Nurses in skilled nursing facilities and other post-acute care settings must be flexible, independent and at the top-of-their game clinically and socially to successfully deal with the dynamic and demanding environment that is long-term care. Here’s a glance at just a few of the unique challenges that keep nurses in this specialty jumping day in, day out.
Growing patient acuity
As patient acuity has increased in acute-care hospital settings, the same change has taken place in long-term care settings.
“[N]ursing home resident populations have changed dramatically—the acuity level of residents is much higher than it was 20 years ago,” said Randy Lindner, executive director of the National Association of Long Term Care Administrator Boards. “Nursing homes have become mini-hospitals. They are now more like subacute care centers, while assisted living is becoming what nursing homes were 20 years ago. “
Acute care hospitals are also discharging patients earlier, sending those not ready to go home to long-term care sites for post-acute treatment. As a result, many long-term care facilities are now treating two distinct populations: patients there for a few weeks as they recover from specific illnesses or injuries, and residents who live there because they require skilled nursing care to live.
For the former, the focus is on continued gains. For the latter, the focus is on preserving what independence and health they have. For both, nurses are called on to provide appropriate care and do all they can to prevent rehospitalizations. It’s a broad spectrum of responsibility.
Lack of clinical staff
Unfortunately, there often aren’t oodles of licensed nurses available in long-term care sites, either. Skilled nursing facilities have one of the highest staff turnover rates in healthcare. Most of the licensed nurses are LPNs, and RNs tend to take on the management-level roles (despite a lack of management training in most RN programs).
Working in isolation is common in long-term care, keeping nurses busy, self-reliant and, sadly, task-oriented rather than patient-focused.
“Being the only nurse on the unit too often forced me to confine my duties to immediate priorities, such as dispensing medications and dressing pressure ulcers,” said Alison Kris, PhD, RN, recalling her first position at a San Francisco-based nursing home. “There was rarely time to thoroughly assess or treat the patient’s symptoms and, consequently, many suffered needlessly.”
Scarce professional development
The need for geriatric-specific care has received much attention in the past decade, and geriatric expertise is making its way into specialized hospital units and specialty nursing education. For good reason, too. In the elderly, diseases and infections can present differently, medications are absorbed at different rates, cognition is more often impaired, psychosocial issues are more likely, and priorities are simply divergent from what they are for younger patients.
“Geriatric nursing is about promoting a patient’s function, maintaining their independence as much as possible and doing anything we can to improve their quality of life, with the caution that you understand how they define quality of life, because we all define it differently,” said Jenny Kim, MSN, GNP-BC, geriatrics focus area coordinator for the adult nurse practitioner program at Vanderbilt University School of Nursing.
But long-term care, ironically, has some catching up to do. Despite the fact that it’s the most common setting for elderly patients, the majority of nurses in skilled nursing facilities lack formal education in geriatric nursing and fewer professional development resources are available for staff. To serve their patients well, nurses must learn quickly on the job and educate themselves outside of work on the special needs and presentations of their patients.
So, why stay?
Clearly, long-term care is hardly a walk in a retirement community (nurses say it’s more like a frantic run). The challenges are weighty. But those who continue to stick with it will tell you that, so too, are the rewards.
Hearing patients reflect on their families, their grandchildren, their lives—and often being with them in their final moments—offers a professional and personal significance that keeps many long-term care nurses right where they are.
“Just as a midwife thinks it’s an honor to bring people into the world,” said Abby Parish, DNP, APN-BC, “I think we have a similar honor to help them leave this life in the manner they would have wanted.”
Have you ever worked in a long-term care nursing setting? What did you think of your experience? Tell us in the comments section below.