I've worked in long-term nursing care as administrator, nurse, and everything in between for 35+ years. AMA!

I've been wanting to go back to school to become a nurse practitioner.

• What would you say are the most challenging parts of your job?
• Any advice?
• What would you have changed or done differently on your path?
• What is the best part of your job?

Thank you for this AMA>

It's always a challenge because you are dealing with people's lives and you can't make a mistake. In that respect, there is a lot of stress.

The only advice I have is that if it's something you really want to do, stay committed and learn as much as possible. The more secure you feel in your knowledge, the better practitioner you will be.

In my own career path, I wish that 25 years ago nurse practitioners were more respected and valued. But I am glad I took that path and glad I later became an administrator. Being a nurse practitioner is a huge advantage to being an administrator.

The best part of my current job as an administrator is knowing that I have created an environment in which employees love their jobs and the patients feel satisfied and content. It's great to be able to surpass expectations… a wonderful feeling.

What are good signs to look for when choosing a retirement home for your loved ones ?

Great question. While there is a bit of a difference between skilled nursing facilities and retirement homes (which don't offer the same intensive medical oversight) there are some generalizations about both you can use to judge whether the facility is of a good quality.

When you walk into a facility uninvited, without a tour, do the residents seem happy? Does the staff? Are there planned activities and entertainment for the residents, or are people just sitting around watching TV? Finally, there is probably no better measure of quality than unfiltered testimonials from residents. Talk to as many as you can and get their impressions.

I have a very specific question for you because I don't know where to turn...so why not Reddit, right?

I'm in health information management, but relatively new. My office was just dropped by an insurance company (an HMO who is going to only work with on doctor in the area). We are allowed to file an appeal.

How do I file an appeal? What do I say? Do you have any resources you can point me towards? I'm completely at a loss and need to write more than "Come back to us come back to us come back to us!"

Also, I used to have to go with my doctors to nursing homes to do all of the notes, it was very depressing honestly. It seemed like the nurses consistently ignored alarms that were going off in front of patient rooms, and patients were left in the halls yelling for attention. It was very frustrating...I hope all nursing homes aren't like that.

It's unfortunate that you had such an experience. The truth is that good nursing facilities don't allow that to happen. Keeping a good ration of caregivers to patients will help as will a full schedule of recreation and therapy. And most importantly, if the staff is supported and nurtured properly by management, they will care for the residents properly and this won't happen.

Tell us your ghost stories. Long term nursing homes always have at least a few.

Not exactly a ghost story, but it is creepy: In a small facility I worked in a number of years ago, I had a small office in the basement. One of my first days there, I was enjoying lunch at my desk when someone wheeled in a gurney with a body on it, covered in a white sheet. I was quite surprised and said, "What's that?!"

"Oh that's Mrs. Jones. She expired," the nurse said casually.

It turns out they used my little office as a temporary morgue, as it had one of the best airconditioners in the building.

I just want to say that we are lucky to have Jill Smoller do this AMA. She is a great person to work with and runs a top notch facility!

-Gil from 1st Choice

Surprised to see you here! How funny! Thanks for the kind words.

It seems like most people have a "mean nurse" story.. In your experiences, have you ever had to deter one of your fellow nurses from being mean/ bullying/ taking out their frustration in some other way on a patient? I understand everyone has rough days and we all deal with them differently, but if there are certain strategies you have for someone who can be consistantly unpleasant. Thanks!

In our facility, we have a no tolerance policy for unkind behavior. Unfortunately in this setting, there really is no room for a bad day. The best strategies in this case are hiring strategies: making sure that you hire the right person in advance. Also as an administrator, doing nice things for the staff and acknowledging and rewarding and appreciating the staff's hard work does wonders for keeping up morale and pleasantness in the workplace.

I'm a CNA in LTC/rehab and I want to get into hospice. Any suggestions?

