High school students interacted with chronic nursing home patients in dyadic and group activities. By the middle of its fourth year the program had involved 175 patients and 235 students. During the second year, using a before and after design, one 15-week program selected for study was found to have a beneficial effect on ten patients. Patients reported increased social interaction, reduced daytime sleeping, increased mobility and decreased voluntary confinement.
Psychosocial Rehabilitation for Chronic Geriatric Patients: An Intergenerational Approach1
Among the elderly population those who are chronically ill and institutionalized are particularly needy. They tend to be deprived of psychosocial stimulation. Their families are often not available to them. The frequency of visits by families who are available tends to decrease as the stress, guilt, and resentment toward the patient's dependency develops with lengthening institutionalization. A program involving children with a geropsychiatric population made by Thralow and Watson (1974) was responsive to the perceived social deprivation of chronic patients. It was initiated in a highly structured project using remotivation techniques (Long, 1962). Sixth graders served as student therapists for 45-min periods twice a week. After 11 weeks, the patients demonstrated significantly greater improvement than did the control groups, specifically in areas of self-awareness and self-esteem (Thralow & Watson, 1974). Behavioral changes were not analyzed in this program. Program Development
To develop an interactional program at a Veterans Administration (VA) hospital one of the authors (H.F.W.) contacted nearby Monroe 'Supported in part by the Geriatric Research Education and Clinical Dr., VA Medical Ctr., Sepulveda, CA 91343. ! Chief, Division of Ceropsychiatry, VA Medical Dr., Sepulveda, CA 91343, and Dept. of Psychiatry, Univ. of California, Los Angeles, CA 90024. 'Chief, Occupational Therapy, Rehabilitation Medicine Service, VA Medical Ctr., Sepulveda, CA 91343. 'Geriatric Research Education and Clinical Ctr., VA Medical Ctr., Sepulveda, CA 91343, and Dept. of Psychiatry, Univ. of California, Los Angeles, CA 90024. Present address: Brentwood VA Medical Ctr., Los Angeles, CA 90073.
High School which expressed interest in establishing community-service placement opportunities as part of its alternative education program. In a cooperative effort, students enrolled in this special curriculum volunteered to participate in a psychosocial project with chronic Nursing Home Care Unit (NHCU) patients. Most of the subject patients residing in the NHCU had had few visitors in recent months. Many complained about feelings of isolation and loneliness which had developed over the period of their illness. The average length of hospitalization for these patients was almost three years at the time of the project's initiation. It was hoped that patients participating in the project might feel less isolation, increase their social interactions, become more mobile and function more self-sufficiently. While the primary direction of the program was toward enriching the lives of these patients, both the school faculty and VA staff felt that many benefits might accrue to the students as byproducts of their contacts. These included: a perspective of agi ng as a developmental process; a vivid experiential perception of impaired persons separate from their illness; the gratification found in improving the quality of life for chronic patients; and finally, the chance to share experiences with a generation who might otherwise be largely lost to them. Remotivation techniques (Long, 1962) were attempted with the first group of students but were soon abandoned because of the adverse reaction from the 16- and 17-year-olds to the
464
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
Howard F. Wallach, MD, 2 Frances Kelley, OTR,3 and Joel Peter Abrahams, PhD4
Vol. 19, No. 5,1979
465
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
structural constraints of these techniques. The of the students after their return to the classroom. latter were replaced by program operations Faculty members met with hospital staff at intertailored to the special capacities and desires vals for purposes of both planning and review. of the students. Sharing of life experiences and reinforcement of the attributes of each Program Process student and patient in a group setting were The developers of the project anticipated that particularly effective techniques. Each student residents of the NHCU would be delighted at the selected a patient partner, based upon initial opportunity to interact with the students. They contacts in a "get-acquainted" session. Staff also expected that students would have initial assistance was occasionally required. Sessions difficulties, but ultimately would find gratifying consisted of both one-to-one encounters and rewards in the opportunity afforded them by group discussions; following sessions, students active cross-generational communication. Not met with project staff members to discuss their only were these expectations not met in the first experiences. In addition, the students main- program, but a pattern of student and patient tained personal journals of their experiences reaction was established that was repeated with and shared these with the staff as well as their few variations in subsequent programs. The patients entered the program very hesitantly; own school faculty. The curriculum was designed to cover topics some even refused. Others appeared to enjoy the of potential interest to both students and patients. first encounter. Of these, many continued but Controversial subjects such as politics, religion others found multiple excuses for not returning. and sexuality were included for discussion in the Of the reluctant patients, after seeing a few of curriculum. The students participated in semi- their fellow residents enjoying themselves, many nars in basic gerontology. The first three of these returned to the program and actively particiseminars were used as an orientation to the pated. program. Other seminars were inserted