The authors report on an interdisciplinary, continuing education, training program and its effect on residents and trainees and its impact within the long-term care setting. This N I M H project was sponsored jointly by the Adelphi University Schools of Nursing and Social Work and the evaluation study was conducted by the Bureau of Educational Evaluation of Hofstra University. The paper examines the problem, theoretical base, planning, objectives, design, methods, and evaluation of the project. It is the author's belief that this demonstration training project can be replicated and that the mental health status of residents can be positively affected.
Elaine B. Goldman, MS, RN,2 and Pierre Woog, PhD3 The design, methodology, and faculty of the Mental Health in Nursing Homes Training Project provided an opportunity for trainees to increase their knowledge, skills, and resources in order to create a structure and a climate conducive to improving the mental health status of nursing home residents. Sponsored jointly by the Schools of Nursing and Social Work of Adelphi University, Garden City, NY, this interdisciplinary, continuing education program consisted of three sequential courses: Mental Health and Gerontological Practice, Group Process and Group Dynamics, and Training Group Leaders. This series was repeated at different geographical locations on Long Island. To determine the efficacy of the Mental Health in Nursing Homes Training Project, the Bureau of Educational Evaluation of Hofstra University, an agency totally independent from that of the project, constructed an evaluation design prior to the project's implementation. The success of this NIMH Project, as reported in this paper, was a result of a blend of planning, hard work, and maximum cooperation. Two schools, the School of Nursing and the School of Social Work within one University, Adelphi, jointly conceived, wrote, and implemented the project. A third school, School of Education from another University, Hofstra, conducted the evaluation. In addition, selected faculty, consultants, and a Steering Council from community mental health centers, long-term care institutions, 1. This project has been supported by NIMH, Health Services and Mental Health Administration. DHEW, Contract No. HSM42-72-218. Paper presented at the annual meeting of Gerontological Society, Nov., 1973, Miami Beach. 2. Director of Training Project, Mental Health in Nursing Homes, and Assistant Professor, School of Nursing, Adelphi Univ., Garden City, NY 11530. 3. Director of Evaluation Project Mental Health in Nursing Homes, and Assistant Professor, Bureau of Educational Evaluation, Dept. of Educational Psychology, Hofstra Univ., Hempstead, NY 11550.
April 1975
and concerned governmental agencies were instrumental in the planning and implementation of the project. This cooperation cannot be minimized. It was from this premise, maximizing interpersonal relations in cooperation, in order to have a direct beneficial effect upon nursing homes as institutions and residents of those homes as people, that made this project possible. Problem
As of 1970, there were 289,609 persons in the Long Island, New York, region over 60 years old. The number of institutionalized aged is rising at a rapid rate as population patterns change. For the most part, institutionalized aged are crowded into both proprietary and public nursing homes, with proportionately fewer hospitalized in State Dept. of Mental Hygiene facilities. The increasing numbers of institutionalized aging, coupled with the shifts caused by overcrowded facilities, have added to a stressful experience for the aged and have affected the nature and quality of their care (Curtin, 1974). In order that persons residing in long-term care facilities can be supported toward the maintenance and retention of levels of healthy functioning, they must be approached, like people at other stages of life, as individuals, and their problems dealt with accordingly. These residents include mentally impaired individuals for whom practitioners need to assume the role of patient advocate on behalf of his needs and rights as a human being as well as the alert and/or ambulatory resident whose needs go beyond physical security, watching television and "busy work" activities. The usual caretakers and decision makers at all levels need to become aware of their own attitudes, feelings, and behavior toward residents and their families. They