The most important part about working in a hospice is having genuine compassion. You can demonstrate your compassionate qualities in, say, an interview by sharing relevant anecdotes or stories about how you have contributed to the comfort (emotional or physical) of a patient. Also, some LTC facilities have an attached hospice unit. You might look at them as a bridge between your current position and future goals. Best of luck!

I'm definitely planning to go back to school ( getting my BSN in December). I want to be a Certified Nurse Midwife for sure. A local school has the option of doing a joint program to be a CNM/FNP. If you were me, would you tack on the extra year for both to be more marketable?

There are plenty of opportunities for both jobs, so I don't see it as necessary to do both. If you are committed to being a midwife, I suggest you do that wholeheartedly. From my point of view, there isn't a need to split your time and attention (not to mention spend the extra money). Best of luck whatever you decide!

How do you deal with being not treated so nice by some of your crankier or ruder residents? It must wear on some people after a while.

That's a very good question. One that that I have learned and that I try to teach my staff is that their anger or rudeness is not really directed at you. I try to realize that the patient may be sick or in pain and simply looking to vent or have someone listen. It can be rewarding to have a conversation with them or offer treatment that can raise their spirits even a little. And often, you can always listen for a bit and then change the subject to something that brings them a bit of happiness (family, hobbies, etc.) Even in perfect conditions, though we can only be 99 percent successful at this. There are always some people.....

Hi! I'm a 24 year old male about to start college for nursing. Any basic advice or tips, words of encouragement, etc? Thanks!

It is wonderful that you are a male going into nursing. There is a huge demand for male nurses and many of our elderly nurses prefer/enjoy having a male nurse. Good luck, I wish you the best!

I was a CNA a little before college, will these skills helps if I wanted to pursue a degree in Nursing?

Tremendously. The work CNAs do is the foundation of all nursing work at any level. Plus, the personal skills you develop working with patients is crucial for a successful career.

Hello. I worked for a few months in a LTC. I vowed to never work in LTC again.

The home I worked at was constantly rated 5 stars, but behind the facade I would never want a family member in this type of place.

I am hoping that what i experienced was not the norm for an LTC. I was a freshly minted LPN and worked the 7p-7a shift. Is it common for 2 LPNs to handle 85 patients? With that split in half, I usually had 42-43 PTs on my 2 wings, the other LPN with the rest on her 2 wings.

The job was very stressful.

So is this common to have 40 ish PTS (atleast half on crushed meds?)that include.......10 or so Diabetics, 3 or 4 PEG tubes? Assigned to 1 Nurse?

Unfortunately since staffing is not regulated, it is at the discretion of the facility's owner or administrator to determine appropriate staffing levels. Many factors must be taken into account including medical complexity of the patients, behavior issues and other ancillary jobs that nurses may be responsible for completing during their shift. It's sorry that you had this bad experience. I hope you won't generalize to all LTC facilities. Some really are outstanding and others have lots of room to improve.

Is there still a shortage of nurses? I have considered majoring in that.

I can only speak for the New York tri-state area, but there is strictly speaking no longer a shortage of nurses with degrees. However there is always a shortage of competent, passionate, talented nurses!

Do you think that quantity of life has become more important than quality of life? And do you think that outside of a living will a person should have the right not just to refuse treatment, but peacefully depart from life without a doctor's order? And thank you for taking time to answer these questions.

Legal issues aside, I think a person's right to live or die is a very personal decision that should be made with family and from the depths of one's heart. I have watched people struggle time and time again with this very difficult decision. There is no right or wrong.

I'm a recent graduate from a health management systems program. I've studied LTC and I find it interesting.. What sort of non-clinical entry level positions are there available for recent graduates in LTC?

Thanks for doing the AMA!

Admissions, Nurse scheduling, billing, all kinds of administrative support positions. At my facility we also have guest relations positions who perform a concierge kind of role helping residents acclimate to the facility on admission and helping to make sure their daily needs are met (if they would like to order out for meals or rent a DVD or something like that).

