Question for nurses

dawnb70 · Feb 7, 2006

I'm an LPN in a LTC facility...wasn't sure if you only wanted RNs to respond. The RNs and LPNs have equal responsibility in the facility that I work in. Many of the LPNs are IV certified/trained and are as competent as the RNs.

I have never worked in any other setting, so I'm a little unsure of what other duties nurses have. We basically do all duties except the CNAs do the majority of hands-on patient care. I do occasional transfers, and many repositionings, but have only given 2 showers in the 3 1/2 years I've worked there.

Most of the RNs that I work with have an associate degree. Of course we have continuing education in the form of "inservices", and occasional seminars to attend.

There are daily obstacles to overcome, but I'm sure that's the case in any field of nursing. We deal with the families issues/complaints. We also call the doctors and pharmacy on a daily basis to obtain new orders or order prescription refills. Then there's the issues of the resident. So many are lonely or bored. Few families visit except for holidays and birthdays. The patients emotional well-being is as important to us as their physical well-being.

I love my job, and it brings me joy everyday. Good luck on your research. I hope I was of some help to you, despite my rambling on! :)

Marylou1102 · Feb 7, 2006

Long term care is the most regulated industry in the United States. Many of the things that go on in the hospitals would never be allowed in the LTC. For instance, we are not allowed to use any restraints without following a particular protocol. You always must use the least restrictive form of restraint possible and document the use and how it worked. Of course it must be care planned too. After an appropriate number of days if it is not effective then you can move on to the next level and go through the whole thing again. Simple things like siderails and locking the brakes of a wheel chair are both considered restraints. So the State doesn't want the resident restrained but if the resident isn't protected and is injured then the facility will get cited too.

In order to have a catheter, the resident must have a qualifying diagnosis.

There are also protocols for G-tubes etc. Weights are monitored at least monthly and quite frequently weekly or even daily. Every single thing the resident is fed is recorded and all liquid intake is documented because we have to prove to the State inspectors that our residents are receiving adequate hydration and nutrition. This is for every single resident all the time.

With medications you must know which pharmacy the residents meds are comming from. Facilities have their own that they will contract with but the resident doesn't have to use it. It is up to the nurses to make sure the medications are reordered early enough so the resident doesn't run out but not too early. Medicare/medicaid/insurance companies will only allow one refill every 30 days. All medications must be given within 1 hour of its scheduled time even if you are passing for 40 or 50 ambulatory residents. I stress ambulatory because many times you have to run the building looking for them.

We cannot do any thing for the resident without a specific order from the doctor. LTC facilities do not have the freedom to give even the most basic of care without a Dr. order. This includes sending a resident to the hospital.

Absolutely everything that happens to a resident is documented. In LTC all new orders, incidents and any unusual behavior are called to the families at the time of occurance. Failure to do so will result in a citation by the State.

Then you have the staffing issues. The Nursing department has to follow its budget guidelines for staffing which may not be as much as the State would like to have. Then if an employee calls off, you either try to find someone to come in, stay over or you do without.

Nurses and CNAs in the nursing home must be able to think on their feet. With the elderly things can happen a lot faster and more severly due to the residents advanced age. The LTC does not have a Dr. in the building,or respiratory therapy, a pharmacy or a specialized team for codes. We have to handle things by ourselves. Frequently the Dr.s don't want the resident sent to the hospital. They expect the staff to care for and monitor the resident. When we do call the paramedics we are frequently treated like imbeciles because if we were any good as nurses we would be working in the hospital.

Any time a resident or family member thinks they have been wronged they can call the ombudsman and/or the state. Then there is the list of state reportables. Certain occurances that must be reported to the State within 24 hours and a follow-up resolution within 5 days. We never know when an Inspector will enter the building and they never tell you what they are there for. The State Attorney Generals office will do the same thing.

This is just the tip of the iceberg. I haven't even mentioned skin and wound care, chemical restraints and bowel and bladder management. Heven help you if you have an in house acquired pressure ulcer. Then there is also the State mandated training every year including 12 hours of Alzheimers training.

There are those families that will never be happy with the care their loved one gets no matter how much you do for them. I am sure part of that is guilt. That is not to say that the LTCs are blameless. The problem comes when a disgruntled family succeeds in getting a law passed which may contradict another law already in existance.

Sorry if this sounds like a rant. I'm really tired of some of the other nurses thinking that LTC nurses have it easy. We are here in spite of the rules and restrictions. In spite of the difficult hours, annoying and complaining families and the myrad of rules and regulations because we truly love what we do. This is no different from any of the other specialities. And this is a speciality. If you don't think so, try walking a shift in my shoes.

