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Behavioral Interventions to Facilitate Growth

Module #6
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Age and Motivation

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This is Learning Module #6. It provides you with motivational approaches for ADL refusals and adminstering to increase your residents' ADL indpendence. Remember, as mentioned in the other Modules, you are trying to create an atmosphere of ADL success for your residents. This module deals with motivating your resident to do his or her ADLs. However, now we are dealing with the topic of motivation in brief, only as it relates to a resident's performance of Activities of Daily Living. There are residents in most every ALF that have the abilities and capabilities to do portions of their own ADLs, but they just choose not to do them.

Directed Self-Reflection #1: Think about a resident in your facility that fits into this category and write his or her first name after question one. If this question does not apply to your situation, write "N." To select and enter your answer go to Test.

Directed Self-Reflection #2: Write the ADL or ADLs he or she is refusing to perform. If this question does not apply to your situation write "not apply." See above

♦ 9 Categories of Refusal
Think about the person whose name you just wrote, and decide if they could fit into any the following categories:
1. Maybe he or she has never been a real go-getter or a self-starter all of their life.
2. They may be the type of person that, if they can get someone else to do something for them, they will.
3. They are manipulative, and like to feel the power of getting others to do for them.
4. They have had a physical disability for a long time, and are used to having others at their beck and call.
5. They may refuse to do ADLs related to hygiene because they never have valued cleanliness as being important.
6. They still hold the emotional scars of the Depression Era, and don't want to waste the water to wash themselves, or to have their clothes washed.
7. None of these could be true, and they may be in the early stage of Alzheimer's. Because they feel that they are losing their grip on their memory, they mask their fear by being overly demanding, or overly dependent. They may have an attitude of, "If I don't try, I won't fail."
8. They may be disoriented and get a sense of comfort from wearing the same clothes over and over.
9. Or they may be disoriented and are unaware of wearing the same soiled clothes over and over.

Directed Self-Reflection #3: Decide if your resident is oriented enough to know that he or she is refusing or being demanding. If this question does not apply to your situation write "not apply." See above

In this Module, we are not talking about the forgetful Alzheimer's resident, or the frail resident who truly cannot do for themselves. We are talking about the person who decided that they don't want to perform an ADL for a reason other than health reasons. In motivating a resident to do an ADL and creating an environment of success, here are three approaches that are most commonly used.

Let's talk about the resident who may take a commanding voice tone and demands your assistance to put on her shoe, comb her hair, or wash her hands even though she

♦ 1. The Soft Line Approach
The first approach to try is a soft line approach. What you say is, "Helen. There's an old saying that states, what you don't use, you lose." If you feel she needs more information, continue, "And what that means is, physically, if you don't use a muscle, you gradually lose the use of that muscle."

If needed, continue further, "Now I am interested in helping you keep the hand and arm movement that you have." Pause for a moment for her to reply, then say, if it seems appropriate, "Here's your brush." You then hand Helen her hair brush with a friendly, expectant smile.

We talked about facial expression in Learning Module Five, on non-verbal communication. It goes without saying -- always treat the resident or tenant with dignity and respect in order to foster success.

Directed Self-Reflection #4: A soft line approach with a demanding resident is to state what? Test
Question #1.

♦ 2. Simple, Technical Explanations Approach
Here's a second approach if you feel that a simple, but more technical explanation may be useful. If Hester says, "What are you talking about?" or "I don't believe you," state in a factual, but friendly tone, "Hester, when your hands and arms are held immobile, the blood supply to your muscles is slowed, thus causing your muscles to become stiff. Over time with this decreased blood supply, muscles become more and more stiff, and less and less able to move."

Directed Self-Reflection #5: When a resident's hands and arms sit (what) and do not move, the blood supply to their muscles is (what). This causes the resident's muscles to become(what). Test Question #2.

♦ 3. Motivate behind her Action Approach
A third approach for Helen, who refuses to perform an ADL which she is capable of performing, is to motivate behind her action. In short, why should she be assisted with her ADLs? With a kind, gentle, but professional manner, inform her that your Assisted Living Facility is only able to provide a certain level of care for residents, and when care increases beyond a certain level, Helen is no longer an appropriate placement in your ALF.

Now, a major word of caution here: Be aware of the tone of voice that you use when presenting these facts. Be sure to present them in a factual manner, and not as threat. Here's what I mean:

♦ Three Negative Qualities in Voice Tone
Three qualities in a voice make it sound negative, unprofessional, and threatening. First, emphasizing certain words by saying them louder. Secondly, clipping off or ending quickly some words. And thirdly, using several pauses which have the effect of adding a certain emotional drama, and raises emotional intensity.