As the administrator, did you have to deal with getting funding? And does your nursing home recover funding through the Good Samaritan Funding? I'm curious because my mother is the CEO of a nursing home in Illinois. She's days funding is the biggest stressor of the job! Aprpreciate what you all do though!

Recieve* not recover

Thanks for your question! Different kinds of nursing homes get their funding in different ways. Like most for-profit facilities, the nursing home I work in participates in the Medicare/Medicaid program and gets its income through reimbursement from the government. In the not-for-profit world, it is much more common to have to rely on grants and other ways of raising money to cover the budget. Though I don't have any experience with Good Samaritan, I understand they do excellent work (though I understand how frustrating it must be to have to wait on others to hear about getting much-needed funds).

Do you have any experience with mental health nursing? I want to go back to school to work in hat field (mostly VA)

Patients in many nursing facilities have psychiatric diagnoses. There are a lot of challenging and specific treatments/interventions necessary. Some facilities have dedicated units designed to handle the special needs of these populations. I routinely deal with residents with dementia, wanderers, aggressive types, and other conditions. It is an interesting field for those who want to embrace it. It takes a special person to reach out to the special needs population. I admire your efforts. Good luck!

I've decided to go the physician assistant route instead of being an NP because I strongly believe my passion is surgery, not care-based practice. If you can, please tell me why PA's are doing surgeries instead of DNP's when the latter has more schooling? I admire nurses' work immensely, so from the bottom of my ventricles thank you for doing what you do.

Sorry but that is not really my expertise so I can't answer. But thank you for the question. PA's are great. Good luck with your career!

x-posted from your thread in r/nursing.

-How does your clinical background help you as an administrator? -Do you ever find yourself thinking back to not-so-great things your administrators have done to nursing staff in the past? Do you work to improve that, or do you see their rationales in retrospect? -What are the biggest changes that you've seen in healthcare? Everything from styles of nursing to standard medication sets for X problem to change of LTC/SNF population post medicaid changes? -What is your biggest challenge as an administrator? -Do you ever help out on the floor? If not and you can't, do you ever feel compelled to? I'm so curious. Thank you for doing this!

Since 80 percent of running a nursing facility has to do with the provision of care, having a nursing background enables me to understand diagnoses and treatments needed as well as the actual workload of the nurses and all the other behind the scenes elements of providing that care. I have been successful as an administrator in large part because of my years of clinical experience.

These days, I don't get directly involved in the nuts and bolts of nursing care (like handing out meds) but I interact with the patients every single day. I always roam the halls to visit and check in with our residents and I am able to intervene if there is any question or issue. Also if any personal issues arise with residents' family members or between patients and staff, I will take up the problem personally so that the nurses are freed to do their work and so that the patient (or their family) understands that we take their problem seriously.

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Sorry but it's been so long that my experience may no longer be relevant. I can tell you there is a lot of classroom teaching as well as clinical practice of examinations on fellow students or volunteers. Additionally, there are clinical rotations so it is a very busy, busy time.

Don't think of it as feeling overwhelmed. Think of it as total immersion in your personal development. Embrace it and you will enjoy it and be even better at your practice!

Wait, you're a FNP and you left that role to get into LTC?

Why did you make the jump?

When I first became an FNP 25 years ago, it was an up-and-coming field and didn't have the same regard that the field has today. We had a tremendous amount of responsibility and we had a caseload just like a physician, but were given very little respect (and compensation) for the very difficult work. Eventually I decided my talents would best be put to use somewhere else. TOday, FNPs are widely accepted and recognized as an important part of health care, and rightfully so. In fact, they play an important part in many nursing homes as well.

My dream job is doing Palliative FNP, hopefully in nursing homes. But I took the Policy/Management route - working for non-profit and government positions.

Your story gives me a bit of hope, since maybe that dream job is still on the table (with my partner's blessing, of course!)

Anyway ~ how do you feel about nursing unions? Do you work with them in the LTC industry?

