Activities for the Institutionalized Elderly - Coursework Example

Activities for the Institutionalized, Elderly Introduction Long-term care institutions share common, clearly identifiable features, although the degree to which they may be classified as "total institutions" varies. Nursing homes are one type of total institution defined by Erving Goffman in his classic work on institutions. Goffman (1960) describes total institutions as "social hybrids, part residential community, part formal organization. These establishments are the forcing homes for changing persons in our society. Each is a natural experiment, typically harsh, on what can be done to the self" (p. 453). Total institutions as described by Goffman (1960) have the following characteristics in common: First, all activities are conducted in the same place and under the same authority. Second, each phase of the resident's daily activity is carried on in the immediate company of a large batch of others, all of whom are treated alike, and are required to do the same thing together. Third, all phases of the day's activities are tightly scheduled, with one activity leading a prearranged time into the next, and the whole sequence of activities is imposed from above by a body of officials. Fourth, the various enforced activities are brought together into a single plan, purportedly designed to fulfill the official aims of the institution (p. 11). Goffman (1960) further suggests that individuals who enter a total institution undergo both a "stripping" process and self-mortification. The person entering an institution, according to Goffman, is stripped of property, personal possessions, pets, and thus personal identity. Life-long habits and styles are abandoned for a scheduled and routinized existence dictated by strangers. The stigma of occupying a devalued state is known as "spoiled identity" (Goffman, 1963). With the loss of individuality, a sense of sameness occurs and individuals are stripped of the uniqueness, personality, and personhood that makes them who they are. A consequence of institutional totality of the type that Goffman (1963) describes may be the lack of, or a diminished, self-determination in nursing home residents. Reduced self-determination, freedom, functional capacity, and competence often accompany growing old in a nursing home or institutional setting. Feelings of having no choice and feelings of loss of control lead to feelings of helplessness, which are psychologically debilitating. The nursing home resident becomes estranged from family, friends, neighborhood, church, and the outside world itself. Disculturation occurs when persons are stripped of the stable social arrangements of their homes and forced to accept a different set of values and attitudes associated with the institution. Ideal Case Scenarios – Nursing Home Recreational and social activities are group oriented, and part of daily life for approximately 15 percent of the residents who participate regularly in scheduled activities. Church services and Mass are held weekly. Approximately 10 residents participate in a bell choir and practice weekly in the chapel. A favorite among the residents is the monthly birthday party honoring those whose birthdays fall during the month. Singers and other musicians periodically come to entertain the residents. During the Christmas season, a children's group comes to sing carols and distribute gifts. Exercise classes and Bingo are among the other favorite activities in the facility. Shopping outings, fishing trips, and picnics away from the facility are offered less frequently, but some residents can and do participate in these activities. There is no pet therapy program included in the monthly activities. The residents of the nursing home are primarily female (70 percent) and white (99 percent). The average age is 82 and many are 90 years and older. The oldest resident is 101 years of age. Over 40 percent of the residents are diagnosed as having a major cognitive impairment, mental illness, or emotional disturbance. Only 15 percent of the residents are able to ambulate independently and perform normal tasks of daily living without assistance. Most need some assistance with these activities. Approximately one-third of the residents need full assistance with all daily living activities. In addition to the administrator, assistant administrator, and director of nursing, the nursing home employs sixty-three full-time staff members including four RNs, nine LPNS, a social worker, an activity director, and forty-eight aides/orderlies/technicians. The institution does not employ a medical director or principal physician. Most of the day-to-day care of residents is provided by aides or technicians, many of whom have high-school educations or less. Staff members participate in a brief orientation period before beginning work on the resident care units. Full-time aides and orderlies are paid the minimum wage; others, employed