Reality orientation has been popular in the literature since the late 1960s. It has been cited as a technique which may be used with elderly persons who have moderate to severe degrees of confusion. Reality orientation was first described by Taulbee and Fblsom1 and was the major undertaking of James C. Folsom, MD starting in 1959 at the Winter VA Hospital in Topeka, Kansas.
Major contributors to this program were Letcher, Fteterson, and Scarbrough,2 for their historical study of 125 patient records of persons who participated in a reality-orientation program in conjunction with other rehabilitation activities between the years of 1965 and 1970. This particular article was the one which received national attention in regard to this therapy.
Reality orientation is a two-part program which includes classroom orientation to time, place, and person, and 24hour-a-day, seven-day-a-week reality orientation on the unit. Total participation by all staff members is required to maintain consistency.
While this therapy has been promoted for its successes, there are studies which have found nonsignificant results of decreased confusion levels. Five studies have been critically reviewed in hopes of finding particular areas of weakness which may account for these discrepancies and focus on our need for further research in this area.
Individual Article Critiques
1. Hogstel MO: Use of reality orientation with aging confused patients. Nurs Res 1979; 28<3):161-165.
This investigation sought to determine if a specifically planned program of reality orientation wiil decrease the degree of confusion in elderly confused residents of nursing home. The investigation is significant to nursing since the majority of care provided to the elderly, especially in the nursing home setting, is provided by nursing. Identifying ways of decreasing confusion in the elderly will increase quality of life. The problem is clearly and concisely stated and it may be answered with empirical evidence.
The literature review is relevant to the study, yet it appears that the author is addressing the population she is interested in as confused with functional, reversible nature. However, she does not refer to this type of older adult subject specifically or directly anywhere else in her research. Literature review of aging, confused adults is weak; however, reality orientation is well-reviewed from both a historical and current perspective. A range of opinions and varying points of view are documented in regard to this therapy. Documentation of sources is clear and complete. The organization of this review is logical, although it is not concluded with a brief synopsis of the literature, nor its implications for the problem.
No theoretical or conceptual framework is documented as the basis for this study. The hypothesis is stated in the null hypothesis form. This form reflects a more objective statement of the relationship between the variables.
The research approach used is a four-cell experimental design. This is a frequently utilized, highly valid experimental approach. The target population is clearly described. While the researcher attempted to control for variables of confusion within the target population by excluding those who were receiving narcotics or tranquilizers, had a history of psychosis, or impairments such as inability to speak, hear, or see, other important variables of reversible, temporary confusion states were not addressed. These variables include recent relocation to the nursing home setting, a recent loss, such as of a spouse, or other traumatic situations, such as recent hospitalization or diagnosis of a disease.
Factors such as these play a major role in the success of a reality-orientation program and can skew results of the study. The instrumentation and procedures are appropriate for this study and may be replicated if the 18-item questionnaire devised for this study is made available. A test-retest reliability coefficient of .96 was obtained for this tool. The steps in the data collection are well-documented and clearly described.
The sample size was 22 for the experimental group and 20 for the control group. It is large enough for the sampling procedure. A sample size minimum of 15 subjects per group for experimental studies is a generally accepted guideline. The sample is homogeneous of a confused, elderly population, although one believes it is imperative to thoroughly assess, distinguish, and separate reversible from irreversible confusion states.
Limitations of the study are not stated. Protection of human rights is well-documented and carefully considered. This is particularly important when working with this type of subject.
A two-tailed t-test was used and is appropriate for this study. The results of this research are statistically nonsignificant, a fairly common consequence in reality-orientation studies. Other positive aspects not related to the research, such as increased socialization, activity participation, and family involvement are cited as positive outcomes. The researcher identifies the need for a longer than three-week study to observe changes in orientation level and obtain significantly measurable results. One does not believe a longer period of time would notably affect results of the cogniti vely- impaired client who is a victim of Alzheimer's disease or organic brain syndrome.
The major strengths of this research are its description of the research process, protection of human rights, and data collection. Its weakness lies in a lack of identification and comparison of subjects in reversible or irreversible confusion states.
2. Nodhturft VL, Sweeney NM: Reality orientation therapy for the institutionalized elderly. J Gerontol Nurs 1982; 8(7):396-40t.
This investigation sought to answer the question: What is the difference in the mental status of institutionalized elderly persons receiving reality-orientation therapy as compared to institutionalized elderly persons not receiving this therapy? The investigation is significant to nursing as it relates to the increasing number of people living longer who require institutionalization. and nursing's responsibility to discover and deliver an optimal milieu in which these older adults may live.
The literature review is relevant to the study in regard to past studies of reality orientation. This review includes both a well -documented historical and current perspective. Documentation of sources is clear and complete with a range of opinions and varying points of view. The organization of the review is logical, presenting historical as well as current information. A literature review of institutionalized elderly is not specifically provided. This study includes a brief synopsis of the literature review incorporated into its theoretical rationale.
