In Defense of the LTC Nurse

[Oswin]

Warning, rant ahead. I'm upset by a couple of recent experiences.

1.

So I was running into the store before work the other day and was wearing scrubs. While I'm putting things in my car this middle-aged man at a nearby car asks if I'm a nurse. I said yes, and he asked what kind of nurse I was. Before I could answer he continues, with a big smile on his face, "are you saving lives in the ER? Or little babies in the NICU?"

I responded, "Actually I'm a long-term-care nurse."

The smile instantly vanished and he looked down at the parking lot, and mumbled, "oh... well... that's important, too."

I just responded with a smile and said "Yes, I know it is."

And he quickly left without making eye contact again.

#2

I'm at a party and I'm introduced to another nurse. She looks really excited to talk to me, tells me that works medsurg. I give her the slightly more detailed answer of my facility is primarily LTC with a rehab to home wing.

"Oh..." as she looks down at the floor, suddenly looking evasive with that barely perceptible facial cringe I've grown to expect when I say what I do, "excuse me, I need to say hi to a friend." she says as she slips away and I don't see her again for the rest of the night.

~ ~ ~

What is with this perception that LTC nurses are less important, less skilled, or do less valuable work than hospital nurses? The perception in my nursing class was essentially that you only went into LTC if you couldn't get a hospital job, and then it was only for short term experience to get a "real" (hospital) nursing job.

Don't get me wrong, we don't use all the clinical skills that are needed in the hospital. I mean, I had to watch a video on central line dressing changes before doing one the other day, just because we don't get them often and I hadn't done one in four years. But we have our own set of skills that are needed to do our job, and not everyone can do it!

We (in my facility) manage the care of up to 35 different people at once, supervising 3-4 CNAs, and there are only two nurses on the floor at a time, and on night shift only one nurse. We have to know each resident's routine (because they don't stay in their rooms), how/when they take their meds, their individual quirks, their general health history/skin issues and treatments. We also have to know which CNA will need reminders or more direction on tasks, and have to be watching our CNAs and other residents who might be wandering or getting into things while we pass pills, do treatments, and assess our residents. This is all often interrupted by a multitude of phone calls and faxes, and cnas complaining about other cnas and their assignments in general, door alarms and wanderguard alarms, and talking to family, etc. The ability to multitask, stay organized, and prioritize is vital.

We get to take care of the same people every day, sometimes for years. We get to know them and their individual needs. We get to know their families and names of their grandkids.

We know that the first sign that Mrs. Jones has a UTI is repeated fits of anger at the staff, and if we don't address it promptly she'll quickly go septic before she ever has any urinary complaints.

We know that Mr. Smith will stop his PT early and refuse to continue if we don't get him a pain pill before he goes.

We know that if Mrs. Jacobs doesn't complain about taking her medicine there's something wrong.

Our doctors might go two months without seeing someone if they don't have a major change, so it's on us to watch vitals and skin tone and call/fax the doctor to ask for things. Our assessment skills and attention to detail have to be good because elderly persons tend to go bad fast if a problem's not picked up early, and with our patient ratios we don't get much time with them to spot issues.

Our prioritization skills have to be excellent because if three of our people start going south at once, there's only one other nurse in the building to help (and any of her 35 patients might be having issues, too.)

If my coworker is an LPN and someone needs an IV or stat labs (and she's not certified) and I can't get it, there's no one else to try unless someone volunteers to come in during their time off to try it. So that means I have to drop everything else and go try until I get it, because I'm not letting my inability to draw a lab be the reason someone has to leave their home to go to the hospital.

Don't get me wrong, you critical care nurses are bada**. But LTC is also a challenging and important nursing specialty, just in a different way. We're still taking care of people who can't take care of themselves. But instead of working to get someone through something that went wrong, Our focus is providing day to day care to people who've lost the ability to do it themselves. We work to preserve dignity in life and death. We work to encourage someone's highest possible functioning in life, and support and care and advocate for them in death. We reposition them to protect their skin when they can't anymore, and chart bedside while holding someone's hand so they don't die alone. We also sing and dance and laugh and have impromptu mini engagement parties when one of the dementia patients comes up all exciting saying her beau just proposed to her. We see our residents more than their families and in some cases we're the closest thing to family they have. We're necessary for society because the simple fact is that it's incredibly difficult to care for an elderly parent/grandparent and many people are unable to do it safely, especially if there's a dementia component.

I used to be an ER tech. I've been infuriated by nursing home residents that came in soiled and unkempt. But I've also had residents who got up in the middle of the night because they had to pee, tried to hurry to the toilet, then fell in their hurry, smacking their head on the dresser and breaking their hip and obtaining several skin tears, and then becoming incontinent - and then struggling around in pain and covering themselves in blood from the skin tears. I've then made the decision to send them out soiled because my priority then shifted to getting them assessed for serious injury and pain control. Undressing and turning someone who's screaming in pain because of a likely broken hip that hasn't been x-rayed yet, who has no pain meds onboard, in order to clean them up is not something I'm going to do. I am sorry for the times I've had to send someone out in a state of disarray, because I want my residents to look and feel their best! But sometimes things happen. There are bad nurses in every specialty and every location, but there are also good nurses who are doing their best, too.

