Navigating Long-Term Care - A Practical Approach for Nurses

By Sylvia Abbeyquaye

Despite the training nurses receive in school, nothing prepares them for the reality of working in a long-term care facility.

 

Achieving success as a long-term care nurse requires understanding organizational structures, state and federal regulations, and work processes. It can be discouraging when the quality of one's work is questioned, especially after putting in hard work. It is even more morally distressing when one is hardly oriented to or trained on their work processes, as is common in long-term care practice.

 

Feeling morally distressed creates a toxic work environment, leading to burnout and turnover among nurses. Change must happen, and it must be sooner if we are looking to recruit and retain more nurses and achieve quality care in facilities throughout the United States and beyond. 

 

Navigating Long-Term Care: A Practical Approach for Nurses is a comprehensive guide for long-term care nurses to enhance their understanding of organizational structures, state and federal regulations, and work processes. This 15-chapter manual uses the nursing process as a critical thinking framework and covers crucial aspects of resident care.

 

In this  book, you will learn new strategies on how to:

 

• Navigate your role as a long-term care nurse
• Communicate effectively with clinicians and the interdisciplinary team
• Accurately complete resident admission processes -assessments, medication reconciliation, and order transcriptions
• Manage discharge procedures, including acute transfers and RN pronouncements
• Navigate the care planning process
• Prevent and manage infectious disease outbreaks
• Prevent and manage resident fall incidents and other sentinel events
• Navigate Quality Assurance and Performance Improvement (QAPI) processes and much more.

 

Also included are case studies and post-chapter questions to evaluate understanding, making it an excellent resource for facility educators and training purposes.

 

This book differs from what already exists as it is candid and geared to empower long-term care nurses to provide high-quality care that meets the standards set by the Centres for Medicare and Medicaid Services (CMS) and their organizations.

 

Facility educators will benefit from the unique approach presented in this book, as it offers engaging and interactive methods for new hire orientations, annual staff retreats, and ad-hoc training.

 

This book is an essential tool for new grads and all long-term care nurses seeking to improve their practice and provide the best care possible to residents and their families.

• Language: English
• Publisher: NSD PUBLISHING
• Release date: Aug 1, 2023
• ISBN: 9798985097207

Book preview

Sylvia Abbeyquaye PH.D MPA RN

NAVIGATING LONG-TERM CARE

Copyright © 2023 by Sylvia Abbeyquaye All rights reserved.

No part of this book may be used, reproduced, or stored in a retrieval system or transmitted, in any form or by any means, including mechanical, electronic, photocopy, recording, scanning and methods not invented or in common use at the time of this publication, without the prior written permission of the publisher. The use of short quotations or occasional page copying for personal or group study is permitted and encouraged. Permission will be granted upon request.

Publisher

NSD Publishing www.nsdxpert.com

First Edition

ISBN-13: 979-8-9850972-0-7 - Ebook ISBN-13: 979-8-9850972-1-4 - Paperback ISBN-13: 979-8-9850972-2-1 - Hardback

Printed in the

United States of America and United Kingdom

Produced by

Vike Springs Publishing Ltd. www.vikesprings.com

For bookings, permissions and speaking engagements, contact: [e-mail]

Our books are available at special discounts when purchased in bulk for training, promotion or as donations for educational and training purposes.

Limit of Liability/Disclaimer of Warranty

This publication is designed to provide accurate and authoritative information regarding the subject matter covered. It is sold with the understanding that the publisher and author are not engaged in rendering medical or clinical advice, and the author makes no representations or warranties with respect to the completeness of the contents of this work. Case studies used in this book are fictitious and solely for educational purposes, and the names of persons or organizations used do not exist. Neither the publisher nor the author shall be liable for damages arising here from. The fact that an organization or website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information that the organization or website may provide or recommendations it may make. Due to the ever-changing information on the web, Internet websites and URLs listed in this work may have changed or been removed. All trademarks or names referenced in this book are the property of their respective owners, and the publisher and author are not associated with any product or vendor mentioned.

Dedication

To my mother, Mrs. Mary Araba Aryeetey RN.

