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Long-Term Care Survey Alert

Abuse Prevention:

7 Ways To Help Caregivers Keep Their Therapeutic Cool Under Verbal Attack

Published on Fri Sep 24, 2004 Print Friendly and PDF PDF

Don't let residents who levy racial epithets or other insults open the door to resident neglect or worse

Remember that old playground taunt, "Sticks and stones may break my bones ... but words can never hurt me?" It wasn't true then and don't count on it being true when nursing home residents hurl racial slurs and other negative epithets at their caregivers.

Words can hurt and cause unprepared caregivers to avoid - or even retaliate - against residents who verbally abuse them.

"Residents engaging in racial name-calling has become a bigger problem because staff today is composed of people from so many different cultures," notes David Lennox, PhD, founder and president of QBS Inc. in Holliston, MA. 

The bottom line: "The facility's managers and inservice trainers have to talk to staff about these issues as part of training on abuse prevention," says Lennox.

To educate and prepare staff to deal with residents whose disease or other issues cause them to lash out verbally, address these key elements:

1. Provide an overview of how  various diagnoses, including dementia and traumatic brain injury, can cause people to do and say things they normally wouldn't. The goal: If the staff person understands that the resident acts the same with all or most of the staff and others in his life, she will be more prepared for the resident's behavior. "You want the staff person to emotionally depersonalize the behavior and view it as a symptom that requires certain strategies," Lennox says.

2. Provide sensitivity training to staff that includes role-playing situations involving verbal abuse by a resident. That's the strategy Don Ashmann, MEd, uses in training staff at a nursing facility in Jacksonville, IL. Divide staff into pairs where each person takes turn playing an abusive resident who calls the caregiver "fat, stupid, ugly," or uses a racial or gender-related insult.

The goal: "Role playing for staff helps desensitize the staff person to that kind of behavior and leads to discussions about feelings, responses, and reasons residents might behave that way," Ashmann says. 

3. Cover the general strategies and ground rules for dealing with verbally abusive residents. "Just telling the staff to keep their cool isn't enough," says Lennox. "You have to give them some tools they can use to intervene and cope."

Make sure staff know to ask for a "time out" if they feel like they are losing their composure and may become abusive to the resident in return, say experts. "Everyone has that particular resident who can get to them ... it's OK to ask for help," says Ashmann.

Teach CNAs to report a resident's offensive behavior - or behavior out of the norm for a resident - the very first time it occurs, advises Reta Underwood, a consultant in Louisville, KY. "You don't want a culture where CNAs are afraid to report because they feel embarrassed by the behavior or like they are 'telling on' the resident," she says.

Schedule a Mental Health Consult

Underwood advises scheduling a mental health consult for any resident who repeatedly makes racial remarks, verbally abuses others or sexually acts out.
Use the consultation to determine the following:

  •  Whether the resident's behavior is due to a geropsychiatric diagnosis or perhaps a medical condition (such as pain or a neurological problem) or a lifelong pattern of abusive behavior;

  •  how added stress may be figuring in the equation; and

  •  whether counseling might help the resident correct the behavior. For example "in some cases, the resident may be using words that he learned growing up which are no longer considered appropriate," notes Ashmann, who has conducted cultural awareness and sensitivity sessions for staff and residents in nursing facilities.

    Remember: For counseling to work, the resident has to be cognitively intact enough to benefit - and must be willing to participate.

    Look for Patterns

    When care planning to deal with resident's verbal abuse, identify the "stimulators and stressors" that appear to trigger the behaviors, suggests Underwood. Ask these questions:

  •  Does the behavior occur in certain situations, such as during personal care or only when one caregiver is present?

  •  Does the resident avoid engaging in the offensive behavior when family members are present (such as a spouse or adult child) or when there are two caregivers?

  •  Does the person appear to use racial epithets or make unkind remarks about a staff person to get his/her attention?

  •  Does the resident behave better for certain caregivers than others?

    Individualize Strategies

    By identifying the resident's pattern of behavior, you can sometimes sidestep problems. For example, try a buddy system where two people care for the person during situations when he behaves in a demeaning way toward staff, Underwood suggests. You can also assign caregivers who have the best luck dealing with the person.

    Use care plan and staff meetings to share techniques known to work - and not work - with a specific resident, Underwood suggests.

    Potential communication and behavioral strategies that may eliminate or at least reduce attacks of verbal abuse by residents include:

    1. Try to reach the person on a feeling level, e.g., tap into the underlying emotional reason the person is being abusive. This strategy can be helpful if the resident is cognitively intact enough to address his underlying motivation, Ashmann says. For example, is the resident frightened or angry about something else and feels safer expressing it indirectly to the staff person?

    Note: This technique might best be used by a nurse or counselor.

    2. Ignore the abusive verbal message but address the resident's underlying feeling. "If the resident says something abusive or uses a racially charged comment, don't get angry or withdraw from the person," suggests Francis Battisti, a social worker and nursing home consultant in Binghamton, NY. "Instead, validate the underlying feeling of powerlessness, anger and frustration by saying: 'You're upset. Let's figure out what you want,'" he suggests. This technique can work with people who have cognitive impairment.

    3. "Catch" the person doing something positive instead of just paying attention to negative behavior. You might say, "'I saw you helping Mr. Smith during activities. That's very kind,'" advises Ashmann. "Some residents may have come from a background where they only got attention in negative ways," he notes. "So if staff gets angry or confronts the person when he acts out, he's getting what he wants" or is used to getting, Ashmann says.

    "There's a happy part to everyone - encourage staff to find a way to help that resident smile or find ways to engage him in a positive way in the facility, as a goal," Ashmann adds.

    4. Use "planned ignoring" as a behavioral strategy. "This approach may work for a resident who doesn't really have a geropsych diagnosis or medical condition causing his abusive behavior," says Lennox. When the person becomes verbally abusive, the staff person turns his head and walks out of the room (as long as the resident is safe), explains Lennox. Then the staff person returns in about 60 seconds and resumes her care.

    If you're going to use planned ignoring as a behavioral intervention, make sure it's part of the care plan, based on accurate assessment - and the resident is left momentarily in a safe situation, emphasizes Underwood.

    "Planned ignoring" won't work for residents with certain psychiatric diagnoses, especially personality disorders, in Ashmann's view. "The person will just find another, potentially worse, way to get your attention," he cautions.

    Ideas: Some facilities are doing cultural assessments on all residents/families upon admission to identify and meet their cultural and language needs (see the sample form, p. 107). They are also hosting celebrations to showcase the food, music and art of various cultures represented by people in the facility.

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