Skilled Nursing

What Is the Skilled Nursing Specialty? The Ultimate Guide

The demand for skilled nursing is on the rise as the US population ages. In fact, a survey by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) found that nearly all nursing homes and assisted living facilities are currently in a staffing crisis. Therefore, skilled nursing is an excellent alternative for newly graduated nurses worried about landing their first jobs as well as for seasoned nurses from other healthcare settings looking for a career change.

Whichever your current situation may be, this ultimate guide to skilled nursing will cover everything you need to know about this specialty to help you decide whether skilled nursing is the right career move for you.  

Table of Contents

What Does SNF Stand For?

Skilled Nursing Specialty

The abbreviation SNF stands for “skilled nursing facility.” Aside from referring to a physical location, SNF refers to a type of care, including administering medications, caring for wounds, and feeding patients through tubes. In fact, this type of care is not only provided in skilled nursing facilities per se but also in nursing homes, assisted living facilities, hospitals, and even private homes. 

Skilled Nursing Facilities

By definition, a skilled nursing facility is an institution or part of an institution that primarily provides skilled nursing care and related healthcare services for residents requiring around-the-clock nursing or medical care. SNFs may also offer rehabilitation services for injured, sick, or disabled people.

SNFs may be referred to as nursing homes, rehabilitation centers, or convalescent hospitals. However, these facilities should not be confused with others that primarily provide residential care and only occasional medical care, such as assisted living facilities.

What Does Skilled Nursing Mean in Medical Terms?

A skilled nursing facility provides skilled nursing care and rehabilitative services around the clock. SNF residents are usually chronically ill or recovering from an illness or surgery and therefore need frequent nursing care and related healthcare services. These facilities provide medical and social services that are usually not met in a residential care setting or at home.

In addition to being under the care of a physician, residents have an individual care plan that may include all of the following services

  • Dietary services
  • Social services
  • Skilled nursing pharmacy services
  • Recreational therapy services
  • Access to dental care
  • Rehabilitation services, including gait training and bowel and bladder training
  • Specialized care for dementia residents
  • Regular administration of potent injectable and intravenous medications and solutions
  • Ancillary services, such as physical, occupational, and speech therapies

As the length of hospital stays steadily decreases, skilled nursing facilities are increasingly serving as transitional care between a hospital stay and a patient’s home. In some cases, residents remain in these facilities long-term since they are unable to receive the care they need at home. 

What Is a Skilled Nursing Unit in a Hospital?

Some skilled nursing facilities are within or on the same grounds as hospitals. These SNFs may be called Distinct Part Facilities. As is the case with all SNFs, Distinct Part Facilities serve people requiring around-the-clock skilled nursing and rehabilitative services but usually offer treatment for acute illness or injury and intensive rehabilitative services as well. Hospital patients may be transferred to these facilities when their care needs transition from requiring acute to post-acute skilled nursing and rehabilitative services.

Residents of these facilities may be recovering from an acute illness, injury, or surgery. They usually stay for a maximum length of three weeks and are then discharged to an SNF or back home.

Skilled Nursing at Home

Skilled nursing facilities offer PRN jobs for RNs LPNs CNAs

People requiring intermittent or even frequent care usually must leave their homes to receive that care. However, in some cases, people may receive skilled nursing care at home, such as those with severe mobility issues. In these cases, insurance and government programs are more likely to cover the costs of receiving skilled nursing care at home.

Skilled nursing care at home may include any of the following services:

  • Dressing changes
  • Wound care
  • Blood draws and injections
  • Intravenous (IV) therapy, such as for chemo
  • Catheters
  • Feeding tubes and other forms of nutrition
  • Mediports
  • Health monitoring
  • Occupational, physical, and speech therapy
  • Training of family members to perform some healthcare procedures

Assisted Living vs. Skilled Nursing

Although 66.1 percent of assisted living facilities provide skilled nursing care, their primary purpose is to provide assistance with basic activities of daily living (BADL) and instrumental activities of daily living (IADL), including the following:

  • Personal hygiene
  • Dressing
  • Going to the bathroom
  • Transferring or moving about
  • Eating
  • Managing finances
  • Taking medications
  • Preparing food
  • Housekeeping
  • Doing laundry

Residents of assisted living facilities require assistance with everyday care but not as much as residents of SNFs do. In fact, residents of assisted living facilities are often relatively independent, living in their own apartments or rooms and sharing common areas.

What Is the Role of a Registered Nurse in a Skilled Nursing Facility?

Skilled nursing facilities employ a variety of healthcare workers, typically including the following:  

  • Certified nursing assistants (CNAs)
  • Licensed practical nurses (LPNs)
  • Registered nurses (RNs)
  • Nurse practitioners (NPs)
  • Occupational therapists
  • Physical therapists
  • Dietary aides

A registered nurse in a skilled nursing facility is responsible for assessing patients and planning, providing, and documenting nursing care for a group of patients based on the physician’s plan of care. An important aspect of an RNs role in an SNF is coordinating and supervising the care and services provided by LPNs and CNAs. For this role, skilled RNs must have extensive nursing knowledge as well as teaching skills. 