in the The students were another matter. They began program as the students appeared receptive to with verve and ideas, but each new group exmore information input. pressed the desire to experiment with their own Each program covered a school semester. structure. Staff members were challenged to Students averaged two hours of service per ses- innovate alternative programming with contrision, two sessions a week, for a 15-week period. butions from both students and patients. The project was started with 10 students, all from Students preferred to become acquainted with one high school, and 10 male patients from patients as their individual needs dictated and to NHCU. Now in its fourth year, the project has bridge the gap created by age difference and grown to include 80 patients and 80 students chronic illness according to the uniqueness of per semester, aged 14 to 18, of both sexes, from their own personalities. A basic element of each three schools. The mean age of involved patients program was the blend of the dyadic sharing is 68. Since the program inception 175 different interaction of each student-patient pair with the patients have participated in the program for one different exchange that arose through group to three semesters. Two-hundred and thirty-five activities. The latter included group games, different students have participated for one or range-of-motion exercises, creative art projects, two semesters. All patients selected for the pro- singing, role-playing, and opportunities for autogram required skilled nursing care, but were biographical anecdotes as well as the aforeregarded by the coordinating staff as having the mentioned discussions. capacity to interact with students. The initial staff The students began with enthusiasm tempered included the authors, a part-time coordinator, by anxiety, seeking ways to deal with the culture a hospital librarian and an art therapist. As the shock of disabilities so apparent in a nursing program grew, a full-time coordinator and an home population. Attempts to extend the orienassistant coordinator were funded through the tation period did not alleviate this shock. They Geriatric Research Education and Clinical seemed deeply concerned with their own perCenter (GRECC) and the Psychiatry Service of formance — wondering, for example, why they the Veterans Administration Medical Center were unable to "get through" to the patients (VAMC), and carried basic responsibility for immediately. They were encouraged by favorthe project, utilizing the authors as consultants able reactions from more responsive patients or supervisors. School faculty enriched the pro- and distressed by others who gave little feedgram through discussing the hospital experience back. Some students were discouraged by the
466
threw her arms around her, and hugged her warmly. B. was surprised, since she had never met the woman. The daughter explained that her father, barely a month before his death, had requested and received B.'s picture and had shown it proudly to his daughter, telling her of his feelings of closeness and gratitude for this young women who cared. B. and the daughter cried together, each consoling the other. The remaining students, sensing the humanity of the event and reacting empathetically to B., were sobered, saddened, and yet warmed by this intimate and bittersweet life experience. The second vignette concerns a patient who had had urinary incontinence that was considered to be primarily psychological. After participating in the program, he was able to manage without a catheter for the first time in years. He had become convinced that the gains from attention accompanying his disability could be achieved more comfortably without the catheter. Moreover, he appeared proud to share his victory over his disability with his student partner. Relationships between students were open and novel. They shared feelings of resentment when certain students were noted to bear less
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
"dullness" of their particular patients. Most, however, became content with smaller patient responses, slowly allowing for erosion into their adolescent omnipotence. A few students remained ebullient throughout each program. Despite their individual differences, each group of students rapidly became cohesive, developing leaders and followers. Toward the middle of each semester, students began to seek more structure and greater depth of interpersonal activity. They complained about the sterile hospital atmosphere, but considered it, at least partially, their own responsibility to alter this atmosphere. Some of the effects of the program on its participants are illustrated by two anecdotes. The first centers on one of the resident participants who died over a weekend. When the students were informed, four of them decided to attend the funeral. Only one of the four had ever attended a funeral previously. On the way to the funeral they were in generally good humor. Upon arrival at the chapel, they found surprisingly few people, only a handful of relatives and two representatives of veterans' service organizations. Upon seeing the students, the deceased's daughter ran to B., the student partner of the deceased,
Vol. 19, No. 5,1979
Termination of each program presented special problems for both patients and students. Separation anxiety was minimized by a farewell party, a time of mixed emotions for all concerned, a taste of life as well as cake and ice cream. Notable was the experience of program staff and nursing staff alike, that the students appeared less resilient in termination of their association than did the patients. Apparently the latter had become more inured to the pain of loss of important relationships throughout their later years. Evaluating the Program
In order to evaluate the effectiveness of this program, the Sickness Impact Profile (SIP) was used to assess changes in the psychosocial, mental, and behavioral status of participating patients. The period evaluated covered the 15 weeks comprising the third semester of the program. The ten patients selected for evaluation were ones who had not had previous experience with the students in either of the first two semesters. The SIP (Bergner et al., 1976) is a 14-scale questionnaire designed to assess the effect of physical illness on a patient's daily activities,
