Changing Perceptions of Long-Term Care Nursing

The history of long-term care (LTC) nursing is not so glamorous, and once researched it is easy to see why so many stakeholders, including nurses, have had to work hard to change practices in order to change perceptions. Around the start of the 20th century in America, poorhouses, almshouses, and poorfarms were terms commonly used for the place elders went to live when they could no longer care for themselves at home. Of course, elders at that time were much younger than what we think of today, with people in their late 40s and early 50s considered elderly. Regardless of what the institutions were called, they often included a vast mix of residents, such as children, homeless individuals, criminals, and the mentally ill, contributing to poor care and conditions.

In the 1920s, the US Department of Labor reported on the indecencies and inadequate living conditions of many almshouses throughout the United States. In 1925, Harry C. Evans wrote The American Poorfarm and Its Inmates in his appeal for a radical change that called for abolishing poorfarms. Although the horrible conditions of poorfarms were well documented, it was not until a decade later that the passage of the Social Security Act in 1935 enabled Evans’ vision to come to fruition. Following the Act, states started closing their almshouses and returning the inhabitants to their families or placing them in more suitable private institutions, where they were finally accepted because of their new monthly Social Security payments. Still, this process took many years, and people continued going to poorhouses even into the 1940s and 1950s. It was not until 1950 that LTC providers were allowed to receive payments for the care they provided and that regulations were established to address the living conditions and the quality of care provided. Finally, amendments to the Social Security Act in 1965 resulted in the creation of Medicare and Medicaid, which have been crucial in securing quality care for elders, but have posed numerous dilemmas over the years, including today, a little more than 45 years later.

Today’s LTC nurses struggle with a new barrage of challenges related to regulatory and compliance issues, and it often feels as though we are walking through a minefield while juggling a number of balls labeled MDS, PPS, RUGS, PPDs, F-Tags, HIPAA, State Regs, among others. How do we keep all the balls in the air while avoiding the multitude of landmines in the field? LTC has evolved into such a complex area of care that it requires the brightest and most skilled nurses, social workers, therapists, dietary managers, activity professionals, and others who are committed to learning and developing their skills.

Although LTC services are extended to adults 18 years and older, the majority of those who require either short-term assistance or LTC services are older than 65 years. This demographic often presents with complex comorbid conditions that require multiple disciplines to provide a variety of interventions to promote the highest practicable well-being in older adults. Even in the face of illness and complex disease processes, people can achieve a state of well-being through services that address their physical, cognitive, emotional, and spiritual needs. Homeostasis, defined as the state of a balanced and stable condition, can be achieved and maintained when all needs in these areas are identified and consistently met. Serenity, peace of mind, being able to focus on a meaningful moment, engaging in a joyous event, socializing with others, having a satisfying and nutritious meal, and feeling valued and loved are all important factors that can affect homeostasis, yet when a person enters LTC, he or she may feel stripped of human dignity and the ability to partake in these joys of life, resulting in a poor outlook for the future. 

LTC nurses who are dedicated to their profession, however, can change this bleak outlook by coupling the science of care with the art of care to execute and maintain standards in the LTC setting, an environment where nurse-resident relationships are built on respect and trust. The LTC niche in nursing is best served by educated individuals who understand that personhood does not decline with illness and that those in need are still contributors to the human condition. Interacting with elderly persons can be rewarding in indescribable ways, as there is much to be gleaned from these individuals’ tremendous life experiences. Even residents suffering from end-stage cognitive impairment may have a moment where they engage with others via a look, touch, or smile.

The dedication and commitment of LTC nurses is easily found in skilled nursing facilities, assisted living centers, and home health agencies throughout the United States. Although the reimbursement cuts, staffing issues, and management of pharmacy and other ancillary services are challenges that will continue into the foreseeable future, and all of these issues will need to be managed, nurses will tell you that the most important facet of their job is their residents. They will often talk passionately about how they advocate for the rights and wishes of their residents and how they will work long hours to accomplish what is needed for their residents. Nurses will also speak of fondness of their seemingly small victories, such as their success healing a stage 4 wound or how they were able to ensure that a resident who suffered a stroke received the therapy needed to regain functioning. Such small victories and meaningful moments shared with residents make the job worthwhile and rewarding.

Elevating the reputation of LTC nurses has been a rocky road. Changing our actions, values, and perceptions, as well as the rules and expectations at facility and governmental levels, all take time and repetition. Associations such as the American Association for Long Term Care Nursing (AALTCN) have worked hard to organize and focus nurses’ efforts to increase care quality and promote resident choice, leading to positive outcomes that are continuously changing the face of patient care in an area that was once considered undesirable and depressing. The AALTCN also recognizes the importance of professional growth in LTC, an area where the knowledge and expertise required surpasses many less complex areas of nursing. 

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The AALTCN comprises an executive board, thousands of members, and numerous business partners who understand the importance of continued advocacy and support of nurses working to make a difference in LTC. We as a group know that there is power in numbers, and that increased passion and ongoing professional development is key to attaining and maintaining excellence. The AALTCN offers many avenues of education and certifications to augment the knowledge base of LTC nurses and gives recognition to this growing nursing subspecialty.

As a director of nursing and licensed nursing home administrator, my goal is to motivate, educate, mentor, and support my organization’s registered and licensed practical nurses, certified nursing assistants, and ancillary staff in such a way that they feel both valued and vital to maintaining our mission to truly make a difference in the lives of our residents. Supporting nurses in their professional development has a direct impact on their confidence and competence. Further, allowing them time to enhance their relationships with their peers leads to the staff feeling connected to their team, which also has a positive effect on resident care.

I am proud to say that more than 90% of the nurses in my facility are certified in LTC nursing, and they have often thanked me for this educational opportunity. Although on-the-job learning is invaluable, the education received in a classroom setting should not be undervalued. I have often heard nurses say things like “this class really connected the dots,” or “the information was relevant and made me finally understand the big picture.” For example, with the often frenetic pace at LTC facilities, it may be impossible for a nurse to take the time to determine how the entire care team works together from a care plan to assist a resident in achieving various goals, but this is a topic that class discussion can quickly shed tremendous light on. AALTCN’s certification classes are well balanced, addressing many important facets of LTC nursing, such as leadership, regulatory issues, finances, and meaningful documentation, including the multitude of ways documentation is used.

A staff that feels prepared, knowledgeable, valued, and connected with their team will be better equipped to care for residents, leading to better outcomes and increased resident and staff satisfaction. They will also be more likely to stick with their employer, resulting in less turnover, another factor that can have a tremendous effect on care outcomes. Providing ongoing meaningful education is a win-win situation all around and can factor largely into our ability to further improve the perception of LTC services.