Count it all joy when the Lord gives you the opportunity to serve humanity. He has given you an opportunity to bless you.

–Mrs. Mary Araba Aryeetey RN (my mother, my role model, and my confidant)

Rest in peace.

Foreword

Caring for the older adults who live and receive care in our nation’s 15,500-plus nursing homes is both a privilege and a joy. Like Dr. Abbeyquaye, I learned much about how to be a caring member of society from my mother. Indeed, in her practice as a Director of Nursing in a small private nursing home near the home I grew up in, she modeled compassion and dedication both at home and in her practice. When I was 16, she telephoned me one weekend, saying, Please put on one of my uniforms and come down here. I need you. I did so, of course, and then I was hooked. The residents opened up the world to me. They had lived rich lives, worked, traveled, raised families, laughed, celebrated, and grieved losses. I became a nursing assistant in that very nursing home, working evenings and the occasional day shift on weekends. There was no book such as this one, nor formal training for the nursing assistant role at that time, nor was there certification. I learned on the job from my mother, the other dedicated nurses, and the other nursing assistants. I didn’t question this at the time; it was simply how things were.

Fast forward to 2023, where we see a care setting that is diverse, complex, under-resourced, and understaffed. On the heels of the COVID-19 pandemic that shut down the US and the world in March 2020, nursing facilities find themselves with perhaps the most critical work- force challenges they have ever faced. Shifting demographics and demand had already created a looming healthcare workforce crisis before the pandemic. In the aftermath, nursing facilities have yet to see staffing recovery even to pre-pandemic levels, which were often inadequate. What gives me hope is that while so many left their healthcare jobs in nursing facilities during the pandemic, many leaders and frontline carers stayed. Their risk in showing up every day as they did was considerable. They put themselves and their families at risk because they cared. They loved their residents, and their residents loved them. As they watched nurses and healthcare workers in other settings being dubbed in the press as heroes, they carried on their mission without those same accolades.

Nursing facilities offer nursing students and all members of the nursing team the oppor- tunity to apply and hone their highest clinical skills while simultaneously deepening their relationships with residents whom they come to know and love as family. Every complex chronic illness is present among the resident population; there could not be a richer environment for learning about wellness, illness, life, and death. Yet nursing schools often don’t see the nursing facility as a clinical placement where nursing students can hone advanced assessment, critical thinking, and care planning skills, nor do they encourage graduates to seek roles in nursing facilities. As for practicing nurses and aides, it takes a special dedication to commit a career to serve the frailest of the frail in an environment where neither compensation nor respect is commensurate with other care settings.

Dr. Abbeyquaye is uniquely qualified to contribute to this timely, first-of-its-kind, compre- hensive training guide. Her deep understanding of the care setting from decades of experience, combined with her dedication to learning and teaching and exceptionally clear and accessible writing, will make this book an instant essential resource. The volume is organized in such a way that it can be used either as a quick reference guide on a unit, as a companion to classroom learning, or as a self-study guide – or all three. Each chapter offers invaluable training tips for educators, case studies, and essential conceptual and summary information presented as tables or diagrams. From start to finish and from A to Z, this book contains everything the nurse needs to know to practice safely and effectively in a nursing facility.

As for the future, there is much good work going on at the policy level in institutions of higher learning, and nursing associations to improve the care provided in nursing facilities. And there is no more important factor in quality care than qualified, committed, and well-trained staff. This book offers a road map for nursing facilities to follow in orienting new staff, refreshing learning for existing staff, and ultimately – bridging the gap between recruitment and retention. We need to hire the best of the best into nursing facilities, and we need them to stay. This book closes a training gap. In implementing it, nursing

facilities will be able to provide the necessary preparation for nurses to understand their roles, practice at the top of their skillset, and find fulfillment in their work. Nursing facilities won’t need to piece together training – they can simply buy the book. What an enormous accomplishment and contribution.

