTC facility and things have generally run along well with other colleagues. We have had a very supportive team.

Recently two younger but experienced nurses were hired to work on my floor opposite me. I am not sure of their backgrounds, but both have worked fairly extensively in acute care prior to this, but I believe they both have come into their new positions with some LTC experience.

As the weeks and months go by I and a few of the other nurses have become alarmed at the aggressive nature that these nurses appear to display in the way they seem to manage the problems on the floor. There are always a bunch of residents on antibiotics at any one time, a reddened area under a breast or groin will have a request flying to the doctor for an antibiotic, a urine result that is contaminated will do the same, or any cloudy appearance. Lab results are scrutinised and faxed to doctors (who get the results anyway) with remarks and suggestions on what treatment options should be thought of, asking them to initiate certain treatments that we others feel are not necessary and not in the interests of our elderly residents, and are concerned that this approach can undermine our good relationships with our doctors.They do procedures which we others feel,are uncalled for, but get "its the only way to do it." kind of thing. I am not the only nurse that feels this way. I mean, this place where we work are these residents' home, its not a hospital. And its not that we do not want to work and learn new things, and support our colleagues. We generally have had a very supportive team. The problem is that when we have approached these two nurses with some of these issues they become quite aggressive and emphatic. Our nursing manager is very nice and helpful when we need her, but we are getting the idea that we think she doesn't quite know how to handle this, or maybe is unaware of how it is affecting things. We haven't had this as a problem before. The acuity is increasing, the workload is becoming unmanageable and I think its time for us older ones to nip this in the bud. How do you think we should tackle this and still keep the supportive culture in our facility intact??

Honestly, I would love to have this kind of nurse attend to my grandparent in a LTC facility. The elderly die of uti's and other infections that are easily treated, so what's wrong with doing skin checks & getting antibiotics ordered?? A far larger problem in LTC is neglect & understaffing -- I'd rather have the extra attention any day! And as for faxing info & getting orders, they're doing the right thing in my opinion! They're acting as advocates for their patients.

Nurses in acute care often see pt's from LTC facilities admitted to the hospital for conditions that spring from neglect -- uti's, contractures, poor dental hygiene, skin breakdown, and common infections. It's so, so sad. I understand the sense of urgency & passion that these nurses you describe have for this population!!!!

I am a new nurse and based on the OP's description, I'd qualify as one of those "acute minded nurses". I advocate treatment for any condition treatable uless my resident is on hospice. I'd rather be called an agressive acute minded nurse any day than a "nursing home nurse" with all the negativity I've heard attached to that in the past.

Specializes in Education, Acute, Med/Surg, Tele, etc.

I was one of those nurses! LOL! But after about a year or two I was able to get to know how to get things done in less of a 'hospital' type mannor, what interventions maybe a bit less invasive (ie sending to the MD when able or hospital..which sometimes hospital is more stressful than waiting a day for the MD office). It just took time for me to get to know the needs of my residents individually instead of thinking so acutely about them as a whole (like going into acute autopilot or 'by the book' exclusively without thinking of the ramifications to the resident).

It took time, but I learned to be more intuned to the needs and rational ways to do things, vs the more invasive stressful ways of treat quick (of course given the situation..somethings you HAVE to do on the fly and quick!).

But alas...I still have that acute/ED gal in me...and I am the best at emergency situations at my facility! My residents love me for that...and say they trust me so much to help them in acute situations and adore when I can slow down and just be their helpful nonrushed nurse :).

Specializes in Nephrology, Cardiology, ER, ICU.

Triage RN 34 - I know exactly where you are coming from - I too am always on auto-pilot, ER style. I am thinking about applying for positions outside the ER, but am unsure how my "always ready for an emergency style" will be received.

I am a new nurse and based on the OP's description, I'd qualify as one of those "acute minded nurses". I advocate treatment for any condition treatable uless my resident is on hospice. I'd rather be called an agressive acute minded nurse any day than a "nursing home nurse" with all the negativity I've heard attached to that in the past.

Ummm, I'm a nursing home nurse. :rolleyes: Damn good one too! Look at where you are posting....this is a Long Term care nurses forum.

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