ince its initiation in the 1960s, reality orientation has been advocated as a beneficial intervention for confused or disoriented patients in nursing homes. As designed in the Veterans Administration, the goal of reality orientation is to enhance mental status by 1) having staff constantly orient patients to time, place and person and by 2) constantly exposing patients to repetition of fundamental information in a classroom setting. Numerous therapeutic effects have been attributed to reality orientation including improvements in patients' confidence, sociability, activity level, eating, dressing and grooming habits, as well as enhanced mutual respect between patients and staff.1 Most gerontological nursing texts include reality orientation programs as a major nursing intervention in their discussion of mental confusion. However, the pattern of results from experimental studies indicates only modest, temporary gains from reality orientation programs, not significant long term benefits.
A number of questions about the effectiveness of reality orientation are raised after careful review of the existing literature.
1) Is reality orientation uniformly effective for patients with varying levels of cognitive impairment?
2) Do differences in institutional setting account for discrepant results?
3) What, if any, components of reality orientation are necessary to produce desired changes in patient status? Are some components more essential than others?
Inadequate resolution of these issues has compromised evaluation studies on reality orientation. Until they are resolved a definitive answer to the question of whether reality orientation is an effective treatment for confused patients in nursing homes is not possible.
What is reality orientation and how is it supposed to help nursing home patients maintain or regain an alert mental state? Varying therapeutic techniques may be incorporated under the rubric reality orientation. Generally, the term reality orientation has become primarily associated with two components. One is the 24-hour restructuring of the environment accomplished by having all who come in contact with the confused person consistently remind the individual of time, place and person.2 The second is small group classes offered to reduce social isolation and reiterate basic information such as date, time, weather or names of common objects. In addition to these two components, there was initially a third component, intensified staff involvement with patients. In the Veterans Administration one of the major concerns at the time reality orientation was developed was to enhance motivation of the staff of geriatric mental wards. Nursing assistants were encouraged to suggest and plan activities with small groups of patients which would maintain and expand their functional capacities.3 Hie staff initiated useful patient activities such as yard work, and consequently created a more hopeful environment. Unfortunately, enhanced staff involvement with patients has subsequently been a neglected component in most studies of reality orientation.
Despite the enthusiasm generated by those who introduced the program, the evidence of the effectiveness of reality orientation programs has never been strong. Much of the early work on reality orientation was unsystematic, relying primarily on case histories and staff evaluations. A retrospective analysis of the rehabilitation program at the Veterans Administration in Tuscaloosa, Alabama provided results which "are indicative of the effectiveness of a total rehabilitation program with reality orientation as a significant part, rather than a measure of the reality orientation program alone."4 Nevertheless, it is useful to examine these results, bearing in mind that they are outcomes of a program which included in addition to reality orientation, activity therapy, physical and occupational therapy and remotivation. The primary dependent variable, in this retrospective study of 206 participants in reality orientation at the Veterans Administration between 1965 and 1970, was the level of nursing care required by the patient. This was graded on a four point scale from minimal-level (I) to intensive-level (IV). When patients in all four levels of nursing care were considered, the results obtained were disappointing: 68% of the 125 patients for whom complete data were available remained at the same level of care, while 32% improved.
These data raise an important issue about the effectiveness of reality orientation namely, for what group of patients is reality orientation most likely to succeed. Reality orientation was designed for patients with a moderate to severe degree of organic cerebral deficit resulting from arteriosclerosis.5 However, in a study by Brook, Degun and Mather6, the patients rated the least disoriented benefited the most from reality orientation whereas patients with the greatest deterioration did not benefit. The retrospective analysis of Veterans Administration records also indicated that high self-sufficiency of patients predicted greater improvement with reality orientation.4 If, as Brook et al suggest, the very confused and disoriented respond superficially or not at all, then serious doubts about the efficacy of reality orientation are raised.6 In order to answer the question for whom reality orientation is effective, careful measure and control of variables that can influence mental confusion must be achieved.
Difficulties in obtaining reliable diagnosis and ensuring comparability of experimental and control groups have plagued studies of reality orientation. Confusion and disorientation in the elderly can reflect either depression, organic impairment, or both. Because symptoms overlap, one cannot assume that patients who exhibit similar degrees of disorientation have comparable disabilities. Symptoms of one patient might reflect temporary changes in mental status resulting from environmental change and sensory alterations, whereas symptoms of another might reflect organic impairment. Sensory deficits have long been recognized as potential inhibitors of cognitive performance; yet, in studies of reality orientation, patients with marked deficits of speech, hearing or vision are often lumped together with patients with no such handicap.7·8·9 Although it may be unrealistic to expect that precise documentation of brain changes can be obtained on all subjects in reality orientation studies, at the least experimental and control groups should be equated with respect to sensory and motor impairments.
