KJW Articles - "Clinical Therapeutic Recreation For Elders, An Often Misunderstood Concept."
By: Kathy J. Ward
Date: June 2003
Published by: WAGECC, The Washington D.C. Area Geriatrics Education Center Consortium Quarterly Newsletter.
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Overview: For the past seven I have been working in the field of Therapeutic Recreation (TR) for elders (Independent Living, Assisted Living and Alzheimer's/Dementia.) Prior to that my career was in International Development working for the world Bank/IMF. The decision to leave my previous career was neither a quick nor an easy one, but I listened to my heart and the satisfaction of working for elders has been rewarding beyond imagination.
My first assignment was as "Activities Assistant" and then "Activities Director," both in Assisted Living. Then I was offered a position as "Recreation Director" in an Independent Living facility. It sounded interesting but I was not able to understand the difference between "Activities Director" or "Recreation Director." On more than one occasion I was called "Activities Director" instead of "Recreation Director." I was interviewed by four qualified interviewers and offered the job. Today after 8000 working hours in this field not only I am very clear about the differences, but I also see the need for letting other know about Therapeutic Recreation for Elders. I am presently a Recreation Director for an Independent, Assisted Living and Alzheimer's/Dementia Care Unit. I constantly notice the lack of knowledge and misunderstanding of the role and purpose of the Recreation Department in this facility as well as from my colleagues, family members, volunteers, and staff in other facilities.
I'd like to review some important concepts before I move on. Activities are everything that a person does during the day, i.e. walk, take a bath, eat, read the newspaper, make a bed, brush their teeth, shop, garden, sing, pray, watch TV, play Bingo, etc.
Recreation Therapy is a deliberate and purposeful use of an intervention process aimed at helping people with illness and disabilities to improve their psychosocial, physical, spiritual, health and quality of life.
The Clinical Practice of Therapeutic Recreation is also a systematic and planned use of recreation and other activity interventions with the intent of affecting positive change in a person's attitudes, beliefs, behaviors and skills necessary for psychosocial adaptation, health and well being.
Moving from an "Activities Department" to a "Therapeutic Recreation Department".
What is the vision and value of Therapeutic Recreation for elders? It is not about keeping our elders busy or to 'kill time with them.' It is about finding the proper 'interventions' or programs that can help them to:
Improve cognition (the process of thinking) and cognitive functioning (attention and creativity). The physical plan or environment affects the way elders behave and interact with each other.
Improve functioning, motor-coordination skills, basic locomotion. Some interventions are: Yoga, Tai-Chi- chair exercises, walking club, line dancing, aerobics, shuffleboard, etc.
Decrease depression, anxiety and stress. A fulfilling life for older adults is characterized by social integration that is inter-actions with other people. Frail elders, especially in Assisted Living, often show a significant decrease in levels of social participation and engagement. For example, a prospective study of new nursing home admissions found that on admission and after one year, approximately 50% of the residents were not participating in recreation programs. (1) One determinant of these declines in social functioning may be deterioration of the cognitive abilities needed to process social information.
Adapt to changes brought on by illness or a disabling conditions. Some interventions: Low Vision Support Group, Hearing and Speech Support Group, Alzheimer's Support Group, Health Talks, The Positive Thinkers Club, Large Print Books and Talking Books, etc.
Increase ability to problem-solve, with a focus on the strengths and abilities of the individual. Some interventions: In house-volunteer program, creative arts, welcoming committee, etc.
Improve relationships with family and friends. Some interventions: Intergenerational events, mother-daughter tea socials, etc.
Increase sense of independence and control. Some interventions: Use of Recreational areas at leisure (computer room, library, exercise room, audio library, beauty salon, etc.) It is important to make ATMs available at the facility!
Facilitate settings to identify benefits of social involvement/social creativity. Some interventions: Network with Art Associations in the community or Book Clubs, Mentoring program with local Elementary Schools in the area, etc.
Increase sense of positive self-image, self-esteem, self-worth and self-confidence. Some interventions: In-house community service, neighbor-to-neighbor committee, library committee, newsletter committee, etc.
There are other essential and basic steps in the process of providing Therapeutic Recreation (TR) for our elders. The notion of the individual needs and the proper therapeutic recreation intervention can only be obtained by assessing our residents. Assessments provide Recreation Therapist (RTs) and other caregivers, with a guide to identify and understand all domains of care: medical information; background information; occupational background; interest and abilities; personal care; mealtime; physical activities; social gatherings; intellectual activities; spirituality and hobbies; current abilities; cognitive skills (short and long term memory; perception; attention; language communication; judgment. (2)
The Therapeutic Recreation Assessment (TRA) is considered to be a multi-disciplinary tool because of the overall patient information documented. The TRA is valuable in assisting the treatment team in decision-making concerning the appropriateness of patient care. The TRA considers interacting mental, medical psychological, social and leisure factors to plan and implement interventions according to a patient's functional level.
Direct Patient Care. An RT provides both individual and group therapies. The main purpose of the treatment is to increase a person's functional level through diversified modalities or interventions; art, drama, music, jazzercises, discussion groups, etc.
One of the differences between a TRA in Long-Term-Care and Assisted Living is that LTC patients are not only participating in therapy sessions but also learning Activities of Daily Living (ADL) skills, Instrumental Activities of Daily Living (IADL) skills, social prevocational and leisure skills through activity therapy participation.