––––––––

JoAnne Reifsnyder Ph.D., MSN, MBA, RN, FAAN Professor, Health Services Leadership and Management University of Maryland School of Nursing

Baltimore, MD

Preface

I have been a Registered Nurse for about seventeen years, working primarily in long-term care settings in different roles. Before becoming a Registered Nurse, I was a Certified Nursing Assistant for four years. In 2018, I earned a Ph.D. in nursing and returned to work as the Director of Nursing Services in a geri-psych facility. Five days into a new job and role, one of the residents of the long-term care facility died unexpectedly. This incident elicited an investigation by the Department of Public Health. The investigation became a wake-up call for me and all the nurses working with me at the time. It called into question our understanding of the legal aspects of nursing, specifically, the Nurse Practice Act.

Many long-term care nurses need more understanding of their role as nurses and the significance of their practice to the Nurse Practice Act, the tenets and regulations of the long-term care industry, and work processes within these settings.

I made it my mission to bring awareness of these issues to long-term care nurses and to retrain them on work processes and practice skills. I began by offering four-hour leadership training sessions for all nurses on the weekends. The course’s principles were based on applying the nursing process as a critical thinking and work process model. The idea for this course emerged from findings from my dissertation on the process of transitioning adults from long-term care settings to the community under the Medicaid waiver program. The course feedback was positive, and soon the word got out, bringing on board new nurses who desired to work within the facility. The nurses yearned for more as they became more enlightened about working in long-term care settings. As a result, the quality of care at the facility improved. In addition, the staff and facility were rewarded with good comments on the DPH survey that year.

This fifteen-chapter book was written to share these educational concepts with the world of long-term care nursing. First, the book unravels what it means to work asa nurse in a long-term care setting. It provides teaching content for the long-term care facility educator and the nurse to practice prudently, safely, with authority within their jurisdiction and to understand their work processes. This book addresses issues such as the role of the long-term care nurse, time management, and customer service, using the nursing process as a critical thinking tool. It also presents a simplified step-by-step guide to complete standard long-term care clinical work and resident care processes, such as admissions, discharges, and care planning. In addition, the book presents realistic case studies that are intended to initiate conversations to improve practice. Each book chapter includes post-chapter test questions to help nurses evaluate their understanding of the chapter content.

Finally, the book suggests activities facility educators can use during in-person training sessions to make training fun and engaging.

I can attest that finding a trained facility educator or staff development coordinator who understands how a long-term care facility must function is a daunting task, especially with the current nurse shortage. Therefore, it is common practice for the Director of Nursing to appoint the Assistant Director of Nursing (ADON) or an experienced long-term care facility nurse to perform the role with no formal training. I strongly encourage nurses in such situations to obtain and read this book. In addition to Administrators, Directors

of Nursing Services, Licensed Practical Nurses, and Registered Nurses, this book is useful for those working in long-term care settings or those considering such a career.

This book will improve nursing practice and the quality of care for all residents living in long-term care settings.

Acknowledgment

Since I was little, I’ve wanted to write a book. The time has finally come. This journey has been rewarding and has helped me redefine and rediscover my mission in life. This dream has been realized with the help of God and, literally, the help of a village.

I want to thank my father, retired Ghana Air Force Group Captain George Aryeetey. Your parental style inspired me to strive for greatness. There is no doubt that your work, values, and ethics have influenced me and contributed to molding me into who I am today.

My husband, Dr. Tetteh Abbeyquaye, you are my greatest critic and support. I appreciate you answering my questions and putting up with my concerns and self-doubt. Your feedback has helped this book transition from merely a book on long-term care to a training manual that may spur improvements in long-term care nursing practice. I’ll be eternally grateful and forever indebted to you. I also thank my children, Banafo Abbeyquaye, Nai Abbeyquaye, and Parbi Abbeyquaye, for your suggestions and critiques and for helping me choose the final book cover.

To my sisters, Marilyn, Georgette, and Rosetta – thank you for all the support.