467
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
responsibility than others for the success of the program. They discussed each other's level of participation and met the challenge of self-grading. Several students indicated they would be interested in pursuing a career concerned with aging. Reports from teachers indicated academic gain by many of the student participants. Experiences in early programs led to several changes in project format, including longer "feedback" sessions at more frequent intervals and increased participation of patients in planning and evaluation. The coordinators maintained continuity in the program, assured accurate evaluative procedures, supplied information to students, patients, and NHCU personnel and facilitated harmonious operation. With the coordinators acting as catalysts, organizers, and conduits for interchange, a high level of interest on the part of the students and NHCU patients was maintained. Nursing personnel on the NHCU appeared stimulated by the frequent presence of students on the unit. Staff cooperation was evidenced by their rescheduling of nonprogram activities of the patient participants so as not to interfere with the student-patient interactions. Several nursing staff visited the program and assisted on several occasions.
Table 1. The 10 SIP Scales and the Significance Level of Change (N = 10). Scale A B C D G H I K M N
*p = < .02
Behaviors Assessed
t value
Social interaction Ambulation Daytime sleeping Self-feeding/Nutrition Mobi I ity/Confi nement Body movement Communication Intellectual functioning Mental status Personal hygiene
4.009** 2.061 4.596*** 1.336 2.923* 1.498 1.236 1.602 .598 1.422
**p = < .01
***p = < .001
Commentary on Age Differences and Their Impact on Subject Interactions
Student performances were reviewed, taking into account the differences that had been anticipated between them and the sixth-graders previously studied (Thralow & Watson, 1974; VA Hospital, 1974). The high school students were noted to be: (1) more inclined to develop their own structure and plan their own program; (2) more easily discouraged by the lack of observable-changes in the patients; (3) more curious about the nature of the patient's disability; and (4) more critical of the hospital's atmosphere. The patients appeared to respond to these high school students as they might do with
One of the areas remaining to be demonstrated is the effect on the quality of relationships between young and old following increased
468
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
psychosocial skills, and mental status. The 189 items are forced choice, and the scales are not independent. For this program evaluation only 10 of the scales were used; the remaining four scales were not considered appropriate for chronically hospitalized patients. Each patient was interviewed by a project staff member at the beginning and at the end of the evaluation period. As shown in Table 1 the psychosocial rehabilitation program had an impact on several dimensions of the lives of the patient participants. The results indicated that there was increased social interaction, increased mobility with decreased voluntary confinement, and reduced daytime sleeping. The changes in these three dimensions were statistically significant (p = < .02). Increased self-sufficiency by the patients was not noted to a significant extent. The changes reflected by this instrument are not simply a function of the students' presence since the behavioral assessments were made while the students were not on the premises (for the design of this study see Abrahams et al., 1978.)
young adults rather than with children, discussing topics of interest to mature people, and, for the most part, not condescendingly. Patients appeared to enjoy and benefit from the youthful vibrance exuded by many of the students. These observations suggested that the program's effects might be linked to its approach using widely spread generations. Extended group interactions between students and the elderly appear to be uncommon. Actual programs promoting such relationships run counter to community trends. The Foster Grandparents (Salt, 1971) program is one such program but it does not deal with student groups. Most elderly programs are intragenerational rather than intergenerational. When intergenerational mixes do occur in the community, it is noted that adjacent generations generally maintain the closest relations (Treas, 1975). Hill (1970) observed that visiting occurs infrequently between grandparents and grandchildren. In contrast to the paucity of actual programming there has been increasing interest by investigators in the nature and extent of relationships between the young and the old (Bronfenbrennen, 1977; Kalish, 1967; Rosow, 1967; Rynerson, 1972; Thomas & Yamamoto, 1975). Kalish (1967) reasoned that children should have important contacts with elderly so that when they become adults they will be less prone to turn away from dependency needs displayed by the elderly toward them. Bronfenbrennen (1977) noted that decreased closeness in extended families is associated with children's tendency to see less of grandparents and greatgrandparents. According to Rosow (1967), a large proportion of the elderly wish they had more friends and more contact with children. This finding apparently reflects a sense of interpersonal deprivation on the part of the elderly. The rehabilitative program reported here appears to at least partially gratify these needs in a selected group of socially isolated chronically ill patients. Rynerson (1972) in his studies of the elderly has related selfesteem to feelings of usefulness through activities which involve them with younger generations. He found life satisfaction to be positively correlated with social interaction. Thus, it is not only activity but also contact with others that is important for the preservation of the personality.
