Written 20 July 1998
Why choose geriatric nursing as a profession?" This is a question
which was asked of me many, many times during the course of my career as a nurse in long-term care. It isn't always an easy one to answer. Most people's
concept of the "nursing home" nurse is that of a person in a dead-end career.
The "nursing home" nurse does not enjoy the respect given to other members
of the healthcare profession, because many people do not see us as being
"real" nurses, but as custodians for a confused elderly population and
as persons who possess few technical skills beyond that which is needed
to pass a few medications and apply a few bandages.
The reality of the situation
is actually quite different. With the advent of Medicare's DRGs,
and the new HMOs, PPOs, and other forms of managed healthcare, patients
in hospitals (most of whom are elderly, by the way) are being discharged
much sooner than they ever used to be. The result of this is that
people discharged from hospitals are much sicker than they were before,
and much more in need of assistance. Many of them lack caregivers
in the home, and are not yet in a condition to care for themselves.
This has most definitely had an effect on the long-term care profession.
Most patients admitted to an extended care facility come directly from
the hospital, not from the home. Many of them are still acutely ill,
and almost all of them require skilled nursing services or specialized
rehabilitation, at least for a short period.
The advent of the new "subacute
units" in many extended care facilities has made many demands upon the
skills of the "nursing home" nurse. These patients enter our facilities
with a variety of complex needs, including but not limited to ventilator
care, dialysis, hyperalimentation, cardiac rehab, post-op care, hospice
care, and so on. Many of these patients come into the facility
as "full codes," and all of the nurses on these units are expected to have
some skills in advanced life support. Where for many years, the average
"nursing home" nurse was an LPN, it is not unusual at all to find an extended
care facility staffed heavily with RNs, some with advanced degrees.
Most extended care facilities prefer nurses with extensive med-surg and
critical care experience when hiring nurses to staff these subacute units.
The assumption of many student nurses that they will lose their hard-earned
skills if they accept employment in long-term care is no longer accurate.
Nurses in long-term care are expected to perform with the same level of
professionalism, skill and expertise as their hospital counterparts.
Their job may be even more challenging, as documentation requirements in
long-term care are much more stringent than they are in the hospital setting.
Although nurses in long term
care, I believe, tend to have to work much harder than the average hospital
nurse, due to lower staffing rates and increased documentation requirements,
we enjoy certain benefits which our hospital counterparts do not.
The first, and not the least, of these benefits is job security.
As I indicated earlier, the average hospital stay is getting shorter and
shorter, and managed health care is greatly reducing the number of people
who are admitted to hospitals in the first place. As this trend continues,
the census of the average hospital will continue to plummet, and so will
the job opportunities for hospital nurses. This does not necessarily mean
that people are getting healthier, but rather that patients are going to be cared
for in environments which are much more cost-effective than the hospital.
The long-term care and home health care industries are booming businesses
at the current time, and I really expect that most of the job opportunities
for nurses in the next few years will be in these areas.
Another advantage which I
have enjoyed as a nurse in long-term care is the versatility of the skills
which I have had to develop . In hospitals, especially the larger
ones, you have a wide variety of resources to help you to get the job done.
There is the IV team to start your IVs, the respiratory therapist to perform
breathing treatments, tracheostomy and ventilator care, the enterostomal therapist to
do your complicated wound care treatments, and so on and so on. In the long-term care setting,
the caregiver nurse is expected to perform ALL of these tasks and to be
proficient at them. Many nurses in long-term care, including myself,
have certification to perform such complicated tasks as insertion of
PICC (peripherally inserted central catheter) lines, a procedure which
was formerly done only in the hospital by a physician. This enhancement
of skills and ability to perform in many patient care situations greatly
increases a nurse's desirability as an employee.
began my first job in long term care at the age of 17, as a nursing assistant.
I have always enjoyed being around the elderly, and this is probably the
primary reason which I love being a "nursing home" nurse. The opportunity
to really "connect" and build relationships with your patients is not something
which is often found in the hospital setting, where patients stay only
for a few days. There is a real challenge which comes along with
taking care of someone for a few months or years as opposed to a few days.