I want to express my profound thanks to JoAnne Reifsnyder, Ph.D., MSN, MBA, RN, FAAN, for writing the foreword to this book. In your capacity as former Senior Vice President and Chief Nursing Officer of Genesis Healthcare, your appreciation for this book as a comprehensive resource for developing long-term care nurses must not be underestimated. I am also grateful to Donna Zucker, Ph.D., RN, FAAN, a professor emeritus at the University of Massachusetts, Amherst, who graciously agreed to review and proofread the book. You have provided valuable feedback and input to this book as a leader, scientist, and nurse educator. Additionally, I am grateful to Karen Hesselberg, BSN, RN, a retired nurse educator at Quinsigamond Community College, for her careful review and extensive editing of this book. As indicated earlier, getting this book across the finish line has taken a village. I also want to thank Theresa Kittredge, RN, the past Director of Nursing at Holden Rehabilitation and Skilled Nursing Center, for reviewing the book. Your forty years of experience in long-term care and over ten years as a Nursing Director make you an expert in the field, and your feedback and discussions certainly feel like an endorsement of this book. Your text message, It’s awesome reading and much needed. Where was it years ago when we could’ve benefited? says it all! Thank you!

I cannot forget other leaders in the long-term care industry who mentored me and allowed me to experience what it meant to work as a Director of Nursing in a long-term care facility. My experiences certainly helped shape the development of this book. Among these are Scott Picone, BA, AD, CMCN, LPN, Essex Management Group; Debbie Wade, BSN, RN Wachusett Healthcare; Michele Auger, RN, Essex Management Group; Emily Vasquez, Esq., MSW, LICSW, LNHA; Deborah Frascatore, BSN, RN; Robert Juma, RN, CMC, Genesis Healthcare; and Regina Brown BSN, RN, Leominster Rehabilitation and Nursing Center.

It takes a team to be successful in this industry. A special thank you to Dr. Nelson Awer, Catherine Ojo, BSN RN, Jennifer Keddy, LNHA, Ruchi Patel, LNHA, Faith Bandama, SW, LNHA, Rodica Anghel, LNHA, RN, Felicity Abankroh, RN, Yaa Brago, NP, Theresa Urbanovitch, LPN, and Bernadette Capoccia, CNA. I also thank the nursing and certified nurse assistant staff I have been honored to work with.

Apart from the writing, there are many technical aspects to the development of a book. Thus, I would like to thank Victor Kwegyir and his team at Vike Spring Publishers for their excellent work in publishing this book. A special thanks goes out to Mr. Emmanuel Abbeyquaye, Peter Lippit, and their teams for coordinating and developing the initial illustrations for the book and coordinating the book design.

Furthermore, I would also like to thank my special friends, Roseline Yaaba Agyeman Prempeh, Stella Adu-Gyamfi, PMHNP, and AliMarie Galindo, Ph.D., MSN, ARNP – FP, for their kind words of encouragement and prayers and for being my greatest cheerleaders.

Last but not least, I want to thank the following companies for letting me use their copyrighted materials:

· Briggs Healthcare

· Centre for Policy of Ageing (formerly NCCOP), London, UK

· Nursing Times

About the Author

Dr. Sylvia Abbeyquaye, Ph.D., MPA, RN, is an experienced Registered Nurse and administrator with over 20 years of experience in long-term healthcare. She has a proven track record, having served in various roles, including CNA, staff nurse, nursing supervisor, and Director of Nursing (DON). In addition to her impressive career, Dr. Abbeyquaye is also a dedicated nurse educator, sharing her expertise with students aspiring to careers in healthcare through NSDxpert Education and Consultancy LLC, which she founded.

Dr. Abbeyquaye’s educational journey began at the University of Science and Technology in Kumasi, Ghana, where she received a Bachelor of Science in Biochemistry. She then migrated to the US and acquired a Master’s degree in Public Administration from Clark University in Worcester, Massachusetts. After that, she added a Bachelor of Science in Nursing from UMASS-Amherst, Amherst, Massachusetts, to her credentials. Finally, in 2018, she earned her Ph.D. in Nursing from UMASS-Amherst, Amherst, Massachusetts.

Her background encompasses a blend of nursing, rehabilitation, and education. She began her professional journey in nursing and rehabilitation, where she gained ten years of hands-on care experience and supervisory skills. Later, she transitioned to higher education, teaching pharmacology as an adjunct nurse educator at Salter College in Worcester, Massachusetts, for three years. Simultaneously, Dr. Abbeyquaye served six years as a nurse reviewer for the University of Massachusetts Medical School’s Acquired Brain Injury and Moving Forward Plan (MFP) Medicaid Waiver Program.

