Journal of Gerontological Nursing

Reality Orientation Therapy for the Institutionalized Elderly

Virginia Lohmann Nodhturft, RN, BSN, MA; Nancy M Sweeney, RN, BSN, MA

Abstract

Introduction

As increasing numbers of people live longer, society becomes more aware of the problems inherent in aging. However, the nuclear and extended family structures seem to besubject tochanging norms. Fewer families keep elderly members at home until they die.

In today's fast moving, technological society, younger family members claim not to have the time to care for elderly relatives. The "wisdom of the aged" seems to be an anachronism; old people are considered incapable of understanding change and knowledge gained from their life experience is discounted. Many retired people find themselves being placed in institutions as soon as their mental and physical faculties start to fail them.

Rather than dispute a sociological trend, there should be a movement to match the needs of society with superior care. It becomes the charge of the health professionals involved in research and direct care of the elderly to discover and deliver an optimal milieu in which these people can live.

The institutional atmosphere should foster maximal use of remaining faculties, continue socialization, and provide a place to die with dignity and comfort. Keeping mental faculties at an optimal point is important since it has beenshown that people who are allowed to degenerate mentally (cognitively and emotionally) also deteriorate physically (in activities of daily living, hearing, continence, etc.) This study will explore the value of Reality Orientation (RO) Therapy to improve and maintain the mental status of institutionalizedelderly persons. Mental status will be measured by a tested tool.

Problem

The specific problem to be investigated is: What is the difference in the mental status of institutionalizedelderly persons receiving Reality Orientation Therapy as compared to institutionalized elderly persons not receiving this therapy?

Definition of Terms

Mental Status

Menial Status is the state of mental awareness and health of an individual as measured by a score on one scale (disorientation-memory) of the Mental Status Schedule. The Mental Status Schedule is an interview created by Spitzer, Fleiss, and Endicott that will be used to measure disorientationmemory. The lower the score, the better the mental status. It has been used successfully with elderly patients.1

Reality Orientation Therapy (RO Therapy)

RO therapy is conducted to reorient the client to the current situation {time, place, environment, and person) and to foster interpersonal communication between individuals and the people with whom they reside. As described by Folsom, RO therapy is threefold, consisting of 1) daily intensive group therapy, 2) 24-hour-a-day reality orientation, and 3) attitude therapy.

Review of Literature

Folsom2 discusses the evolution of RO therapy as he had worked with it. A pilot study done in 1959 had nursing assistants on a rehabilitation service for geriatric mental patients plan and implement multiple activities for their patients. Activities such as yard work and ceramics were added to the previously unstimulating daily routine of the subjects. The patients reacted by increasing their physical activity levels, interacting with other patients and staff, and seeking more structured activities.

Folsom implemented attitude therapy in a study done in 1960 at a mental health institute. Male and female geriatric patients were residents of the nursing unit used. Attitude therapy consisted of a "baseline of acceptance, concern and expectation of participation in one's own recovery.. .a feeling of calmness, consistency and security was communicated to the patient."2 Folsom began formulating the concept of reality orientation therapy by reminding subjects of who they were, where they were, etc. The first six months of this study showed 49% of the patients returning to the level of their pre-hospital adjustment while, at the end of the full year of the study, 57% of the patients improved to the level…

Introduction

As increasing numbers of people live longer, society becomes more aware of the problems inherent in aging. However, the nuclear and extended family structures seem to besubject tochanging norms. Fewer families keep elderly members at home until they die.

In today's fast moving, technological society, younger family members claim not to have the time to care for elderly relatives. The "wisdom of the aged" seems to be an anachronism; old people are considered incapable of understanding change and knowledge gained from their life experience is discounted. Many retired people find themselves being placed in institutions as soon as their mental and physical faculties start to fail them.

Rather than dispute a sociological trend, there should be a movement to match the needs of society with superior care. It becomes the charge of the health professionals involved in research and direct care of the elderly to discover and deliver an optimal milieu in which these people can live.

The institutional atmosphere should foster maximal use of remaining faculties, continue socialization, and provide a place to die with dignity and comfort. Keeping mental faculties at an optimal point is important since it has beenshown that people who are allowed to degenerate mentally (cognitively and emotionally) also deteriorate physically (in activities of daily living, hearing, continence, etc.) This study will explore the value of Reality Orientation (RO) Therapy to improve and maintain the mental status of institutionalizedelderly persons. Mental status will be measured by a tested tool.

