Long-term care nurses speak out: Midwest nurses speak freely about their likes and dislikes in long-term care. (Feature Article).

The healthcare industry is facing an international nursing shortage, and implications of this crisis are emerging for the long-term care (LTC) industry. With this crisis there is no question that services and care for elderly clients will suffer, but more alarming is that the survival of many small- and medium-sized facilities will be threatened. Fortunately, there are a few strategic forces LTC administrators can draw on which are not available to acute-care administrators. To develop this defense, however, LTC administrators need to listen and respond to the priorities and values of their nurses, as well as address their concerns and frustrations.

In an effort to better understand nurses who work with elderly clients, we interviewed 50 nurses about their typical days, satisfactions and dissatisfactions, and feelings about their coworkers and patients. Half of these nurses worked in nursing homes, five worked in assisted living facilities and 20 in home care agencies (see sidebar). They all had direct patient care responsibilities, primarily caring for the elderly. Each nurse's interview was scheduled for one hour and had open-ended questions so the nurse could decide what stories or feelings she wanted to share with the interviewer. All interviews were tape-recorded, transcribed and then analyzed, with all personal and facility names deleted from the transcripts. (Interviews were conducted by Dr. Buelow and two graduate students. Both authors analyzed transcripts.)

Most of the nurses seemed to enjoy their interviews and thanked us for our interest. Although we paid them for participating, many said they felt uncomfortable getting money for being able to have someone listen to them.

Typical Days

To describe nursing home work, one 30-year-old registered nurse succinctly stated, "Passing meds to 35 to 40 people, taking care of all the treatments, doctors' orders, charting, overseeing all the nurses aides and dealing with people that are in a crisis situation." A nurse in an assisted living facility stated she performed primarily the same duties that her counterparts in nursing homes did, only with less pressure. One assisted living nurse said, "I do things like setting up their medications, [getting them ready for] going to the doctor, getting their letters ready, doing all the quarterlies and assessments. If there are certain ones who don't have family around, I take them to the doctor's office.... [Also], I am the supervisor of the aides."

In comparing long-term care to hospital work, most nursing home and assisted living nurses emphasized that they took care of patients for an extended period of time, so they got to know patients and their families much more than hospital nurses do. One nursing home nurse stated, "In the hospital your basic agenda is life saving. In this facility, your basic thing is comfort and quality of care."

Satisfactions

In response to "What's the best thing about working here?" a common theme was heard from nurses in all three organizations: "The best part of our work is caring for our patients and doing worthwhile work." Many of the nurses working in nursing homes and assisted living facilities emphasized how emotionally close they felt to their residents because they had known them and their family members for such long periods of time. One nursing home nurse said, "I guess why I have chosen to stay in this type of setting is that I enjoy seeing the patients for a lot longer stay than in the hospital. It's nice to get to know the patients and their families." Another nursing home nurse said, "I like the feeling that you're doing something for the resident and making life just a little easier for them, being that they have to be here."

The assisted living facility nurses agreed, but said they also appreciated their less stressful atmosphere because of residents' relatively minimal care needs.

These intrinsic satisfactions, however, are only possible for nurses when the facility administrator is sensitive and receptive to nurses' dissatisfactions. To the extent this falls short, the LTC industry finds itself in the same nurse staffing crisis as its acute-care counterpart.

Dissatisfactions

To determine dissatisfactions, nurses were asked the question, "What is the worst thing about working here?" The nurses' initial response was often quick and off the cuff, as though they preferred to move on to a more client-centered dialogue. So, after we listened to the nurses describe their clients, their needs and typical requests, we asked, "What interferes with you giving clients this care that they desire?"

The nurses' answers moved into their areas of dissatisfaction and provided the details we sought. Surprisingly, not one nurse said that she felt her clients were truly satisfied and getting all the care they wanted. Some said they gave the best care possible under the circumstances, but knew there was more they could do--if only they had more resources. "You never have enough time to do all the things you'd like to do," was a response often heard.

One nursing home nurse explained, "Spending a little bit of time with the residents is something we can't do because we just have to give them their [essential] care and move on to the next thing." Another nurse elaborated, "The one thing that prevents [caring for the residents] is low staffing. This means you become very resourceful of the time that you do have. You need to utilize every minute in a good manner and you need to maintain a steady pace in your work because you never know what's going to happen an hour down the road."

Assisted living nurses recognized staffing problems as interfering with caring, too. One such nurse validated this by saying, "I guess what interferes with that [resident care] is when the nurse-to-patient ratio is 1:40, you don't have the time to sit down and visit with them as much as you'd like to."

Most nursing home and assisted living nurses inferred that staffing problems or, more specifically, the high resident-to-nurse ratios, were at the root of their dissatisfaction. Although most of their answers centered on staff vacancies or absenteeism, related aspects of this core problem were often verbalized. Descriptions such as "poor morale," "ambivalent administrators" and "undependable aides" were often heard. One nurse, with a frustrated sigh, said that the worst part of her job was "staff turnover, staff morale and staff confidence."