Other factors which can influence measurement of cognitive status in the elderly such as malnutrition, inadequate fluid intake,10 drug interactions," or duration of patients' confusion prior to the onset of treatment are often not controlled in studies of reality orientation. None of the studies reviewed indicated the average medication level and few attempted to ensure that medication levels were constant throughout the course of the study. For example, in Hogstel's study,12 where patients were selected for an experimental and control group in two different nursing homes, the selection procedures were such that one group may have been inadvertently more heavily medicated than another. Disorientation may arise soon after hospital i zation among older persons with acute medica! or surgical needs. 13 It may also occur after long term institutionalization when apathy and indifference set in or physical disability is aggravated. Since our present scales of cognitive performance do not differentiate between impairment of function due to physical or due to psychiatric/psychosocial factors, we cannot determine whether reality orientation is as useful for patients with cognitive dysfunction secondary to major sensory or motor impairment, as it is for those whose dysfunction is due to environmental change.14
Measuring Dependent Variables
Adequate assessment of the effects of reality orientation requires that repeated measures of a broad range of behaviors be obtained under comparable conditions by trained raters using sensitive instruments. Unfortunately, these criteria are seldom met. Typically, a mental status examination is used to screen patients for level of organic impairment and to assess outcomes of a treatment program, while other measures of cognitive performance are ignored. A frequently selected mental status exam, the Mental Status Questionnaire, measures orientation and memory with ten questions. However, mental status exams seldom evaluate other variables that mediate performance levels, such as anxiety and depression and are not considered appropriate for evaluating cognitive changes resulting from an intervention program.15·16·17
Problems of insensitive measures of cognitive status are compounded by questions of the validity of verbal responses to a single series of questions. The motivation of older persons to perform on cognitive tests can readily be decreased by the testing situation. Repetitive questioning on basic information may become so boring that patients do not attend and deliberately or inadvertently provide responses that don't reflect their true capabilities. Valid measures are more likely if the measurement tasks are seen as relevant by the elderly person.
One solution to the problem of inconsistent responses on measures of cognitive status is to obtain repeated assessments which can be pooled for a more accurate outcome measure. It is hazardous to rely on single pre- or posttreatment measures because cognitive performance in chronic brain syndrome patients can fluctuate rapidly within a few hours due to circulatory changes,18 However, unless the format of repeated measures is varied, for example with equivalent forms, the obtained responses may reflect effects of practice as well as real change.
By measuring a broader range of behaviors than simply orientation to date, time and place, a more meaningful index of the effectiveness of reality orientation may be obtained. SaIzman et al argue that clinical evaluation of elderly patients should always include assessment of memory functions, since memory is essential for carrying out daily activities.17 One might anticipate that group interaction in reality orientation classes might relieve depression and a common symptom associated with it, transient impairment of memory.
Ratings by nurses, which are based on observations of daily activities in a wide variety of circumstances and are one of the most valid indicators of patients' daily functioning, can be important measures of the therapeutic effects of reality orientation programs when they are obtained under comparable conditions by the raters . l4 However, disparities can arise in measures of ward behavior, if there is not a standardized procedure for eliciting and observing behavior. Two different raters can have different expectations concerning how long they should wait before rating a patient as either engaging in a target behavior on his or her own or requiring assistance. Unless a standardized time length has been established for the observation, a comparata! ve framework does not exist.
Staff who undergo reality orientation training may have higher expectations of the physical and mental capacities of the elderly than do staff members of a control group who do not receive such training. Simply asking staff regularly to assess behavior of patients can produce changes and progress in the patients, either due to increased staff awareness of patients' needs and behaviors or to patients' awareness of staffs interest.19
Staff Contributions - Although staff contributions are not well documented, it is clear that many investigators believe the role of staff to be crucial to the success of reality orientation. Positive reinforcement of the oriented behavior of nursing home residents by staff members is the basis of reality orientation according to Browne and Ritter.20 Research by Baltes and Lascomb indicates that social contact by nurses can be highly reinforcing for some patients and produce dramatic improvements in oriented responses by patients when it is contingently administered.21 When reality orientation has failed, staff behaviors such as inappropriate contingency management have been suggested as the cause.22
It is unfortunate that so little attention has been paid to measuring the effect of reality orientation on staff attitudes and behavior. Perhaps the key to the success of reality orientation is consistency of care and participation by all members of the staff.23 A manipulation check, a procedure for determining whether a program is implemented as it was designed to be carried out, is an essential aspect of clinical investigations and one way to assess staff compliance. Many studies claim that reality orientation is provided 24 hours around the clock but none incorporated measures of staff behavior or provided objective evidence that patients are, indeed, constantly reminded of time, place or person. Without independent assessment of staff adherence to a treatment program it is impossible to determine which, if any, components of a multifaceted treatment program are responsible for the outcomes.
Environmental Factors - Staff attitudes are only one of many environmental factors which play a major role in determining how elderly residents of nursing homes respond to the initiation of reality orientation. Other factors, such as characteristics of residents, physical layout and geographic location can also influence the type of social environment that emerges in sheltered care settings.24·25 Most studies of reality orientation programs implemented in nursing home settings generally neglect social contextual variables even when vigorous efforts to modify the social environment have been made. Increases in staff/resident ratio, initiation of a friendly visitor program or provision of additional space to residents are examples of environmental modifications that may occur concomitant with a reality orientation program but have not been evaluated separately.
