After describing the downside of working in long-term care-long hours, relatively low pay, mountains of paperwork and a terrible public image-Sherrie Dornberger, RN, does not hesitate when asked why she has stayed in the field for 26 years, 19 as a director of nursing at Pitman Manor in New Jersey.

"There's this little guy who rolls down the hall to my office," she said. "He has dementia; he doesn't know my name. He'll sit in that doorway and look at me like I've never been looked at before and sing me a song that I can't even make out the words to."

Dornberger knows that every morning, aides at Pitman Manor take care to dress the man and put aftershave on him. She knows that they make sure another resident who wants hot oatmeal for her breakfast has it every morning. She knows that her staff takes the residents out to see the decorative lights during the holiday season and puts on fashion shows for them.

"Even if it makes them happy for five minutes of their day, that's the five minutes they'll remember," she said. "And that's what makes you feel good about your work that day."

It's a feeling that Dornberger, president of the National Association of Directors of Nursing Administration in Long Term Care, would like to share with her fellow nurses. "I would like more nurses to know," she said, "that it's really OK to be in long-term care."

Long-term care has never been a particularly attractive specialty to nurses fresh out of school and eager for excitement. Hospitals have always paid better and offered more fast-paced environments. Nurses with advanced degrees have tended to enter into private practice or community health.

In recent years, a host of other reasons-including older and sicker residents, reports of high staff turnover, stories of abuse and neglect and increasing litigation-have contributed to a reluctance among nurses to enter traditional long-term care settings. The number of license exams administered to directors of nursing has fallen by about 40 percent since 1988, said Randy Lindner, executive director of the National Association of Boards of Examiners of Long Term Care Administrators.

Add that reluctance to an aging population and a nursing shortage and you have an impending disaster, said David Lipschitz, MD, Ph.D., professor of geriatrics and director of the Donald W. Reynolds Center on Aging at the University of Arkansas for Medical Science.

"I view long-term care as the No.1 health care crisis facing the United States today," he said.

The solution to this crisis remains elusive, according to those involved in long-term care. Some are fighting for staffing ratios, others are trying to improve the image of long-term care and market it to young people as a career. Some say nothing will work until state and federal governments provide enough money to pay for care.

In the midst of this debate, a number of long-term care facilities are pioneering new models of care for the elderly, including homes in which people can grow old and skilled nursing facilities that offer residents more choices and participation in their own care.

These facilities and a growing number of services, such as home health care, are spurred on by a generation of consumers who are becoming increasingly selective about where and how they want to grow old.

Then and now

About 20 years ago, long-term care meant a skilled nursing facility in which nurses and aides cared for elderly residents in varying stages of health or board-and-care homes for people who could get around, but needed some help with tasks such as bathing, walking and eating.

Today's long-term care also encompasses home care, adult day care, adult foster care, community programs for seniors, senior housing developments, assisted-living facilities and subacute units for the very ill. Various programs provide meals, cleaning services, health screenings and transportation for people in their homes. Visiting nurses and therapists provide extensive home health services.

In assisted living facilities or residential care, residents mostly live independently, with access to help with cleaning, bathing, meals and medications. Some long-term care providers have campuses that combine independent-living services, such as senior housing and home care, with a skilled nursing facility providing a continuum of care for people as they grow older and are less able to care for themselves.

"People want options to be able to stay as independent as possible for as long as possible," said Marilyn Rantz, Ph.D., RN, FAAN, professor of nursing at the University of Missouri-Columbia and co-author of The New Nursing Homes: A 20-Minute Way to Find Great Long-Term Care.

As a result, by the time they reach a skilled nursing facility, residents often are older and sicker than they were 10 or 20 years ago. They have complicated conditions from multiple chronic illnesses.

"People don't live in nursing homes like they used to," said Margaret Nelson, MS, RN, director of specialty services for the Evangelical Lutheran Good Samaritan Society, which runs long-term care facilities in 25 states. With 23,000 staff members and 27,000 residents, Good Samaritan is the largest nonprofit provider of long-term care in the United States, Nelson said. "We used to see people come in at a lower level of acuity and live with us," Nelson said. "Now, they stay home longer because they have more choices."

