Positive and Negative Baselines in Long-Term Care

Long-term care in America is all but completely broken. This is a result of systemic failure on every level of care. This article is about one of the basics: understanding long-term care patients, usually called long-term care “residents.” Understanding long-term care residents entails the ability to put ourselves in their shoes, otherwise known as “empathy.”

An inability to understand residents will lead to a dual frustration on the part of caregivers and the residents also. The point here follows: misunderstanding on either part leads to a disruption in care and care quality. Care communication and interaction must be therapeutic. Real care is not only a task that addresses physical needs but also addresses spiritual, emotional, and psychological needs. This is not optional. A caregiver that does not care for the whole person is not competent.

LTC facilities make overtures with things that contribute to empathy. Sympathy is not empathy. Sympathy means we feel sorry for the individual; empathy means we understand the plight the resident presently finds themselves in. Empathy enables care that is therapeutic. One overture that facilities make is the posting of resident biographies by their doorways. These biographies reveal that most residents lived an amazing prior life. This is where empathy begins, the realization that the former amazing life has been taken from them. It is not hard to relate to that, simply take an inventory of your present life as it is, and imagine that it is suddenly gone and replaced with something much less.

It’s commendable that LTC facilities post the biographies of residents, but how many facilities require their caregivers to read them? Indeed, if empathy is important to the foundation of holistic care, and it is, how can there be empathy without knowledge of what the resident has lost? How many facilities ask the following question: “How can we get empathy into the minds of our caregivers?” What would be wrong with a director of nursing taking time to discuss each biography with caregivers, and exploring what the resident has lost in their present standing?

Of course, this idea would be scoffed at due to staffing shortages and subsequent time constraints, but staffing shortages are the direct result of systemic incompetence in LTC. The only way to mend the present crisis in LTC is to rebuild, starting with the basics. And there is no chasm or struggle between ownership administration and care; quality care leads to higher census’ and subsequent profits.

As a nurse, I never cease to be amazed at what I hear caregivers complain about. These complaints reveal what caregivers don’t understand about residents, and unfortunately, the lack of understanding is usually plenary. A lot of the misunderstanding comes from nurse aides not having a nurse aide theory or identity. In other words, they don’t adequately understand their role or the people they are trying to care for. In every profession but healthcare, it is assumed that little understanding of the worker’s true role and what the worker is working on will lead to catastrophic failure. Again, what caregivers complain about reveals what they don’t understand about their own role and the people they are caring for. They complain about the behavior of the residents, and they complain about resident families. That’s never good.

Understanding the behaviors of LTC residents is the focal point of this article. We are going to employ the study of negative and positive behaviors in psychosis for purposes of understanding. This is a little tricky because in the study of psychosis, negative and positive behaviors do not mean good behavior versus bad behavior or acceptable behavior versus unacceptable behavior.

In, for example, schizophrenia, positive behaviors are defined as any active behavior such as mania, hallucinations, delusions, or even aggressive behavior. This is contrasted with negative behavior, which might be catatonic, withdrawn, or without any kind of emotions.

Nurse aides or nurses who have cared for the catatonic will tend to look at positive behaviors in a more positive light because the resident is active in some way and cares about things. Applying this definition to non-psychotic residents, they may be mean, offensive, or hard to please, but this is favorable over a completely withdrawn state. Oftentimes, residents who have suffered significant loss will completely withdraw. Caring for these individuals poses a significant challenge, but is not the subject of this post. Those who have lost everything will often have a distorted sense of purpose, but it is at least a purpose, nonetheless.

Furthermore, this gives the caregiver a positive baseline to work with. Rarely, if ever, in the case of non-psychosis care, does a negative baseline change to positive behaviors. Positive behaviors can be improved through the right therapeutic care that considers the whole person. Obviously, personal negative feelings that judge the behavior will not lay the groundwork for holistic care.

Lastly, the resident’s family is part of the care team in a big way. As a nurse, I am dismayed by the general attitude towards families in LTC. Again, non-involved families are a sort of hopeless negative baseline that is very sad. An involved family is a positive baseline, and with all positive baselines, it isn’t always pretty, but it gives us something to work with. More than not, difficult families can be won over, IF they are treated with respect and their concerns are taken seriously.

A positive baseline is always better than a negative baseline. Positive baselines always offer the opportunity for encouraging change, and should always be perceived in that way.

Paul M. Dohse, STNA, MA-C, LPN