Recently, a comprehensive environmental assessment technique, the MuItiphasic Environmental Assessment Procedure, has been developed which is well suited for assessing how the social environment of a long term care setting changes when reality orientation is implemented.26 The Multiphasic Environmental Assessment Procedure measures physical and architectural resources, policy and program resources, residential and staff resources and social-environmental resources. Moos and Igra found in their assessment of 90 sheltered care facilities that the better staffed facilities placed less emphasis on independence and resident influence, suggesting that increases in staff ratio may actually inhibit residents from doing things on their own and increase the extent to which staff restrict and control residents.25 Without some measure of social environmental factors, it is impossible to tell whether improvement attributed to a therapeutic intervention is the result of that program and not the result of an environmental interaction that is perhaps less obvious but even more potent.
One of the challenges in evaluating the effectiveness of reality orientation is to determine whether all components of the program are responsible for the outcome or whether some aspects are chiefly responsible for changes in patient status. Reality orientation may be regarded as simply a process of constantly orienting residents to time, place and person, whether in a classroom, or wherever staff come in contact with residents. However, most reality orientation programs incorporate many other changes in the nursing home environment, including:
1) Fostering social interaction in a group setting
2) Raising expectations for residents' self-care behavior
3) Broadening social contact by providing trips outside the nursing home or by bringing volunteers into the home
4) Increasing the number of activities available to residents
A few attempts have been made to examine separately the effectiveness of the components of reality orientation. When the effect of a supportive therapist in a stimulating classroom environment was contrasted with a control group that lacked a therapist, the control group failed to maintain the gains initially made when patients were taken out of their ward environment.6 The importance of the social interaction component of reality orientation has also been underscored by Voelkel who compared a reality orientation group with a resocialization group in a nursing home.8 She reported that the resocialization group, which emphasized reminiscence, benefited more than a tri-weekly six week reality orientation group. Aluiough some argue that reality orientation classes alone cannot succeed, even when the 24-hour component is present, no strong evidence exists that reality orientation produces major changes in enhanced orientation , or improved functioning in activities of daily living.9'23
Since few of the components of reality orientation are unique, it is appropriate to consider whether alternative approaches to treating disorientation might be equally successful. When comparisons have been made with other interventions, such as sheltered workshops or resocial ization groups, the outcomes of reality orientation have not been favorable.7·8 Other alternatives which restructure the environment to make it more demanding, and which motivate elderly people to increase their cognitive activity may lead to improvements in memory that generalize to other behaviors . 27 At present there is no satisfactory evidence of carry-over from reality orientation classes to activities of daily living or social interaction.9
Pros and Cons
Some evidence is accumulating that the initiation of a reality orientation program can have negative effects, such as crying, resistance to participation, and lowered staff morale,8·12'28 In a study by MacDonald & Settin, life satisfaction substantially declined in patients participating in reality orientation but increased in the group of sheltered workshop participants.7 Dissatisfaction with reality orientation by patients and staff seems more likely to occur when reality orientation is administered indiscriminately to residents of a nursing home without careful selection of patients. Involvement of all staff of a nursing home in the design of reality orientation programs and encouragement of creative expansion of classroom experiences can diminish the chances that staff members will be bored teaching reality orientation classes.
Is reality orientation futile? Is it useless to reorient patients with clocks and calendars and to teach patients the names of their fellow residents as Hellebrandt maintains?29 In some cases, the answer is clearly no. All reality orientation programs have benefited some patients, although in many cases the gains made in enhanced orientation have been small or had only a temporary effect. Dramatic improvements have occurred in individual cases when reality orientation has been implemented, particularly when the dysfunction of mental status seems to have arisen from the depression and loss of hope that often accompany the move to an institutional setting. Such improvements are rarer when mental dysfunction results from severe physical limitations.
Reality orientation programs have succeeded in sensitizing the staff of nursing homes to the possibilities of improvement by elderly residents.30 To the extent that these programs enrich the environment and broaden opportunities for social interaction they may enhance morale of staff and residents and motivate both groups to use their capabilities to the fullest. Documentation of these changes with social environmental measures is still awaited. Rigid adherence to a reorientation routine without continuous relationships which provide meaningful social interaction is unlikely to produce long- or short-term gains in cognitive status. Continuing group experiences focused on life review, discussion of daily news, musical expression, exercise or production of socially relevant projects might prove equally effective alternatives for reorienting the confused person with less likelihood of loss of morale.
At the present time there seems to be no justification for the trend identified by Kohut, Kohut and Fleischman towards public agencies requiring the use of reality orientation because little evidence exists for the long term effectiveness of reality orientation.31·32
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- Smith BJ, Barker HR: Influence of a reality orientation program on the attitudes of trainees toward the elderly. Gerontologist 1972; 12:262-264.
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