A theoretical framework, Disengagement Theory, is provided for this study. It is unclear how disengagement from the world relates to the problem being addressed, forming its framework.
The hypothesis is stated in the research form, identifying a positive correlation between the variables, with a high level of significance set at 0.01.
The research approach is experimental in nature with a pretest/posttest design of both the control and experimental groups. The target population is not clearly described. This study took place on one unit of a 250-bed VA hospital. Persons who were aphasie, did not use English as their native or fluent tongue, or had psychiatric illnesses were not accepted into the study. The population of this unit was rated as each person matched the criteria for the study.
When critiquing this study, it is unclear as to the criteria they matched, other than being elderly and confused. The Mental Status Schedule tool is not explained, nor is it clearly documented that this is the tool used to match the criteria. Again, one believes this sample does not distinguish between reversible and irreversible causes of confusion.
Sample size is adequate and randomly selected with 17 subjects in the control group and 18 subjects in the experimental group. Limitation to the sample is documented by the fact that all subjects are male. Protection of human rights is also wet !-documented in this study.
The instrument and procedure used is appropriate for this type of study and may be replicated. The author includes a copy of the Mental Status Schedule used to measure mental status which has a 0.84 internal consistency reliability. This study may be replicated as the procedure is given in detail. except in the area of criteria matching for subject selection.
A t-test was used and is appropriate for this study. This test demonstrates significant results. The researchers also proclaim that while there was not an actual increase in ADL participation physically, the staff reported subjects as having more interest in their ADL and hygiene activities. This result was not initially for measurement.
The researchers document that some of their significant results may have been caused by the Hawthorne Effect; therefore, they recommend some type of positive intervention, such as altitude therapy, for the control group to control for this variable in future studies. One is surprised that this is recommended and not controlled from the start, since Voelkel3 had already discussed this variable in the same journal as this research is published. No reference of Voelkel's article is cited in this study.
While this study documents significant statistical results, it is weak in distinguishing reversible from irreversible states of confusion. One has no way of determining if the subjects' confusion was of a reversible state, such as depression from sensory deprivation, or an irreversible state, such as Alzheimer's Disease. This fact may have affected the significance, or insignificance, of this study.
3. Letcher PB, Peterson LP, Scarbrough D: Reality orientation: A historical study of patient progress. Hosp Communitv Psychiatrv 1974; 25(12):801-803.'
This investigation sought to determine the effect of reality orientation, as one aspect of a total rehabilitation program, on the confused and disoriented patient. Other aspects were activities therapy, physical and occupational therapy, and remoiivation. The investigation is significant to nursing because it involves the promotion of quality in life for the confused and disoriented patient.
It is difficult to be sure of the researchers' meaning of confused or disoriented. One may be led to believe that the authors are utilizing these concepts synonymously with withdrawal, as evident by this statement:
Regardless of the reason for institutional ization. it is not uncommon to find the older patient withdrawing, breaking off relationships with others, and becoming less concerned with the simplest mechanics of daily living. Reality orientation attacks the deterioration process by continually stimulating the patient through repetitive orienting activities and by placing him in a group where he meets and socializes with other patients (p 801).
Further definitions or explanations of confusion are not present. This raises the following questions: Is it reality orientation or the resoci al ization process which makes the difference? Are we dealing with reversible or irreversible causes of confusion? The research question itself was clearly written, although it is placed within the introduction of the article.
The literature review is limited. Little research material was published concerning reality orientation at the time. Studies published up to this period, including Folsom, are reviewed. No literature review is performed for confusion, disorientation, or withdrawal.
A theoretical framework is not provided in this study. It is reported that this is a historical study; therefore, there is no control group. The effectiveness of the program has not been measured under standardized research conditions of a formal study, yet progress has been consistently reported through staff evaluations and individual case histories.
The target population reviewed includes 125 men who participated in reality orientation within a five-year period from 1965-1970. Selection of participants was made by the treatment team a few days after patient admission. If the patient "seemed" confused or disoriented, the team prescribed 24-hour reality orientation and classroom reality-orientation therapy. Again, one cannot determine if the patient was withdrawn and depressed or demonstrating confusion of an organic nature. Since these patients were newly admitted, their confusion may have been caused by relocation crisis. The word "seemed" leaves question in itself.
Results are displayed in numbers and percentages of levels in nursing care before and after reality orientation. This display of results is appropriate yet weak, since there are no other tools used to measure success. Nursing levels, as documented, are subjective in nature. No mention is made whether the same person consistently reviewed and reported changes in levels of care. Meritorious changes in levels of care are common upon adjustment to new environments, which may also play a major factor in positive results. A great limitation to this study is that reality orientation may not be individually rationalized as an effective treatment program because it was only one aspect of a total rehabilitation program.