Vol. 19, No. 5,1979
ters. Third, this program engaging high school students in a group with impaired elderly persons, provides a sizeable and valuable additional resource of volunteers for an inadequately served and needy population. For chronically institutionalized older persons, volunteers add a new qualitative dimension to their lives. Conclusions This psychosocial rehabilitative project appeared to have important effects on several dimensions of the lives of the participating patients. Social interaction and mobility increased, while voluntary confinement and daytime sleeping decreased. This program demonstrated that high-school age students successfully function as psychosocial rehabilitation therapists with chronically hospitalized nursing home patients. This finding substantially extends the age range of student therapists from that first reported by Thralow and Watson (1976). Even though sixth-graders and eleventh-graders are at profoundly different developmental stages, youngsters in both age groups appeared able to be therapeutically effective, though in different manners.
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contact. Plans have been made for future programs to include healthy middle-aged or elderly volunteers as participants with the students and the chronically ill elderly. They would offer, through ongoing participation, a stabilizing link from one school semester to the next. In addition, they would provide a picture of aging different than that seen by the students in their dealings with the elderly impaired. This type of program is not without cost. Responsible personnel are required to coordinate, prepare and train students", enabling them to work with patients and obtain school credit toward graduation for their participation. Another kind of cost is the emotional one created by the temporary quality of the student-patient relationships. To lessen the impact of students leaving at the end of each school year, many of the patients are given the opportunity of returning to continue their participation with new students during the next semester. The yield of this project can be visualized in three major areas: First are the behavioral changes, as reported here. Second is the capacity to sustain the interest and satisfaction of students and patients alike over seven successive semes-
Hill, R. Family development in three generations. Schenkman, Cambridge, MA, 1970. Kalish, R. A. Of children and grandfathers: A speculative essay on dependency. Cerontologist, 1967, 7, 65-69. Long, R. S., Jr. Remotivation — fact or artifact, Mental Hospital Service. American Psychiatric Association, 1962, 151, 1-8. Rosow, I. Social integration of the aged. The Free Press, New York, 1967. Rynerson, B. C. Need for self-esteem in the aged — a literature review. Journal of Psychiatric Nursing and Mental Health Services, 1972, 10, 22-26. Salt, R. Aging persons as child-care workers in a fostergrandparents program: Psychosocial effects and work performance. Aging and Human Development, 1971, 2, References 314-340. Abrahams, J. P., Wallach, H. F., & Divens, S.: Improvement in behavioral functioning of chronic-care geriatric Thomas, E. C , & Yamamoto, K. Attitudes toward age. An exploration in school-age children. International Journal patients: Results of an age-integrated psychosocial of Aging and Human Development, 1975, 6, 117-129. remotivation program. Journal of the American Geriatrics Thralow, J., & Watson, C. S. Remotivation for geriatric paSociety, 1979. (in press) tients utilizing elementary school students. American Bergner, M., Bobbitt, R. A., Pollard, W. E., Martin, D. P., & Journal of Occupational Therapy, 1974, 28, 469-473. Gilson, B. S. The sickness impact profile. Validation of a Treas, J. Aging and the Family. In D. S. Woodruff, & J. E. Birhealth status measure. Medical Care, 1976, 14, 57-67. ren (Eds.), /Aging. D. Van Nostrand Co., New York, 1975. Bronfenbrennen, U. Doing your own thing — our undoing. Veterans Administration Hospital, St. Cloud, Minnesota. A Child Psychiatry and Human Development, 1977, 8, School-hospital remotivation program. Hospital and 3-10. Community Psychiatry, 1974,25, 661-664.
Finally, as an interface between the world of the hospital and the outside community, this project helped provide important intergenerational and societal linkages. The students gained knowledge and a perspective of the aging process and in some cases a career-orientation toward gerontology; the residents gained social contact, stimulation, and positive behavioral changes in their daily lives.