What Do Nurses Do at a Skilled Nursing Facility?

skilled nursing

One way to describe the responsibilities of a registered nurse at a skilled nursing facility is to understand what constitutes skilled nursing care. With that in mind, although RNs may have multiple other responsibilities in an SNF, the following duties represent skilled nursing care

  • Intravenous or intramuscular injection of drugs, administered at a frequency of every eight hours or more frequently
  • Initiation of intravenous (TPN) feeding
  • Initiation of nasogastric tube feeding, gastrostomy, and jejunostomy feeding
  • Naso-pharyngeal and deep tracheal suctioning
  • Treatment of stage three or stage four decubitus ulcers or other complicated wound care requiring multiple dressing changes within a twenty-four-hour period
  • Care of a colostomy during the early postoperative period in the presence of complications
  • Initial care of urinary catheters (suprapubic or “in and out” catheterization)
  • Training or teaching of the patient and caregiver as appropriate for the above services 

How to Become a Skilled Nurse and How Long Does It Take

There are many pathways to become a skilled nurse since nurses at many levels of education can work in skilled nursing care.

  • The fastest route to work in a skilled nursing facility is to first become a CNA—which can take as little as four weeks—while studying to transition from CNA to RN.
  • The next fastest option is to complete a one-year LPN program.
  • Another alternative is a two-year associate’s degree in nursing (ADN), which qualifies graduates to take the National Council Licensure Examination (NCLEX) to become registered nurses. 
  • Another way to become an RN is through a four-year bachelor’s of science in nursing (BSN), which gives these nurses a competitive edge over RNs with ADNs.
  • RNs may also pursue higher education to become nurse practitioners (NPs), which takes at least another two years.  

It is interesting to note that more CNAs (34 percent) and LPNs (35 percent) work in skilled nursing facilities than in any other work setting. On the other hand, only 6 percent of RNs work in skilled nursing and residential care facilities combined, and the number of NPs in SNFs is negligible. 

For nurses at any level of education, skilled nursing is an excellent entry-level position. That said, some jobs may require at least one year of nursing work experience in areas such as rehabilitation, medical-surgical nursing, or home health

What Is SNF Certification?

Essential certifications that all nurses should have, regardless of work setting, are basic and advanced life support certifications. Additionally, nurses may wish to pursue certifications especially created for SNF nurses. The following are some of the certification options currently available for SNF nurses:

  • The Association of Rehabilitation Nurses offers the Certified Rehabilitation Registered Nurse (CRRN®) credential for nurses assisting individuals with disabilities and chronic illness in restoring, maintaining, and promoting optimal health.
  • Harmony Healthcare International offers the Certified Harmony Healthcare Rehabilitation Professional (CHHRP) training geared toward providing patient care, regulatory requirements, and reimbursement in an SNF setting. This training is available for SNF nursing staff and management. 
  • MedBridge has the Skilled Nursing Facility Essentials certificate for nurses and other healthcare staff working in skilled nursing facilities. This course provides a strong foundation necessary to provide quality, competent, and safe care to older adults as a member of a diverse healthcare team. 

How Much Do Skilled Nursing Facility Nurses Make?

Salaries for nurses and nursing assistants working in skilled nursing facilities primarily depend on the type of license each healthcare worker holds. The following are the average salaries of CNAs and nurses working in SNFs:

Certified nursing assistants: $32,090 annually or $15.43 hourly 

Licensed practical nurses: $53,670 annually or $25.80 hourly 

Registered nurses: $72,260 annually or $34.74 hourly

What Is Skilled Nursing Nursing Like?

Skilled nursing offers nurses the opportunity to truly get to know the residents they care for since they are often together for long periods of time. Furthermore, they are able to offer residents emotional support in addition to physical care. That said, schedules can be rough since skilled care must be offered around the clock, and patient-to-nurse ratios can be very high. Let’s see what SNF nurses on Reddit have shared about what it’s like to work in this nursing field.  

“…for the most part they are extended care facilities for patients that are too ill/weak to go home but not “sick enough” for an inpatient hospital stay…If you find one that is associated with a larger hospital, it may be closer to a step down unit. I worked in one for 7+ years and we had vents, trachs, complicated wound vacs, IV abts, in-house dialysis, etc. There we got a good variety of skills and learned to pass meds like a boss. 😉” – Reddit user SamHoneycrochet

“Six years in a nursing home as a floor nurse, and recently one year as a nurse manager in a nursing home. We dealt with every medical issue except labour and delivery. Some issues are chronic and some are acute. I would never go back to a hospital setting unless it was geri-rehab or geri-psych. My residents ranged in age from 28 to well over 90. The ratio varies between shifts for staff to resident ratio. The smaller nursing home had 88 residents and it was 1 nurse to 35 residents, but we had between 3 and 5 health care aides for those residents.” – Reddit user Tricky_Excitement_26

Is Skilled Nursing Hard?

skilled nursing

It is relatively common to hear nurses complaining about skilled nursing—especially the incredibly high patient-to-nurse ratios—and claiming that once you get into skilled nursing, you can’t move on. However, another group completely disagrees, stating that they have learned a lot in skilled nursing and that—worst case scenario—a nurse with any experience will be more competitive than a new grad. As generally is the case, there are truths to both sides. 