Although this research has many weaknesses, one believes its importance must not be underestimated. This research study has historical rhetoric in the promotion of reality orientation as a therapy in confusion management.
4. Parker C, Somers C: Reality orientation on a geropsychiatric unit. Geriatric Nursing May/June 1983, pp 163-165.
This investigation sought to answer the question: Could a 24-hour realityorientation program, including some physical changes of the unit, have a positive effect on the patients1 level of function? While this problem is clearly defined, at first glance there appears to be a paradox in the dependent variables. A significant component of reality orientation is keeping changes to a minimum. Upon further investigation, one finds that all environmental changes are related to the promotion of reality orientation. These changes include large door signs, a bulletin board, and colorcoded patient rooms.
There is no literature review documented in this study, yet the researchers state they have reviewed the literature on reality orientation, attended a conference, and observed reality orientation as carried out in a nursing home. References are few, as three are cited.
No theoretical framework is provided for this study, nor is a hypothesis stated. The tool used is the Geriatric Rating Scale. What this scale actually measures is not identified, nor is the fool's reliability; therefore, this research cannot be duplicated as written.
The population studied was the total population (N=6) of a geropsychiatric unit reserved for patients with impaired levels of orientation, judgment, memory, and intelligence. This unit was housed in a 192-bed, private, acute-care psychiatric hospital. The primary diagnosis of the patients admitted to this unit was major depressive disorder. No statements regarding protection of human rights are documented. There is a description of intervention with prospective patients or their families to determine whether the patients had mild or moderate memory loss. The reason stated for this intervention is that ". . . only patients with early stages of Alzheimer's disease can respond to reality orientation" (p 164). While one may agree with this assumption, the researchers do not back this statement with documented proof. A review of the literature asserts reality orientation as appropriate therapy for moderately to severely confused persons.1,4
The research procedure included the administration of the Geriatric Rating Scale prior to implementation of environmental changes and introduction of the reality-orientation program. No sooner than two weeks after the program began, retesting with this scale was performed. The results found are inconclusive; two persons scored at a higher level when retested, two scored lower, and two showed no change.
This research cannot be replicated because it lacks concrete documentation of sample population, assumptions, protection of human rights, description of tool, and data analysis.
5. Voelkel D: A study of reality orientation and resocialization groups with confused elderly. J Gerontoi Aforjl978;4<3):13-18.
This investigation sought to determine the relationship between functional levels of confused elderly persons receiving reality orientation and those receiving resocialization before and after the initiation of these therapies. The investigation is significant to nursing as it examines various methods of increasing quality of life for the confused elderly. The problem is obscurely stated: therefore, one must deeply review this article to find the problem actually being investigated.
The literature review is superficial. yet this researcher addresses "chronic" and "acute" brain syndromes. The reference list includes both historical and current literature for the period of time in which this research was published. If a person reading this article is not well acquainted with reality orientation, he will have difficulty conceptualizing this therapy from examining this review.
It appears that a theoretical framework is included in the research, but it is only mentioned within the introduction. Maslow's hierarchy is used to demonstrate why a person cannot feel love and belonging if he doesn't even know his name or where he lives.
The research hypothesis is not directly stated. However, the researcher points out that other investigators have observed that attention given by the group leader to individuals is what creates improvement in patient behaviors rather than the constant reminder of time, place, and person in reality-orientation therapy.
The research approach is quasiexperimental. It is documented as a comparative study. Two tools were utilized: The Short Portable Mental Status Questionnaire (SPMSQ)1 which measured mental status for subject selection, and the Physical Self-Maintenance Scale (PSMS), which measured ADL function pre- and postgroup implementations. The reliability of neither scale is mentioned.
The target sample population is those residents living in a nursing home who scored between 5 and 9 on the SPMSQ tool. One is unable to identify the characteristics of a person who scores within this range because the SPMSQ tool is not described, nor are the particular characteristics of persons with this score range referenced. Of 115 subjects tested, 20 scored between 5 and 9. These 20 subjects were randomly placed within one of the two groups. Protection of human rights is not addressed. Although the researcher did mention reversible (acute) and irreversible (chronic) states of confusion, this was not taken into account during subject selection- The author places a strong emphasis on reminiscence in the resocialization group. Reminiscence has therapeutic value beyond resocialization. which causes a possible misinterpretation of concepts. Perhaps this study should have addressed the differences in functional levels of persons receiving reality orientation and reminiscence therapy.
A t-test for matched pairs was used for significant differences between the mean of the pre- and posttest scores. While the author acclaims the results as significant with greater improvement seen in the resocialization group, no numerical value is shown. In discussion of the study, the researcher states that the changes which occurred were qualitative in nature, therefore, difficult to measure by quantitative statistics. These "changes" are not described, and the statement is a direct contradiction relating to the use of a t-test and the attainment of significant results.