on a part-time basis, receive no overtime pay for extra hours worked. Each aide or orderly is responsible for approximately ten residents per shift. The staff turnover rate in 1984 was 75 percent. The majority of the aide's work is "bed-and-body work." Aides and orderlies awaken residents, clean, groom, bathe, feed, turn, and assist with their toileting needs. For the most part, RNs and LPNs pass medications, chart, do paperwork, and, at times, assist with unit activities. Although the mission statement in the official staff handbook gives priority to the emotional and spiritual needs, as well as physical needs, the bulk of staff time is spent on meeting residents' physical needs--keeping residents clean, dry, well fed, and well groomed. There is little time in the busy schedule to meet the socioemotional needs so necessary to maintain some degree of normalcy in daily living--just to chat, play a game of checkers, or help with dressing. Suggestions for Activities CREATIVE ARTS THERAPY The use of dance, song, and visual arts in religious and magical ways to cure physical or emotional ills dates back to antiquity. Aristotle recognized the value of dramatic play for relaxation "as a medicine" and noted the value of tragedy as catharsis because it allows for the "purgation of emotion" (Courtney, 2003, p. 10), and Greek tragedies encouraged the expression of such emotions as pity and fear as the actors identified with characters. During the twentieth century, there has been dramatic growth in and acceptance of the use of creative arts or expressive therapy with the sick. Creative arts therapies are closely allied with and have been greatly influenced by psychoanalysis, humanistic psychoanalysis, and humanistic psychology. The therapeutic value of the drawing or painting of dreams, which are experienced as visual images and difficult to express in words, was recognized by both Freud (1955) and Jung (1964). The arts allow for creative expression, development of personal insight, and self-awareness. Similarly, spontaneity, flexibility, and originality resulting from the creative process are encouraged through the use of creative therapies. Art, whether in music, visual media, drama, or dance, is naturally therapeutic. Often, the creative process enables persons to uncover aspects of the self that are blocked from conscious sight. The arts provide a means of expanding the consciousness, of naturally becoming more aware of the self, particularly of the connection between mind and body. It forces persons to become more in personal tune with their senses (sight, hearing, and touch) and bodies. The arts also provide a means to achieve identity. The search for identity, the sense of who one is and where one stands, has always led to music, art, and drama. Visual Arts Many therapists have effectively used the visual arts as therapy with the elderly (Weiss, 1984). Art therapy has proven to be particularly effective for persons experiencing chronic pain. The expression of pain and the accompanying feelings of anger, rage, guilt, or sorrow through artwork permits catharsis and leads to successful management of the feeling (Landgarten, 2001). Artwork is one method of working through feelings of depression for older adults. Artwork expressing feelings can be shared and discussed with positive results. Individuals can obtain therapeutic benefits by examining their own feelings and emotions as expressed in concrete form in art works. Music Therapy Practitioners have used music therapy effectively with the elderly. Music therapy has been used with older participants as an outlet for creative expression, as a vehicle to invoke powerful emotions, and as an aid in grief work and in dealing with the experience of death and dying. Music encourages group participation. Alleviation of feelings of loneliness, hopelessness, depression, and despair in elderly participants has been reported (Bright, 1985). Music therapy has been used to treat a number of different problems of elderly clients. It has been used effectively with aging residents in long-term care facilities to help alleviate depression and stress (Kartman, 1980). Exposure to player piano music resulted in improved life satisfaction and feelings of well-being for elderly subjects (Olson, 1984). The role of music in combating the loneliness, isolation, and depression of older people has been emphasized by R. Bright (1985). Music is useful in psychotherapy with the old. Through its strong powers of association and memory-evoking properties, music can help to bring past and present feelings and emotions to the surface so they can be expressed and therapeutically explored. Psychodrama As a therapeutic technique, creative dramatics has its roots in dramatic play and is closely related to psychodrama. Psychodrama grew out of Jacob Moreno's (1934) experience with Viennese children at play. Derived from the Greek terms psyche, meaning "mind or soul," and dramein, meaning "to