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470
Psychosocial Rehabilitation for Chronic Geriatric Patients: An Intergenerational Approach1
Among the elderly population those who are chronically ill and institutionalized are particularly needy. They tend to be deprived of psychosocial stimulation. Their families are often not available to them. The frequency of visits by families who are available tends to decrease as the stress, guilt, and resentment toward the patient's dependency develops with lengthening institutionalization. A program involving children with a geropsychiatric population made by Thralow and Watson (1974) was responsive to the perceived social deprivation of chronic patients. It was initiated in a highly structured project using remotivation techniques (Long, 1962). Sixth graders served as student therapists for 45-min periods twice a week. After 11 weeks, the patients demonstrated significantly greater improvement than did the control groups, specifically in areas of self-awareness and self-esteem (Thralow & Watson, 1974). Behavioral changes were not analyzed in this program. Program Development
To develop an interactional program at a Veterans Administration (VA) hospital one of the authors (H.F.W.) contacted nearby Monroe 'Supported in part by the Geriatric Research Education and Clinical Dr., VA Medical Ctr., Sepulveda, CA 91343. ! Chief, Division of Ceropsychiatry, VA Medical Dr., Sepulveda, CA 91343, and Dept. of Psychiatry, Univ. of California, Los Angeles, CA 90024. 'Chief, Occupational Therapy, Rehabilitation Medicine Service, VA Medical Ctr., Sepulveda, CA 91343. 'Geriatric Research Education and Clinical Ctr., VA Medical Ctr., Sepulveda, CA 91343, and Dept. of Psychiatry, Univ. of California, Los Angeles, CA 90024. Present address: Brentwood VA Medical Ctr., Los Angeles, CA 90073.
High School which expressed interest in establishing community-service placement opportunities as part of its alternative education program. In a cooperative effort, students enrolled in this special curriculum volunteered to participate in a psychosocial project with chronic Nursing Home Care Unit (NHCU) patients. Most of the subject patients residing in the NHCU had had few visitors in recent months. Many complained about feelings of isolation and loneliness which had developed over the period of their illness. The average length of hospitalization for these patients was almost three years at the time of the project's initiation. It was hoped that patients participating in the project might feel less isolation, increase their social interactions, become more mobile and function more self-sufficiently. While the primary direction of the program was toward enriching the lives of these patients, both the school faculty and VA staff felt that many benefits might accrue to the students as byproducts of their contacts. These included: a perspective of agi ng as a developmental process; a vivid experiential perception of impaired persons separate from their illness; the gratification found in improving the quality of life for chronic patients; and finally, the chance to share experiences with a generation who might otherwise be largely lost to them. Remotivation techniques (Long, 1962) were attempted with the first group of students but were soon abandoned because of the adverse reaction from the 16- and 17-year-olds to the
464
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
Howard F. Wallach, MD, 2 Frances Kelley, OTR,3 and Joel Peter Abrahams, PhD4
Vol. 19, No. 5,1979
465
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
structural constraints of these techniques. The of the students after their return to the classroom. latter were replaced by program operations Faculty members met with hospital staff at intertailored to the special capacities and desires vals for purposes of both planning and review. of the students. Sharing of life experiences and reinforcement of the attributes of each Program Process student and patient in a group setting were The developers of the project anticipated that particularly effective techniques. Each student residents of the NHCU would be delighted at the selected a patient partner, based upon initial opportunity to interact with the students. They contacts in a "get-acquainted" session. Staff also expected that students would have initial assistance was occasionally required. Sessions difficulties, but ultimately would find gratifying consisted of both one-to-one encounters and rewards in the opportunity afforded them by group discussions; following sessions, students active cross-generational communication. Not met with project staff members to discuss their only were these expectations not met in the first experiences. In addition, the students main- program, but a pattern of student and patient tained personal journals of their experiences reaction was established that was repeated with and shared these with the staff as well as their few variations in subsequent programs. The patients entered the program very hesitantly; own school faculty. The curriculum was designed to cover topics some even refused. Others appeared to enjoy the of potential interest to both students and patients. first encounter. Of these, many continued but Controversial subjects such as politics, religion others found multiple excuses for not returning. and sexuality were included for discussion in the Of the reluctant patients, after seeing a few of curriculum. The students participated in semi- their fellow residents enjoying themselves, many nars in basic gerontology. The first three of these returned to the program and actively particiseminars were used as an orientation to the pated. program. Other seminars were inserted in the The students were another matter. They began program as the students appeared receptive to with verve and ideas, but each new group exmore information input. pressed the desire to experiment with their own Each program covered a school semester. structure. Staff members were challenged