Improving the image of LTC nursing

A dear friend of mine was recently admitted to hospice. In the course of discussing my friend’s care, I asked her nurse how long she had been a hospice nurse.

“Fourteen years,” she said.

“Well, then, you must love it,” I responded.  

She said yes, and then asked me what field of nursing I was in. When I told her “long-term care,” she asked—in the nicest possible way—if I was in this field because I was “stuck.” I said I do not feel that way; that I love long-term care. We were interrupted and did not continue our conversation, but this exchange got me thinking once again about the image of LTC nursing.

I have to admit I originally went into long-term care because I was working in intensive care at a large Denver county hospital and there were just too many attending physicians, residents and medical students for me to ever use my physical assessment skills in my practice. So I moved to long-term care as a director of nursing—and then the pressure was really on. I knew if I missed a possible health issue with a resident, that resident would likely die. Still, I enjoyed the challenge of loving residents, knowing them well and understanding that if I failed to report my observations to physicians, residents would be in serious danger.

This is what I loved about long-term care: The pressure to be a great nurse drove me. My finest moments as a nurse have been when, by knowing a resident, I could bring together her physical, psychosocial and medical needs so she functioned at her highest level until the time of her death. These were some of the richest experiences I have had in life.


Since the early ’80s, when I was a DON, there has been a huge shift in case mix. Residents are much sicker now with more complex care needs. Nurses are under even more pressure to understand what they are observing and report to physicians or physician extenders. Residents now have multiple comorbidities and are at even more serious risk of dying in the absence of nurses who have expert physical assessment skills, critical thinking skills and expert knowledge of the residents and their histories.

Given the pressure to be the highest-functioning nurses in healthcare, with little physician oversight, and with some of the sickest people in the healthcare system entrusted to our care, how did it come to pass that we in long-term care would be the disrespected “stuck” nurses? How do we make it clear that we are not stuck in our jobs and are not the ugly stepchildren of the healthcare field?

It is critical that we make our case for the expert care we provide, or the future will be quite bleak for elders who are admitted to long-term care—a future that is not far away. As clearly indicated in the Institute of Medicine’s (IOM) 2008 report, “Retooling for an Aging America: Building the Health Care Workforce,” we are looking at a growing elderly population with an insufficient nursing workforce. Nurse leaders will be tasked with managing their nursing staff to care for more residents with fewer nurses. The report points out the lack of new direct-care workers as well as nurse leaders specializing in geriatrics, and then blames it all on high turnover, low pay, poor working conditions, high rates of on-the-job injuries and low opportunity for advancement.

This is supported by a more recent 2010 IOM report, “The Future of Nursing: Leading Change, Advancing Health,” which indicates the importance of nurses being involved in healthcare decision making while having the opportunity to practice to the full extent of their education. The report called for more doctoral-prepared nurses, ensuring we are capable of providing adequate education to new nurses in this changing environment. It also suggests better overall supervisory relationships, greater opportunities for growth and more commensurate salaries for nurse educators and leaders.


To summarize our present dilemma:

1.There is a growing number of elderly in the United States.

2.The nursing population is growing at a much slower rate than the elderly population.

3.There are not enough doctoral-prepared nurses to provide adequate education and training to new nurses.

4.There is a high turnover rate of both direct-care workers and nurse leaders in long-term care.

Where can we as nurse leaders support LTC nursing while making it clear this is our profession of choice? First, we must take pride in the care we provide and speak out about the field we love. Next, we must use every teaching opportunity with residents, families and the public to convey how important our work is and what we do on behalf of residents. We must also take a stand with other nurses and stop the bias—if not outright prejudice—that exists in our own profession, which sees us as second-class citizens. And finally, we must begin advocating for our professional work through legislative and policy channels to reinforce that we are not “stuck” and are in fact some of the highest-functioning nurses in healthcare—after all, without our expert skills, residents die.

Years ago, the flight attendants in Denver went on strike and their bumper stickers read: “I’m not here to serve you. I’m here to save you.” I believe the same argument could be made for LTC nursing. We save lives and it is time others were aware of it.

Diane Carter, RN, MSN, CS, is the President, CEO and founder of the American Association of Nurse Assessment Coordination, a nonprofit organization dedicated to education, networking and advocacy for nurses in long-term care.

Topics: Articles , Leadership , Staffing