Approximately 5% of the elderly population consists of institutionalized individuals. If the diagnoses of patients in long-term care institutions were analyzed, a very large percentage would include chronic brain syndrome, senile dementia, or senile psychosis. Indeed, symptoms like confusion, disorientation, and faulty recent memory frequently are factors that make institutionalization necessary, because they interfere with the abilities of the elderly to function on their own, and make it very difficult for family members who try to take them into their homes. While the etiology is unclear, sensory impairment and social isolation usually are cited as contributors. Institutionalization may heighten these symptoms, because it places people in unfamiliar environments, disrupts social ties and daily routines, and reduces sensory stimuli.
This confusion and disorientation in the elderly may be functional, organic, or a combination of both, but there is no longer the attitude that nothing can be done. Both physical and psychosocial interventions are being tried. For persons who are disoriented about time, place or person, reality orientation is the psychosocial technique usually tried.
In the late 1960s and early 1970s reality orientation was described as the new "behavioral approach to rehabilitating acutely confused patients"1 and as being "particularly useful in nursing homes."2 As a result, many long-term care facilities invested considerable human and material resources to implement this widely publicized reality orientation program.
As described in the literature generally and specifically by Gubrium and Ksander,1 the reality orientation program is twopronged. One aspect is a formally structured classroom-like setting held for 15 to 30 minutes once a day. During this formal class four or five patients are given specific information, visually and verbally, about their environment, e.g., the day, date, or state of the weather. Each patient is then asked to respond to specific questions that would necessitate recall of the information provided.
The less structured aspect of a similar program is called 24-hour reality orientation. This includes providing environmentally orienting stimuli like clocks and calendars. It also includes behaviors of the staff aimed at increasing patients' awareness of the environment. Examples of such behaviors are calling the patient by name, telling the patient the name of objects in the environment, or asking the patient to name objects.
The positive outcomes anticipated from the implementation of these described programs, however, either have not materialized or have been far less dramatic than projected. For example, Letcher and colleagues4 reviewed staff evaluation reports of 125 male patients hospitalized at a Veterans Administration Hospital in Tuscaloosa, Alabama, between 1965 and 1970 who were treated with reality orientation. They described the effects of a formal reality orientation program on the level of nursing care that a patient required and the behaviors the patient exhibited. According to their definitions there were four levels of care. Level I was described as minimal nursing care, where the patient's behavior seemed normal. Level IV was labeled intensive nursing care, where the patient's behavior seemed overt and exaggerated. The retrospective chart audits of the 125 participants indicated that "68 percent of the participants remained at their initial level of functioning while only 32 percent improved. . . ." It should be noted that this program generated the original nationwide attention for reality orientation.
Two more recent investigations on the effectiveness of reality orientation programs were reported by Voelkel5 and Hogstel.6 Both investigators reported that the degree of confusion in their participants who were treated with reality orientation did not change significantly.
We can infer from these studies that there is a lack of empirical evidence to support the general effectiveness of the reality orientation program as it is formulated currently. This does not mean, however, that the concept of reality orientation as a treatment technique should be abandoned immediately. Rather, it indicates that thereshould be a careful reassessment of the program based upon analysis of two theories that relate to the reality orientation. The relearning of reality orientation is based on learning theory, with particular focus on behavior modification through positive reinforcement of desired behavior. Critical to the effectiveness of the reinforcement used is sound disengagement theory. A careful analysis of these two theories will result in identification of a critical problem in the reality orientation program that has resulted in its ineffectiveness. Furthermore, the principles of behavior modification can help to identify possible changes in the program that would enhance its effectiveness.
Our reality orientation program, particularly in the formal classes, is based upon the theory of behavior modification. Typically the term "behavior modification" has not been linked to the term "reality orientation"; in fact, many nurses who are proponents of reality orientation programs tend to respond with suspicion and skepticism at the suggestion of using behavior modification with patients.3 However, if behaviors described for the reality orientation classes are analyzed, it is clear that they are derived from basic principles of behavior modification. The classes are structured on a model similar to the one described by Homme et al.8 as behavioral engineering (Figure 1).
The technology of stimulus control is an integral part of reality orientation in both the 24-hour program and in the formal classes. In the 24-hour program, control of stimuli is accomplished by providing stimuli like clocks and calendars. Additionally, the caregivers control stimuli in interaction by frequently telling or asking the client his name, the time of day, etc., and by providing correct information when the client makes a statement indicating disorientation. In the formal class the nurse provides the stimulus control in two ways: by bringing the patients into a room for a class, thereby attempting to control extraneous environmental stimuli, and by a very direct stimulus intended to elicit a desired performance. That is, the nurse asks the patient a direct basic question about the patient or the environment.
The performance aspect of reality orientation has been articulated clearly: patients are to respond appropriately to a specific basic question about themselves or their environment. The ultimate performance goal of reality orientation is that clients are oriented and able to function in the environment with socially accepted behavior.