do or to act," psychodrama refers to the doing or acting of thoughts and emotions through speech, gestures, and movement (Duke, 2003). In psychodrama individuals play roles and create parts; the emphasis is on spontaneity, creativity, action, process, self-disclosure, risk taking, and the here and now. The individual acts out unconscious thoughts, feelings, and impulses to recapitulate unsolved problems and experience catharsis. The group drama encourages empathy as the players identify with one another. Like psychodrama, creative expression of thoughts, feelings and emotions are encouraged through verbal and non-verbal means of communication. In the last decade, creative dramatics has been used increasingly with older persons. From data she collected on the effects of drama on the elderly, P. Gray (1974) cites the following as major benefits: opportunity to be of service to others, increased self-confidence resulting from successful memorization and good performance, communication and social interaction skills developed through the group experience, and the emotional outlet provided by the experience. One study demonstrated that elderly individuals who participate in the creative drama experience begin to communicate and see themselves as useful again; life takes on new meaning. Based on her study, B. Davis (2005) reports that "drama helps older adults integrate their thoughts, words, actions, and emotions through original improvisation in which they draw on their life experience" (p. 315). Based on analysis of quantitative and qualitative data, P. Clark and N. Osgood (2005) concluded that participation in applied theater decreases loneliness and increases life satisfaction. Those who engage in the drama activities see themselves as younger than those who do not. Dance Dance as a form of therapeutic intervention has its basis in the development of modern dance and has been used successfully with older adults. S. Zandt and L. Lorenzen (1985), who have used dance with seniors, found that dance helped people relax, reduced stress, and provided tranquility. Older dancers said they felt less lonely, less depressed, and more self-assured as a result of their dancing. E. Garnet (1974) used movement sequences that employ rhythmic use of swings, twists, stretches, pulls, and pushes to meet physical needs and stimulate somatic and psychological feelings of comfort, ease, and humor in elderly subjects. I. Fersh (2001) concludes that dance/movement therapy with elderly clients can be an enlightening experience that can inspire the therapist and clients to face life and death with love and energy. Therapeutic Values of Creative Arts Therapy Creative arts offer the older adult choice. In creative art activities the individual chooses the medium (clay, wood, and fibers), chooses the colors and textures, chooses what to make and how to make it. The art object is personalized. Dance and drama activities also offer opportunities for individual expression. The individual decides what to say or do and in what manner. Choice builds pride, confidence, self-esteem, and a sense of control to offset the negative psychological effects of loss. Through participating in creative activities older adults come to view themselves as active, vital, useful human beings. The arts are inspirational, infusing the older adult with spirit and zest for life and hope for the future. Creative therapy is a valuable means of releasing fear and doubt, guilt and grief, and decreasing hopelessness, emotions that plague many potentially suicidal elderly individuals. Creative therapy provides a positive experience of participation in a social group, with accompanying feelings of acceptance and belonging, self-esteem and self-concept, and personal competence, mastery, and accomplishment. As such, the arts represent a major technique for reducing suicidal risk in older adults. SUPPORT GROUP THERAPY Support group therapy is one therapy that can effectively reduce depression and suicidal behavior in older individuals. Social support encompasses interpersonal communication and interaction, protective feedback, love and understanding, caring and concern, affection and companionship, financial assistance, respect, and acceptance. Social support is usually provided by family members and kin, close friends, and neighbors. Such support can also be provided by a support group composed of individuals who are facing the same problems and have the same needs and concerns. Therapeutic Values of Support Groups The principle of mutual aid or joint struggle against common problems underlies the development of mutual help or support groups. Support groups are patterned after the family or small community and are expressive in nature. They offer members understanding and acceptance as unique personalities with both good and bad qualities, with both strengths and weaknesses. They offer a place where emotions can be freely expressed and where recognition, status, and