Ten years ago, residents in their mid-60s came to live at Pitman Manor, a United Methodist Home campus that features senior apartments and a skilled nursing facility, Dornberger said. "Now, they're moving in at ages 87 to 90."

Younger nursing home patients often have some form of early dementia or Alzheimer's disease, said Jean Bronson, RN, director of Country Care Convalescent Hospital in Atascadero, Calif., and a past president of the National Association Directors of Nursing Administration of California. She described eight of the residents in her 60-bed facility as "quite alert." The rest are in various stages of dementia, she said.

Many skilled nursing facilities also serve as rehabilitation centers for people coming from short-term hospital stays. These patients, who once would have recovered in the medical/surgical unit of a hospital, often require equipment such as central IV lines and ventilators.

"Ten years ago, we wouldn't get anybody with an IV. Now, it's just second nature to us," said Karen McDonald, RN, senior vice president of clinical services at Integrated Health Services Inc., a for-profit nursing home chain with 260 homes and 16 hospitals around the country.

Assisted-living centers, which are not required to have an RN on 24-hour duty, also are experiencing greater acuity rates, Dornberger said. "Long-term care today is what acute care used to be and assisted living is like what long-term care used to be," she said. In some cases, residents stay in assisted-living facilities longer than they should because they don't want to leave and the staff doesn't want to make them leave, Bronson said.

Although most directors of nursing say they would like to have more registered nurses on staff-and a number of studies have shown that residents in long-term care facilities have better outcomes when RNs are involved in their care-most long-term care facilities hire RNs only as supervisors. They usually hire LVNs and certified nursing assistants to take direct care of the residents.

Nationally, the annual turnover rate among CNAs is 76.1 percent, according to a report released last year by the American Health Care Association, which represents nonprofit and for-profit long-term care facilities and services. In some places, it is more than 100 percent.

Most assistants make little more than minimum wage-the national average is $8.60 an hour. As a result, RNs and LVNs often find themselves supervising a poorly paid, constantly changing staff.

A report released in February by the U.S. Department of Health and Human Services found that more than 90 percent of nursing homes in 2000 did not have enough aides to properly care for residents.

Increasing litigation and a list of regulations that is second only to the nuclear power industry also make nurses fear losing their licenses, even in homes that provide top-quality care.

"It makes me dread September and October" when surveyors do their inspections, Bronson said. "We have a good reputation, but that could go in an instant."

First impressions

But Bronson believes that the industry's poor public image is what keeps nurses away from nursing homes more than anything else.

"In the old days, this was seen as a no-place job," she said. "It wasn't considered abusive, it was just boring. Now, it's considered abusive and boring."

Many nursing homes do the best they can with the resources they have, she said, but they are not the ones that receive media attention. Janice Cameron, MS, RN, executive director of the American Society for Long Term Care Nurses and CEO of Geriatric Healthcare Consultants in Broomall, Pa., agreed. "What you hear about are a couple of bad apples and you write more regulations for everybody," she said. "The majority of nursing homes do a wonderful job."

Although the industry is trying to change its image, with campaigns aimed at junior high and high school students, it is having a difficult time attracting and keeping nurses.

The national turnover rates for LVNs and RNs are 51.5 percent and 55 percent, respectively, according to the health care association report. Many are moving into home care or moving out of nursing altogether, Cameron said.

McDonald said that although her facilities have a 1 percent vacancy rate for directors of nursing, about 60 percent of them stay at least two or three years. The other 40 percent turn over constantly within two years, she said.

Directors of nursing report that it has always been difficult to attract nurses out of school to long-term care. Nursing schools often do not present long-term care as much of an option, they said. But the hospital nursing shortage has made it even more difficult to attract new nurses.

More than 20 percent of RN positions in nursing homes were vacant last year, according to the health care association. The need for RNs in nursing homes is expected to increase by 44.2 percent between 2000 and 2020, according to the report.

"When the hospitals get hit, we get hit worse," Cameron said.

Although nurses in long-term care generally do not leave to work in hospitals, bonuses and higher salaries are probably keeping some from leaving hospital jobs for long-term care, nursing directors said.

Reformers, nursing organizations and organizations for the elderly favor staffing ratios to ensure that nursing home residents receive a minimum amount of care. The Health and Human Services report recommends a minimum of 1.3 hours of care per resident from RNs or LVNs and 2.8 hours from aides. Many nurses and reformers think it should be higher.