Contingency management, that is, providing a reinforcer following an appropriate performance, is clearly intended as a part of reality orientation. Several authors refer to verbal reinforcers in describing reality orientation: "Verbal rewards are immediately paid when correct responses are given. . ."'; "Verbal rewards and praise should immediately follow desired response or behavior. . ."'; and "Reward persons for correct responses with verbal praise, touch, smiles, etc."2
In order to understand contingency management one must understand the principle that every person responds differently and uniquely to the same "reinforcer:"
A reinforcer is any event that increases the strength of the behavior it follows. The only way to determine whether or not a given consequence is a reinforcer is to observe its effects on the behavior it follows. Consequences that are reinforcing for some pupils may not be effective as rein fort er s for other pupils. A teacher may find that a third grade boy will beam and work harder when told, "John, you're such a fine boy!" The same statement may (ause a high school junior to withdraw and quit working.10
In further description of reinforcers, Hall states that there are two types of reinforcers, primary and secondary. Primary reinforcers are consequences that satisfy certain biologic needs, such as food to a hungry animal. Secondary reinforcers are consequences like attention, praise, and money, which do not directly relate to biologic needs but have acquired reinforcing power. When reviewing the reinforcing event in a reality orientation program, it can be deduced that the intended effectiveness of reality orientation is based upon the premise that verbal praise by the nurse is a reinforcer for the elderly patient.
It is inappropriate contingency management that results in the frequent failure of reality orientation. Cumming and Henry" proposed a theory of social disengagement that hold implications for understanding why the technology of contingency management as used in a reality orientation program is inadequate for some people.
They defined disengagement as "an inevitable process in which many of the relationships between a person and other members of society are severed, and those remaining are altered in quality." They stated that the process of disengagement is universal, and that this severing or alteration in relationships results in an equilibrium for the elderly.
The theory of social disengagement has generated a great deal of controversy. Other writers tend to discount its universality and indicate that it is applicable to only a portion of older people.12'13 It seems that the disoriented nursing home resident who is not oriented to even basic social knowledge like name, place, etc., would be someone to whom this theory would appear applicable. This applicability is supported by research reported by Henthorn,14 who compared the degree of disengagement of 50 nursing home residents and 50 community registered voters living outside of nursing homes who were 65 years or older. The nursing home residents were "judged by nursing home personnel to be mentally and physically capable of being interviewed. .. ." Henthorn reported that "nursing home residents were significantly more disengaged than the community registered votors. ..." Additionally Lieberman,15 in reviewing studies of the elderly who resided in nursing homes, indicated that, according to the literature, these "residents tend to be docile, submissive, show a low range of interests and activities, and to live in the past rather than the future. They are withdrawn and unresponsive in relationship to others. . . ." Given that the confused elderly patients in nursing homes are exhibiting social disengagement, one is led to the conclusion that social response by another person, e.g., praise, would be of limited value. Therefore, praise could not be utilized initially as a reinforcer for contingency management.
FIGURE 1: Relationships between the three- term contingency and behavioral engineering
Based upon these analyses of the problematic area in implementation of the reality orientation program, alterations may be proposed. These alterations are directed toward creating the situation of effective contingency management. The first change would be implementation of a system for determining the objects or events that actually serve as primary or secondary reinforcers for the patient. The second change would be development of a program structure that would allow these reinforcers to be provided to the patient when desired behaviors are exhibited (rather than merely saying "very good").
Consideration of these changes can lead to questioning what implications this holds for nurses and nursing care. When viewing these changes within a framework of nursing process, i.e., assessment, planning, implementation, and evaluation, there are clear implications for nursing.
The change in assessment would be an expansion of the content of the typical patient data base. A section to be added would identify previous and present patient reinforcers. The identification of these reinforcers would increase the workload for nurses; it has been noted by Closurdo16 that determining objects or events that are reinforcers is "not always a clear or easy task. ..." Closurdo indicated that a patient should be observed during normal activities to determine which of those activities appear to be pleasurable to the patient. Additionally, Cautela17 described an instrument that was originally developed "as an aid to the interview and observation of others, and to provide a list of possible stimuli to present upon the performance of a response in order to increase its frequency." Nurses could modify and utilize an instrument like Cautelai in order to develop a systematic approach to assessing the patient for potential reinforcers.
Once reinforcers appropriate for the patient have been determined, the nurse must develop a plan that includes orientation activities for the patient. The written plan should indicate the current level of orientation and list items found to be reinforcers. The plan should include designated times for individual formal orientation sessions, similar to the described formal classes. It is important that initially the sessions be held on a one-to-one basis so that the identified reinforcers can be available and provided immediately for the patient's appropriate responses.
It is important to note that the 24hour program should be continued within the institution. The change in implementation would be in the formal classes; as indicated in the plan, these classes should be conducted at least originally as individual sessions. This would afford the nurse the opportunity to provide the patient specifically with the identified reinforcers. During these sessions the nurse should combine statements like "very good" with the provision of the reinforcers, in an attempt to develop the social response of the nurse as a secondary reinforcer for the patients. In order to incorporate the needed changes nurses would alter their assessment of patients, and develop and implement individualized orientation sessions for the patients.
It should be understood that the proposed changes are based upon theory and have not been tested empirically. It is suggested that this paper serve as the conceptual framework for the design of research.
The principles of behavior modification are utilized appropriately when analyzing the generally accepted reality orientation program for treating confused elderly. Consideration of the theory of social disengagement leads to the conclusion that inappropriate contingency management in reality orientation can be an important variable in some failures. In order to make reality orientation more effective, the therapist must determine actual reinforcers and provide them to the patient immediately after a correct response. This approach to reality orientation may be time-consuming, because it requires time spent in determining appropriate rewards and in assuring their availability at each orientation session. Additionally, it would make reality orientation classes more complex to implement because each patient might require a different reward. However, if the increased time produced the desired results, it would be far more economical than spending less time without achieving desired results. That is, if orientation is truly desired by and for the elderly, we may be required to invest more human and material resources in order to achieve it.
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