Problem

The specific problem to be investigated is: What is the difference in the mental status of institutionalizedelderly persons receiving Reality Orientation Therapy as compared to institutionalized elderly persons not receiving this therapy?

Definition of Terms

Mental Status

Menial Status is the state of mental awareness and health of an individual as measured by a score on one scale (disorientation-memory) of the Mental Status Schedule. The Mental Status Schedule is an interview created by Spitzer, Fleiss, and Endicott that will be used to measure disorientationmemory. The lower the score, the better the mental status. It has been used successfully with elderly patients.1

Reality Orientation Therapy (RO Therapy)

RO therapy is conducted to reorient the client to the current situation {time, place, environment, and person) and to foster interpersonal communication between individuals and the people with whom they reside. As described by Folsom, RO therapy is threefold, consisting of 1) daily intensive group therapy, 2) 24-hour-a-day reality orientation, and 3) attitude therapy.

Review of Literature

Folsom2 discusses the evolution of RO therapy as he had worked with it. A pilot study done in 1959 had nursing assistants on a rehabilitation service for geriatric mental patients plan and implement multiple activities for their patients. Activities such as yard work and ceramics were added to the previously unstimulating daily routine of the subjects. The patients reacted by increasing their physical activity levels, interacting with other patients and staff, and seeking more structured activities.

Folsom implemented attitude therapy in a study done in 1960 at a mental health institute. Male and female geriatric patients were residents of the nursing unit used. Attitude therapy consisted of a "baseline of acceptance, concern and expectation of participation in one's own recovery.. .a feeling of calmness, consistency and security was communicated to the patient."2 Folsom began formulating the concept of reality orientation therapy by reminding subjects of who they were, where they were, etc. The first six months of this study showed 49% of the patients returning to the level of their pre-hospital adjustment while, at the end of the full year of the study, 57% of the patients improved to the level of pre-hospital adjustment.2

In 1965, Folsom began a program of formal Reality Orientation Therapy for elderly mental patients. The therapy consisted of attitude therapy, reality orientation groups (classes), and 24hour-a-day reorientation. The program ran for a year with 64 patients starting it and 29 remaining for the full year. Four patients showed no improvement and two could not cooperate. Seventeen patients completed basic and advanced classes. Five patients were discharged, two transferred to domiciliaries, one was sent on trial visit at home, one was placed in a foster home, and eight remained in the hospital with improvement of mental status.2

In 1973, Barnes conducted reality orientation classes for six weeks at a nursing home.3 The six subjects in his study were elderly people with moderate to severe degrees of memory loss, confusion, and disorientation. Barnes had designed his oWn tool to measure orientation/confusion. His results were not significant but he concluded that, since the trend was in the right direction, had the therapy period been longer, results would have been significant. The director of nursing rated the subjects in a free response manner and fell their orientation had improved.

Letcher, Peterson, and Scarbrough4 noted improvement in 206 elderly, institutionalized veterans who received RO at the Tuscaloosa, Alabama VA Hospital over a five-year period.

Harris and Ivory5 then did a study incorporating all three aspects of Folsom's Reality Orientation Therapy. For five months, 48 female geriatric patients received therapy and were rated on their 1) ward behavior, 2) verbal orientation behavior, and 3) aide therapist observations and impressions. Ward behavior scores were erratic and lacked pre-treatment comparability, so they were thrown out. Six of the nine verbal orientation behavior scales showed significantly different post-test scores for the control and experimental groups. The third rating scale showed subjects in the experimental group to rate significantly higher in orientation and lower in bizarre verbalization. There also was a trend toward more appropriate interaction. Harris and Ivory questioned the magnitude of the effect of the attitude therapy aspect of the program, thinking that therein might lie the major clue to reorientation of the confused elderly.

Çitrin and Dixon6 studied 25 elderly residents of a geriatric institution as they scored in tests of reality orientation (The Reality Orientation Information Sheet, as designed by the team at the Tuscaloosa VA) and of behavior (Geriatric Rating Scale). Control and experimental groups ran for seven weeks with the reality orientation scores of the experimental group improving significantly over time and differing significantly from the post-test scores of the control group. The behavior scale showed inconclusive results.

Hogs tel7 conducted a study to determine if there would be a significant difference in degree of confusion among selected patients over 65 years old in a nursing home who received RO for three weeks. Forty-four patients were assigned randomly to experimental and control groups. Analysis of data at the completion of the RO program reported that eight patients were less confused, eight were more confused, and four remained the same. Authors concluded that a longer period of time is necessary for definite changes to be measurable. Although Hogs tel does not report significant differences in degree of confusion by patients in the two groups, she does report that the patients were interested and cooperative and family members were pleased to hear their loved ones talking about current events.