Dr. Abbeyquaye assumed the Nursing Director position at Essex Management Group in Worcester after her Ph.D. There, she developed and implemented a nursing leadership program specifically designed for long-term care nursing staff. She has extensive experience as a Director of Nursing in long-term care facilities. Currently, she holds the position of Assistant Professor of Nursing at the Massachusetts College of Pharmacy and Health Sciences (MCPHS) University in Boston. In addition, she is an adjunct professor at Endicott College, teaching advanced courses in qualitative research methods and measurement development at a Ph.D. level.

She is a visionary in the field of long-term care nursing, driven to implement reforms to enhance the quality of care and work processes. Her research focuses on developing staff and optimizing work processes in long-term care facilities to increase efficiency and deliver exceptional care.

List of Abbreviations

––––––––

AA: ADLs: ADON: AED:

A-FIB: AIMS: ANA: AV: BiPAP: BM: BIMS: BP: CDC:

C-DIFF: CHF: CLIA: CLIA: CNA: CPAP: CPR: CVAD: D/C: DME: DON: DPH: EHR: EKG: EMAIL: EMAR: EPA: ER: ESBL: ETOH: FAX:

GI BLEED: G-TUBE: HCP: HIPAA: H&P: HPPD: IADL:

ICD-10: ID: IDT:

IV: LAB: LBM: LPN: LTC:

Alcoholics Anonymous Activities of Daily Living Assistant Director of Nursing Automated External Defibrillator Atrial Fibrillation

Abnormal Involuntary Movement Scale American Nursing Association Atrioventricular

Bilevel Positive Airway Pressure Bowel Movement

Brief Interview of Mental Status Blood Pressure

Centers for Disease Control and Prevention

Clostridium Difficile

Congestive Heart Failure

Clinical Laboratory Improvement Amendment Centers for Medicare and Medicaid Services Certified Nurse Assistant

Continuous Positive Airway Pressure Cardiopulmonary Resuscitation Central Venous Access Device Discontinue

Durable Medical Equipment Director of Nursing Department of Public Health Electronic Health System Electrocardiogram Electronic Mail

Electronic Medication Administration Environmental Protection Agency Emergency Room

Extended-Spectrum Beta-Lactamase Alcohol

Facsimile Gastrointestinal Bleed Gastrointestinal Tube Healthcare Proxy

Health Insurance Portability and Accountability Act Health and Physical

Hours Per Patient Day

Instrumental Activities of Daily Living

International Classification of Diseases, Tenth Revision Identification

Interdisciplinary Team Intravenous Laboratory

Last Bowel Movement Licensed Practical Nurse Long-Term Care

MAR: MDRO: MDS:

MED ROOM:

Medication Administration Record Multidrug Resistant Organism Minimum Data Set

Medication Room

MED-SURG: Medical Surgical

MMQ: MOCA: MOLST: MRSA: NHRA: NPO:

O2 Sat: ORIF: OT: OTC:

P: PASSR: PCP: PCR: PDPM: PERRLA: PHI: PHQ: PIP: PMH: POCT: POLST: PPD: PPE: PPSV 23: PRN:

PT:

PT-1: PT/INR: QAPI: RA:

RN:

RR:

RX: SBAR: SNF: ST:

TB: TEMP: TAR: TPN:

VIT B-12: VRE: VS:

Managed Minutes Questionnaire Montreal Cognitive Assessment

Medical Orders for Life-Sustaining Treatment Methicillin-Resistant Staphylococcus Aureus Nursing Home Reform Act

Nothing by Mouth Oxygen Saturation

Open Reduction and Internal Fixation Occupational Therapy

Over the Counter Pulse

Pre-Admission Screening and Record Review Primary Care Physician

Polymerase Chain Reaction Patient-Driven Payment Model

Pupils, Equal, Round, Reactive (to), Light, and Accommodation

Protected Health Information Patient Health Questionnaire Performance Improvement Projects Past Medical History