CoffeeRTC, BSN, RN · Feb 7, 2006

:yeahthat: and then some. LTC nurses need to wear more than the nurse hat. At times I need to act in the social service role, taking a referal, doing a tour for a potential new admit, discussing admissions and discharges.

Sometimes I need to do housekeeping/ maintanance....clean a spill, fix a borken siderail or bed crank, changing batteries in the bed alarms, fix a leaky toilet, restart the boiler (i kid you not!).

Then there is the dietary part...snacks in the middle of the night, etc.

This is a smaller facility and I mostly work off hrs, so that is why I'm doing these odd ball things.

Now taking care of your pts is one thing, then there is the supervisor and customer relations BS you need to get into. Finding replacements for call offs, making the schedules for the CNA daily, making sure all the staff are doing what they should be doing, dealing with family or pt complaints or questions.

After doing all the above, actual nursing care does get done. Med pass (including Po, IV, injections, blood sugar checks and tube feeding) and treatments/ wound care is done. Charting is also a biggy. Most often I spend at least 1.5 hr or more per shift charting.

As far as education....it varies. Most have a 2 yr degree, I have my BSN. In Pa, there is no requirement for CEUs for maintaining our license, but each facility needs to give madatory monthly inservices to thier staff.

The biggest obstacles I see is the lack of staffing, decrease in reimbursments from the fed gov which affects our budgeting and the constant turn over from staff.

LPN1974, LPN · Feb 7, 2006

Long term care is the most regulated industry in the United States. Many of the things that go on in the hospitals would never be allowed in the LTC. For instance, we are not allowed to use any restraints without following a particular protocol. You always must use the least restrictive form of restraint possible and document the use and how it worked. Of course it must be care planned too. After an appropriate number of days if it is not effective then you can move on to the next level and go through the whole thing again. Simple things like siderails and locking the brakes of a wheel chair are both considered restraints. So the State doesn't want the resident restrained but if the resident isn't protected and is injured then the facility will get cited too.
In order to have a catheter, the resident must have a qualifying diagnosis.
There are also protocols for G-tubes etc. Weights are monitored at least monthly and quite frequently weekly or even daily. Every single thing the resident is fed is recorded and all liquid intake is documented because we have to prove to the State inspectors that our residents are receiving adequate hydration and nutrition. This is for every single resident all the time.
With medications you must know which pharmacy the residents meds are comming from. Facilities have their own that they will contract with but the resident doesn't have to use it. It is up to the nurses to make sure the medications are reordered early enough so the resident doesn't run out but not too early. Medicare/medicaid/insurance companies will only allow one refill every 30 days. All medications must be given within 1 hour of its scheduled time even if you are passing for 40 or 50 ambulatory residents. I stress ambulatory because many times you have to run the building looking for them.
We cannot do any thing for the resident without a specific order from the doctor. LTC facilities do not have the freedom to give even the most basic of care without a Dr. order. This includes sending a resident to the hospital.
Absolutely everything that happens to a resident is documented. In LTC all new orders, incidents and any unusual behavior are called to the families at the time of occurance. Failure to do so will result in a citation by the State.
Then you have the staffing issues. The Nursing department has to follow its budget guidelines for staffing which may not be as much as the State would like to have. Then if an employee calls off, you either try to find someone to come in, stay over or you do without.
Nurses and CNAs in the nursing home must be able to think on their feet. With the elderly things can happen a lot faster and more severly due to the residents advanced age. The LTC does not have a Dr. in the building,or respiratory therapy, a pharmacy or a specialized team for codes. We have to handle things by ourselves. Frequently the Dr.s don't want the resident sent to the hospital. They expect the staff to care for and monitor the resident. When we do call the paramedics we are frequently treated like imbeciles because if we were any good as nurses we would be working in the hospital.
Any time a resident or family member thinks they have been wronged they can call the ombudsman and/or the state. Then there is the list of state reportables. Certain occurances that must be reported to the State within 24 hours and a follow-up resolution within 5 days. We never know when an Inspector will enter the building and they never tell you what they are there for. The State Attorney Generals office will do the same thing.
This is just the tip of the iceberg. I haven't even mentioned skin and wound care, chemical restraints and bowel and bladder management. Heven help you if you have an in house acquired pressure ulcer. Then there is also the State mandated training every year including 12 hours of Alzheimers training.
There are those families that will never be happy with the care their loved one gets no matter how much you do for them. I am sure part of that is guilt. That is not to say that the LTCs are blameless. The problem comes when a disgruntled family succeeds in getting a law passed which may contradict another law already in existance.
Sorry if this sounds like a rant. I'm really tired of some of the other nurses thinking that LTC nurses have it easy. We are here in spite of the rules and restrictions. In spite of the difficult hours, annoying and complaining families and the myrad of rules and regulations because we truly love what we do. This is no different from any of the other specialities. And this is a speciality. If you don't think so, try walking a shift in my shoes.

