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In it for the long term

Long-term care nursing comes into its own as a challenging career

Jun 01, 2011

It can be intimidating, if not downright scary for RNs considering a career in long-term care (LTC) to hear that patient-to-nurse ratios can be 50-to-1, or even 100-to-1. But many RNs working in LTC find their jobs to be professionally and personally rewarding. Josie Ryan and James D’Astolfo are two of them. 

Ryan, director of In Care Living at Northwood, an LTC facility in Halifax, emphasizes the number of career opportunities that are available to nurses who choose to work in LTC. “We have hospice nurses, nurse practitioners, nurse managers, nurse clinical leaders, facility supervisors, educators and occupational health nurses. You might start as a staff nurse, but there are places to go.”

James D’Astolfo, an RN who has been working in LTC in the Toronto area since graduating in 2007, believes a lot of new grads shy away from the field because they are under the impression that only diploma RNs work in LTC: “They think of it as a lesser setting where they would lose their skills,” he says. D’Astolfo insists that’s not the case, explaining that nurses in LTC have to make full use of their skill sets, ranging from assessments to supporting and interacting with families, often times more so than in acute care settings.

A major study on LTC facilities by the Canadian Healthcare Association reports that staff who thrive in this environment share characteristics such as empathy, patience, and a desire to learn and make a difference in the lives of others. Pamela Slobodesky, a hospice-palliative care consult nurse at Northwood, suggests, however, “it’s not a walk in the park. Many of our residents are very sick people, so it’s quite challenging and you learn a lot about yourself quickly. You have to depend on your own skills and knowledge base, and for some nurses it can be too much responsibility to handle.” Being organized and knowing how to prioritize are key for success in the job, she adds.

Long-term care in Canada, by the numbers

Number of public and private long-term care facilities in 2007: 2,577
Number of beds in 2007: 217,969
Estimated number of residents by 2031: 560,000 to 740,000
Number of RNs working in long-term care in 2009: 25,433
Percentage of all RNs working in long-term care in 2009: 9.9%
Number of RNs with CNA Certification in gerontological nursing in 2010: 2,118

Sources: Canadian Healthcare Association, Canadian Institute for Health Information, CNA

So is the makeup of the care team. In most LTC facilities, an RN supervises licensed practical nurses (LPNs) and personal support workers (PSWs), who comprise the largest group of employees on the unit. Interprofessional collaboration is the foundation of the care model, with each member of the team working to the full scope of practice. Although each resident is assigned a physician (or has a personal physician of his or her own), it is the nurses who are onsite 24 hours a day. RNs are responsible for assessments, care planning, scheduling and charting. Nursing treatments such as skin and wound care, medication administration, tube feeding, ostomy care and ventilation assistance are planned and performed by the RNs and LPNs. Help with toileting, eating, hygiene and dressing is usually provided by PSWs under the supervision of the RNs and LPNs. Nutritionists, social workers, pharmacists and physio and occupational health therapists round out the team and are an essential, if intermittent, part of the care most patients receive.

One of the most important, yet often overlooked, parts of the nurse’s role is communication, both with residents and their families. In today’s patient-centred environment, family members are becoming much more involved in the care of loved ones than they were in the past. They are more likely to ask questions and to want to participate in the physical care and be informed of changes in care plans or health status. Some facilities have instituted family councils ¾ a formal mechanism to bring forward any concerns and give input in the planning of programming and facilities. Family involvement has even decreased the need for volunteers in some roles. At Northwood, for example, a group of trained palliative care volunteers sit vigil with dying residents, so they won’t be alone in their final hours. In the last five years, however, there has been a shift, and many residents now have loved ones who will perform that role.

Not just seniors

According to Statistics Canada, in 2006 almost 25,000 people under the age of 65 were living in a special care facility — nursing home, senior citizen’s residence, chronic care facility or long-term care facility. These younger residents may have brain injuries, multiple sclerosis or be severely disabled and unable to live at home, even with support.

The trend toward family-provided care means that seniors are staying in their homes for as long as possible. The vast majority of Canadian seniors — 93 per cent — live in some form of private dwelling, whether it’s their own or one of their relative’s. Even still, the number of seniors living in long-term care facilities in 2007 was estimated to be more than 230,000. With the country’s population predicted to grow to 35 million people in the next 30 years, and the number of Canadians aged 85 and older nearly doubling in the next 15 years, the demand for long-term care beds will only increase. It is the onset of dementia or incontinence that often necessitates admission to an LTC facility. Dementia affects eight per cent of seniors over age 65, and its prevalence increases with age — up to 35 per cent of people aged 85 years and older. The percentage of residents requiring complex care, such as dialysis, suctioning, transfusions and lung aspiration, is also increasing.

These numbers speak volumes about the need for eager and dedicated professionals willing to enter a field long considered somewhat second-rate. D’Astolfo says that not enough nursing students are exposed to LTC settings. “More education needs to be done to get students thinking about it as a career option, and more practicums should be offered as well.” Although some nurses believe that you need to have experience in acute care before even attempting to work in LTC, others maintain that with the proper support and mentoring a lot of young nurses who are bright and want to develop their skills can do very well.

For Evelyn Sutherland, a nursing manager at Northwood, the residents are what drew her to LTC. “I love the geriatric population,” she says, “and I feel very strongly about being their advocate.” She laughs at the misperception that a move from acute care to LTC is a way for nurses to slow down. “I’ve heard some say, ‘I’m just coming here because it’s easier.’ They think it’s like semi-retiring. Nothing could be further from the truth.” And she adds, there is a unique privilege in being able to care for those who are getting ready for the most important journey they will ever have to make — “their celestial discharge.”