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When One Patient Affects the Care Other Patients Receive

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Specializes in Rehab/Nurse Manager. Has 6 years experience.

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TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

52 minutes ago, cynical-RN said:

Yes, perhaps not total waste, but in the grand scheme of things, LTC was indeed a heap of rubbish in retrospect. I am one to look for learning opportunities and advancement of the self in all aspects of life. The ceiling for growth in LTC is very low. What is one supposed to aspire to become? DON? MDS coordinator? Granted, I was an LPN at the time and opportunities were generally limited. As such, I regrettably ended up doing SNF/LTC. I have since rectified that regret and moved on to loftier endeavors. Nonetheless, had I known what I know now, I would have gone straight to community college for ASN, then get the BSN and skip the LPN part.

I think LTC/SNF is an excellent setting for the marginalized LPNs and perhaps some unambitious or nearing-retirement ADNs. However, any credentials past that is an overqualification for the responsibilities within the LTC setting. Half of what you learn in school will in fact go to waste in LTC. I would dissuade any RN, especially with grad school aspirations to stay away from LTC. For most nurses, after 1 yr in LTC, they will have experienced >95% of what they will ever see in that setting. Contrast that with the acute setting, and the inherent opportunities for growth, career-wise and educationally, it is candles to chandeliers. I'm not knocking LTC, but the aforementioned facts are indubitably inarguable. 

If you experienced marginalized clinical growth in LTC, sorry but you weren't looking hard enough. With the multiple co-morbidities that geriatric patients have these days both physical and psychological, these patients require closer medical management than generations past, and closer management than what they usually receive. It is becoming more and more important for LTC and SNF's to be able to handle a broader range of acute issues in house versus sending to the hospital, especially since the pandemic has started. At my facility, our residents don't see a physician very often, it is pivotal that a competent nurse is assessing their chronic conditions routinely to catch subtle changes and deal with them before they become bigger issues. Some nurses will simply either send residents out over a paper cut or ignore things until they're in distress and then send them out. That's not the way to do things. Not to mention, the relationships you form with residents and their families is very special, you can literally take care of these people for years at a time and that allows us to provide a tremendous amount of support to elders and their families in the final days of their lives.

I've worked a wide range of settings over the years, and one of the things that I like about LTC is that I get to utilize my experience from all those settings in order to problem solve. I don't have a RRT, I don't have an in house MD, IV team, in house pharmacist, but I still have to render care that to treat acute conditions and exacerbations of chronic conditions without the resources and access to other professionals that are available in a hospital. We do this all while providing more personalized care than what would be received in a hospital as well.

Obviously, we have limitations in what we can provide but we're far from useless.

I'm sorry that you had such a negative experience in LTC, and sadly that is very common. But I believe our elders deserve better than what the standard has become, and at least at my facility I do my best and many other nurses do their best to improve the quality of care and the standards of care. 

19 minutes ago, TheMoonisMyLantern said:

If you experienced marginalized clinical growth in LTC, sorry but you weren't looking hard enough. With the multiple co-morbidities that geriatric patients have these days both physical and psychological, these patients require closer medical management than generations past, and closer management than what they usually receive. It is becoming more and more important for LTC and SNF's to be able to handle a broader range of acute issues in house versus sending to the hospital, especially since the pandemic has started. At my facility, our residents don't see a physician very often, it is pivotal that a competent nurse is assessing their chronic conditions routinely to catch subtle changes and deal with them before they become bigger issues. Some nurses will simply either send residents out over a paper cut or ignore things until they're in distress and then send them out. That's not the way to do things. Not to mention, the relationships you form with residents and their families is very special, you can literally take care of these people for years at a time and that allows us to provide a tremendous amount of support to elders and their families in the final days of their lives.

I've worked a wide range of settings over the years, and one of the things that I like about LTC is that I get to utilize my experience from all those settings in order to problem solve. I don't have a RRT, I don't have an in house MD, IV team, in house pharmacist, but I still have to render care that to treat acute conditions and exacerbations of chronic conditions without the resources and access to other professionals that are available in a hospital. We do this all while providing more personalized care than what would be received in a hospital as well.