Point of Care Testing

Physician Orders for Life Sustaining Treatment

Purified Protein Derivative

Personal Protective Equipment Pneumococcal Polysaccharide Vaccine-23 As Needed

Physical Therapy

Provider Request for Transportation

Prothrombin Time and International Normalized Ratio Quality Assurance and Performance Improvement Room Air

Registered Nurse Respiratory Rate Prescription

Situation-Background-Assessment-Recommendation Skilled Nursing Facility

Speech Therapy Tuberculosis Temperature

Treatment Administration Record Total Parenteral Nutrition Vitamin B-12

Vancomycin-Resistant Enterococci Vital Signs

Figures

List of Tables and Figures

Figure 1: The Nursing Process as A Critical Thinking Tool

Figure 2: A Sample Organization Structure in A Skilled Long-Term Care Facility Figure 3: The Chain of Infection

Figure 4: An Illustration of Handwashing

Figure 5: An Illustration of Alcohol Hand Rub Use Figure 6: A Step-by-Step Illustration of Donning PPE

Figure 7:A Chart Illustrating the Pour-Chart-Administer Process in Medication Administration

Figure 8: The Stages of Pressure Ulcer Development

Figure 9: A Step-by-Step Illustration of Wound Measurement

Tables

Table 1: Center for Medicare and Medicaid Short-Stay Quality Indicators Table 2: Center for Medicare and Medicaid Long-Stay Quality Indicators Table 3: ANA Nurse Sensitive Quality Indicators

Table 4: The Scope and Severity Grade Level of Long-term Care Facilities Table 5: The Residents’ Bill of Rights

Table 6: Sample Call-Out Monitoring Log

Table 7: A Chart Showing the Oxygen Delivery Devices Used in Long-term Care Settings Table 8: A Sample Assessment Schedule in a Long-Term Care Facility

Table 9: Interpretation of the Brief Interview for Mental Status (BIMS) Score

Table 10: The Abnormal Involuntary Movement Scale AIMS Scoring Guide

Table 11: Interpretation of the Abnormal Involuntary Movement Scale (AIMS) Scores

CHAPTER 1: INTRODUCTION

It takes a special group of nurses to care for residents in skilled long-term care facilities. Not every nurse is apt to take on this challenge, and many nurses I have had conversations with often admit that they cannot work in such settings. Long-term care nursing is complex, as it entails managing subacute and chronic disease processes in adults and the older adult population. The nurses in these settings deal with the nuances of caring for older adults (65 years and above), some with cognitive impairments and behavioral dysfunctions, and adults 18–64 years with chronic diseases and disabilities. A few facilities also manage children and teenagers with chronic diseases and disabilities. Individuals in these settings are considered the most vulnerable in our communities and need support and advocacy. Physiologically, these individuals have multiple comorbid conditions and are often on numerous pharmacologic agents that the nurse must manage daily. These pharmacologic agents can alter mental status, putting the individual at risk for falls and causing behavioral dysfunction. Therefore, the long-term care nurse must always be vigilant to maintain each resident’s safety.

Physiological changes occur in all organ systems with aging. For example, as individuals age, cardiac output decreases leading to poor perfusion. Blood pressure increases, and kidney function decreases, as evident in creatinine clearances. There are also degenerative changes in bones, joints, and muscles. The loss of skin tone and elasticity has also been reported. Other physiological effects of aging are seen in the lungs, where there is a decrease in vital capacity and slower expiratory flow rates (Boss & Seegmiller, 1981). Finally, metabolic functions significantly slow down as we age, and urinary incontinence is widespread in older adults, particularly women.

Considering that many residents are older adults, they, too, will experience many significant physiological changes. Therefore, nurses in these settings must demonstrate specialized skills in identifying and managing new physiological changes as they occur while maintaining already existing health conditions.

Adults aged 18–64 with disabilities and chronic diseases also present unique challenges that the nurse must manage concurrently with those of the older residents. For example, many in the adult population have chronic mental health issues, acquired brain injuries, spinal cord injuries, and other progressive chronic disabilities, such as multiple sclerosis and lupus erythematosus. The ability to manage this wide range of disease processes makes long-term care nursing a unique and challenging area of practice.