Just so you know, nurse practitioners and nurse management is never part of a union. But yes, many nursing homes do use unionized direct care staff. I believe that if management supports and appreciates the staff, then very few union-related issues arise. In some facilities where management is abusive or takes their caregivers for granted, this can lead to tension. We're fortunate not to have that problem here.

What are the biggest changes you have noticed between when you first started and now? Would you have picked a different area of nursing given the opportunity? Do you ever feel underappreciated?

I found out about 2 hours ago I passed all my courses for my first semester of nursing and I am excited and terrified. Only another 2 and a half years to go!

Congratulations on the start of what will be a tremendously rewarding career! I am very happy with the route I took, though many years ago FNPs were not very appreciated, which led me to working in long-term care. Times have changed and I feel like everyone in my facility is rightfully appreciated for the great work they do.

Why did you chose long term care? When I was in nursing school, no one wanted to do long term care. In the area I live in it's one of the only places to get a job right after graduating.

Why in, your opinion, do nurses eat their young? I've encountered some nasty nurses during clinical, and I wonder why they're even nurses.

How long did it take you to get through school? I've been at community college for 4 years since graduating high school, and I have a learning disability that contributed to me having to retake several classes. I had to withdraw from nursing school this last semester, and I didn't get back in for the fall but hopefully I will get back in for the spring (January). But at the moment I feel pretty hopeless.

Thanks for doing this!

Stick with it! You'll get there eventually, and will find a very rewarding career. I have mean nurse story of my own: When I was a junior staff nurse, we were permitted an hour for lunch, but I never, ever left the building to take my lunch break. One time, I did ask permission finally from my supervisor to go out to lunch and her response was shocking: "Are you kidding? I may as well shove a broom up my a** and sweep the floor, too!" Well, I didn't take my lunch break that day, but I didn't let her deter me from the work I loved so much.

I chose long-term care because of a great admiration and respect for older people. You have to wake up in the morning and feel good about your work. I enjoy an older population and also feel they appreciate in their hearts the efforts of nurses like us.

I suspect you've worked with the various dementias in LTC...my question is how you feel about sending patients to acute psych facilities when they get out of hand? I work in an acute geropsych unit and I feel that there there is a lot of animosity between us and some of the local nursing homes. We get them back to baseline, or as close as possible, then sometimes, they call and say nothing's changed. We send directions for redirecting, what works with them, etc. So, I guess I'm asking what can we do better? Sometimes their new baseline includes some aggression. If we just keep them sedated, they have no quality of life, if we don't, we get complaints.

Unfortunately, there is a break in the system where there really are no long-term places for geripsych patients who maintain difficult behaviors to live. They really do not fit into basic nursing facilities because they may disrupt other patients and may be harmful to themselves, yet they are really not appropriate for placement in a psych hospital. It's a conundrum.

It is a very difficult situation for nursing facilities when patients act out and have behavior issues. It's difficult for a nursing facility where the staff are not usually trained in handling all socially in appropriate behaviors. At my facility, we are appreciative and grateful for acute geripsych facilities that temporarily take our patients and return them back to baseline. It is unfortunate that some facilities don't appreciate these important interventions. I can only hope other facilities realize that these are havens for our patients and we are all doing as well as we can!

Hi Jill! I have a few questions, as my career goal is working in long term care as a registered nurse in Canada. What is the most challenging part of your job? I know that working with death is something that scares people, is this something that you get used to? Do you find it hard to distance yourself from your patients? Any other advice to a nursing student would be greatly appreciated. Thanks!

You never do or want to become apathetic or hardened to death. It is the loss of human life. However in the course of nursing, you learn that there is a sense of peace that arises when the end is inevitable. It always remains a difficult part of the job, but knowing that you have helped to bring some comfort and peace to a patient in their dying days gives you a measure of solace. My advice is simply to stay passionate and dedicated... it's one of the most rewarding things you can do with your life.

