Behavioral Interventions to Facilitate Growth

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In this Learning Module, you will learn the six steps of giving effective demonstrations to increase your residents' or tenants' ADL independence. As you are aware, some residents need additional assistance in grasping a concept beyond mere verbal instruction, which was discussed in the last learning module. This is where demonstration, or showing a resident the ADL procedure becomes a valuable tool.

In order to do this, you have to break an ADL down into its separate steps, or parts. For example, let's say that you have a resident or tenant, Mildred, in the early stages of Alzheimer's who has recently had a hip replacement.

The transfer from her bed to her wheelchair involves several parts:
1. Scoot to the edge of the bed
2. Sit on the edge of the bed and place her feet on the floor
3. Push herself off the bed to stand
4. Support her weight while standing
5. Reach and grasp one arm rest of the wheel chair, positioned by her bed.
6. Pivot or turn
7. Grasp the other arm rest
8. Ease herself into the chair.

Let's say that, in the past, Mildred has been able to do all parts of the transfer independently. But, this morning, you observe that her eyes are not open as wide as they usually are. Instead of looking at you when you speak, she looks at the floor. You ask if she feels okay. Mildred states that she was worrying about her daughter's visit, and did not sleep well.

Now, one extreme option you have upon noticing her disorientation is that you could make the decision that she is completely unable to transfer. You call for an assistant and physically lift her into her chair. However, this obviously goes against your ALF's philosophy of independence, choice, and perhaps even dignity, since she is merely seeming temporarily lacking mental clarity. Her behavior does not, at this point, seem to warrant such an extreme measure.

Of course, if there were a fire in the building, yes. But when you give too much assistance to a resident, you are giving them the message that they are incapable of performing the task themselves. Also, by placing Mildred in her chair, you may be taking away any ADL confidence that she had built up over the months after her hip replacement.

Question #1: When you give a resident too much assistance you give them the message that they are what? To select and enter your answer go to CE Test Question #1.

The "Happy Medium"
Somewhere between total dependence and total independence, you have to make a decision of how to find a happy medium. This morning, based upon your observation of Mildred's unusually foggy state of mind, you decide to suggest to her, "Why don't you sit in bed for a little while longer until you wake up a little more, Mildred. I'll be back in about 15 minutes." Mildred agrees. So you assist the resident in the next room to brush her hair. When you return, Mildred looks slightly more alert, and states that she doesn't want to miss breakfast and wants to be in her wheelchair.

Question #2: If you feel that your resident needs a little extra time to get focused in the morning, you should do what? See above

You decide to start with verbal instructions in the form of some question because she still looks a little dazed. You ask, "Mildred can you scoot to the edge of your bed and place your feet on the floor?" You observe that she is slower than usual, and a little clumsy, getting her feet slightly tangled in the sheet. So you assist by pulling the sheet and covers out of her way. To reinforce her independence you say, "Good job Mildred, I know you don't feel the best this morning and that took some effort on your part." Since Mildred has had a stroke affecting her left side, you place her wheelchair on her right, unaffected side.

However, instead of standing, as in the past, she now sits on the edge of her bed staring off into space with a dazed, unfocused look in her eyes. She does not seem to know what to do next. You really feel that if you instruct her to get into the wheelchair, she might be at risk of a fall. Once again, you could physically assist her, or call for someone to help you. But keep in mind, since her admission two months ago, she has performed this transfer with no physical assistance.

In summary, step one in demonstration is, after you observe your resident's alertness level, decide between physical assistance, demonstration, or a combination. Your decision to demonstrate, or show a resident rather than physically assist, brings us to the core challenge any caregiver faces daily regarding ADLs Your challenge is as follows. Do you uphold the philosophy of your ALF to encourage Mildred's independence? Or, do you play it safe and give physical assistance, which takes away independence?

Now it goes without saying, you can demonstrate, and then give physical assistance as Mildred does the transfer, but often times we merely give the physical assistance and never give a thought to the option of giving a demonstration first. You make the judgment call. So as an alternative to physical assistance, you say to Milldred, "Let me show you what to do. I know you've done this before"

Question #3: The core challenge in any ALF is independence versus what? CE Test Question #2.

Step 2 - Positioning
Now let's get back to Mildred. Step number two in demonstration is Positioning. With Mildred, to position your demonstration of the transfer, move her wheelchair towards the end of the bed about one or two feet away. Then, you sit next to Mildred on her bed after asking her permission.