security are offered. Most support groups are established by and for individuals who are stigmatized, for either a short time or permanently (Traunstein & Steinman, 1973). For example, widows may feel they are "misfits," "marginals," or "fifth wheels" in a couple-oriented society. The very word widow has negative connotations and carries a stigma for many women. In a support group, these individuals can find acceptance among others suffering the same plight. When everyone shares the same stigma, one finds acceptance, and feelings of isolation and marginality are reduced. In a support group, the members (1) learn by their participation in developing and evaluating a social microcosm, (2) learn by giving and receiving feedback, (3) have the unique opportunity to be both helpers and helpees, and (4) learn by the consensual validation of multiple perspectives. The group offers opportunities for people to confront feelings of alienation by providing for free expression of feelings and experiences with group members who are "in the same boat." Participating in a support group can instill hope in members who see others successfully coping with similar problems or life experiences. Types of Support Groups In the last decade the popularity of support groups has greatly increased. Currently, support groups exist for widows and widowers, Alzheimer's victims and their family caregivers, cancer patients, heart patients, persons with arthritis, and depressed elderly dealing with the problems of grief, loss, and aging. Those working with support groups have noted the many positive effects of such groups on the elderly. Burnside (2006) has described her success with groups of grievers, indicating that such groups help the members by facilitating adjustment to the loss of a spouse and preventing subsequent problems. B. T. Moeller Petty, and R. Campbell (1976) organized support groups for elderly persons with arthritis. Most of the individuals were experiencing moderate depression in adjusting to the aging process. Participation in a support group decreased feelings of loneliness, depression, and unhappiness, increased knowledge of physical functioning, and resulted in better communication with family and friends and a desire to be more actively involved in life. The members also came to feel that their frustration and problems were "normal" and a part of aging. They made new friends and learned how to use community resources more effectively through their participation in the group. Weekly discussion groups were successful in alleviating feelings of loneliness and providing assurance that the widow was not unique, that others faced similar challenges. Members of the groups cited emotional support as the major benefit obtained from participation. Someone to listen and give sympathy were the benefits most valued by the widows. Older adults in the community and in institutions can profit from involvement in support groups of all types. Clinicians working with depressed residents in institutions will find support groups a valuable adjunct to therapy. The recently bereaved, those suffering from a particular physical condition such as arthritis, those dealing with the loss of physical function or mobility, and residents who have recently moved in and are experiencing difficulty adjusting to their new environment could all benefit from participation in a support group. Characteristics of support groups are a consideration. Based on experience with groups, there are three important factors in effective group work: authority, structure and language, and sharing common symbols and meanings. The group's structure must provide a basis for relating and accomplishing group goals. A format or standard procedure and use of a common language will serve to provide this structure. By including authorative research and sharing of emotions and feelings, the group becomes a support system that provides new ways of thinking about issues. PSYCHOSOCIAL NURSING INTERVENTIONS Loneliness is a universal phenomenon. More than 80 percent of the institutionalized elderly are likely to show symptoms of isolation and loneliness ( Aguilar, 1978). Depression is also prevalent among older residents of long-term care facilities. Residents of long-term care institutions often express feelings of loneliness and emptiness, loss of self-esteem and diminished morale, and loss of control during depressive episodes. Thus it is of utmost importance that morale, self-esteem, and a sense of control in older adults be preserved. Interpersonal strategies to alleviate depressive symptomotology are effective interventions with older clients. Openness, acceptance, trust, honesty, and respect characterize role behaviors of participants in therapeutic interactions. The key to achieving success or failure is the quality of the relationship between health care providers and older persons. Nurses are instrumental in all types of group work in long-term care