Obviously, we have limitations in what we can provide but we're far from useless.

I'm sorry that you had such a negative experience in LTC, and sadly that is very common. But I believe our elders deserve better than what the standard has become, and at least at my facility I do my best and many other nurses do their best to improve the quality of care and the standards of care. 

I respect your premise. I think your interests are in the right place. You have had the privilege of testing the waters in other settings which is what I would encourage most new nurses to do.

Nonetheless, I don't think your response addressed my point of contention -inherent opportunities for growth or lack thereof in LTC. I more than tripled my skills, knowledge, and potential by switching from SNF/LTC to the hospital acute setting. I was able to network with more allied professions and ended up carving a path that would have been implausible had I stayed in LTC.

When I started in the ICU, one nurse mentioned something quite humbling that I have held dear to my heart since. He said, "you don't know what you don't know". I think it would be quite unfortunate for new RNs to start and end careers in the LTC setting. LTC nurses are needed and worthy. I don't know why you would infer uselessness regarding any nurses irrespective of specialty. 

Edited by cynical-RN

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

8 hours ago, cynical-RN said:

I respect your premise. I think your interests are in the right place. You have had the privilege of testing the waters in other settings which is what I would encourage most new nurses to do.

Nonetheless, I don't think your response addressed my point of contention -inherent opportunities for growth or lack thereof in LTC. I more than tripled my skills, knowledge, and potential by switching from SNF/LTC to the hospital acute setting. I was able to network with more allied professions and ended up carving a path that would have been implausible had I stayed in LTC.

When I started in the ICU, one nurse mentioned something quite humbling that I have held dear to my heart since. He said, "you don't know what you don't know". I think it would be quite unfortunate for new RNs to start and end careers in the LTC setting. LTC nurses are needed and worthy. I don't know why you would infer uselessness regarding any nurses irrespective of specialty. 

I think there is lower ceiling for growth in LTC due to the differences in "command" structure and clinical roles of nurses. As far as tripling your skills, knowledge, and potential, I think that may be your perception. I think the reality is that each specialty requires a different skillset. Acute care and critical care nursing do have overlapping skillsets with skilled and long term care but they also have vastly different skills as well. Proper management of chronic illnesses and health maintenance in geriatric patients can be quite complex, and the acuity of skilled units is increasing every year. I think that with the exception of extraordinary events such as pandemics, that the need and demand for skilled care in LTC/SNF, LTAC, and home health settings are going to outpace the need for acute care as more and more problems are able to be managed outside of the hospital.

I will admit that I started my career in acute care as a nurse and a good bulk of my experience is in acute care, so perhaps my opinion is misinformed. I do know that when I precepted nurses from LTC/SNF in the hospital that they tended to do well and adjusted rather easily. I think that LTC/SNF settings can be a very good way to start a nursing career as it can foster skills in time management, assessments, chronic care management, tactile skills such as IV's, foleys, trachs, wound care management, palliative and end of life care, behavioral management. All these things can allow easy transition into home health, hospice, geriatric psych, acute care, LTAC. My point is that, I think you may have gained more from your experience in LTC than what you think, I could be wrong, as everyone has different experiences. 

I will say that I am very thankful for my experience in acute care, and you never know, I may not stay away from it forever. 😉

Davey Do

Specializes in around 25 years psych, 10 years medical. Has 42 years experience.

13 hours ago, Kooky Korky said:

JK, DD.  I'm sure you would do a decent appraisal.

One of the great things about being self-assured and comfortable with one's abilities is the fact that there's not a  need  for external validation, especially from non-involved entities who don't know the whole story.

1 hour ago, TheMoonisMyLantern said:

I think there is lower ceiling for growth in LTC due to the differences in "command" structure and clinical roles of nurses. As far as tripling your skills, knowledge, and potential, I think that may be your perception. I think the reality is that each specialty requires a different skillset. Acute care and critical care nursing do have overlapping skillsets with skilled and long term care but they also have vastly different skills as well. Proper management of chronic illnesses and health maintenance in geriatric patients can be quite complex, and the acuity of skilled units is increasing every year. I think that with the exception of extraordinary events such as pandemics, that the need and demand for skilled care in LTC/SNF, LTAC, and home health settings are going to outpace the need for acute care as more and more problems are able to be managed outside of the hospital.