to Students averaged two hours of service per ses- innovate alternative programming with contrision, two sessions a week, for a 15-week period. butions from both students and patients. The project was started with 10 students, all from Students preferred to become acquainted with one high school, and 10 male patients from patients as their individual needs dictated and to NHCU. Now in its fourth year, the project has bridge the gap created by age difference and grown to include 80 patients and 80 students chronic illness according to the uniqueness of per semester, aged 14 to 18, of both sexes, from their own personalities. A basic element of each three schools. The mean age of involved patients program was the blend of the dyadic sharing is 68. Since the program inception 175 different interaction of each student-patient pair with the patients have participated in the program for one different exchange that arose through group to three semesters. Two-hundred and thirty-five activities. The latter included group games, different students have participated for one or range-of-motion exercises, creative art projects, two semesters. All patients selected for the pro- singing, role-playing, and opportunities for autogram required skilled nursing care, but were biographical anecdotes as well as the aforeregarded by the coordinating staff as having the mentioned discussions. capacity to interact with students. The initial staff The students began with enthusiasm tempered included the authors, a part-time coordinator, by anxiety, seeking ways to deal with the culture a hospital librarian and an art therapist. As the shock of disabilities so apparent in a nursing program grew, a full-time coordinator and an home population. Attempts to extend the orienassistant coordinator were funded through the tation period did not alleviate this shock. They Geriatric Research Education and Clinical seemed deeply concerned with their own perCenter (GRECC) and the Psychiatry Service of formance — wondering, for example, why they the Veterans Administration Medical Center were unable to "get through" to the patients (VAMC), and carried basic responsibility for immediately. They were encouraged by favorthe project, utilizing the authors as consultants able reactions from more responsive patients or supervisors. School faculty enriched the pro- and distressed by others who gave little feedgram through discussing the hospital experience back. Some students were discouraged by the
466
threw her arms around her, and hugged her warmly. B. was surprised, since she had never met the woman. The daughter explained that her father, barely a month before his death, had requested and received B.'s picture and had shown it proudly to his daughter, telling her of his feelings of closeness and gratitude for this young women who cared. B. and the daughter cried together, each consoling the other. The remaining students, sensing the humanity of the event and reacting empathetically to B., were sobered, saddened, and yet warmed by this intimate and bittersweet life experience. The second vignette concerns a patient who had had urinary incontinence that was considered to be primarily psychological. After participating in the program, he was able to manage without a catheter for the first time in years. He had become convinced that the gains from attention accompanying his disability could be achieved more comfortably without the catheter. Moreover, he appeared proud to share his victory over his disability with his student partner. Relationships between students were open and novel. They shared feelings of resentment when certain students were noted to bear less
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
"dullness" of their particular patients. Most, however, became content with smaller patient responses, slowly allowing for erosion into their adolescent omnipotence. A few students remained ebullient throughout each program. Despite their individual differences, each group of students rapidly became cohesive, developing leaders and followers. Toward the middle of each semester, students began to seek more structure and greater depth of interpersonal activity. They complained about the sterile hospital atmosphere, but considered it, at least partially, their own responsibility to alter this atmosphere. Some of the effects of the program on its participants are illustrated by two anecdotes. The first centers on one of the resident participants who died over a weekend. When the students were informed, four of them decided to attend the funeral. Only one of the four had ever attended a funeral previously. On the way to the funeral they were in generally good humor. Upon arrival at the chapel, they found surprisingly few people, only a handful of relatives and two representatives of veterans' service organizations. Upon seeing the students, the deceased's daughter ran to B., the student partner of the deceased,
Vol. 19, No. 5,1979
Termination of each program presented special problems for both patients and students. Separation anxiety was minimized by a farewell party, a time of mixed emotions for all concerned, a taste of life as well as cake and ice cream. Notable was the experience of program staff and nursing staff alike, that the students appeared less resilient in termination of their association than did the patients. Apparently the latter had become more inured to the pain of loss of important relationships throughout their later years. Evaluating the Program
In order to evaluate the effectiveness of this program, the Sickness Impact Profile (SIP) was used to assess changes in the psychosocial, mental, and behavioral status of participating patients. The period evaluated covered the 15 weeks comprising the third semester of the program. The ten patients selected for evaluation were ones who had not had previous experience with the students in either of the first two semesters. The SIP (Bergner et al., 1976) is a 14-scale questionnaire designed to assess the effect of physical illness on a patient's daily activities,