Directed Self-Reflection #6: If a resident continues to be demanding, staff may need to point out factually that the resident's level of care may increase to the point of being too (what) for the ALF? See above

Directed Self-Reflection #7: What are three tones to avoid in your voice that can make it sound threatening? See above

♦ Changing Voice Tone
First, lower the tone of your voice. Remember, you learned about the importance of voice tone in Learning Module number four on verbal prompts. Secondly, keep the volume level the same for all words. Thirdly, phrase the words with a smoother, sincere, caring pace and feeling. You have that intangible underlying quality to let Helen know that you care about her. This is not only reflected in my voice, but also in my facial expression, as described in Learning module five nonverbal prompts.

Directed Self-Reflection #8: What are three ways to change your voice tone with a resident to sound professional and caring? See above

One last word about giving your uncooperative resident the facts. Keep in mind, as you know, what you are telling her really is the truth. If Helen is disrupting your facility by being very vocal and demanding, as well as demanding more ADL care, then, initially agreed upon when entering your facility, she will end up having to move to a more appropriate setting. However, if you are unsure about using approach three of presenting the facts in a factual manner, it is best to check with your director or supervisor first.

In review the first motivation approach to do an ADL is, "What you don't use, you lose." The second approach is, provide a more detailed explanation. Approach number three is reminding your resident of the terms or conditions of their level

♦ 4. Approaching a Depression-Era Client
The fourth motivational technique is used with a different kind of resident . A resident, Joe, who refuses to change his clothes because he remembers all too well, the Depression Era. He feels that he may not want to waste the water that it takes to provide him with clean clothes daily. It's not that he wants to be waited on, as with Helen, but in addition to saving water, he simply may have never valued or thought it to be important to be clean.

If you feel that odor and hygiene are becoming a concern due to lack of cleanliness, the time has come for a more firm stance regarding ADLs with resident Joe.

♦ a. Statement, not Question
In Learning Module One on instruction, you learned about the importance of giving your resident a choice. But, in this case, the best approach takes place in four steps. The first step is to make a statement, not ask a question. Say something like, "Joe we need to change your shirt now."

♦ b. Repeat
Step two, if he states a refusal like, "I don't want to," or "No, it doesn't," then go back to step one, repeat, "Joe we need to change your shirt now." Make sure that the volume and tone of your voice is low. Do not increase volume on certain words. Do not clip off the ends of your words, or your statements may escalate and get an emotional reaction.

♦ c. Judge Level of Refusal
Step three requires a judgment call on your part as to how emphatic Joe is in his refusal. If you feel he is on the fence, so to speak, you might unbutton one button of his shirt. But, how do you tell if Joe is on the fence and that it's okay to approach him? Look at his face and listen to volume and emphasis in his words. This reflects how determined he is not to comply. Just listen, he may say, "I don't want...no" or "I don't! want... no!"

Directed Self-Reflection #9: What are two ways to tell if it is OK to approach a resident who refuses ADLs? (look at his face, listen to the volume and emphasis in his words). See above

♦ d. Inform the Resident You Will Return
Many residents will give in at the point when you start to unbutton the shirt. However, you definitely do not want this to escalate into a full blown confrontation. So, if he still remains negative to create an environment for success, go to step four and say, "Well, I'll leave now, but I'll be back in a little while. And we do need to change your shirt."

If you don't return, and someone on the shift after you approaches him, that just makes it much harder tomorrow for you to get Joe to comply. So, if you state that you are going to be back in a little while, do so. If it's at the end of your shift, state this by saying, "Well Joe, that shirt needs to be changed. I'm going off shift now, maybe Alice will have better luck."

However, you'll win no popularity contest if this becomes a standard ploy on your part, when the next shift has to do your work. So, plan better. The next day, approach Joe toward the beginning of your shift to allow you an opportunity to revisit, and request several times the shirt change.

Directed Self-Reflection #10: It's best to approach a resident who refuses ADLs (blank) in the day to allow time to reapproach them several times later during your shift. Test Question #3.

♦ Summary
In summary, there are four steps with someone who is at the point of lack of ADL performance which affects others, due to odor, and also affects their health. The first step is to make a statement, "We need to change your clothes now." You do not request, because you've tried, and requesting has not worked. Step two, calmly repeat your statement, "We need to change your clothes now." Step three, judge the level of refusal. If he seems to be close to complying, physically start the clothing change. Step four, if you feel the resident's refusal is too emphatic or emotional, as reflected by his facial expression, voice volume, etc. inform the resident that you will return. Then, plan your care schedule accordingly, to accommodate revisiting the resident.

Of course, the very last step with Joe, as with Helen who demanded care, is the "Why should I?" reply. You inform Joe that he may become an inappropriate placement for your ALF, requiring a level of care too high for your facility, and would need to

♦ Facility Policies on Clothing Changes
It goes without saying, be very clear about your facility policy on clothes changes. Obviously, one resident's rights end where another one's begins. By that I mean, if the odor from Joe is to a point of bothering other residents, or incontinence is presenting a health hazard to Joe, the firm, three-step method stated above needs to be considered. Depending upon your policy, distractions might be used, like washing Joe's clothes while he is in the whirlpool, or if he takes them off at night, while he sleeps.