This challenge comes from trying to meet the patient's emotional needs
as well as the physical needs, to provide a comfortable, "homelike" environment
for the person, and to provide support, encouragement, and education for
the patient's family members. The rewards received from meeting this
challenge are significant, and are probably the major reason that those
of us in long-term care stay in the profession. When I look back
on my career, many years from now, the things which I will remember will
not be how hard I worked, or what technical skills I was able to perform
successfully. The memories which will stay with me will be those
of someone's face lighting up when I entered the room; the reminiscences
of days gone by, told to me by someone who actually lived them; the times
when I laughed and cried with my patients or their families; the batch
of cookies made for me by a patient's daughter in gratitude for my care
of her mother. These are the things which make my job worthwhile,
and the reason which I look forward to going to work each and every day.
To those nurses who think of long-term care as an unrewarding, dead-end
job, I strongly urge you to think again...and maybe even to give it
a try...You'll be glad you did.
UPDATE, THURSDAY 23 NOVEMBER 2000:
It has been more than two years since I first wrote the above words. At the time, I believed them with all my heart, but so much has happened since then. I am more sad than I can say to tell you that after all these years, I am leaving long-term care altogether. Tomorrow will be my last day on the job as a "nursing home" nurse. The memories I will be taking with me are rich and rewarding, and I still don't want to think about how difficult it is going to be for me to say "good-bye" to all the wonderful residents I have cared for for so many years. Unfortunately, my memories will be tainted with more than a little bit of bitterness. I never thought I would be writing these words, but my disappointment and anger are still pretty overwhelming. So is my sense of defeat. But I have finally realized that one person alone cannot change the system...and I have decided, for better or worse, to walk away from a situation which has become intolerable to me...
Over the past two years, I have seen staffing rates and overall quality of patient care plummet. The corporate "suit" types are very quick to blame the Medicare cuts for the problem, but most of us know that it was the corporate greed to drive up charges and drain the Medicare budget (not to mention our parent Corporation's conviction for millions of dollars of Medicare fraud) which caused the need for cuts in the first place.
Of course, what do you think got cut when the money stopped rolling in so quickly? Do you think that there was a thinning out of all the superfluous corporate paper-pushing, numbers-crunching jobs? Do you think that the corporate "suits" took a pay cut? Or maybe you think that the corporation contented itself with maintaining the same high standards of care while operating on a smaller profit margin? Wrong, wrong, wrong! Let me tell you what happened, in my little corner of the world, at least...
The first thing that was decided, in light of the new budget, was that it would be necessary to trim the staffing numbers. On a unit with 76 patients, for example, which used to be staffed with a unit manager, two nurses, a QMA and 6 to 7 CNA's, it was decided that the same job should be done by a unit manager, one nurse, a QMA, and 4 CNA's. Similar staffing cuts were implemented on all units throughout the building.
The next thing that happened was that the corporate suits decided we should be providing the same standard of care with substandard or nonexistent equipment. For example, high-quality specialty beds such as the Clinitron (for pressure relief for patients with wounds or who are at high risk to develop skin ulcers) were eliminated from the budget and replaced with the much cheaper, and definitely inferior MediQ mattress overlays. Skin treatments which had long brought about wonderfully dramatic results were eliminated entirely and again, we were forced to use cheaper and inferior products. Dressings, urologicals, incontinence products, etc. were contracted to be purchased exclusively from the cheapest bidder, who might or might not deliver a sufficient quantity of product on time.
To make matters even worse, our administration decided that the nursing staff, already overworked, was not charging out supplies efficiently enough. The solution? Our scant and inferior supplies were locked up in a supply room which staff members could not access -- only 3 people in the building had keys to this room. Of course, these people could never be counted on to be in the building to access the supplies during the off hours. The result? Much wasted time...time which should have been spent by nurses caring for their patients was squandered needlessly because, too many times, nurses had to search, hunt, beg, borrow and even improvise equipment needed to provide even the most basic care.
Also in these past two years, although staffing has been at an all-time low, and nurses have had less time than ever before to spend with their patients, State and Facility documentation requirements have become even more stringent. The blizzard of paperwork expected to be produced by staff nurses has almost doubled in our Facility during this time period.
So far, I have scratched only the tip of the iceberg. If you think this is bad, read on, because it gets worse...