Furthermore, the long-term care nurse deals with the clinical aspects of nursing under the regulatory oversight of the Centers for Medicare and Medicaid Services, the local Department of Public Health, and the State Nursing Boards. It is worth noting that the long-term care industry is one of the most regulated industries in the United States. Currently, there are about 204 federal regulatory groups F550-F949 (Centers for Medicare and Medicaid Services [CMS], 2021) that facilities must comply with, and this does not include the state regulatory provisions. In addition, these regulations come with their own specific requirements and job demands on the nurse.

Finally, the long-term care nurse carries a unique burden of responsibility that many nurses in acute settings may not experience. Like acute care hospitals, long-term care facilities provide 24/7 nursing care, yet unlike the hospital setting, physicians and practitioners are rarely on-site. Consequently, the nurses practice with a broader range of autonomy, are expected to exercise sound clinical judgment, and display proficiency in health evaluations, which clinicians rely on for diagnosis and treatment modalities.

Long-term care nursing is an area of specialty and must be accorded such gravitas among the other nursing disciplines. Yet, interestingly, the nursing profession has long treated these settings as invisible and forgotten. Nursing has relegated care in long-term facilities primarily to Licensed Practical Nurses (LPN) and Associate Degree Registered Nurses (ADN). Only a few nurses with bachelor’s degrees (BSN) find it interesting to work in such settings. Those who do, frequently advance to managerial roles, pulling them away from providing direct care for residents.

Nurses aspire to do more to meet the complex needs of residents. However, the training afforded them by the profession needs to be improved, considering the complexity of long-term care nursing practice. If we learned nothing during the pandemic, at least one thing was obvious: nursing practice in these settings needs reform and re-education of its workforce.

Training the Long-Term Care Workforce

Expecting all long-term care practice nurses to return to school is unrealistic, but education can occur in many other avenues. Currently, all facilities provide training to their staff as required under 42 CFR § 483.95 (Training Requirements, 2016) and use online platforms. These ideas are laudable, but they have their challenges. Long-term care nurses can barely make time to complete this self-paced training, which is a considerable barrier to their professional development. In addition, many courses and training that occur spontaneously in long-term care homes are often part of correction plans in response to a practice deficiency. To be effective, education must be continuous in these settings, and nurse educators, in collaboration with the Director of Nursing, must be proactive in developing curricula to train their staff.

Facilities must organize monthly training workshops, annual retreats, and robust orientation programs to advance their nurses’ practice. Many facility educators have no formal training in nurse education and are unaware of what to do or how to do it. Others face a lack of resources to educate their staff. Ideally, each facility should have a computer lab with dedicated computers for staff education. Also, each facility should have a clinical skills room or lab where staff training can occur. These clinical labs should be equipped with various demonstration mannequins, skill trainers, equipment, supplies, and reference books.

Many facilities require the nurse educator to perform a dual role, with infection control as an added responsibility. Both positions should be distinct full-time jobs if they are to be effective. The nurse educator should collect facility data through audits and reports, analyze the data, and then determine areas where improvements can be made. They should then use current clinical evidence to develop a curriculum to train the staff. Because facilities lack trained educators, the Nursing Directors often manage this role; they are often overloaded and do not dedicate time to staff education. Therefore, a facility educator is a vital component of the clinical team.

This training manual bridges the gap in long-term care staff development by providing content and strategies for facility educators to train nurses in using the nursing process to manage key work processes. The book outlines areas where the clinical skills competencies of nurses need to be strengthened. Long-term care corporations and facilities must invest in staff training to improve the quality of care provided and preserve revenue often lost through monetary penalties imposed for non-compliance with regulations.

The Nursing Process as a Critical Thinking Tool

Critical thinking and problem-solving are skills essential in long-term care nursing practice. Critical thinking is an active mental process in which the nurse approaches situations with skillful perception, analysis, synthesis, and evaluation of collected information. This process occurs through observation, experience, knowledge, and communication that finally leads to a decision for action (Papathanassiou et al., 2014).

The question is, how