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Theoretical Base Having identified the problems and needs for mental health training, it was necessary to develop a working definition of mental health and an approach to facilitate change. The mental health practitioners on our team suggested careful attention to the therapeutic community model at least to explore the social system of the longterm care institution and at best to bring about positive change. Much has been written about the therapeutic community in psychiatric institutions and of the utilization of the therapeutic community model in long-term care institutions (Kramer, Kramer, 1967; Miller, 1966). Concomitantly, mental health has been written about prolifically and defined in a variety of ways. This suggests that mental health does not mean the same thing to all people; it is at best a phenomenon difficult to conceptualize and more difficult to put into a few words. For the purposes of this training program, one needs to associate mental health with three words: mastery, fulfillment, and people. In order for an individual to be "mentally healthy," he or she needs to have: (I) a sense of mastery over what he or she is doing, thinking, and feeling; (2) a sense of being fulfilled or satisfied with what he or she is doing, thinking, and feeling; and (3) meaningful contact with people. We all know someone who is never satisfied with their accomplishments; we also know those who "master" or accomplish their goals and are satisfied but are unable to relate to another person in a meaningful way. Therefore, neither of these persons would be considered mentally healthy. With this description of three components necessary for mental health, one better understands the need for, and the benefit of meaningful contact in a therapeutic com-
munity in long-term care institutions, not only to residents and their families but also to all those who work with the aged and disabled. The Project Planning For 4 months, the Project Director was involved in planning and organizing the following: faculty selection and training, curriculum development, content and methodology, public relations, publicity, and selection of and collaboration with the Bureau of Educational Evaluation of Hofstra University. The director sought advice from the Nassau County Mental Health Board, the Older American Volunteer Committee, nursing home administrators, and other concerned practitioners. The above efforts culminated in the formation of a 40-member Community Steering Council, which represents the community relevant to this particular program and includes representatives of concerned governmental and voluntary mental health agencies, voluntary and proprietary nursing homes, several faculty of the training program, and older persons residing in nursing homes. While the over-all task was to examine ways to continue the linkage between mental health, continuing education and nursing homes, the immediate task of this council meeting was to help publicize and recruit those teams of trainees who would fulfill, in fact, the aims of the program.4 Recruitment and Enrollment A 6-page brochure publicizing the program, including the year's schedule, was mailed 5 weeks before the first section of courses began to every director of nursing and to every nursing home administrator on Long Island. All personnel in nursing homes and extended care facilities were invited to participate as members of an "agency team." A minimum of 3 trainees were encouraged to attend together as a team in order for them to implement the program's objectives in their own facility. Knowing that any change in an institution requires the involvement and commitment of the top administrator, the nursing home administrator was encouraged to become a team member.5 Teams varied in member's discipline, role, and function, but in each training section there were representatives from 4. Some of the content of this paper, e.g., Planning, Framework, Course Descriptions, etc., has appeared in two earlier articles by Goldman (I972, I973). 5. Nursing home administrators were recruited as team members with ease, since the training program received approval by the Board of Examiners of Nursing Home Administration of the New York State Dept. of Health for I04 continuation credits. One hundred credits are required every 2 years for nursing home administrators' relicensure.
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need to realize that (I) by not being in touch with their own feelings, or (2) due to lack of knowledge about the aging process and/or failure to apply knowledge, they inadvertently have increased the patient's dependency, psychosocial decline, and physical impairment, and (3) interdisciplinary cooperation is necessary in order to deliver quality care. One needs little experience in a long-term care setting to become aware that, although residents live together, they have little meaningful contact. This is not surprising when one considers that many people live a lifetime without experiencing tenderness, closeness, and intimacy. In order to rectify these deficiencies, both in residents and staff, a whole new approach was obviously indicated.
administration, nursing, social work, recreation, and their respective assistants. The number of trainees from nursing homes ranged from I to 10 with a median of 4. The total number of trainees was 128, representing 32 nursing homes with more than 6,000 residents. About half of the trainees were nurses. One-fourth of the trainees were administrators and the other fourth of the trainees included almost all conceivable nonresident adults who could be found in a home.
of the group. This 24-week training program model was offered four times during the I-year training period in various long-term care institutions in different locations on Long Island. This enabled participation by nursing home personnel who live and work as far as 90 miles from the university.