Being a soon to be male nurse, do you think males have a better opportunity to be hired for certain positions in or outside of ltc? Also what departments or avenues do u know of where male nurses are most in need

I can only speak in my experience with nursing home and rehab facilities. Male nurses are in great demand. Many geriatric patients simply seem to prefer male nurses. There are lots of opportunities. Demonstrate your passion and you can go where you want!

what's the grossest thing you have ever had to do. Anything ever just make you want to quit and find a new profession?

Working in this field, your definition of what's gross begins to change. It's true that nurses (LPNs, CNAs, etc) have to sometimes complete tasks that are less than pleasant. Not only do we get used to this with enough experience, but it really does makes you feel better that you can help residents with their daily needs with a smile, no matter what.

I just graduated with a degree in Health Administration and I'm trying to figure out what to do with it.

What made you decide to work in long term care as opposed to a hospital or doctors office? Thanks!

My preference in nursing have always leaned toward relationships that can be built over time. Hospitals would have given me the chance to work in a very high-tech, fast paced ICU type environments, but it would have been at the expense of forming the connections with people that I really craved in my work. I have the greatest respect for those who take the hospital route, it simply wasn't to my taste. I don't regret a thing.

Hi! I have one miscellaneous question. Do you ever bump heads with physicians you work with in terms of treatment methods?

Although I have had my fair share of less-than-pleasant interactions with physicians, at my facility we have monthly medical board meetings with all the attending physicians so we are all on the same page and share the same philosophy when it comes to treating patients. It cannot be nursing against medicine ever. It never works.

My 91 year old great aunt just went into a rehabilitation facility for a broken pelvis. What are the most important factors I can look into to make sure she is heading towards a healthy recovery to where she can go home? Is there certain activities or such that I should make sure are being done? Basically any info is highly appreciated.

The most important thing to look for is appropriate pain management. While a certain amount of pain is expected, it should be treated in a way that she is able to go to rehab/therapy. Her pain can't interfere with her ability to go to rehabilitation because that is really what is going to restore her mobility so that she can return home.

Thanks for the AMA, How would you recommend getting into Wound Care?

If you start in a regular nursing position, it may be possible for you to shadow the wound care specialist to learn more about it and see if it would be right for you. From there, ask if you can be formally mentored and then go for your certification! Passion, dedication and a bit of persistence will help you reach your goals. Best of luck!

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I am personally not in favor of the competitive bidding process. I do understand why it was put into place, but the fact is that we have lost some very good vendors due to these changes.

Along similar lines, it is definitely a hinderances to high-quality facilities to slog through the many, many, many regulations imposed on our industry. I certainly can appreciate why many of these are necessary due to some facilities that do not tow the line, but for those who go above and beyond, such bureaucratese can be a distraction from our work.

1. In your experience, which long-term care insurance carriers pay their bills, and which are difficult to deal with?

2. How much does a year of nursing home care cost where you are? (If you can give state or region, would be helpful).

3. If you could make a rough estimate: How many of your nursing home residents are dependent on Medicare/government to pay for everything, versus how many have assets, versus how many actually have long-term care insurance?

1. It is my experience that all insurance policies are difficult. They require cumbersome paperwork and families often complain to me that they are not reimbursed in a timely fashion, if at all, for their costs. I'm sure there are some upstanding companies/policies out there, but I am not personally familiair with them.

2. Here in the NY metro area, private pay rates vary any where from $300 to $500 per day. This excludes medication and specialized services such as rehabilitation.

3. Our facility is somewhat unique. About 75 percent of our population are short-term rehabilitation and so the payer source is managed cage or medicare. The remaining 25 percent are Medicaid. We have a very fleeting number of private pay residents. Most patients admitted to nursing homes (at least in this area) have alternate sources of payment. Savvy people over the age of 65 seek out elder law attorneys to help them protect their private assets in the event they need a nursing home. I would recommend that everyone take this approach.