This research study is believed to support a very important aspect of care: social interaction. It unfortunately loses some of its value by not following accepted research method reporting.
Evaluation of Articles in Relation to Each Other
In consideration of the five articles reviewed, the strongest in documentation of the research process is Hogstel (1979). Although this researcher's results are nonsignificant, strong use of the research process serves this article as a backbone for future documentation of the subject. Nodhturft and Sweeney (1982) followed the research process as well. Other articles reviewed lack this systematic description, making them both difficult to decipher and comprehend.
One may be wondering why the majority of the articles chosen for review are of an earlier date. The answer lies in a review of the most recent literature of reality orientation. Few research studies are to be found; most work is descriptive in nature, attesting to the promotion of this therapy. Actual research currently published in this area is weak in the research process.
Commonly, theoretical frameworks are lacking or poorly developed. Articles which include a review of the literature focus on the dependent variable, reality orientation, and spend little to no time defining or discussing confusion. Perhaps if these studies placed more emphasis on confusion, the target population would be better defined and results would be of a more significant nature.
Hogstel (1979) and Nodhturft and Sweeney (1982) address protection of human rights. Other articles critiqued do not cite this important aspect of research. One believes this is of unconditional importance, particularly for this group, in view of the vulnerability these persons may experience.
From the articles reviewed, it was found that the value of the investigation can be weighed by its use of the research process, not by significance of results. Both researchers and publishers of nursing journals have an obligation to publish investigations representing both significant and nonsignificant results. It is the sharing of information and insight which helps to strengthen nursing's body of knowledge. One must remember that research which is presented without appropriate use of the research process, whether quantitative or qualitative, is weak in justifying its point.
Value in Practice and Further Research
A survey of the literature has disclosed only a surface indentation of research regarding reality orientation. As previously mentioned, most of the current articles published on this topic are descriptive in nature, rather than research oriented. While all information obtained on this topic is important, a continuation of formal research studies will help to further distinguish and define who this type of therapy will truly benefit most and what modifications in the actual program are required.
One believes more must be done than to make surface statements about reversible (acute) and irreversible (chronic) causes of confusion. Better definition and categorizing of these differences are required before and during sample selection. The concept of confusion necessitates development. Perhaps reality orientation is more beneficial for reversible states of confusion caused by current life event Stressors or sensory deprivation, and another therapy approach to reality is required for irreversible confusion states which are organic in nature. A tool needs to be developed specifically for the confused elderly and utilized by researchers and staff members to distinguish these differences. The question posed needs to be researched.
Although it has been stated that staff members have been trained to conduct reality-orientation classes and 24-hour reality-orientation therapy, no studies have reported testing staff members' understanding of what they have been taught. This may be why Gubrium and Ksander5 found inconsistencies in therapy.
The fact that only a handful of formal studies in such an important topic are to be found substantiates the need for nurse researchers in the geriatric setting. If one accepts information which manifests inconsistencies in results and small numbers of actually researched investigations as adequate, injustice is not only done to research, but to the confused elderly population faced with this problem.
Investigations of a transcultural nature never have been reported involving reality orientation. Perceptions of various cultures are different; therefore, perceptions of reality may be different. This is not only true of persons from other cultures, but also of persons born and residing in different regions of this country. By understanding these different perceptions of reality, one may better conceive and provide care to persons of various cultures and regions who are sufferers of disorientation and confusion.
While there is a fair amount of literature on reality orientation, the surface has been only scratched in regard to this area of research. Research studies of a formal nature, whether quantitative or qualitative, are required. Clearer distinction of reversible and irreversible causes of confusion need to be researched and taken into consideration during sample selection. A tool requires development to test for this, specifically in the confused elderly. Testing of staff is required to ascertain their understanding of reality orientation when involved in this project.
The transcultural perspective of this topic never has been formally explored. This area is in dire need of research. It is through commitment to research and continued interest in this topic that the promotion of the highest quality care possible for this growing group of persons may be obtained.
- 1. Taulbee LA, Folsom JC: Reality orientation for geriatric patients. Hospital and Community Psychiatry 1966; 17(5):133-135.
- 2. Letcher PB, Peterson LP. Scarbrough D: Reality orientation: A historic study of patient progress. Hasp Community Psvckietr\ 1974; 25(12):801-803.
- 3. Voelkel D: A study of reality orientation and resocialization groups with confused elderly. J Gerontol Nurs 1978; 4(3):13-18.
- 4. Hogstel MO: Use of reality orientation with aging confused patients. Nurs Research 1979; 28(3): 161 -165.
- 5. Gubrium JF, Ksander M: On multiple realities and reality orientation. The Gerontologist April 1975, pp 142-145.