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Section 22
Rewards and Labeling

Table of Contents | NCCAP/NCTRC CE Booklet

a. Non-traditional Reward: The Ten Second Back Rub a Success Story
The following is a recap of a story presented on the DVD. Skim through it should you wish to refresh your memory regarding the details.

The largest facility that I consulted at was a 400 bed home in Indianapolis. At this particular facility, the activity department wore gold smocks.  As I was going up the elevator with the Activity Director, she was telling me about how she had been at the facility for four years.  There was a resident who could see, hear, speak, use both hands, and was becoming increasingly disoriented due to lack of stimulation.  I will call him, Joe. Like Harold in the previous section, this would be a typical resident that CMS Surveyors would interview.  He refused to leave the hallway that was directly in front of the doorway into his room.  Joe sat in his wheelchair in the hallway just outside the door to his room.  The Activity Director said, “I’ve tried everything with this fellow.  I can’t get him to budge from sitting in front of his room.” 

Now, envision in your mind a long corridor with a window at the end of the corridor.  This fellow’s room is the second room from the end.  You can see this resident outlined by the window behind him, and as you walk down the hallway you see him sitting all scrunched up and hunched over.  You could tell by the way Joe tilted his head that he could see this gold smock coming down the hallway.  He would yell, “I can’t, I can’t, I can’t!”  This is the kind of resident you love when visitors and surveyors are in the building! J  You would have thought this Activity Director had beat this man with a rubber hose!  Now, I walk up to Joe, and after all I didn't have on a gold smock.  I said, “Hi Joe.”  I barely got out "My name is Cathy" when he looked at me and he looked at the Activity Director in the gold smock and yelled, “I can’t, I can’t, I can’t!” 

b. Do You See Impairments as Elephants?
Now when I look at Joe, I see an elephant.  Let me tell you which residents are my personal “elephants” so to speak.  My elephants appear for me when I interview residents for whom all I can see is their impairments.  My concept of residents who are "elephants" goes back to a fable that I heard when I was in elementary school.  It’s the fable about three blind men standing in front of an elephant.  Have you heard this fable before?  The first blind man felt the elephant's trunk and said, "Certainly this must be a great snake."  The second blind man felt the elephant’s side and said, "Certainly this must be a great wall."  The last blind man felt the elephant’s leg and said, "Certainly this must be a great tree trunk."  They were all wrong about what was in front of them for two reasons. 
-- First of all the blind men lacked the ability to explore with all of their senses.
-- Secondly they lacked the ability to put all the pieces together. 
I found with residents that I interviewed, like Joe, I would find myself thinking, “Gee, all he does is yell ‘I can’t,’"  Just like the blind man who only "saw" a wall.  And just like the blind men I lacked the ability to explore.  Also, secondly, I lacked the ability to put all the pieces together.  In other words I lacked the ability to see Joe's capabilities.  I just saw his limitations. 

So let me tell you how I get around my “elephants,” so to speak, in order to enable myself to see the resident’s capabilities and not just his or her limitations.  If I look at a resident long enough, something will occur to me.  Remember, Joe was sitting all scrunched up and bent over.  He was looking very uncomfortable.  I ask him if he was uncomfortable, and he did not reply.  This was like gold, because I was happy that Joe no longer was yelling, "I can't!  I can't!"  I then said, "Would you like a backrub?  Maybe that will make you more comfortable."  As you know, there are some combative residents whom you do not touch.  But, Joe wasn't that type of resident.  I rubbed his back for ten seconds.  The goal we developed is below.

Goal: To receive a ten second back rub without saying "I can't…"
   Approach: To motivate resident by asking, "Would you like a backrub?  Maybe that will make you more comfortable….”

I felt it might be beneficial to provide you with an excerpt from Volume 3 for easy reference, since the idea of stepping back and re-evaluating a resident is explained in further detail in that Volume.

When you feel you are stumped on what to try next with a particular resident, recall the Skill-Level Activity Ladder
--Then, take a deep breath, relax, and access the creative side of your brain. 
--The reason why I say to relax first is because the creative side of your brain works best when you are not scrambling through a massive amount of self-talk. 
--By "self-talk" I mean "I'm late for Care Plan Conference!" "I'll never get all this paperwork done!" "That's right, I have to pick the kids up from soccer tonight!"
--So, you need to consider the following…
Eight Steps to Observe and Adapt
1. Clear your mind.
2. Step back mentally from the resident to gain a new perspective.
3. Observe what he or she is able to do regarding the activity.
4. Observe the parts very specifically that he or she is not able to do.
5. Appropriate level?  Is there any chance at all this activity will work?  Clearly, if the resident is eating the cards in the Concentration Game, the activity is far above your Mabel's ability level.
6. Best materials?  However, for example, if she sort of grasps the idea of the shapes but cannot slide her index finger under the thin playing card to flip it over, glue corrugated cardboard onto the card.  Or is there another way to adapt the materials?
7. Best positioning?  If the working surface were higher, lower, closer, further away, would your Mabel do better?  If the cards, in this case, were placed further to the right or further to the left of the working surface, would this better accommodate a one-handed Mabel with an extremely stiff arm and shoulder mobility?
8. Timing?  When am I doing this activity with my Mabel?  Is she tired right after eating lunch, or more energized?  Would mid-morning be better?  Would late afternoon be better?  Would just before lunch be better? 