Unfortunately I've recently had a bad experience with an Acute Care LTC that my grandfather had to go to. I know there are LTC facilities that exist on both ends of the spectrum, from phenomenal to terrible. But this place disappointed me from day one. It took days for the staff to finally give him a bath, his skin was on his way to breaking down, and I observed improper technique from respiratory therapists multiple times (improper suctioning and not using sterile technique when she should have). It seemed that this place was understaffed, but not terribly so. The staff seemed to move so slowly too, at least compared to the nurses and aides I see in the hospital I work at. Unfortunately it seems that many others in this country have had bad experiences with an LTC.

My questions are, what problems exist in LTC that make it so easy for issues like these to emerge? Does it all come down to lack of funding? I can see how lack of funding could lead to understaffing, which leads to unrealistic expectations for staff and not all the work getting done, which could lead to burn-out. As a nursing student, I like the idea of someday working LTC as it can be very rewarding to work with older patients, but I can't ever see myself working in a place like the one my grandpa was at. And please don't take this as an attack to you or the area you work in or anything like that! I'm sure this is a very complicated issue.

Yes you are right in saying that there is a full spectrum from outstanding to horrible. Generally, good care starts at the top. When you have an involved and studious administration that cares about the quality of care given to the residents, that sentiment trickles down. Good care is rarely about money and more about the attitude of the workers. When you have committed and compassionate staff who really want to do a good job, patients are well cared for. When you have an apathetic administration and an indifferent staff, bad things happen.

What was the funniest interaction with a patient you have had?

What about the most memorable interaction?

Funniest was when a 911 operator called me at work and said the patient in room 213 had called 911 with an emergency. The operator asked me to check on the patient. I ran upstairs to see what happened. When I got to the room, everything seemed fine. The patient was sitting there and I asked her if she had called 911. She said, very calmly, "yes, I did." I asked her what the emergency was and she replied, "I have to go to the bathroom. It's an emergency." (I took her to the bathroom, and we went over the use of the call bell again.)

This is less of a question about working at a retirement home than it is about working in the nursing profession.

I recently graduated nursing school and I've found myself questioning if this is really the sort of profession I want to go in to. I don't know if it's just nerves that are making me feel this way or if it's a sign that maybe I should look in to something else. You've worked in many different nursing jobs for a while, so I was wondering if you could tell me if there was a point where you knew that you were doing what you wanted to do.

I have enjoyed all the positions I've had in their own way. On the other hand, I always welcomed the chance to try something new and develop my career in new ways. At this point in career I do feel like I have arrived, and looking back I couldn't think of anything I would rather do. It is essential to always enjoy your work and be satisfied with your effort at the end of the day.

Is the future of nursing LTC?

Actually short-term rehab is going through tremendous growth at the moment. Nursing homes, at least in my area, are no longer primarily retirement homes. A majority of the patients are middle aged and recovering from knee- and hip-replacements. As these kinds of surgeries and treatments are becoming more common (and as baby boomers age) we seeing far more post-operative recuperation in skilled nursing facilities as opposed to long term/permanent placement. Though LTC may grow incrementally as the population ages, I think short-term rehab is the true growth area in our field.

If you have seen Scrubs, is that serie on point when it comes to how a hospital works?

Scrubs is a very entertaining show. However there are certainly some stretches about what is allowed and what is routine in an actual medical setting. I should also note that nursing homes are highly regulated by many, many state and federal rules (even more so than hospitals, and certainly more than in the minds of TV writers' imagination).

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It's actually a common misperception that nursing homes are dull or boring places. Like most jobs, we tend to see a microcosm of all of life. It can be very frenetic and busy between cutting edge medical challenges, rehabilitation that would challenge even a professional athlete, a constant barrage of entertainment and events, visiting family members, multi-course meals, staffing issues, and more. You might be bored, but it's never boring here.

How much poop have you had to clean up?

Oh, lots. You may have been asking as a joke, but that is part of the reality for nurses in all settings. One of our greatest responsibilities and rewards is to help patients keep their dignity even in challenging situations like that. As a side note, our facility goes through 73 boxes of Depends every week!