As you could expect, quality of patient care declined dramatically in our Facility following all these cuts. Numbers of falls, infections, pressure ulcers, etc. skyrocketed. The corporate numbers-crunchers and Facility administration were not pleased...but no one wanted to listen to the reasons why all these bad things were happening. The Administrator turned a deaf ear to any complaints about the nursing management staff. The Director of Nursing became livid if anyone even tried to intimate that low staffing rates and decreased quality of care were even remotely related to each other. Also during this time, she began to write up nurses for unauthorized overtime if they stayed over to get all of their charting done. Of course, if they didn't stay, they couldn't possibly get their charting done, and they were written up for that, too...
It didn't take too long, at that rate, to burn out many of our good staff -- people who had been with the Facility for years, and who prided themselves on taking care of their residents and who loved those residents as they loved their own families...staff members began to resign in droves, bringing our already stresssed-out staffing numbers into critical levels. Word began to get around town among other nursing staff that our Facility was an undesirable place to work, because the pay was lower and the work was harder than in any other Facility in town...fewer people applied for positions in our Facility. And those who did and were hired rarely lasted for more than a few weeks before they, too, resigned in bewilderment and frustration...and all the while, the greedy corporate types and Facililty Administration kept demanding more, more, more and more of the few people left...
For the past year, our Facility has run for the most part with staffing levels which were critical or even worse. Many, like myself, pitched in to pick up extra shifts, even though exhausted, simply because our consciences could not allow us to go home and wonder how (or even if) our beloved residents were receiving even the most minimal care. Middle management staff like myself found ourselves practically living in the building during the weeks we were on call because there were so many empty staffing slots and no one available to fill them. Calling the local staffing pool was out of the question, of course -- corporate "suits" have mandated that no pool personnel are to be used in any of the Company buildings -- I guess they think it is far cheaper and, therefore, much more desirable to work their own staff members to death instead...
You would think, with a skeleton nursing crew in the building, that the Administration would slow down on admissions of new residents, especially while we were doing such a poor job of taking care of the ones that we already had...Wrong again! Corporate suits were pushing to fill those beds...and fill them, we did. I can recall more than one instance being alone on my unit with only one CNA for help and having two to three admissions during my shift -- unbelievable!
If you think things have been bad for the nursing staff, take a moment to imagine what it must be like for the residents we care for...those poor people who wait for hours to have their call lights answered, or for the family members who walk in day after day and see that their loved ones aren't getting the care they deserve. Dependent residents can go for days without having such little things done for them as having their teeth brushed or their hair combed -- this is unforgivable! Personally, my conscience, my health, and my sanity will not allow me to continue practicing in this environment. I am so tired of leaving the building in tears because I have worked myself into a frazzle and yet my people still haven't received anything remotely resembling decent care...Indeed, I believe that my nursing license itself is in jeopardy if I stay, because it's is only a matter of time before something awful happens on my watch, that I won't be able to prevent because I am stretched too many different directions.
I have spent the past six months of my life in painful indecision -- to leave or not to leave. I know that by leaving, I will be worsening the staffing crisis and in a way will ensure that I become part of the problem. I also know that a lateral move is not really practical -- most other long-term care facilities in the area are suffering from the same understaffing and corporate mismanagement as our Facility is. So, I am leaving long-term care, most likely for good. I recently accepted full-time work on an Oncology floor at a major hospital here in town. I know that hospitals, too, have their share of staffing problems, but even so, it will be heaven compared to the hell I have lived in for the past couple of years. For those of you with the courage to venture into this most noble profession, the care of the elderly, I wish you all the best...and for those of you who are courageous enough to continue in the profession despite all the adversity, God bless you...you are truly special!
UPDATE MONDAY, 13 JANUARY 2003:
My last update on the subject of geriatrics was written more than two years ago. As you can well imagine, much has happened since that time. In the first place, I had been completely unable to quit long-term care entirely. After taking a break for a couple of months, I returned to my former Facility in a part-time, PRN position. I worked the two jobs for a number of months, but in October of 2001, I suffered a brain injury which left me unable to work as a nurse for almost a year...and when I finally received clearance from my physician to return to work, my position in the Oncology department at the hospital had been filled, and there were no other openings anywhere on the unit. The hospital was more than willing to give me a position on the Orthopedics unit. Unfortunately, though, I was more than a little bit intimidated at the thought. I had many friends, and a great "support system" on the Oncology floor, but I didn't know anyone on Orthopedics. I felt that it was going to be just about all I could handle, getting back into the swing of being a nurse again, much less having to learn a whole new specialty on top of it all...As much as I loved the hospital, I felt that I needed to start work again in an environment that was somewhat familiar to me -- and the long-term care Facility which had formerly employed me was very eager to have me back again.