Regarding the positioning of your demonstration, all too often when we demonstrate, we may show the resident a task with an obstructed or blocked line of vision or view. To avoid this common error or problem, note Mildred's eyes. Then look at the area that you want her to observe. See if anything is in the way to prevent her observation.

Interestingly enough, besides the edge of the bed and arm of a wheel chair, the most common obstruction for this demonstration of a transfer is your own body. Often times we show a resident something and our back or arm or hand is blocking their line of vision. So, position your demonstration, then check for any obstruction in their line of sight.

Question #4: In positioning your demonstration, the most common item blocking your resident's view of your demonstration usually is what? See above

Step 3 - Single-Word Instructions
Step Number 3 in your demonstration is single word instructions. You learned about giving single word instructions in Staff Training Module two. The key to be remembered from that module is to use simple one or two word instructions as you demonstrate. In other words, after you explain or introduce what you are going to do, by saying something like, "Mildred, I'm going to show you how to get into your wheelchair," limit what you say to one or two word instructions. A lot of chatter and a long complicated sentence will be distracting and confusing.

Question #5: Single word instruction during your demonstration is important because it does not what? CE Test Question #3.

Step 4 - Check for Understanding
Step number four is checking for understanding of your demonstration. While you are demonstrating, maintain as much eye contact with Mildred as possible. First of all, check if you have her attention. Secondly, check for some sign of understanding like a head nod or perhaps a knowing smile. If she appears to still be in a fog, you might check the pacing of your demonstration.

Repeat it by saying something like, "I know there are a lot of steps involved in this. Let me show you again in slow motion." After the second demonstration, recheck Mildred's understanding by asking, "Did you want to see that again before you try?" So step number four is, as you do your demonstration look at your resident's eyes, facial expression, and gestures to check for attention, understanding, and repeat at a slower pace if needed.

Question #6: During your demonstration, check for your resident's what? See above

Question #7: Repeat the demonstration how? CE Test Question #4.

Step 5 - Active Participation
Step number five is active participation and an added alertness check. Relocate the wheelchair closer to Mildred. Reassess Mildred's alertness. If you feel by observing her posture, eye openness, eye contact, and facial expression that she is alert enough to transfer without physical assistance, you ask, "Okay Mildred, are you ready to try now?" As she starts the transfer, observe for signs of weakness and faintness. Have her sit back down on the bed, if you feel that she is not capable of independently transferring.

Question #8: Before your resident attempts the ADL, especially if their is a risk of a fall, check alertness by looking at your resident's what? See above

Step 6 - Safety
Step number six is safety. Of course, when regarding safety, keep yourself in close proximity or close to your resident should she or he need physical assistance.

Regarding Mildred's transfer, stand close enough to slide your arm under her armpit, and grasp her forearm should she start to fall. Consult your supervisor for other falls procedures. Also, as an added confidence builder, as Mildred performs the transfer, give verbal instruction as a reminder of the steps in the transfer. Use the same single word instructions you just used in your demonstration. When the transfer is complete, use the skills you learned in module one, and reinforce her independence by saying, "Mildred, good job of getting into your chair!" Your compliment uses

Question #9: As your resident performs the ADL, check that what are followed? See above


Summary
Now let's review the six steps in a demonstration that we have just gone through so that you can apply them to any ADL demonstration.
Step 1: Observe the resident's alertness based upon eye openness, eye contact, facial expression, body movement, and speech. Then, decide if your resident could benefit from a demonstration.
Step 2: First, position the equipment or supplies to provide the easiest access for the resident. For example, with Mildred, you placed the wheelchair next to the bed on her unaffected side. If she were brushing her hair, you would place the brush to her right side. Second, make sure that your demonstration is clearly in the line of vision of your resident and nothing is blocking his or her view.
Step 3: Demonstrate using simple words or phrases; then repeat your demonstration more slowly if needed.
Step 4: Look at the resident's face and eyes to see if you have their attention and they understand.
Step 5: Request the resident to perform the ADL.
Step 6: Stay in close proximity, should physical assistance be needed. Also, provide sincere, positive reinforcement or compliment during and at the end of the ADL performance.

Question #10: After the resident performs, or attempts to perform the ADL, give the resident a what?

Question #11: How many times should you repeat your demonstration? As many times as are what? CE Test Question #5.