c. Your Elephants
What may be an elephant for you may not be an elephant for another staff member.  But what I am talking about is getting around the elephant.  By "getting around the elephant," I mean, first, expanding your ability to explore and second, expanding your ability to put all the pieces together.  Here are three steps for getting around your elephants.
a. Use Skill-Level Ladder:  I have a theory that goes like this, and it works for me.  "Something can be done for every resident.”  Section one of this Manual contains a Skill-Level Activity Ladder of Activities which lists numerous ideas for you to use as a reference.  Also in that Section you are asked to create your own Ladder, adding your favorite activities, whether acquired from this course or not.
b. Opening Your Creativity:  Here's a specific technique I use to access the creative side of my brain.  For residents I am really stumped on, before I can think about the Skill-Level Activity Ladder… I usually have to say to myself “Nothing can be done for this resident!  I mean, gee, look at them!  What can I possibly think of!?” I state this to myself, because sometimes these are my initial thoughts.  So with some residents, my real first step is to admit that nothing can be done, and mentally throw my hands up in the air.  By admitting defeat and giving up, for some reason, this helps me to relax and open the creative side of my brain.
c. Look for Capabilities:  Then I say to myself, “You know Cathy, if you look at this resident long enough something will occur to you.”  So I have to first recognize my defeat and accept the limitations I can’t change about the resident, rather than diverting into a plethora of wishful thoughts that start out with "If only he or she could…"   Then I say to myself, "If I look at him or her long enough something will occur to me."   

With the above ideas in mind, let's revisit my story about Joe, and analyze the steps I went through to come up with the idea of a ten-second backrub. 
a. Observe: If you will remember he was sitting all scrunched up.  He weighed maybe about ninety pounds.  His spine was protruding through his shirt. 
b. Try an Interaction:  So I said to him, “You know you really look uncomfortable to me.” 
c. Positive Reaction:  He didn’t say a word.  It was like gold; at least he didn't yell out, “I can’t, I can’t.” 
d. Ask Permission:  So I said to him, “Would you mind if I rubbed your back for a few seconds?” and he didn’t say anything. 
e. Assess:  So I walked over and before I put my hands on his back, I looked at the activities person to see if this was okay.
f. Care Plan Goal:  I gave Joe a backrub for ten seconds, and that became our care plan for him. 

Goal: To have a ten second backrub without saying, “I can’t…” 
Revised Goal: To carry on brief, two or three word conversations... 

g. Easy to Implement:  When the staff member assigned to Joe's wing was doing one-to-one activities, she would say, "Joe, I have a few seconds to give you a back rub."  She would rub his back for one or two minutes and carry on a brief, simple conversation.  Then she would continue with her one-to-ones on that wing.

So with your “elephants” whom you have in your facility, who you really feel stumped on regarding what type of activity might motivate them to become involved…  
1. Maybe you need to first just admit nothing can be done, in order to clear your mind. 
2. The second step, then, for you might be to just stand back and look at the resident.

Here are a few more ideas in addition to a backrub that could fall into the category of motivating a resident by a "Non-Traditional Reward."
   Reading a paragraph from the religious publication entitled, The Daily Word to the resident.
   Massaging a resident's hands with lotion.

What Non-Traditional Rewards are you currently using with your residents?  Brainstorm with your staff. Write them below, then list some additional residents with whom you might try these approaches as a means of involvement in your Activity Program.  Some of the simplest motivational approaches that are quite successful with one resident need to be shared and perhaps used with several other residents.  Thus, you are expanding upon your Mental Database of Activities described earlier.
Residents to motivate by Use of a "Non-Traditional Reward"

Non-Traditional Reward

Residents

Staff or Volunteer Responsible

Backrub

 

 

Reading from The Daily Word

 

 

Hand massage with lotion

 

 

 

 

 

Culture Change CNA Inservice:  Brainstorm about residents whom CNAs feel they could motivate with a “Non-Traditional Reward.”

d. Labeling and Millie Jones Day Success Story
Here's how labeling can act as a motivator.  Do you have any residents who knit, crochet, or do some form of handiwork fairly independently?  Think of a resident who does this handiwork independently for the most part.  No one stays independently motivated forever.  Thus, before your Millie becomes de-motivated, you might decide to have a "Millie Jones Day."  For "Millie Jones Day," you have Millie sit by a table set perhaps at the entrance to the dining room that displays all of her handiwork.  You might use cards and a marker pen to label the length of time it took her to make each item.  Then as residents go into the dining room you bring them past the table displaying her handy work.  As you can see, the recognition given to Millie via this simple technique of labeling can be a viable form of recognition when a resident completes a project.  This works especially well if you have a resident who works independently, perhaps in her room, and does not receive the reinforcement and group support by attending a group activity in the Activity Room or Lounge. 

Residents to motivate by the use of "Labeling"

Labels to be used for…

Items to be Labeled

Residents

Staff or Volunteer Responsible

"Millie Jones Day"

Table scarves, doilies, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Culture Change CNA Inservice:  Brainstorm about residents CNAs feel “Labeling” could be a motivator to encourage involvement.

Goal:  To participate in “Millie Jones Day…”
  Approach:  To motivate resident by the use of Labeling…


NCCAP/NCTRC CE Booklet
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