Are Skilled Nursing Facilities the best work environments for RNs? I say NO and you need the MAX

Skilled nursing facilities are not the best work environments for RNs. I am seeing more RN terminations, LPN terminations, State Nursing Board complaints, and other issues stemming from CNAs "double teaming" or "triple teaming" the RNs usually or sometimes the LPNs, reporting false information to the DON and Administrator which then causes licensure, workplace, or career issues for the nurses.

I will say it again, skilled nursing facilties are not the best work environments for RNs. I had to tell one of my clients from 2005 this just yesterday when she called me regarding "he say she say" issues at a nursing home in Columbus, Ohio.

Skilled nursing facilities are not the best work environments for RNs. Why?

1. The staffing at the a nursing home pits RNs against LPNs because the staffing and work assignments are not written with the State Nursing Practice Act and the principles of delegation in mind. This sets up a constant battle at some facilities between RNs and LPNs, LPNs and STNAs, and RNs and STNAs.

2. There is NEVER enough time to do what needs to be done and perform the assigned tasks in a shift for the residents. Oh but guess what the facility doesn't want its nurses to work any OT. So what do you do?

3. Nursing homes are highly regulated, for a reason I might add. Any incident needs to be reported to the "MAN" or "to the State." What this means for nurses is because we bear most of the accountability and responsibility for patient care, the buck stops with the LPN and/or the RN. The nursing home blames the nurse, fires or writes the nurse up, and reports the nurse to the State Nursing Board.

4. The turnover rates with nursing home administrators, DONs, and unit managers is comparable to the waitress/waiter turnover at your local Waffle House. There is turnover galore from the top to the bottom and from the bottom to the top in nursing homes. So as a RN you are working with different administrators, DONs, unit managers, CNA, LPNs, and other staff every couple of months. What's up with this?

5. I have drank 4 cups of coffee and I am going to say it bluntly here this morning. RNs you have alot of options for employment and unless you LOVE geriatrics you need to do a cost benefit analysis before you decide to work in a nursing home. When you interview for a position, you need to interview your employer and ask around before you jump in head first into the deep end of a concrete swimming pool with 5 inches of water.

6. Any nurse who works in a nursing home needs professional liability insurance with a license defense benefit. You need the max in coverage in baby. Working in a Skilled Nursing Facility as a LPN or RN=MAX in Professional Liability Insurance Coverage with a License Defense Protection Benefit. Go for and obtain the MAX! You may really need it.

7. If you are a RN and you just have to work in a nursing home, work part-time at the SNF and part-time elsewhere or per diem at the SNF and FT or PT elsewhere so that you are bogged down "day and night" with the drama.

8. If you are a RN and you just have to work in a nursing home, move up to management. Which may or may not be too much better because I have alot of legal consultations with nurse managers in SNFs in Ohio, Kentucky, and Indiana and you are starting to see more lawsuits where nurse managers in SNFs are being named as defendants in nursing home negligence cases.

9. If you work in a nursing home FT, develop a risk management plan for your nursing practice. Documentation is extremely important. I read in an article written by an attorney who represents nursing homes that staff in a SNF should provide care first and worry about documentation later. Excuse me? This attorney obviously does not represent nurses before the State Nursing Board.

Your license will not survive a patient care first and then documentation last attitude in a SNF and you will emerge from the State Nursing Board investigation and evidentiary hearing with scars and wounds because you "knew better." Its a do or die mentality in some of these SNFs. RNs and LPNs are being treated like fungible and at-will employed employees who can be tossed about, thrown in the air, and replaced at any time like a garbage bag on a large roll.

10.  You know when its time to leave a facility. Trust your instincts. Don't let your pride get in the way or the fact that its "your hall" or "your cart." Its your license on the line and quite frankly that is the most important item on your agenda because with your license you can work ANYWHERE. You are not licensed by your SNF, thank God, you are licensed by the State and you can practice SOMEWHERE ELSE. There isn't any institutional licensure of RNs and LPNs and I think some SNF administrators need to be reminded of this.

Don't sweat the small stuff and allow the drama in a nursing home to consume you. Keep it moving because you have alot to offer. There is a reason why you see so many nurses working just a few years here, a few months there, and a couple years....

Comments

[LaTonia]

Edie Brous is a nurse attorney who represents nurses. Thank you, Edie for your comment and sharing your experiences representing and advising nurses working in SNFs in Pennsylvania, New Jersey, and New York are similiar to my experiences representing and counseling nurses in SNFs in Ohio, Kentucky, and Indiana.

[Edie Brous]

Perhaps Nurse Exec should publish his/her success with tips to others on how he/she has accomplished the RN-heavy mix, the lack of RN/LPN conflict, low turnover, low self-reported incidents, no in-house acquired wounds, no pending litigation, and never reporting a nurse to the BON. How has this been done? Others could learn from this. I agree with LaTonia that it is not a common experience for those of us who represent nurses before the licensing boards. SNFs are under tremendous cost-cutting pressure and regulatory scrutiny. If Nurse Exec can share the secrets of these accomplishments under such conditions, it would be a great service to the nursing and SNF communities.

[LaTonia]

Dear Latonia,

I've been reading your blog for some time now, and have always found it very informative. However, I was very disappointed with today's entry on SNFs. As a DON in a SNF, I found this entry highly prejudicial, and frankly, just plain wrong on several counts, at least by my experience. I have been an RN for 18 years, 11 of which I spent in hospital nursing (ICU/OR) and the last seven in long term care, 6 of which I have been DON--all in the same building I might add. My building has extremely low turnover for the business--30%. I have many nurses and CNAs who have worked in the building since it was built in 1997.

I have a very RN-heavy nursing staff, due to my short-term rehab focus (over 60% of patient mix). I have very few self-reported incidents, no in-house acquired wounds, and no pending litigation, and I have never had to report a nurse to the board. My nurses give great care, and I'm very proud of them. I don't have issues between my LPNs and RNs, I don't go around firing nurses as often as you seem to think it happens, and I have great state survey results (3 tags last year).

Perhaps my facility is the exception, not the norm. Florida does have extraordinary staffing ratios--the best in the nation actually for CNAs and my building staffs nurses 1:20. CNAs are staffed 1:8. It makes a difference.

I love what I do, and I am extremely proud of my wonderful staff. I just wish you hadn't been so harsh on SNFs--lord knows our elders are going to need nurses to care for them. Nurse Exec.
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Thank you Nurse Exec for your comment. However this post is based on my legal experiences representing, counseling and advising RNs and LPNs who work in SNFs. I am harsh on SNFs because some SNFs are harsh on RN and LPN employees. Of course it doesn't say all SNFs are bad and yours may be the exception to the general rule. That's wonderful and I wish you the best and success with continuing to make your facility a great place to work. However I stand by my blog post: IMO, SNFs are not the best work environments for RNs.