Commonly Heard, Commonly Said: Catchphrases That Hurt Long-Term Care Practice and How to Address the Issues They Imply

Abstract: The perception about how services are provided in a long-term care (LTC) setting matter nearly as much as the actual skills of the health care provider. At times, particularly under large resident care assignments, staff may respond to residents or family members in a way that may cause them to infer that there are problems among individual staff or in the facility in general. This article will identify areas in which staff should be cognizant of the common phrases and assumptions used in LTC facilities that may potentially and unintentionally negatively influence how and why we render care as well as how quality care is communicated and delivered. 

Key words: long-term care, nursing, errors, malpractice

The care for residents of long-term care (LTC) facilities is often delivered in a stressful environment by employees with various educational backgrounds and experience levels who often work with confused residents and concerned family members. During the course of providing care in such an environment, staff members may make statements that, upon reflection, may be considered inappropriate or inconsiderate. These statements may also be indicative of underlying viewpoints or perceptions within the facility.

We as humans tend to fall into patterns of speech we learned long ago or picked up throughout the years, but we rarely have the opportunity to fully examine the impact our words may have on residents or their families. By raising awareness about the issue of language in care delivery, leaders may be able to alleviate tension or stressful atmospheres within their facilities and also improve communication among staff, residents, and family members. 

The purpose of this article is to highlight some common phrases and terms that could potentially be problematic, to provide some terminology and language alternatives to these common phrases, and to discuss the how providers can address the issue through discussions with the staff. LTC managers can then begin a dialogue with colleagues and staff about how what we say can be misinterpreted by both residents and their families and identify their own facility-specific solutions.

“We are short-staffed tonight.” 

An undue burden is placed on residents when caregivers tell them that the unit is short-staffed. It implies that individual residents’ needs might not be met because of the insufficient staffing, and it can increase residents’ anxiety or even lead to their attempting to transfer and toilet without adequate assistance, for example.

The adequacy of staffing in terms of numbers and types is one of the most significant quality indicators in any health care setting.¹ Facilities have long tried to balance personnel costs with the need to provide adequate levels of staff while also meeting minimum standards imposed by their states. Even one certified nursing assistant (CNA) calling in sick for his or her shift can cause considerable difficulty for the remaining staff in meeting the needs of residents on that unit. Staff should work together to prioritize the workload and determine whether ancillary staff or administrative personnel can be used to fill in the gaps of care. Residents and family members should be reassured that the staff will continue to support their health and safety needs, although it may take more time than usual.

“No complaints of pain”

Consider these 2 statements: “No complaints of pain,” and, “Resident denies pain and exhibits no evidence of pain.” The first statement does not necessarily imply that a pain assessment was performed or that the resident was asked whether he or she was in pain. On the other hand, the second statement clearly indicates that a nurse asked the resident about pain as well as assessed for nonverbal indicators of pain. 

Nurses’ narrative notes can sometimes be vague, especially in busy facilities, but documentation practices may be improved by encouraging nurses to focus on documenting nursing-specific care they provided that perhaps a CNA does not provide. For example, facility leaders can prompt licensed nurses to document care provided using the key topics of the care plans, an assessment of vital signs, signs and symptoms of specific disease processes, improvement or deterioration in the status of a wound, responses to new medications or reductions of doses, or assessments of a resident’s level of pain.

“Turned and repositioned every 2 hours” 

Routine nursing interventions such as assessing orientation, changing bed linens, and repositioning a resident in bed every 2 hours and in a chair every 30 to 60 minutes are often not documented by licensed nursing staff.² Information about which residents need to be repositioned and how often can be ascertained using the Minimum Data Set, which will help identify residents who require extensive assistance or who are completely dependent upon staff for bed mobility. Rather than recording potentially redundant interventions, turning and repositioning observations and supervision can be captured on the treatment administration record. Here, the licensed staff can record for each shift that they observed the CNA staff turning and repositioning the resident every 2 hours for the 7-3, 3-11 and 11-7 shifts. It also serves as a prompt to the nurse to supervise that this intervention took place. Residents who require turning in bed and repositioning in a chair should have care plans that include these interventions, and these residents should be identified on the CNAs’ assignments. Licensed nurses should work together with the CNAs to perform turning and repositioning activities. 

“Is your mother falling at home? Bring her here, so she won’t fall.” 

Older adults who fall in the community are likely to continue to fall in an LTC facility, since the underlying causes of falls (eg, weakness, debility, fragility, sarcopenia, orthostatic hypotension, the effects of numerous medications) cannot be reversed simply by virtue of living in a facility.³ Residents are not constantly monitored with cameras while in bed; therefore, staff have a limited ability to intercede when a resident attempts to ambulate from bed to the bathroom. Staff should be well-versed in residents’ history of falls in the community so as to inform other staff, when needed, of residents’ propensity for falls in the facility.

Administrative staff should be frank with prospective residents and their families regarding the probability that the resident will continue to experience falls in the facility. The advantages for an older adult with a propensity to fall moving to an LTC facility are limited to the staff’s ability to assist the resident, to assess for injuries, and to develop a plan of care with interventions designed to minimize rather than eliminate falls. It is imperative to explore the expectations of the resident and family with regard to ongoing falls prior to admission and to provide meaningful education regarding the interventions available to reduce falls in this setting. 