I agree. And I had my run ins with the ambulance crew several times.

The demands of the nursing home got to be too overwhelming for me, and I had to quit. I just worked there part time tho, to supplement my regular job.

LTC nurses have a difficult job, to say the least.

My regular job is with the mentally challenged in a state facility, and I don't think we are as regulated as nursing homes, altho we work under a LTC license. I dont understand the difference.

We DO send people to the ER without a dr's order all the time. If we can't get hold of one of the two physicians who regularly see these people, we load em up and take them to the ER.

But in a nursing home you can't do that.

Also our documentation requirements are not even on the level of a nursing home. We chart on them when they are sick, but not everyday like in the nursing home.

You have to be a special kind of person to work LTC and be able to hold up to all the requirements. LTC would be an easy place to lose your license if you don't know what you're doing.

mal1027 · Feb 8, 2006

Thank you for all your responses. Some interesting stuff here. Can anyone give me a situation where you felt like you were making a difference for maybe one of your patients or facility? And what would you say to nurses who would like to get into the field? My hat goes off to those who work in a nursing home, skilled nursing facility, or out there in people homes. Its a shame that people become neglected just because of the bottom line. I think it should always go back to treat those the way you would want to be treated.

Thank you for the input and I would like to hear more!!

Marylou1102 · Feb 8, 2006

Long term care facilities are unlike any other facility you will ever work at. The residents, families and employees are, many times, like and extended family. Unlike any other place you can ever work you will build a strong connection to the residents and families. You will celebrate graduations, weddngs and births. You will cry at separations and deaths, not only of residents but also their families and friends. You will get to know them so well that they become your friends. They will know you. They will ask after your husbands and wives. They will know your children by names and ages. They will celebrate with you and they will cry with you.

The benefits are when you see a resident walk, or feed himself again. When she is able to speak or even communicate with a smile. When you have relieved the pain of a dying resident. When a resident gives you a hug and you know that for that instant you are her lifeline. There are the big events. We all experience them, but your day is made up of the little ones and you go home knowing you have made a difference in someones life.

My Uncle passed away two weeks ago. He had been in a nursing home for ten years. At the funeral his daughter said that someone asked her if family had been with him when he died. She said yes. The nurses were at his side.

I would tell any nurse that the work no matter how difficult is the most rewarding on earth.

nightingale, RN · Feb 9, 2006

It is very stressful:

Long hours (usuaully 12's) and on your feet...

Med Pass, some facilites make it so complicated...

Constant interruptions (Medical Staff, SS, Family, etc...

Mixed population of rehab and LTC is particularly zanny somedays.

The discharged res to your facility is just as sick as the pt. from the Hospital of years ago... and they can (and do) go south on you to where you need to transport them back to the hospital... fast...

Their demise often happens on your shift... you are sad, so are your staff and the family

The paperwork is enormous

The RN IS the Charge Nurse (no matter what any LPN says)

n_babegurl · Feb 11, 2006

You summed that up very well;except you forgot ,no breaks,no releif if someone calls in,working 12-16 hrs+.I to LOVE my job. I've worked in LTC for 8 yrs now and take pride in what i do.I to have a prob. with nurses that think we babysit,that think we are stupid when having to send a res. into ER for something minor.Then we get a nurse thats never worked LTC ,they're alright till they get stuck doing a job thats for 3 nurses!! They're use to 1-5 pts. were in LTC you may have 15-40 pts.;somebody has to do it and it takes us Special Angels in white!!!

TheCommuter, BSN, RN · Feb 13, 2006

Look for RNs working in a long term care facilities. Interested to learn what areas you practice and why, how long, education, day to day operation/responsibilies, obstacles you face or issues. I am writing a paper on stress of nurses in LTC facilities and need some input. Look forward to hear the responses.

I'm an LVN employed at a nursing home.

There are 3 RNs employed at this nursing home. One serves as the DON (director of nursing) and the other 2 are RN weekend supervisors. The ADON of this facility is a highly-experienced LVN.