I will admit that I started my career in acute care as a nurse and a good bulk of my experience is in acute care, so perhaps my opinion is misinformed. I do know that when I precepted nurses from LTC/SNF in the hospital that they tended to do well and adjusted rather easily. I think that LTC/SNF settings can be a very good way to start a nursing career as it can foster skills in time management, assessments, chronic care management, tactile skills such as IV's, foleys, trachs, wound care management, palliative and end of life care, behavioral management. All these things can allow easy transition into home health, hospice, geriatric psych, acute care, LTAC. My point is that, I think you may have gained more from your experience in LTC than what you think, I could be wrong, as everyone has different experiences. 

I will say that I am very thankful for my experience in acute care, and you never know, I may not stay away from it forever. 😉

Hehe fair enough. You raised valid assertions and I will concede to your point about perception. I did transition fairly smoothly to acute care, thanks to the SNF/LTC time management experience and familiarity of the things you mentioned. I’m not sure if I needed 2 years to be familiar with those skills. Nonetheless, the best thing I did was to go back to RN school and run away from LTC. I particularly disliked how management arbitrarily decided to change the modus operandi as they felt fit without consensus from floor nurses. Granted DONs got fired and hired frequently, the power vested in the DON was excessive and lacked the nuance typically seen in the hospital setting. Though I had and appreciated the rudimentary skills you mentioned, in acute care, the learning opportunities were endless —EKG proficiency, central and arterial lines, swan ganz catheters, ultrasound, variety of medications, etc. Most importantly I saw advance practice nurses like CRNAs, NPs, and even saw nurses go to med school. It was nice to see professionalism, especially from management. 

JBMmom, MSN

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

1 hour ago, cynical-RN said:

Though I had and appreciated the rudimentary skills you mentioned, in acute care, the learning opportunities were endless

I started out in LTC and worked there five years before moving on to acute care. I think that the skills that I gained in that environment have been invaluable to rest of my career. For me, it's all about my knowledge and assessment base. When I started out in LTC I had 30 patients to see in eight hours. These patients weren't going to be seen by a doctor more frequently than once a month, and even then the visit with the doctor in our facility was usually five minutes and unless they were hemorrhaging from every orifice, he wouldn't have noticed. They only have vital signs done weekly, and admittedly I saw some weeks where every patient the CNA got a blood pressure on that day had the exact same pressure- even if I asked them to recheck.  The nurses and aides were the eyes and ears for these patients. I became proficient at noticing small changes in condition and sometimes it was crucial to their care. Wound changes indicating infection, changes in mental status, signs of urinary tract infection, etc. I also became an expert in ostomy care and wound vac troubleshooting- my acute care colleagues often look for me to help with those things. 

I think the only downside to the LTC world as a nurse is the horrendous staffing conditions and the lack of respect from management, and even other nurses. I'm referring to nurses that intend to work in a bedside position for their career. I admit that there is not much room for advancement from the bedside in LTC, but not everyone wants to leave bedside. I don't feel like I would lose a single skill if I went back to LTC. Sure in critical care I have all the bells and whistles with my monitors and my available tests. But EKGs, central lines, etc are all tools to evaluate patients, but they're just that, tools. Learning not to treat numbers but to treat patients with only what you have in front of you is a very valuable thing. 

1 hour ago, JBMmom said:

I admit that there is not much room for advancement from the bedside in LTC. 

Thank you. This is the precise crux of my contention. If I ain't growing, I ain't staying. A wise man once said: 'if you are the smartest person in the room, you are in the wrong room'. Though I hold divergent views, I respect those who choose to do 25-life by the bedside, especially in LTC. 

Edited by cynical-RN

I've worked in LTC, Rehab, ALF, but mostly memory care.  Trust me when I tell you the residents may have dementia, but their families are DEMENTED!  Just Tuesday, I spent 1.5 hours with the ED, DON, and a daughter complaining about Moms over-the counter compression socks not being put on and Dads urinal being left in the room.  Trust me, I feel your pain.  Turn them over to the ED...they get paid to deal with the crazies and families while you care for your other patients.

FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Public Health.

I do have a couple of tips for you.

1. Let go of the fear of being reported. Adopt the attitude that people are allowed to report stuff and your job is not to prevent a report to a governing body, but to respond appropriately to complaints. If someone wants to report you, tell them exactly who the governing body is and how they may file a report. 

2. Respond appropriately to complaints. All responses fall into 2 categories.

a. Change something.

b. Educate someone. (It's always education for a bogus complaint)

3. Document your response-- either the change you made or the education you provided.

 

For your example: my documentation would look like this:

1.Grievance filed by pt daughter for BG of 300. Pt and Pt daughter educated on DM2,  insulin and blood glucose parameters  for calling physician. Pt and Pt daughter educated on pt rights to choose foods and nursing responsibility to educate pt on healthy food choices for diabetics. Pt and pt daughter given further resources from American diabetes association to read on same.

2. Grievance filed for broken TV remote. RN supervisor determined that TV remote was repaired in 15 minutes. Pt and pt daughter educated on facility policy of initial maintenance response time within 2 hours. 

3. Pt grievance about not getting shower on time. RN supervisor reviewed nursing notes. Pt refused shower 3 times in 48 hours. Pt educated on appropriate times for showers. Pt agrees that shower assists are  between 7am and 9am and again between 7pm and 9pm daily. 

And on.

 Management responsibilities must be prioritized just as nursing care does. Just like you can't ignore acute chest pain in bed 1 so that bed 5 can have a ginger ale, you cannot allow bed 2 Pepsi grievance overshadow bed 5 need for transport to higher level of care. 

Immediately provide complaining folks with an avenue to express their grievance that does not take attention from your pressing matters. Tell them to fill out a grievance form and email it to you. You will read and respond within 24 hours. 

 

 

 

 

 

 

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

14 hours ago, FolksBtrippin said:

I do have a couple of tips for you.

1. Let go of the fear of being reported. Adopt the attitude that people are allowed to report stuff and your job is not to prevent a report to a governing body, but to respond appropriately to complaints. If someone wants to report you, tell them exactly who the governing body is and how they may file a report. 

2. Respond appropriately to complaints. All responses fall into 2 categories.

a. Change something.

b. Educate someone. (It's always education for a bogus complaint)

3. Document your response-- either the change you made or the education you provided.

 

For your example: my documentation would look like this:

1.Grievance filed by pt daughter for BG of 300. Pt and Pt daughter educated on DM2,  insulin and blood glucose parameters  for calling physician. Pt and Pt daughter educated on pt rights to choose foods and nursing responsibility to educate pt on healthy food choices for diabetics. Pt and pt daughter given further resources from American diabetes association to read on same.

2. Grievance filed for broken TV remote. RN supervisor determined that TV remote was repaired in 15 minutes. Pt and pt daughter educated on facility policy of initial maintenance response time within 2 hours. 

3. Pt grievance about not getting shower on time. RN supervisor reviewed nursing notes. Pt refused shower 3 times in 48 hours. Pt educated on appropriate times for showers. Pt agrees that shower assists are  between 7am and 9am and again between 7pm and 9pm daily. 

And on.

 Management responsibilities must be prioritized just as nursing care does. Just like you can't ignore acute chest pain in bed 1 so that bed 5 can have a ginger ale, you cannot allow bed 2 Pepsi grievance overshadow bed 5 need for transport to higher level of care. 

Immediately provide complaining folks with an avenue to express their grievance that does not take attention from your pressing matters. Tell them to fill out a grievance form and email it to you. You will read and respond within 24 hours. 

 

 

 

 

 

 

Thank you! This was very helpful 🙂

By-a-thred, RN, ADN

Specializes in M/S, LTC, home care, corrections and psych. Has 30 years experience.

Give her the direct number to your marketing department. Problem solved LOL

 

martymoose, BSN, RN

Specializes in PCCN. Has 18 years experience.

Patients like this are the reason why I hope to quit nursing all together someday soon.