Theoretical Rationale

Review of the above material leads one to surmise that mental status of the elderly is an open system in continuous, mutual, simultaneous interaction with the environmental open system. An environment that supplies sufficient stimulation (auditory, tactile, interpersonal) acts as a positive reinforcer to healthy self-identity and self-esteem of the patient. An elderly person with a healthy self-concept will disengage from the environment at a rate that is appropriate to physical condition and proximity to death. In other words, disengagement from this world is a normal part of the aging process, but should not be fostered by the environment.5

Table

FIGURE 1EXPLANATION OF THE STUDY

FIGURE 1

EXPLANATION OF THE STUDY

A planned project of therapy to reorient people to their situations and to reinforce positive self-image and appropriate engagement with reality can be accomplished by the regular nursing staff. This hopefully will create a therapeutic milieu which will be a rewarding environment in which individuals may live happily, functioning at the highest possible level. This study was undertaken in the hopes of supporting the findings of previous studies while using a sophisticated, validated, reliable tool designed by people not involved in the project.

Hypothesis

Institutionalized elderly persons receiving reality orientation therapy will show an improvement in mental status over similar persons not receiving reality orientation therapy as measured by post-test scores of the Mental Status Schedule.

The level of significance is set at 0.01.

Methodology

Sample

Subjects all were patients at the 250bed Castle Point Veterans Administration Hospital in Beacon, New York. They resided on six different nursing units: three chronic medical units and three nursing home units. The entire population of the six units was rated as each person matched the criteria for the study. In an agreement set forth by the Institution's Research Committee and Special Human Rights Research Committee, the population from which subjects were chosen had the basic tenets of this study explained to them and were given the right to withdraw their names from consideration. (See Figure 1.) When patients were too confused to maki this judgment, their families were contacted. Confused persons without family were the responsibility of the chief of staff. All subjects (or their guardians) signed consent forms before the study began. Each subject also retained the right to withdraw from the study at any time.

Subjects were elderly and confused (mean age = 74.57, SD = 10.59). The mean level of education attained by the subjects was 8.53 with an SD of 2.78. Their hearing, sight, and touch faculties were satisfactory for participation in the planned group sessions. None of the subjects were aphasie and all spoke" English, either as their native tongue or fluently. Patients with documente psychiatric illnesses such as schizophrenia were not accepted into the study, but patients who had been stabilized on psychotherapeutic drugs for at least three months were accepted. Subjects also were required to sit up in chairs or wheelchairs without pâin or difficulty.

FIGURE 2MENTAL STATUS SCHEDULE SCORE SHEE

FIGURE 2

MENTAL STATUS SCHEDULE SCORE SHEE

From the stated criteria, head nurses selected a sample of possible subjects from which investigators randomly chose 41 subjects: 20 for the control group and 21 for the experimental group. Stated diagnoses included organic and chronic brain syndromes, stroke, diabetes, and cardiovascular diseases. Due to the nature of the institution at which this study was done, all subjects were male with a random distribution throughout the six units. During the study period, three members of the control group and two members of the experimental group died and two withdrew, leaving 17 and 18 subjects in those groups, respectively.

Tool

The Mental Status Schedule is an interview developed and tested for validity and reliability to measure psychopathology.1 This study utilized the factor-based scale designed to measure disorientation-memory. (See Figure 2.)

The schedule, according to its creators, lends itself to measurement of mental status in elderly people, especially those with organic brain syndromes. Internal consistency reliability was analyzed based on scores of 2,000 people. Domain validity coefficients also were determined. The internal consistency reliability for the disorientation and memory scale was .84.

Persons administering the Mental Status Schedule practiced with the material until they could conduct the schedule as a friendly interview, not asking all the questions, but answering some by drawing upon previous answers as recommended by originators of the test. Testing time for the scale used here was about 45 minutes.

Apparatus

' A reality orientation chart four feet by four feet was constructed as seen in Figure 3. Letters were three inches high and about one-half inch thick. They were done in black and red ink on a white background. Words that varied were made on strips that could be fastened onto the chart. The chart was placed on an easel in the Reality Orientation Group Therapy room.