After describing their frustration and unhappiness, some nurses seemed a bit uncomfortable with their choice of words and provided excuses for their facility or administrator. Several nursing home nurses stated that their lack of time wasn't because of staffing, as they had the "state-required ratio." One nurse claimed, "We have the minimum number of staff that we have to have for the state, but," she admitted, "it still doesn't seem to go far enough." Another nurse said, "There are a lot of people that we are in charge of during the day.... It's not that we're short-staffed, but it's just impossible to get everything done."

These comments from nurses provide a warning to LTC administrators: The one common denominator for all identified "dissatisfactions" was the denial of quality time for nurses to care for their clients, the aspect of their work that they appreciated the most. It appears that nurses care greatly about their elderly clients, their progress and their comfort. When an institution interferes with this aspect of her job, a nurse's intrinsic satisfaction, as well as her professional integrity, is diminished.

Other Implications for Administrators

Administrators of LTC services cannot afford to be oblivious to the above perspectives. First, nurses are in high demand, and long-term care is just one of many job opportunities in healthcare--and one that is ranked low in terms of professional prestige. Second, nurses are truly the "heart and soul" of longterm-care. For an LTC organization to obtain a competitive advantage, nursing care cannot be compromised. Rumors and reputations concerning a facility's "overworked, frustrated nurses" will not be overlooked during a hiring period. Likewise, the domino effect of nursing frustration on peers, nursing assistants, clients and family members only moves an organization still farther away from success.

A thorough study of the conversations we had with these 50 nurses reveals that most nurses are working with underlying conflicts. Nurses in long-term care value the time they spend with their elderly clients and family members. They treasure the one-to-one communication involved; it provides professional pride and personal rewards. These ideals and internal rewards are in jeopardy, however. Overwhelming staffing ratios, demanding documentation and the impact of staffing problems indicate that nurses' struggle to maintain job satisfaction will continue.

Only through successfully overcoming the identified causes of nurses' dissatisfaction can administrators turn the tables and develop nursing care as their competitive advantage. LTC organizations offer a supportive environment for this: clients with chronic problems, and many with interested family members willing to get involved. Creating policies and practices that recognize the intrinsic satisfactions of LTC nursing can build on this. These might involve allotments of "uninterrupted caring time," staff recognition events and highlighting "caring moments." "Caring" is one of the most recognized trademarks of nurses in general, let alone of those in long-term care specifically. Administrators in long-term care have an opportunity to exploit this motivator, and to protect it and promote it.

RELATED ARTICLE: Home Care Nurses' Responses

The home care nurses interviewed usually gave more details than their long-term care colleagues about their typical days. One description from a home care nurse was, "Typically t see 6 to 7 people in a day and I travel around and visit them in their homes. Sometimes we have admissions to home care and those take longer. More of our time is spent doing paperwork than [providing] care. We draw blood, do dressing changes and help [clients] with tube feedings if they have those." Another home care nurse, who works in an agency that provides each nurse with her own laptop computer, described her typical day this way:

"My day usually starts at 7 a.m. on the telephone.... I usually see my first patient between 7:30 and 8 a.m. I go in and take temperature and blood pressure and talk to them. A lot of times the people we see are homebound and the only people they see in the day is us.... I dress the wound and that's about 45 minutes and I finish charting and go on to the next one. I chart between visits and generally am done by 2 p.m. I come into the office and export my stuff. Paper work is never ending. I'm done between 3 and 4 p.m. usually."

Home care nurses stressed that compared to hospital nurses, they were more able to provide their patients with uninterrupted time, teaching and caring for them at their level of understanding.

Home care nurses generally said that giving care for patients in the comfort of their homes and being able to give sole attention to one patient at a time comprised the best part of their jobs. Some added that another aspect of the job that they considered satisfying was the independence and autonomy it allowed. One home care nurse said succinctly, "The best thing is that I'm in control of what I do."

Home care nurses were the most verbal of the three nursing groups regarding what they regarded as the worst part of their jobs: keeping up documentation for Medicare reimbursement. Some agencies used computers for this work, others still had their nurses doing paper charting, but both sets of nurses complained about the situation. One home care nurse said, "The worst [aspect of work] is the paperwork. It's more than I've done in other areas of nursing. There are so many guidelines and how they apply. My documentation has to be superb to make sure we get maximum reimbursement." Another home care nurse stated, "OASIS [an outcome tracking system mandated by the federal government] is 100% paperwork and has nothing to do with the patients. Why can't they come up with 10 questions instead of 17 pages.... It's killing us. I'm to the point that I don't care if I do my job or not. I love the patients but the stress level around here is enormous."

Janet R. Buelow, PhD, is a professor of health services administration at The University of South Dakota School of Business, and Mariette Cruijssen, MW, at the time of the study, was a graduate student in health sciences at The University of Maastricht, Netherlands. All nurses interviewed in this study worked in organizations located in Iowa or South Dakota. For further information, phone [phone] or fax [phone].