April 1975
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Experiential Learning Consideration was given in the experiential design of the courses to make it possible for The Training Program Model each participant to become more effective in The training program consisted of three se- what he or she is doing and happier in underquential courses: Mental Health and Gerontologi- standing the why as well as the how of human cal Practice in Nursing Homes (one day a week behavior. The process of the training program for 8 weeks), Group Process and Group Dy- focused on the experience of the resident in namics (one-half day for 8 weeks), and Training order to initiate and maintain meaningful contact. Trainees became sensitive to the experiGroup Leaders (one-half day for 8 weeks). The first course, Mental Health and Geron- ence of an older person, that is, what he pertological Practice in Nursing Homes, offered ceives, interprets, and responds to by talking to trainees an opportunity to grasp the relation- an older person about himself and his experiships among sociological, psychological, and ences or by reading personal accounts of how physiological phenomena of aging. Emphasis older persons see themselves and their life situawas placed on maintaining optimal functioning tion. The program utilized techniques that simuof residents through a guided theoretical assess- lated the experiences of the older person. An ment of, and intervention into, the psychosocial, example of simulation equipment used is as folphysiological, and environmental aspects of lows: By means of a specialized tape recorder aging. The intervention included effective utili- (Lomask Engineering, Sharon, CT), which prozation of internal and external resources. Struc- vides delayed feedback of speech and a pair of tured exercises were utilized to promote clinical goggles (Pentagon Device Corp., Syosset, NY), which rotate the axis of the visual field, trainees and interpersonal competence. The second course, Group Process and Group were able to experience a simulated view of Dynamics, was an experiential group course de- neuromuscular disability. When the tape resigned to increase the trainee's effectiveness as corder delays the trainee's speech sounds a fraca group member and as a group leader. Learn- tion of a second, it caused the trainee to retard ing was achieved through the examination of the his rate of speech, increase his pitch and loudactual experience of the group. Trainees had an ness, to falter his vocal rhythm, and to misarticopportunity to: (I) increase their awareness of ulate frequently. This is similar to the speech their feeling experiences and of their reactions patterns of a person who is hemiplegic. When to and impact on others, (2) become more effec- the trainee wore the goggles, which contain an tive in expressing what is going on with them- arrangement of mirrors that rotate the entire selves, (3) become acquainted with processes visual field 5° to 20° to the left or right, he common to a variety of groups, (4) experience walked slowly with hesitation. He also had diffithose forces which influence group behavior, and culty in maintaining his balance and would reach out for someone or something to hold on to, or (5) practice intervention. The third course, Training Group Leaders, was would grasp the wall if it was within reach. a continuation of Group Process and Group DyThis exercise created increased sensitivity and namics. Trainees who were not leading a group more constructive attitudes toward the disabled needed to select a group to work with on a older person. The demonstration helped to imweekly basis. The groups selected were com- part certain facts about the nature of disability prised of either residents, family, staff, or a mix- and how this type of disability produces the ture of these. The purpose of each group was illusion that the subject is suddenly confused or decided by the group leader and/or the group stupid. Trainees were to become aware of resimembers. In this experiential group course, there dents' behavioral changes due to sensory diswas discussion of the trainee's group work as turbances and neurological and neuromuscular well as an examination of the actual experience dysfunctions. As anticipated, these teaching
42-72-218.
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tools engendered many thoughts and feelings design of this program was for all participants on the part of trainees. Some trainees related to lead some group in their agency. For exwhat they experienced to residents whom they ample, participants, in working with groups of know and care about. Some trainees spoke about residents, help them become more expressive, their own process of aging and of their own feel- increase their interactions, reexperience closeings of loneliness. Some of the lessons learned ness, and increase positive group feelings. These from these exercises were: (I) individuals differ in behavioral changes should enable the resident their response to imposed sensory distortions; (2) to come to terms with himself, i.e., with his a perceptual disability affects the total person strengths and limitations, with his fears and longand his effect on others; (3) handicapped persons ings, with his anger and his joy. A t this stage, parhave an inordinate need for personal contact with ticipants would be able to develop program resomeone who is aware of his experience; and (4) lated to the resident's real life situations (Euster, recovery of normal function is facilitated on the 1971; Klein, LeShan, & Furman, 1965; Shore, part of the trainee by active movement (Dinner- 1961). Some participants led staff groups, family groups, and mixed groups of all descriptions. stein & Lowenthal, 1968). Specific objectives.