467
Downloaded from http://gerontologist.oxfordjournals.org/ at Boston University on October 26, 2014
responsibility than others for the success of the program. They discussed each other's level of participation and met the challenge of self-grading. Several students indicated they would be interested in pursuing a career concerned with aging. Reports from teachers indicated academic gain by many of the student participants. Experiences in early programs led to several changes in project format, including longer "feedback" sessions at more frequent intervals and increased participation of patients in planning and evaluation. The coordinators maintained continuity in the program, assured accurate evaluative procedures, supplied information to students, patients, and NHCU personnel and facilitated harmonious operation. With the coordinators acting as catalysts, organizers, and conduits for interchange, a high level of interest on the part of the students and NHCU patients was maintained. Nursing personnel on the NHCU appeared stimulated by the frequent presence of students on the unit. Staff cooperation was evidenced by their rescheduling of nonprogram activities of the patient participants so as not to interfere with the student-patient interactions. Several nursing staff visited the program and assisted on several occasions.
Table 1. The 10 SIP Scales and the Significance Level of Change (N = 10). Scale A B C D G H I K M N
*p = < .02
Behaviors Assessed
t value
Social interaction Ambulation Daytime sleeping Self-feeding/Nutrition Mobi I ity/Confi nement Body movement Communication Intellectual functioning Mental status Personal hygiene
4.009** 2.061 4.596*** 1.336 2.923* 1.498 1.236 1.602 .598 1.422
**p = < .01
***p = < .001
Commentary on Age Differences and Their Impact on Subject Interactions
Student performances were reviewed, taking into account the differences that had been anticipated between them and the sixth-graders previously studied (Thralow & Watson, 1974; VA Hospital, 1974). The high school students were noted to be: (1) more inclined to develop their own structure and plan their own program; (2) more easily discouraged by the lack of observable-changes in the patients; (3) more curious about the nature of the patient's disability; and (4) more critical of the hospital's atmosphere. The patients appeared to respond to these high school students as they might do with
One of the areas remaining to be demonstrated is the effect on the quality of relationships between young and old following increased
468
The Gerontologist
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psychosocial skills, and mental status. The 189 items are forced choice, and the scales are not independent. For this program evaluation only 10 of the scales were used; the remaining four scales were not considered appropriate for chronically hospitalized patients. Each patient was interviewed by a project staff member at the beginning and at the end of the evaluation period. As shown in Table 1 the psychosocial rehabilitation program had an impact on several dimensions of the lives of the patient participants. The results indicated that there was increased social interaction, increased mobility with decreased voluntary confinement, and reduced daytime sleeping. The changes in these three dimensions were statistically significant (p = < .02). Increased self-sufficiency by the patients was not noted to a significant extent. The changes reflected by this instrument are not simply a function of the students' presence since the behavioral assessments were made while the students were not on the premises (for the design of this study see Abrahams et al., 1978.)
young adults rather than with children, discussing topics of interest to mature people, and, for the most part, not condescendingly. Patients appeared to enjoy and benefit from the youthful vibrance exuded by many of the students. These observations suggested that the program's effects might be linked to its approach using widely spread generations. Extended group interactions between students and the elderly appear to be uncommon. Actual programs promoting such relationships run counter to community trends. The Foster Grandparents (Salt, 1971) program is one such program but it does not deal with student groups. Most elderly programs are intragenerational rather than intergenerational. When intergenerational mixes do occur in the community, it is noted that adjacent generations generally maintain the closest relations (Treas, 1975). Hill (1970) observed that visiting occurs infrequently between grandparents and grandchildren. In contrast to the paucity of actual programming there has been increasing interest by investigators in the nature and extent of relationships between the young and the old (Bronfenbrennen, 1977; Kalish, 1967; Rosow, 1967; Rynerson, 1972; Thomas & Yamamoto, 1975). Kalish (1967) reasoned that children should have important contacts with elderly so that when they become adults they will be less prone to turn away from dependency needs displayed by the elderly toward them. Bronfenbrennen (1977) noted that decreased closeness in extended families is associated with children's tendency to see less of grandparents and greatgrandparents. According to Rosow (1967), a large proportion of the elderly wish they had more friends and more contact with children. This finding apparently reflects a sense of interpersonal deprivation on the part of the elderly. The rehabilitative program reported here appears to at least partially gratify these needs in a selected group of socially isolated chronically ill patients. Rynerson (1972) in his studies of the elderly has related selfesteem to feelings of usefulness through activities which involve them with younger generations. He found life satisfaction to be positively correlated with social interaction. Thus, it is not only activity but also contact with others that is important for the preservation of the personality.
