For too long, the stigma of LTC facilities has negatively impacted the delivery of healthcare for the nation’s elderly population. Stigmas that have been associated to LTC nurses and students include impressions that nursing home nurses do not have the same skills as hospital nurses; the nurse/patient ratios are too high in long-term care—inadequate certified nurse aide staffing, most graduate nurses want to work in specialty areas—caring for the elderly is a less attractive option; nursing homes are places where nurses work until they can get hired at a hospital; and other practitioners often look down on LTC nurses.
In a recent literature review, Koh2 concluded that negative student clinical experiences in long-term care may be related to students’ perceptions of caring for the elderly and a lack of pre-placement orientation to the practice environment. Conversely, “student exposure to experienced nurse faculty, or 'link lecturers,' which provided both didactic information and supervision in their own practice settings, was viewed by students as positive and inspirational.”3 The information from this study can be used as a framework to empower nurse educators in developing curricula that incorporate strategies for teaching for a sense of salience and situated use of knowledge.4 Preparing students in advance of their clinical placement with geriatrics experts can optimize the learning experience and reduce the stigmas that have impacted long-term care.
Today, empowered by the work of the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine,1 nurses are realizing their role in this vision. As stated in the report, “the nursing profession has the potential capacity to implement wide-reaching changes in the health care system … by virtue of their regular, close proximity to patients and their scientific understanding of care processes across the continuum of care, nurses have a considerable opportunity to act as full partners with other health professionals and lead in the improvement and redesign of the health care system and its practice environment.”
BARRIERS REPORTED BY LTC NURSES
Geriatric nursing is a person-centered practice and requires the best of nursing. Raterink identified facilitators and barriers to critical-thinking skills for LTC nurses.5 Issues identified include teamwork, staff support, staffing patterns that allowed for consistency in care and team effort, administrative engagement—lack of communication and appreciation for hard work by the management staff, frustration with high volume of paperwork, poor physical state of the work environment and lack of adequate vacation and sick benefits.5 Study participants saw the level of complexity and acuity LTC patients as an opportunity to improve/maintain their clinical and critical-thinking skills. These findings suggest that the organizational structure and culture play a significant role in supporting these skills in LTC nursing staff.
Understanding barriers to effective communication is an essential aspect of safe patient care. In a recent study,6 telephone communication was identified as occurring more often in long-term care than in any other clinical setting. For this reason, it is important to understand nurses’ perceptions of nurse–physician telephone communication that compromise care delivery and to identify strategies for improvement. Barriers include: lack of physician openness to communication, logistic challenges, a lack of professionalism and language barriers.
Physicians in the study reported that nurses needed to be brief and prepared with relevant clinical information when communicating with them. As identified by the researchers, a combination of nurse and physician behaviors contributes to ineffective communication. “Interventions to improve the effectiveness of communication in the LTC setting must target both nurses and physicians to create a culture that facilitates effective communication with improved patient safety and healthcare quality as the ultimate goal.”6
CHANGING THE CULTURE
Across the nation, nursing homes are embracing the philosophy and value of culture change. Nurses thrive in this environment that provides hope and empowerment of the elders and staff. To transform the institutional model, new approaches to care delivery focus on person-directed model, which helps to alleviate the fear of individuals needing institutional care and contributes to the overall job satisfaction of nurses.7
The John A. Hartford Foundation's Centers of Geriatric Nursing Excellence National Nursing Home Collaborative creates opportunities for geriatric nurses to change the structures and processes of elder care in LTC facilities. When nurses engage in creating, implementing and sustaining a professional practice model, they gain a renewed appreciation for nurses.8
The Everyday Excellence Framework for Professional Nursing Practice in Long Term Care is based upon eight guiding principles: Valuing, Envisioning, Peopling, Securing, Learning, Empowering, Leading, and Advancing Excellence.8