21st Century Long-Term Care Demands That Nurses Upgrade Their Competencies


Charlotte Eliopoulos, RN, MPH, PhD

Dr. Eliopoulos is executive director, American Association for Long Term Care Nursing, Cincinnati, OH.

Long-term care (LTC) settings are experiencing dramatic changes. The relatively stable elderly resident population of the past—those who needed basic assistance with activities of daily living and little supervision—has evolved into a clinically complex population representing a wide range of medical and psychiatric conditions, cultures, and age groups. Approximately half of LTC residents are admitted to facilities for rehabilitation or subacute care. The percentage of nursing home residents with multiple physical and mental diagnoses has been steadily increasing. Today’s LTC resident may need specialized care related to diabetes, congestive heart failure, renal dialysis, dementia, ventilator support, schizophrenia, developmental disabilities, and a long list of other conditions. There is also increased demand for cardiac and physical rehabilitation of obese individuals. The LTC population’s complexity is such that almost 25% of the residents admitted to a skilled nursing facility are rehospitalized within 30 days.1 It is clear that today’s nursing homes resemble the hospital units of the not-so-distant past, whereas assisted living communities are caring for the type of person who previously resided in nursing homes.

Additionally, the presence of residents with psychiatric conditions has grown. The US Centers for Disease Control and Prevention report that as many as 25% of LTC residents have diagnoses of depression, with another 20% to 30% displaying symptoms of depression without having the diagnosis. Frailty in the resident population has increased, presenting new safety risks. Between 50% and 75% of nursing home residents fall each year. Although 5% of adults 65 years of age and older live in nursing homes, these individuals account for approximately 20% of deaths resulting from falls in this age group.2

As though the challenges of caring for a more clinically complex resident population weren’t enough, LTC providers face other issues. The workforce has become more diverse, and the problems they face extend beyond caregiving activities. According to data from the US Bureau of Labor Statistics, nursing assistants experience more physical violence than any other institutional-based caregiver, with more than half being victims of assault and battery at least once every week.3 Inadequate staffing levels continue to plague this sector of healthcare and influence higher hospitalizations at a time when pressure to reduce hospital readmissions is rising.3 And, of course, there are regulations and rising consumer expectations for culture change and implementation of other new programs in LTC.

As LTC staff face numerous complexities as well as the burden of having to identify and manage issues with limited professional resources on site, care in the LTC setting would greatly benefit from nurses who are highly prepared and proficient. Unfortunately, that is not the reality. Baccalaureate degrees and higher degrees are underrepresented among LTC nurses. More than half of the directors of nursing (DONs)—who represent the highest position in the nursing department—hold an associate degree or diploma in nursing; less than one-third hold a Bachelor of Science in Nursing degree. Specialty certification, which is associated with higher levels of professionalism, is only held by one-third of the DONs. With so few DONs in nursing homes holding bachelor’s degrees, higher degrees, or specialty certification, it is no surprise that advanced credentials are rare among other members of the nursing department.

There are many LTC nurses with associate’s degrees in nursing who perform excellently, have advanced their competencies by obtaining various certifications, read professional journals, and can outperform other people who have a long list of letters after their names. However, nursing cannot be satisfied with the current situation. To meet the demands in a new era of LTC, there must be an increased presence of nurses with advanced credentials in this setting. This could be accomplished by having LTC facilities collaborate with nursing schools to encourage students to have clinical experiences in LTC settings; working with administrators and owners to develop work environments and benefits that are appealing to nurses with advanced competencies; and redesigning jobs to enable nurses with advanced credentials to implement new models of practice. Nursing schools must also work to provide affordable and convenient programs to working nurses with family responsibilities.

Most importantly, nurses who have been out of school for a long period of time should assume personal responsibility for advancing their education by obtaining specialty certification and otherwise enhancing their competencies. When one considers the many scientific and cultural advances in the past 25 years—Google, robotic surgery, GPS devices, electronic medical records—it is unrealistic to think that the nursing skills and knowledge from years ago are still adequate in today’s practice.

For years, LTC nursing was viewed by many as a practice for nurses who “weren’t sharp enough to work in other settings.” Fortunately, this view is changing. To competently meet the clinical and managerial challenges in LTC settings, LTC nurses must be sharper than the average nurse, and they must demonstrate commitment to sustaining and advancing their competencies. 



1. Ouslander JG, Berenson RA. Reducing unnecessary hospitalizations of nursing home residents.
N Engl J Med. 2011;365(13):1165-1167.

2. US Centers for Disease Control and Prevention. Falls in nursing homes. www.cdc.gov/Home
andRecreationalSafety/Falls/nursing.html. Updated February 29, 2012. Accessed June 14, 2012.

3. Desmarais H; Kaiser Family Foundation. Financial incentives in the long-term care context: a first look at relevant information. www.kff.org/medicare/8111.cfm. Published October 12, 2010. Accessed June 14, 2012.


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