The industry opposes ratios, saying that they don't take into account varying acuity rates of residents and that they could force homes to close if administrators cannot hire enough nurses. Many facilities have already decided that their acuity rates demand more skilled nurses and are staffing above what the regulations require, Cameron said.

Reimbursement debate

Nursing homes have continually lobbied for increases in the payments they receive under Medicare and Medicaid. These government-run insurance programs pay for three-quarters of nursing home residents. Medicaid reimbursements vary from state to state, but are about $100 a day for room, board and nursing care, less than the price of many hotel rooms, several directors of nursing said.

Home health care also has suffered because of declining reimbursement from Medicare, said Carolyn Markey, RN, president and CEO of the VNA of Boston. More than 3,000 agencies have closed because of that decline, she said.

But nursing home reform advocates contend that even when nursing homes had generous reimbursement from Medicare, many put it into profits instead of staff.

Any increase in reimbursement should be tied to hiring more nurses and aides, they say.

Problems related to a lack of quality staff have existed for at least 25 years, said Sarah Greene Burger, MPH, RN, former executive director of the National Citizens' Coalition for Nursing Home Reform and now a consultant for the reform group.

She encourages the industry to look at homes that provide quality care to elderly residents, despite the obstacles, and figure out what they are doing right.

The new nursing home

Because people are staying home longer, many nursing homes are not full, Rantz said. Homes in most states are running at 70 percent occupancy. "It's nothing like it was 10 years ago," she said, when occupancy rates were around 99 percent.

Because of this, people looking for homes can "vote with their feet," she said. If a place looks or smells bad, she recommends turning around and leaving immediately.

Some homes have welcomed new ideas, such as the Eden Alternative, which encourages residents to bring in pets and plants.

Martha and Mary Lutheran Services in Poulsbo, Wash., jointly operates a 190-bed skilled nursing home, 23 senior apartments and a child care center that serves 500 children.

As part of the program, staff members regularly take a group of Alzheimer's patients to the infant care center, where they can cradle and rock babies, said Denney Austin, CEO of Martha and Mary Lutheran Services.

A growing number of homes offer resident-centered care, which allows residents and their families to make their own decisions about meals, activities, hours and general care.

At Pitman Manor, patients and families meet regularly with a team that includes a nurse, a dietitian and a social worker to design a plan of care that encompasses everything from the medications a resident needs to what he or she likes to have for breakfast.

Some homes also have found ways to attract and retain staff. Five years ago, Good Samaritan began a concentrated effort focused on recruitment and retention. The company has made salaries competitive, not only with other nursing homes but also, in some cases, with area hospitals.

It offers options for education and continuing education, including a distance-learning program with the University of South Dakota, where the organization is based. It also offers a CNA-to-RN program on-site, job sharing, flexible scheduling and benefits packages.

"Our turnover rate has certainly gone down," Nelson said. The average stay for a director of nursing at Good Samaritan is 14 years. "The more we lower the turnover, the more people want to stay in our facility," she said.

Almost all of the nurses at Pitman Manor were formerly aides, Dornberger said. Instead of recruiting from nursing schools, United Methodist Homes decided to focus on "growing its own" by offering employee scholarships. As a result, Dornberger said, the new nurses are familiar with residents, and they understand what it was like to be a nursing assistant and can offer the respect and support the assistants need.

A well-run long-term care facility offers a nurse many things a hospital cannot, directors of nursing said. Nurses are more independent. They can make changes more easily than if they had to go through a hospital hierarchy. They can get to know the residents and their families. They can become part of those families.

Recently, Dornberger sent some of her staff to attend a resident's 100th birthday party given by relatives. The aides spent time carefully dressing the resident for her party. They took pictures and made her an album.

Another time, one of Dornberger's aides arranged a special anniversary dinner in the skilled nursing facility for a man who lived in the senior apartments and his wife, for whom the aide cared at the facility. "They think of her as their daughter," Dornberger said.

"I believe there are a lot of nurses who have a genuine love for senior citizens," Cameron said. "It is really true nursing in the sense that you get to know these people and you get to know their families. Nurses will tell you, 'These residents don't live in a nursing facility. I work in their homes.' "

Contact Cathryn Domrose at kaguilar@well.com.