Procedure

The format of this study is a pretest/post-test design. This design was selected with the Mental Status Schedule since the creators claim that the test may be readrninistered without decreasing validity.' At the beginning of the study, all 41 subjects were given the disorientation-memory scale of the schedule. The tests were administered by two experts.

FIGURE 3 REALITY ORIENTATION CHART

FIGURE 3 REALITY ORIENTATION CHART

An inservice education program on reality orientation therapy was given to the entire professional and nonprofessional staff assigned to the experimental group on days, evenings, and nights, and they were told to reinforce RO concepts. One of the co-investigators conducted all Of the teaching sessions. Each day, evening, and night staff member received three hours of classes on reality orientation. Portions of "This Way to Reality," a slide-sound presentation, were shown during class sessions.

Experimental subjects were divided into four groups with five members each. Each day, the co-investiga tor conducted four, half-hour group sessions between 8:00 am and 11:00 am. Group therapy was held Monday through Friday for ten weeks.

Group therapy occurred in a day room with large windows. Members (including the co-investigators) sat in à circle around a table. The Reality Orientation Chart, clocks, and calendars were placed within sight of all members.

Each session began with the coinvestigator introducing herself followed by the members introducing themselves. Attention would then be aimed at the RO Chart, the variable slots of which would start out empty, with members gradually supplying information.

Discussion would then focus on a tangible item thai the co-investigator had brought to the group. Items such as a picture of the president, pictures of members, flowers, or holiday decorations would be passed around for group members to touch and discuss. The coinvestigator tried to bring in items that would elicit long-past memories from patients since they are the last to be lost as one's memory deteriorates.8

The staff assisting the co-investigator was told to reinforce orientation to reality whenever they were with patients. They were told to introduce themselves to the patients, using their name and title along with the patient's name. When in contact with subjects, they were to engage in conversation that would orient the patient to the environment or reality. Another important aspect of their interpersonal communication with patients would be maintaining high expectations of the patient.

Over the ten-week period, group members began to interact with each other more freely, with less direction and input from the co-investigator. At the end of the ten weeks, the remaining 18 experimental and control subjects were again given the Mental Status Schedule

TABLE

TABLE

Results and Discussion

Initially, the data were analyzed using a T-test to see if the difference between the means of the pre-test raw scores for the experimental and control groups for the scale was statistically significant.

A T-test was done on the difference between the means of the post-test raw scores of the control group and experimental group. The proposed alternate hypothesis for the scale had been:

Given thai:

1) the control group's post-test raw scores mean = Mi

2) the experimental group's posttest raw scores mean = M2

3) with an = 0.01 for each scale Then: Mi - M2 0.

The disorientation-memory scale showed a statistically significant difference in mental status (toward improvement) by the experimental group subjects.

The disorientation-memory scale examined orientation to time, place, person, and long- and short-term memory using 13 items. Since subjects were chosen expressly for their high level of confusion, scores were predictably poor on pre-tests. The range of mean pre-test scores for the two groups were 6.1765 to 7.5556. The therapy given the experimental group was aimed directly at the items found in this scale. The attitude of the staff also was changed to one of high expectations of the subjects' ability to answer the questions. Perhaps, also, the subjects had become accustomed to speaking with people about these items whereas the control group remained unaccustomed to social intercourse. So the mean post-test raw scores for the experimental group improved to 2.1667 while the control group's actually worsened at 6.7647. (See the Table.)

There were three other notable factors that make the results more impressive. The RO therapy was implemented by a staff who, from the top to the bottom of the hierarchy, did not believe that significant results could be attained. Inasmuch as attitude is subsumed under RO therapy, it is amazing that significant improvement was made by the experimental subjects.

RO therapy was implemented on four nursing units with experimental subjects being randomly distributed among those units. The fact that improvement in disorientation-memory scores was significant lends credence to the theory that anyone can implement RO therapy effectively.

The therapy occurred only over a tenweek period before subjects were readministered the Mental Status Schedule. In previous studies, the reason often given for nonsignificant results was that the therapy period was too short, as in Barnes' study of a six week period.3 Folsom's RO therapy study had lasted a year to show significant results, although his subjects may have been more disengaged from reality according to his description of them.2

RO therapy so impressed the staff with its effectiveness that it is currently implemented on the nursing units for any patient who is at all confused. Staff have reported verbally that subjects of this study showed improvement in behavior that they would like to see in all patients. For example, although physically incapable of caring for himself, one of the experimental subjects now requests to be shaved daily and goes to the canteen to select his clothing. Prior to RO therapy, he never expressed any opinions about personal hygiene or clothing.