The State officials might well examine and seriously consider the importance of Therapeutic Recreation in their standards and regulations for Long-Term-Care, Assisted Living and Independent Living facilities. If you read the Maryland State Regulations for Assisted Living, it briefly mentions, under "Activities", the need for the facility to have a monthly calendar of activities. It does not elaborate on the protocols, principles or norms of practice. Based on this statement, if we play bingo, then watch TV and then play bingo again, we are meeting the requirements of the law. How many times have we visited a Long-Term-Care or Assisted Living facility and the residents are glued to the TV as if they were waiting to die. WE CAN DO A BETTER JOB. Our elders deserve it.
The proper 'manpower' to deliver Clinical Therapeutic Recreation for Elders.
I have already mentioned my 'adventure' in discovering the difference between Activities and Recreation. I did have a job description and a supervisor that understood my role as an 'Activities Assistant' in the Assisted Living facility as 'the party person and official bingo coordinator.' He also wanted me to clean the bird cage, have manicure sessions twice a week, drive the residents to their doctor's appointments and take them to lunch outings on Fridays. When I mentioned that I played the piano then he said "Great! Let's have a sing-a-long every afternoon during the social hour." Oh! I forgot the 'Matinee and Popcorn' on Mondays, Wednesday, Fridays and Saturdays at 1:30 p.m.
I was determined to put wings to my dreams so I started to search for books and information about the purpose of my role as 'Activities Assistant." Since this is an emerging profession there was not much information available at that time. I visited several Assisted Living facilities, networked with colleagues, and they were doing more or less what I was doing. Seven years later we still do not have a university or college curriculum available in Therapeutic Recreation in Gerontology. The 'four qualified interviewers' that gave me the job as 'Recreation Director' also introduced me to other members of the management team as the new 'Activities Director." During the interview they did not ask for any credentials or studies in the field of activities or recreation. The reason: there are no credentials required by the State Regulations in the metropolitan area to work in Assisted Living or Independent Living in this field. What are we waiting for?
Conclusion and Recommendations. These are some suggestions to achieve better standards of practice in Clinical Therapeutic Recreation for seniors.
1. Introduce a training program, college or university curriculum in Activities, Recreation and Leisure or Therapeutic Recreation in Gerontology that prepares individuals to assess, plan, implement, monitor, document and evaluate appropriate interventions to meet the individual needs of our elders.
2. Teach and facilitate the inclusion of our elders and caregivers in the care plan and special needs of our elders. Address the value of Clinical Therapeutic Recreation with family members and primary caregivers. It is the patient's and caregiver's right to be informed and educated about the aging process, symptoms, challenges, illness, meaning and implications (risks and burdens) and how the appropriate TR interventions can help to improve the patient's quality of life.
3. Utilize community resources and volunteers to encourage social creativity, cognition and social functioning. Providing more opportunities for our elders to get involved in politics, education, art, contemporary issues that the local government is facing, etc. We need to provide the avenues and opportunities for our elders to share their wisdom, experiences and creativity. For example: Elders Speakers Bureau.
4. Develop with your elder population a strong volunteer program inside the community. For example; Neighbord-to-Neighbord Committee, Newsletter Committee, Special Holidays Party Planning Committee, Library Committee,
5. Develop State Regulations that clearly outline the goals of a Therapeutic Recreation program. Provide sample of a good monthly calendar addressing diversity, and encouraging creativity, mental stimulation, physical activities, leisure, social integration, cognitive functioning, spirituality, self-esteem/self-worth, motor coordination and basic locomotion.
6. Address the value of Therapeutic Recreation, making a Recreation Therapist part of the initial admission process (data collection/documentation process) with the rest of the interdisciplinary management team; MD, RN, LISW, PT, OT, etc., to identify the level of care of a new resident. Observation: If we placed an Assisted Living resident in the Alzheimer's/Dementia Unit without properly conducting the cognitive/functional TR assessments, we will limit the chances of this resident to gain a better quality of life and perhaps accelerate the deterioration of their medical condition.
7. Pay attention to the building design. This industry is growing very fast and more often we see new Assisted Living, Group Homes, or big beautiful buildings, decorated like grand hotels but lacking in functionality for addressing the needs of our elders. Perhaps from now on the Interior Designers can consider, beside the chandeliers and expensive wallpapers;
a. A craft or art center, an auditorium or meeting room ensuring enough space for walkers and wheelchairs. If possible, make the décor or the craft and art center as stimulating and inviting as possible.
b. A music room with a good piano, tapes and CD players for low vision and hearing impaired elders.
c. Comfortable armchairs so our elders can achieve healthy posture and reach the floor with their feet.
d. An indoor garden or sunroom with pets, houseplants and fresh flowers. Nature texture materials to be creative and enjoy nature.
e. A small library with large print books, magazines, newspapers, journals, a computer, copy machine, fax machine, world atlas or maps, videos of different countries from all over the world or biographies, etc.
Our elder's new home does not need to look Victorian or Rococo style for our elders to like it!
Clinical Therapeutic Recreation is a lot of work, but at the same time, it is very interesting to see how a structured TR program changes the mood of the facility, like a silent language that communicates the TRUE spirit of HOME.
References:
(1) The Journals of Gerontology. Series B, Volume 58B, March 2003.
(2) Sylvester, C., Voekl, J., and Ellis, G.
Therapeutic Recreation Programming: Theory and Practice. State College, PA. Venture Publishing (2001).
Peace be with you!
Kathy J. Ward
Co Founder of WEL, World Elder Land™
Co Founder of ERT, Elder Recreation Therapy™ Therapeutic Recreation Consultant
National Assisted Living Administrator Certified
Board Member, Activities, Adaptation and Aging Journal
Ambassador of Happiness For Elders
Alzheimer's Association Speakers Bureau
Cell: (240) 393-5456
Connection@KathyJWard.com
www.KathyJWard.com/blog
www.elderrecreationtherapy.com
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