Can we just... respect each others specialties? If all nurses were hospital nurses there would be so many neglected people in the community. LTC needs more good nurses, not just people who can't get a hospital job, but skilled, observant nurses who want to care for others. There are bad homes, just like there are bad units in the hospital. But as a concept, it's a vital part of the community and people shouldn't be looking down on it!

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TL;DR

Annoyed with people looking down on me for working in a nursing home. LTC is a challenging specialty, too, in its own way.

Let's change the conversation.

What do you love about working LTC?

[VivaLasViejas, ASN, RN]

Great post! I worked in LTC and assisted living for much of my career, and I agree with everything you've said. I also worked in the hospital for several years and didn't find it any "easier" than LTC...it was just a different kind of busy. And I always went back to nursing home/ALF nursing and retired from there. Good for you for telling it like it is.

[chare]

[...]

TL;DR

Annoyed with people looking down on me for working in a nursing home. LTC is a challenging specialty, too, in its own way.

Let's change the conversation.

[...]

As you should be. Not only is long term care a specialty in its own right, like those that work the NICU, those of you in long term care work with one of our most vulnerable and needful patient populations, just on the other end of the spectrum.

Thank you for what you do! And the next time you encounter someone similar to the two you mentioned at the beginning of you post always remember this: There's an a*****e in every pair of pants, and you just met another.

Thank you again for what you do!

[Ruby Vee, BSN]

ICU nurse here. I know I couldn't do LTC, so I'm glad there are people out there who love it. I'm especially glad because my mother-in-law has been in LTC since Hurricane Katrina and my mother spent the last six years of her life first in an ALF, then in LTC. I tried taking care of Mother at home, but I just couldn't do it. I have no where near the store of patience required.

Mom was in three separate facilities in rural Wisconsin, and each of them was wonderful. The nurses there took wonderful care of her and, upon occaision, me. There was the last time she knew for sure who I was . . . I knew it was the last time, and I had to leave anyway to make my flight back home to start cancer treatment. That nurse took me aside and reassured me that she'd take good care of Mother. And I knew she would. She loved her job and "her" residents and even if she hadn't told me and my sister (we went to high school with her) we would have known anyway. It showed.

LTC nurses make assessments of minute changes in their residents without all the fancy diagnostics and monitoring equipment I have at my disposal in the ICU. They seem to know which changes represent a UTI or a treatable infection and which ones are a step further down the slippery slope of dementia. They know how to cajole Mildred into taking her blood pressure meds and Wilbur into eating his diabetic diet when everyone else is having pancakes with syrup. They know how to deal with Miss Lettie who is sure there's a little green man watching her from under her roommate's bed and how to handle Clyde who has mistaken the CNA for the commandant of the POW camp in which he was a guest in the '70s. They walk the fine line between caring for patients and looking after residents who are, after all, in their homes. They make assessments and evaluations with far less information that an ICU nurse requires, and they make them accurately and initiate new treatments and strategies with minimal input from a physician too busy to come to the bedside and LOOK at the patient. (We have hot and cold running physicians in my teaching hospital.) I have a lot of respect for LTC nurses, and it seems to me that anyone who LACKS respect for them doesn't truly understand what a difficult job they have and how it only looks easy because they make it look easy.

LTC nurses are my heroes. They made Mom feel secure, at home and loved even when she was at her worst. I couldn't do that. Anyone who CAN do that, and especially someone who can do that, make it look easy and demonstrate that they love their jobs is someone I sincerely look up to.

[amoLucia]

To OP - you'll get no argument from me!!!

It's just that we have an old reputation (it was esp bad, at times, I will concede) that is hard to rise above. Then when you add the glorification of high tech, adrenaline pumping units or the emotional-grab your heartstring units, like MCH, it's still more of an uphill climb.

But when you recognize that the geri population in LTC is quickly bypassing other specialties by exploding numbers, it'll will soon be more common and more accepted.

Just not right now at any time soon, I regret.

But thank you for your support, commitment and your enthusiasm. So sorely needed.

[ruby_jane, BSN, RN]

Can we just... respect each others specialties? If all nurses were hospital nurses there would be so many neglected people in the community. LTC needs more good nurses, not just people who can't get a hospital job, but skilled, observant nurses who want to care for others. There are bad homes, just like there are bad units in the hospital. But as a concept, it's a vital part of the community and people shouldn't be looking down on it!

Massive amount of respect for you and all LTC nurses for doing what you do. Thank you for this post!