Since I still had many good friends at my former place of employment, and since I was more than familiar with the work enviroment and the routine there, I positively jumped at the chance to return. My first day back on the job was 16 July, 2002. I was more than a little bit nervous, but in many ways, it felt like I was coming "home" again...Yes, the problems which made me want to leave in the first place are still there -- even worse than before -- but I feel challenged at the opportunity of being part of the solution to the problems, and very, very proud of the fact that I've been able to perform so well thus far. In many ways, I feel that my recent experiences as a patient with a brain injury, having to go through rehabilitation, as so many of my patients do, has made me a much better nurse than I ever was before.
UPDATE SUNDAY, 24 APRIL 2005:
Shame on me for being so dilatory about keeping this site updated! I've spent hours online today, fixing broken links and updating information, and I'm still not even close to having this site completely updated...I really should try to update at least once a month and attempt to keep things at least halfway "fresh" around here. I promise to try hard to do better, really! Anyway, as you can well imagine, quite a lot has happened in the past two years and three months since I last updated this page. I am no longer working in the long-term care Facility which previously employed me. Not only am I no longer there, but I can't imagine anything which could possibly entice me to put my head back in the door, even for a visit! As I indicated in my last entry, the staffing, supply, and other issues had not improved, not in the least way. If anything, they had only gotten worse. I did my best to hang in there and to try to make a difference somehow, but I quickly became discouraged. The final straw that broke the camel's back this time was a harrowing shift that I put in during July of 2003. I had picked up the night shift that night, and was amazed to find that not only were we critically staffed, but the staffing was BEYOND critical! I was the only nurse for two different units, the Subacute South Unit as well as the B-Wing Intermediate Unit. On the Subacute Unit, I also did not have one single CNA to assist me. So there I was...I was legally responsible that night for 58 patients, 19 of whom I was ALSO responsible for providing primary care. Needless to say, I was most unhappy about the situation, and paged the nurse on call. The nurse on call was an LPN who was also responsible for doing staffing for the building. When I explained the horrible staffing situation I was dealing with, not only did she refuse to come in, but she had the nerve to tell me to "deal with it and get over it." At the end of my shift, the bitch had the temerity to call me back and tell me that her husband was waiting for me to call him with an apology, because I woke up everyone in their house that night with my phone call! I told her that he'd be waiting an awfully long time...told her that she was on call and that I had every right to call her, and that she owed ME an apology for not only screwing up the night shift schedule, but for refusing to provide me with support when I asked for it. I then hung up on her and promptly wrote up my two weeks' notice, which I turned in at the desk as I walked out the door.
I spent the next year and eight months at another long-term care facility in town, which my best friend Doug had moved to, and for the most part, I was reasonably happy there for about a year, and in fact had been there less than a month before I was promoted to night shift supervisor. Of course, I was what could be called a "working supervisor," because of all the nights I worked in that building, I believe there was only ONE night in which I did not take responsibility for a group (and in many cases, an entire unit) of patients. Although I had a so-called "permanent position" on the neuro-rehab unit of that building, it became apparent to me that I was being used by management staff as the night shift "float" nurse. At first, it didn't bother me awfully much, because I've always known that I can work anywhere, and I've often felt that it was a great advantage to know every single patient in the building, as well as their medical histories, etc. After awhile, though, I began to notice that no single OTHER full-time nurse in the building was expected to float, and I did tell the management staff that I was a bit resentful about being held to different standards and expectations than the rest of the full-time staff in the building. I was promised that other nurses would, indeed, be expected to take their turns floating "as soon as we can get them oriented to all of the different units. Excuse me? As soon as you can get them oriented? I never received one single day of orientation on ANY of the units in that building! Over a number of months, seeing new nurses being hired in who WEREN'T expected to float while I continued to be used as "Miss Fill-in-the-blank" for the night shift became really aggravating, and my resentment increased at least tenfold. On top of that were numerous other staffing issues which made me extremely angry.