The following testimonials from skilled nurses help paint a picture of the challenges of this type of nursing without going to either extreme:

“one: patient overload, even though they are fairly stable chronic cases. two: you get a couple of psychotic cases that takes your time away from your other 28 patients. three: you are also handling a team of at least 2 LVNs and 6 CNAs who have their own patient care routines. four: nursing homes are highly regulated — and this is apart from the facility’s own policies and procedures — which makes audits and documentation tedious…” – Reddit user hapidee

“There are patients who vacuum up time and there are patients who basically take a few pills, do rehab, and don’t make a peep…Sometimes there are multiple emergencies or admissions, and sometimes it’s quiet. Sometimes you develop awkward pseudo-family relationships with some of your patients, and sometimes you get to spend weeks with a patient who hates you no matter what. It’s all the same stressors and rewards of being a nurse in the hospital seems like. It’s just which stressors predominate and in what proportion.” – Reddit user ledluth

Why Choose Skilled Nursing

One reason to choose skilled nursing is that SNF nurses are in very high demand. Therefore, if you’re having trouble finding a job, finding jobs in skilled nursing is practically a sure thing. However, job security is not the only reason to work in skilled nursing. Many skilled nurses love the relationships that they are able to develop with residents and, therefore, wouldn’t change their jobs for any other. Let’s take a look at some testimonials from some of these nurses:

“It definitely gets better. SNF is a nurses biggest nightmare and blessing. Once I became comfortable with everyone (the 3 Margarets, 4 Bills, etc) I truly enjoyed my residents. I set an alarm to pee and would joke with them about it being my pee time. They totally understand. When they smile and put on a brave face with families, they cry and complain with you because they feel comfortable with you and depend on you. They truly do care and if you can give it a chance, do so. Scheduling problems caused me to leave the SNF and I miss it.” – Reddit user lcmontana1

“I worked in a SNF/LTC for over 7 years and absouletly loved it. I formed such a bond with my residents and their families. I know it’s not for everyone but honestly I found this line of work the most rewarding.” – Reddit user Secret_Yam_4680

What Makes a Good Skilled Nurse? Tips for New Nurses

Aside from the knowledge and experience acquired during your nursing program, the following are some skills and attitudes that a nurse working at a skilled nursing facility should strive to develop:

  • Be compassionate: The truth is that all nurses should be compassionate with their patients, and most are—if they are not completely burned out. However, in skilled nursing facilities, residents deal with the added challenge of requiring a longer period of care than the average patient does. Furthermore, even if their stay in a skilled nursing facility is not very long, many residents return to assisted living facilities instead of their own homes. In other words, many residents of skilled nursing facilities must resign themselves to the fact that they can no longer live independently—and for many, this is not an easy pill to swallow.
  • Communicate clearly: Remember that the residents and their family members probably didn’t go to nursing school! Keep your language simple and clear when explaining their care plan, including any procedures and medications they may need. That said, the simple fact of explaining what procedure you need to carry out or what medications you are giving them will be much appreciated, even if they don’t fully understand what you say. After all, communication is a sign of respect.
  • Be organized: One of the undeniable challenges of working in a skilled nursing facility is that nurses have heavy patient loads. You can expect a learning curve, but as soon as possible, you must figure out a system or routine that allows you to cover all your duties without feeling overwhelmed—and without ignoring your own needs for food, water, and bathroom breaks.
  • Ask questions: No one expects a new nurse to know everything, so don’t pretend that you do! Ask as many questions as you need to to ensure you are doing the best job possible. Also, ask seasoned nurses at your facility for tips to help you find a routine that works for you.
  • Take care of yourself: Although self-care seems incompatible with nursing, addressing your own needs will help you better care for others. If you are hungry, dehydrated, or overdue for a trip to the bathroom, you will be forgetful and moody, and no one will be better off for it. Granted, you will not be able to take a leisurely lunch, but at least give yourself time to eat some healthy snacks, stay hydrated, and go to the bathroom whenever you need to.

Final Thoughts on Working in a Skilled Nursing Facility

Nurses are in high demand in skilled nursing facilities, and although patient-to-nurse ratios are high, SNFs are great places to begin your nursing career and obtain invaluable experience offering nursing care. Remember that skilled nursing need not be a dead end; you can always transition to other types of nursing if you feel you could use a change. Are you ready to give skilled nursing a try?

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