facilities. Communicating through one-on-one interaction and touch can combat loneliness, increase self-esteem and control, and reduce depression in older adults. These interventions will be discussed in the following paragraphs. Group Work The role of nursing in group work with the elderly has been well documented by Burnside (2005) and others in the discipline of nursing. Group therapy, is the treatment of choice in many cases, and the testing of the efficacy of working with groups of elders is left for the most part to nurses. Success in group work can be measured in part by decreased interpersonal friction, personal isolation, and a noticeable change in affect. Interventions such as counseling, group activities, and physiologic assessment are well within the skill repertoire of the clinician and advanced practitioner in gerontologic nursing. Nurses in long-term care play a pivotal role in forming and leading support and reminiscence groups. Group work requires well-developed interpersonal skills necessary for supportive listening, encouraging self-expression, facilitating interaction among members, and motivating staff to support group development. Nurses working in long-term care settings can cultivate these skills. Nursing home staff can support group work by helping elder group members select clothing, providing ample time to prepare for attending the group, demonstrating interest, listening, assuring the elder's attendance at groups, rewarding even small attempts to change behavior or complete tasks ( Burnside , 2005), and treating older adults with positive personal regard. Conclusion One effective nursing intervention is the development of one-to-one relationships, interpersonal relationships that promote nurturance, warmth, and feedback and provide meaningful relationships with the elderly. Therapeutic interventions by staff include taking time to talk with residents, expressing interest in their activities, and orientating them to reality. Facilitating self-help, establishing and maintaining scheduled activities, assisting residents to keep a daily schedule, offering choices, providing clear feedback, providing privacy when giving personal care, and listening are all integral to maintaining the relationship. It has been repeatedly observed by numerous studies; of loneliness in a group of nursing home residents, found that nursing intervention in the forms mentioned above reduced loneliness significantly. Works Cited Aguilar, V. B. (1978). Intervening on loneliness in a group of nursing home residents. Unpublished Master's thesis, School of Nursing, Virginia Commonwealth University, Richmond. Bright, R. (1985). Music in geriatric care. (2nd ed.). New York: Alfred. Burnside, I. M. (2005). Nursing and the aged. New York: McGraw-Hill. Courtney, B. (2003). Play, drama, and thought. New York: Drama. Petty, B. J., Moeller, T. R., & Campbell, R. Z. (1976). "Support groups for elderly persons in the community". Gerontologist, 15(6), 522-528. Duke, C. (1974). Creative dramatics and English teaching. Urbana, IL: National Council of Teachers of English. Davis, B. W. (2005). "The impact of creative drama training on psychological states of older adults: An exploratory study". Gerontologist, 25(3), 315-321. Fersh, I. (2001). "Dance/movement therapy: A holistic approach to working with the elderly". Activities, Adaptation, and Aging 2(1) 21-30. Freud, S. (1955). Origin and development of psychoanalysis. Chicago: RegneryGateway. (Original work published in 1917.) Goffman, E. (1960). "Characteristics of total institutions". In M. R. Stein, A. J. Vidich, and D. M. White (Eds.), Identity and anxiety survival of the person in mass society. New York: Free Press. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity (pp. 449479). Englewood Cliffs, NJ: Prentice-Hall. Gray, P. (1974). Dramatics for the elderly: A. guide for residential care and senior centers. New York: Teachers College, Columbia University. Jung, C. G. (1964). Man and his symbols. Garden City, NY: Doubleday. Kartman, L. L. (1980). "The power of music with patients in a nursing home". Activities, Adaptations, and Aging, 1(1), 9-15. Landgarten, H. D. (2001). Clinical art therapy: A comprehensive guide. New York: Bruner/Mazel. Moreno, J. (1934). We shall survive: A new approach to human interaction. Washington, DC: Nervous and Mental Disease. Olson, B. K. (1984). "Player piano music as therapy for the elderly". Journal of Music Therapy, 21(1), 35-44. Osgood, N. (2005). Suicide in the elderly. Rockville, MD: Aspen. Traunstein, D. M., & Steinman, R. (1973). "Voluntary self-help organizations: An exploratory study". Journal of Voluntary Action Research, 2(4), 230-239. Weiss, J. C. (1984). Expressive therapy with elders and the disabled: Touching the heart of life. New York: Haworth Press. Zandt, S. V. & Lorenzen, L. (1985). "You're not too old to dance: Creative movement and older adults". Activities, Adaptation, and Aging, 6(4), 121-130. Read More