Narrativizing the Resident

I’ve seen it far too often in long term care: the staff’s tendency to create narratives around their residents, the same way that major news outlets cherry pick quotes to create talking points.

It starts with the electronic medical record or EMR. There’s an old saying in nursing: “if it’s not noted, it didn’t happen.” Nursing notes are meant to justify care, protect patient and facility from malpractice, and communicate abnormal situations between shifts and departments. I’ve spent hundreds of hours reviewing nursing notation on a professional level. Typical nursing notes from nurses and other medical professionals includes items such as vital signs, lab results, and convalescent progress such as a course of antibiotics, or healing wound. But when it comes to human behavior, you can always tell the difference between a nurses’ notation and a social services professional. Nurses are straight to the point, and when a resident displays abnormal interactions, nursing labels it with that dirty, awful, reductive word “behaviors.” Their notation looks something like this:

Mr. Jones was aggressive towards staff during hour of sleep care, swung and struck at staff. Vital signs taken. Urine obtained. Will monitor and update PRN.

Healthcare, especially in the nursing home setting, is a land of meetings. There’s meetings about meetings. One such meeting is the IDT meeting or interdisciplinary team, commonly known s orning report, in which members of social services, nursing, therapy, and dietary get together and discuss important issues including resident behaviors. In those meetings, nursing notes containing only action and reaction, become a kind of identifier for the resident. Mr. Jones, who never said a cross word, but had extraordinary arthritic pain last night, gets labeled as “aggressive” because he slapped an aide’s hand during care. I’ve been in thousands of such meetings in which staff develop easily digestable narratives around charted resident interactions. These narratives seek to assign attributes and qualities to residents based on snippets of information and incidents that are out of the ordinary.

The problem is, this way of thinking is reductive, and dehumanizing, conflating a discrete action with personality and baseline behavior. Speaking about residents this way yields no understanding of the underlying causes of the behavior, and results in nothing but canned responses and boilerplate interventions.

I’ve spent a majority of my career teaching fellow staff members to resist the urge to narrativize their residents. By reducing them to a mere talking point, you run the risk of limiting proactive care options by accepting that’s just the way that resident is.

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