[Charge200J, BSN]

ICU nurse here. I have huge respect for step down unit, LTC, and LTACH nurses and techs. Our patients leave our ICU physically alive, but often mentally and emotionally broken and physically deconditioned. Families are exhausted and terrified as they anticipate a seemingly never-ending rehab/recovery. When the patients come back to visit us full of vitality and strength and color in their faces it's all thanks to you guys for getting these challenging total care patients out of bed every day to strengthen their body and mind and nourishing them spoonful by spoonful with a whole lot of hard work and tlc. It's you guys who make these patients and families whole again.

[Neats, BSN]

I just love this thred. I first started working in a SNF as an aide back when you did not need to be certified. I got certified and my certification number was only 2 digits. I eventually became a RN and LNHA.

Looking back I have developed into an expert assessment nurse. Here are SOME QUALITIES not inclusive that a LTC Nurse has. I can tell you every LTC nurse I have hired for the hospital has been better than any other nurse. Yes my preference/bias is showing

1. LTC Nurses have better assessment skills

2. LTC Nurses have better communication between families/staff, and administration

3. LTC Nurses are better at proactive patient issues I,e, discharge anticipation, signs/symptoms of infection...

4. LTC Nurses see the big picture

5. LTC Nurses can do IV, Tube feedings, Vents (if applicable) and injectable medication and many of us can do hard stick lab draws.

6. LTC Nurses are good at wound care needs

7. LTC Nurses are great at encouraging patients into doing the right thing i.e. getting up and out of bed, doing their won ADL's.

8. LTC Nurses are real good at charting

9. LTC Nurses know CMS regulation and local M/Caid rules

10. LTC Nurses are knowledgeable about chronic care medications and their associated patient education

11. LTC Nurses are good at delegation and working with others

12. LTC Nurses are good with time constraints

13. LTC Nurses really know the disease Diabetes, what it can do to your body, insulin dependence and the signs/symptoms of resulting diabetic high/low values

14. LTC Nurses can provide for care to patient with a wide spectrum form Acute rehab i.e. status post cardiac, Neurology, Orthopedic, and a host of other active healthcare concerns that need to be addressed as inpatient all the while continued monitoring for acuity changes.

15. LTC Nurses usually have a working knowledge of mental health issues, sign/symptoms and how to deal with these patient

16. LTC Nurses do not just have the patient we truly have the family as well.

17. LTC Nurses have so much independence to work within our scope of practice, no micro managing here so you must be at the top of your game.

18. LTC Nurses are Registered Nurses who have chosen a specialty just like any other Register Nurse.

LTC Nurses are some of the best nurses I have ever come across. I have been discriminated against with people thinking I am too dumb to work in a hospital..(I use to be a flight nurse and Army Nurse). It has been my choice and privilege working in a SNF, working with some of the best people I have ever come across in my life from the staff to the residents. When other nurses decide I am not worth their time because I am a geriatric nurse I do not lose sleep over this, it is their loss. I am afraid it will remain like this until we get some sort of reimbursement and additional staffing in the SNF's. This would have to be mandated from the Federal Government and then our SNF positions would be even more regulated. Until then I just smile, go my own geriatric focus way and brush off the naysayers for they do not know what they are missing.

[Have Nurse, ADN, RN]

Well said!!! I blame the media though really. All those hot-shot emergency hospital dramas. They seem to inspire glamour to the medical profession and it really does do a dis-service to those who care for the elderly long term.

[Oldmahubbard]

I am a PMHNP in LTC. God Bless a good LTC nurse of any flavor, both LPN and RN!

A good one sees the big picture, and knows patient history, which I need, that is probably not in the chart.

They do a relatively low-paid job, and usually are in a for-profit system where they don't get paid for all the hours they work.

[djh123]

I'm a bit too tired and distracted to read the whole post, but I agree with what I did read, and am pretty sure I'd agree with all of it. I've also had a couple of those 'Oh' reactions when you tell a relative, friend, or just about anyone that you work at a LTC facility. As I told a favorite cousin and her daughter (before she started nursing school), "I ain't just handin' out Tylenol!", and I proceeded to tell them what a typical shift was like. But as we all know, a 'typical' shift can change to an atypical one in a New York Minute, as Don Henley wrote...

[hibiscus6, BSN]

Almost 25 years ago I moved from acute care (oncology, orthopedics) to long term care. I was tired of nursing and thought a change would be good, and, as an introvert, I found meeting new patients each day exhausting. It was a good move for me. I liked knowing the patients (and their families) for years, and I liked that, as the OP said, we staff would become family for patients who had none.

And, I have certainly experienced the pained grimace and awkward silence that follows my telling someone where I work. Luckily, I know I work for a good company that gives nurses the tools they need to do a good job. And I take pride in the work my colleagues and I do.

Thanks to the OP for standing up for us.