“Comfortable people don’t fall.”

After spending decades using bed and chair alarms as common interventions to reduce falls, staff members have increasingly embraced the idea of resident-centered care with an emphasis on comfort instead. If residents are physically uncomfortable where they are or displeased with other environmental factors, they will likely try to move or leave without proper assistance. Determining contributing factors to resident discomfort could prevent unnecessary or unassisted movement. Causes of discomfort may include hunger, thirst, fatigue, overstimulation (eg, call bells, televisions, and bed and chair alarms), anxiety, feelings of being misunderstood, breaks in routines, the introduction of unfamiliar foods, inactivity, therapeutic activities that do not meet the needs of the individual, or being placed in a large congregate area. 

Particular behaviors exhibited by residents nearly always hold meaning—even in residents with dementia; thus, encouraging staff to carefully note specific patient behaviors may hold the key to discovering underlying causes of discomfort that can then be remedied, thereby reducing the potential for falls. By encouraging the facility staff to consistently observe residents for expressions of discomfort, the team increases the possibility of more successful fall prevention and reduction of falls.

“If it isn’t documented, it wasn’t done.” 

This saying has become quite popular in recent years. It is expected that medications and treatments will be signed out on the medication administration records or treatment administration records; however, many basic nursing interventions provided for residents may not be appropriately captured. When thinking about this statement, many nurses will agree that they often have conversations with residents and visitors in order to develop a relationship, discussing such things as the weather, the type of work the resident did before retiring, the number of children and grandchildren, and other information that can foster a bond with the resident. This type of information is often not included in the narrative nurse’s note, even though the conversation did indeed transpire. 

It is not possible to write a nurse’s note that completely captures all of the information shared between a nurse and a resident; therefore, the goal is not to document everything but to attempt to include the most relevant information as possible. Determining what is most relevant for each case will depend on each individual resident. For example, if the resident’s orientation during these conversations is a particular issue, staff taking notes should include a mention of even seemingly trivial conversations that may be helpful in treatment discussions of cognition later.

“Licensed nurses know the Braden Scale and don’t need in-services on completing the scale.”

The Braden Scale was designed to identify residents at risk for pressure ulcer development by examining 6 areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Most hospitals, homecare agencies, and LTC facilities require that nurses complete a Braden Scale score upon the resident’s admission and at regular intervals thereafter. But the scale was not designed to be limited to only the 6 elements; staff are expected to exercise professional judgment in determining the resident’s level of risk.⁴ The Braden Scale does not contain a section for actual pressure ulcers or a history of pressure ulcers—2 additional factors that are significant for determining current pressure ulceration risk. Thus, staff should expand efforts by also asking shrewd questions. 

Determining subsequent relevant questions to be asked as part of the scale may not be as straightforward as one may think. For example, residents’ sensory perception may be altered by dementia, the use of narcotics, paralysis, or a host of other problems. Moisture includes feces and saliva as well as perspiration and urine. Newly admitted residents may be unaware of nutritional intake or weight loss but could identify whether their clothes are fitting tighter or more loosely, an indicator of weight changes. 

Nurses may need more formal instruction in the proper completion of the Braden Scale and the need to use their professional judgment in determining risk. If the facility provides interventions based narrowly on the Braden Scale score, inaccurate scores may result in a delay in providing appropriate interventions to an individual resident. Quality assurance and performance improvement teams should identify residents who developed pressure ulcers during their LTC residencies and then examine their Braden Scale scores to determine whether the nursing staff underestimated the risks. Interventions can then be geared to improving the accuracy of the use of the scale through education and examples.

“Nurses learn management and leadership skills in nursing school.” 

The possession of a nursing license does not imply that the nurse has attained specific knowledge or expertise in how to be a leader, how to discipline staff, how to manage staff with various backgrounds, how to provide constructive criticism, or how to use a situation as a teaching moment to correct technique or interactions with residents and families. Indeed, these are typically skills that are learned through practice and after many experiences, not in a classroom. Professional development training may be useful to provide for staff on a formal or informal basis in the form of specific in-service and mentorship support to improve nurses’ ability to effectively manage teams. When it comes to hiring new staff, part of the skills checklist completed at the time of hire could ask for specific knowledge or examples of leadership and management skills. 

Conclusion

Improving the quality of communication between LTC residents and staff and among staff members is a significant area of concern. By examining common catchphrases geriatrics and LTC professionals have learned in school and in practice, care facilities can begin to identify the prevalence of these phrases and thus potential issues among staff. Identification of phrases and terms that may be inconsiderate or result in miscommunication is the first step toward meaningful action to correct flawed perceptions and/or unrealized personal dispositions that may hinder effective, person-centered care delivery.

References 

1. American Health Care Association. The Long-Term Care Survey: Phase 2. Washington, DC: American Health Care Association; 2017.

2. National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Haesler E, ed. Cambridge Media, Osborne Park, Western Australia; 2014.

3. Willy B, Osterberg CM. Strategies for reducing falls in long-term care. Ann Longterm Care. 2014;22(1):23-32.

4. Braden BJ. The Braden Scale for predicting pressure sore risk: reflections after 25 years. Adv Skin Wound Care. 2012:25(2):61.