Implications

Any future studies that might be done in this area would want to include in their design consideration of the Hawthorne Effect, that is, some provision for mere attention to be given to the control group rather than just continuing nursing care. It might be interesting to have a control group that receives attitude therapy while (he experimental group receives RO therapy.

Certainly any future studies would want to utilize nursing diagnoses rather than physician diagnoses in describing the criteria for subjects. Diagnoses are labels rather than behavior descriptive statements and often fall short of the need of researcher and reader. For instance, in this study, the researcher considered organic and chronic brain syndromes as diagnoses in the medical field.

The researcher, by disqualifying patients with "documented psychiatric disorders," meant to screen out catatonic schizophrenics and the like who could not have been given proper attention in this study. Using a nursing diagnosis instead of a medical diagnosis may not have resulted in disqualifying potential subjects. A careful review of the literature revealed that other researchers grouped organic and chronicbrain syndromes under psychiatric diagnoses. After accepting subjects with psychiatric diagnoses, they did not delineate what those diagnoses were so that other researchers were not sure of what their sample had been like. To remedy this, the researchers next time would use nursing diagnoses that would be behavior-descriptive in statement of criteria for our description of subjects. Physician diagnoses would be dealt with in an analysis of the data to see if physician diagnoses correlated with significant or nonsignificant improvement following therapy.

The study points out that nurses working with elderly persons are in a position to become advocates for change in a health care setting that views the elderly as "incapable of change." The increasing aging population demands that nurses today be challenged to use their resources to provide a climate of acceptance of the behavior of the confused elderly in regard to their needs and foster positive attitudes toward the elderly requiring rehabilitation.

Rehabilitation traditionally has been viewed as a maintenance status quo service rather than a dynamic, everchanging, restorative service. A successful RO rehabilitation program promotes self-respect and independence. The restructured environment with a consistent review of identity, time, and place contributes to the resumption of former successful patterns enhancing one very important aspect - quality of life.

Nurses must take an active role in modifying patients' inappropriate behaviors by use of environmental aids to orientation (calendars, large clocks, color coded areas, etc.) to sustain physical, social, and emotional life-supports. The nurse's role in environmental modification often can be the deciding factor in repatterning a patient's behavior.

Nurses carry a real responsibility for exercising significant leadership in initiating and implementing health services for our elderly population and becoming involved in nursing research. Professional practice is creative and imaginative. It is rooted in abstract knowledge, intellectual judgment, and human compassion. If we are not careful, we can end up supporting the system at the expense of practicing nursing dynamically, creatively, and "holistically." Positive changes requiring new directions for educational thought and practice are needed in caring for the elderly. Concentration on the human condition is what's required to care effectively for theelderly patient.

Understanding human beings and their interactions well can no longer be viewed as "icing" in planning rehabilitation programs for the elderly in the future. The future demands emphasis on values, processes, human problems, and the human condition. Nurses must concern themselves with attitudes, beliefs, feelings, and values if they are to provide effective nursing care for the elderly. The future role for nurses in the area of gerontology is that of patient advocacy.

References

  • 1. Spitzer JR., Fleiss J, Endicott J, et al: Mental status schedules, properties of factor-analytically derived scales. Arch Gen Psychiatry 16:479-493, 1967.
  • 2. Folsom JC: Reality orientación lor the elderly patient. J Geriatr Psychiatry
  • 1:291-307, 1968.
  • 3. Barnes JA: Effects of reality orientation classroom on memory loss, confusion, and disorientation in geriatric patients. Gerontologist 14(2): 138-142, 1974.
  • 4. Letcher PB, Peterson LP, Scarbrough D: Reality orientation: A historical study of patient progress. Hosp Community Psychiatry 25:801-803, 1974.
  • 5. Harris CS, Ivory P: An outcome evaluation of reality orientation therapy with geriatric patients in a state mental hospital. Gerontologist 16(6):496-503, 1976.
  • 6. Citrin R, Dixon D: Reality orientation, a milieu therapy used in an institution för the aged. Gerontologist 17(l):39-43, 1977.
  • 7. Hogstel MO: Use of reality orientation with aging confused patients. Nurs Res 28(3): 161-165, 1979.
  • 8. Ferm ' L: Behavioral activities in demented geriatric patients. Gerontología Clínica i6(4):I85-I94, 1974.

FIGURE 1

EXPLANATION OF THE STUDY

10.3928/0098-9134-19820701-08

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