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ters. Third, this program engaging high school students in a group with impaired elderly persons, provides a sizeable and valuable additional resource of volunteers for an inadequately served and needy population. For chronically institutionalized older persons, volunteers add a new qualitative dimension to their lives. Conclusions This psychosocial rehabilitative project appeared to have important effects on several dimensions of the lives of the participating patients. Social interaction and mobility increased, while voluntary confinement and daytime sleeping decreased. This program demonstrated that high-school age students successfully function as psychosocial rehabilitation therapists with chronically hospitalized nursing home patients. This finding substantially extends the age range of student therapists from that first reported by Thralow and Watson (1976). Even though sixth-graders and eleventh-graders are at profoundly different developmental stages, youngsters in both age groups appeared able to be therapeutically effective, though in different manners.
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contact. Plans have been made for future programs to include healthy middle-aged or elderly volunteers as participants with the students and the chronically ill elderly. They would offer, through ongoing participation, a stabilizing link from one school semester to the next. In addition, they would provide a picture of aging different than that seen by the students in their dealings with the elderly impaired. This type of program is not without cost. Responsible personnel are required to coordinate, prepare and train students", enabling them to work with patients and obtain school credit toward graduation for their participation. Another kind of cost is the emotional one created by the temporary quality of the student-patient relationships. To lessen the impact of students leaving at the end of each school year, many of the patients are given the opportunity of returning to continue their participation with new students during the next semester. The yield of this project can be visualized in three major areas: First are the behavioral changes, as reported here. Second is the capacity to sustain the interest and satisfaction of students and patients alike over seven successive semes-
Hill, R. Family development in three generations. Schenkman, Cambridge, MA, 1970. Kalish, R. A. Of children and grandfathers: A speculative essay on dependency. Cerontologist, 1967, 7, 65-69. Long, R. S., Jr. Remotivation — fact or artifact, Mental Hospital Service. American Psychiatric Association, 1962, 151, 1-8. Rosow, I. Social integration of the aged. The Free Press, New York, 1967. Rynerson, B. C. Need for self-esteem in the aged — a literature review. Journal of Psychiatric Nursing and Mental Health Services, 1972, 10, 22-26. Salt, R. Aging persons as child-care workers in a fostergrandparents program: Psychosocial effects and work performance. Aging and Human Development, 1971, 2, References 314-340. Abrahams, J. P., Wallach, H. F., & Divens, S.: Improvement in behavioral functioning of chronic-care geriatric Thomas, E. C , & Yamamoto, K. Attitudes toward age. An exploration in school-age children. International Journal patients: Results of an age-integrated psychosocial of Aging and Human Development, 1975, 6, 117-129. remotivation program. Journal of the American Geriatrics Thralow, J., & Watson, C. S. Remotivation for geriatric paSociety, 1979. (in press) tients utilizing elementary school students. American Bergner, M., Bobbitt, R. A., Pollard, W. E., Martin, D. P., & Journal of Occupational Therapy, 1974, 28, 469-473. Gilson, B. S. The sickness impact profile. Validation of a Treas, J. Aging and the Family. In D. S. Woodruff, & J. E. Birhealth status measure. Medical Care, 1976, 14, 57-67. ren (Eds.), /Aging. D. Van Nostrand Co., New York, 1975. Bronfenbrennen, U. Doing your own thing — our undoing. Veterans Administration Hospital, St. Cloud, Minnesota. A Child Psychiatry and Human Development, 1977, 8, School-hospital remotivation program. Hospital and 3-10. Community Psychiatry, 1974,25, 661-664.
Finally, as an interface between the world of the hospital and the outside community, this project helped provide important intergenerational and societal linkages. The students gained knowledge and a perspective of the aging process and in some cases a career-orientation toward gerontology; the residents gained social contact, stimulation, and positive behavioral changes in their daily lives.
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