I'll never forget being the shift supervisor during a recent holiday. Not only did I work short-staffed that night as well as take charge for the entire building (I worked one of the skilled units, with 33 patients, with only one CNA to help me), but I was stuck dealing with myriad call-offs for the holiday. FIVE staff members called in sick that morning. Do you think I could find ANYONE who was willing to come in on their holiday off? I ended up calling the nursing manager on call and got no response. She was not answering her home phone, her cell phone, or returning her pages. I received absolutely no support from nursing management staff, and ended up staying over for the day shift to try and help out. The day shift supervisor was also unable to get anyone in nursing management to return her calls. And, unbelievably, after the holiday was over, the on-call manager said at a meeting "Well, I would have come in and helped, but NOBODY ever called me." Basically, she was saying that I, along with the day shift supervisor, were liars! Talk about adding insult to injury!
Things only went downhill from there. The Administrator of the building fired Doug early this spring, because he refused to falsify documentation on nosocomial pressure ulcers in the building. Once Doug was gone, (and fired for SUCH a reason!) I honestly lost all enthusiasm for the place. After they put a new DON in charge who had no supervisory experience, precious little clinical experience, and positively nonexistent skills when it comes to dealing with staff members, I quickly became convinced that the "suits" really didn't give a hairy rat's ass about the staff members who've worked so hard to make them so successful. After dealing with further staffing nightmares, I finally accepted a job on the Inpatient Rehabititation unit of a local hospital which has an excellent reputation, not only for patient care, but for employee satisfaction. I'm about to begin my third week on the job, and I love it there! While I sincerely miss my former co-workers and former patients, I feel that I can function much more effectively in an environment where management at least makes it POSSIBLE for an employee to be successful. Those of you who'll continue to stay in the "rat race" of extended care, I do take my hat off to you...you're far better people than I'll ever be.
UPDATE WEDNESDAY, 15 AUGUST 2007:
Wow! I can't believe I've neglected my website for so long! For so many years, I maintained this site faithfully...and lately, I've neglected it shamefully. Yes, I've been busy at work, and I've also been tied up with the day-to-day operations of my everyday life. Still, it's shameful that I've neglected this site for so long, especially when you consider the amount of money that I pay every month just to keep it online...
Anyway, a lot has changed since my last update -- no real surprise there, considering the fact that it's been more than a year since then. Unfortunately, despite my good intentions, I only lasted a little more than one year on the rehab unit of my current hospital...rehab nursing is a whole different philosophy that what I'm used to -- and despite the fact that it DOES, indeed, have its place, quite frankly, after a year on that unit, I was getting entirely too fearful that I'd lose all of my hard-earned nursing skills. Quite frankly, when over that year, I've done nothing more technically challenging than transfusing a unit or two of blood and providing trach care on an occasional basis, I had reason to be concerned. My concern became outright FEAR, when I saw how completely intimidated my rehab co-workers were whenever they were floated to the medical and/or post-surgical units. I can see why they were intimidated...if the most "technical" stuff that you normally do is pill passing and "potty patrol" duties, undoubtedly, you're going to be intimidated when you have to perform REAL nursing responsibilities! Obviously, I did NOT want to find myself in a similar position, so, as much as I loved rehab nursing and my co-workers on that unit, I decided that it was high time for me to make a transfer...and, since June of 2006, I've been working on the critical-care stepdown unit of my current hospital, have become ACLS (advanced cardiovascular life-support) certified, and have added to my nursing skills in a big way overall. And yet, while I love the excitement of my current position, I STILL have pangs for the "old days" in the ECF environment. At the most, I care for the patients on my unit for only a few days before they're transferred to the medical unit or discharged home. Obviously, I don't have the opportunity to form "relationships" with my patients as I would if I'd been able to care for them for months or even years. With that in mind, I have high hopes for my best friend, Doug's, new position...he's recently accepted a DON (director of nursing) position in an ECF in Michigan City. Supposedly, the Administrator of said Facility subscribes to Doug's nursing ethics and will allow him to staff the building appropriately. We'll see...if this turns out to be the case, you might actually see me returning to my first love, the ECF (or "nursing home") environment. I'll believe it when I see it, though...