Directed Self-Reflection #11: Especially where odor is involved, one resident's rights end where another's what? See above

Directed Self-Reflection #12: Incontinence can present a (what) due to lack of ADL performance? See above

Unfortunately for some, only when the consequences occur do they feel a motivation to change. Just like the confirmed smoker may not be motivated to learn techniques to breaking the nicotine habit until he or she has a sore throat that will not go away, or has trouble breathing. Thus, your obstinate resident may not be motivated to cooperate with ADL requirements until he or she is actually transferred to another facility.

♦ Two Principles of Motivation
Up to this point, we've talked about ADL refusals regarding residents who are demanding, and your residents who do not value cleanliness. Let's shift gears to talk about how two principles of motivation can assist your teaching residents to self-administer medication, and how to provide an environment of success.

Often times, stiff fingers and limbs, as well as shaky hands make it a challenge for a resident to take medications or apply ointments independently. As you know, performance of these tasks may be a criteria for placement in your ALF and the use of a Home Health Agency.

♦ Principle 1. Helping Your Resident "See the Need"
The most basic motivators to learn, or in this case relearn, a skill is first for your resident to see a need to do the task. So, as you are asking Mary or Maude to stretch that extra inch to put the ointment on her foot, or raise a shaky hand to her mouth to take a medication, she needs to be aware that independence in taking medications is needed to maintain her current level of care.

Therefore, the motivation comes from being aware that independence in taking medications is part of a larger concept. The concept is their placement in your ALF, and the level of service required, rather than just an isolated task.

You say to Mary, "I know it's hard for you to reach your toe to put on the ointment. I'll help you uncap the tube. Put some on your finger, and guide your hand to your toes. But, I am not qualified to apply the ointment for you."

Directed Self-Reflection #13: Independence in taking medications is explained to your resident, as it related to what two areas? Test Question #4.

♦ Principle 2. Associate the Action with a Past Action
Secondly, in providing an environment of success in motivating your resident to do the medication task that is a challenge for her, associate it with something that she has done in the past, perhaps hundreds of times before. Here are some examples: As the resident reaches down to put the ointment on her foot, you might motivate her by stating, "Mary, remember the garden you talked about yesterday? Just pretend that you are reaching down to pull those weeds or plant a seed."

Maybe, if Mary is an extremely neat person, you might relate putting on the ointment to picking up a piece of thread or lint off the carpet. For a male resident who had played some sports, you might say, "Reach down to your foot like you are picking up a golf ball, baseball, or horse shoe." Use your imagination. This approach works best if you know your resident and if the example applies closely to something he or she can relate to.

For the cap on a medicine bottle, you might ask, "Remember putting the lids on jars when you did canning?" If you have the unit dose blister cards, relate it to pushing a button for an elevator or electric light. Some old-fashioned light switch wall plates used to be push buttons. Or, if the resident sews, how about pushing the bobbin into their machine?

Directed Self-Reflection #14: In motivating your resident to do the medication task that is a challenge; associate it with what? Test Question #5..

♦ Summary
In summary, to provide an environment of success with residents demanding ADL care, take a soft line approach of "what you don't use, you lose," provide more details of what this means. Repeat as needed, and inform residents of the level of care provided by your ALF. Be aware of your voice volume, tone, and be sincere.

For residents refusing ADLs, try making a statement starting with, "It's time to..." Repeat your statement, return later, try physical assistance, inform the resident of the level of care provided by your ALF, and use distractions. For medication administering, provide assistance only. Inform resident of the level of care provided by your ALF. Relate the task to one they have enjoyed in the past.

In this Learning Module, number six, you've just learned about motivation with residents who refuse ADLs, or are demanding. We have also covered medication administration, to effectively increase your resident's ADL independence, and create an environment of success.

Congratulations! You have completed all six modules! You need to follow through to do, and to get what is necessary to make this information work for you. And, be a tool you use with your residents to provide an environment of success. Remember, take action!

Peer-Reviewed Journal Article References:
Harris, J. A., Kwok, D. W. S., & Gottlieb, D. A. (2019). The partial reinforcement extinction effect depends on learning about nonreinforced trials rather than reinforcement rate. Journal of Experimental Psychology: Animal Learning and Cognition, 45(4), 485–501.

Higley, C. A., Lloyd, C. D., & Serin, R. C. (2019). Age and motivation can be specific responsivity features that moderate the relationship between risk and rehabilitation outcome. Law and Human Behavior, 43(6), 558–567. 

Kalenzaga, S., Lamidey, V., Ergis, A.-M., Clarys, D., & Piolino, P. (2016). The positivity bias in aging: Motivation or degradation? Emotion, 16(5), 602–610. 

Queen, T. L., & Hess, T. M. (2018). Linkages between resources, motivation, and engagement in everyday activities. Motivation Science, 4(1), 26–38.

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Module 6 - Course Manual (Motivation Principles)
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