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Article
published by WAGECC
The Washington
D. C. Area Geriatric Education
Center Consortium.
June
2003.
Clinical
Therapeutic Recreation For
Elders
An Often
Misunderstood Concept
By: Kathy
Ward
www.kathyjward.com
connection@kathyjward.com
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).
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