—Specific program objecTraining was carried out predominantly in small group work with a mixture of trainees in each tives help participants: (1) Increase their knowledge of the psychosocialsmall group. These group experiences helped physiological process of aging with emphasis on how participants to deal with interpersonal and the aged experience themselves and their problems. group-living problems with depressed, regressed, (2) Increase interpersonal competence enabling them confused patients and their families. In addition, to establish and maintain meaningful contact with residents and staff. A . Understand: ( I ) the way one sends these experiences helped in exploring and resolva n d / o r responds to messages; (2) different life styles ing intergroup conflict caused by the racial, and value systems: (3) how feelings influence behavior. ethnic, and socioeconomic composition of staff B. Develop skill in: ( I ) listening; (2) sharing emotional and patients. In order to accomplish all this, relereactions to planned or spontaneous behavior; (3) practicing communicating one's feelings and ideas in vant findings were utilized from sociology, social helpful ways. work, physiology, psychology, psychiatric nursing, (3) Increase ability t o assess physiological, psygroup work, and adult education. Participants chological, and sociological needs. received a bibliography and a workirfg library of (4) Become skilled in detecting and preventing the maladaptive patterns of the institutionalized aged. reprints and reports selected for relevance and (5) Develop an awareness of the special needs of clarity. Participants also purchased several paperthose residents presenting problems in institutions and back books which were required reading (list of provide skilled intervention to maintain optimal funcreading materials available upon request). tioning. This model of mental health continuing edu(6) Increase their knowledge and utilization of available internal and external resources. cation included structured and unstructured ex(7) Develop group leadership skills. A. Sensitivity periences which facilitated personal growth and to group process and dynamics; B. Techniques for the transfer of learning to the long-term care group leaders. setting. An important goal was to affect change Evaluation Design in the trainee's behavior at work. The ripple The evaluation design included trainee evalueffect built into the program also helped change ation and impact evaluation.6 Impact evaluation the behavior of personnel who were not in the training program. Ultimately, all those who refers to that area of evaluation which is concame into contact with residents, including rela- ducted on-site and deals specifically with the tives, became part of the therapeutic commu- clients-residents, of the training rather than the nity and helped rehumanize the lives of residents. trainees. The size of the nursing homes had great The training staff reinforced the idea that resi- variability. The range of possible residents was dents are a source of meaningful human contact from 16-1000, with a media n of 150 a nd a tota I of to each other when the structure, climate, and 6,058. The range of possibly affected residents was 10-83, with a median of 55 and a total of 1,185. personnel foster this kind of relatedness. Trainee Evaluation In order to foster this planned change, the In order to assess the effect of the project training program provided participants with the opportunity to: (I) become aware of their atti- training upon those directly trained, two formal tudes toward themselves and toward older per- pre- post-strategies were employed; attitudesons, (2) develop authentic relationships; (3) affective and knowledge-cognitive. To measure deal openly with conflict; and (4) organize and 6. For a complete report of the Project Evaluation, see NIMH lead groups of residents. A major thrust of the Health Services & Mental Health Admin., Contract No. HSM-
April 1975
project's specified objectives; namely, Group Functioning and Interagency Communication. It was hypothesized that nursing homes would have a significantly positive change in their total score as measured by the Impact Evaluation Instrument of Agencies (IEl). Random selections of residents were interviewed in order to determine whether, as a result of the project, there was significant positive change in their mental status. Mental status was operationally defined as the scores from three well-established measures of mental status: Life Satisfaction Index (Neugarten, Havighurst, & Tobin, 1961) (LSI) long form, Mental Status Questionnaire (Kahn, Goldfarb, Pollach, & Peck, I960) (MSQ), short form and Face-Hand test (Kahn et al., I960). Once the impact evaluation was designed and instruments were selected, modified, and collated, observers were obtained and trained in the use of the instruments. Observers were carefully selected. All had previous experience in the field of collection of data. All were professionals in an area that dealt in human service. All had previous formal training in interpersonal relations. Because the impact evaluation was conditioned by the specific entry point of an agency's participation in a project, the time between preand post-impact evaluation varied. For the first course cycle, the elapsed time between pre- and post- was 7 mo., for the second, 6 mo., for the third, 3 mo., and for the fourth, 2 mo. Only for the first two cycles did trainees go through all three courses. These two constraints of the project, when added to expected deterioration of residents in nursing homes, mitigated against any positive findings. The results show that, over-all, there was a significant positive change, as measured, in the nursing homes, although this change could not be isolated in the dimensions. This is probably a function of the impreciseness of each dimension in isolation. The finding does demonstrate that within a very short time, with the constraints already mentioned, institutional change did occur. To gain more insight into this finding, agencies were dichotomized into: (I) those agencies for which trainees attended more than one course and at least 5 months lapsed between pre- and post-testing; 19 agencies, and (2) those agencies for which trainees attended but one course and less than 3 mo. lapsed between pre- and posttesting; 8 agencies. On the average the mean total gain for the first group was 43.63, while the mean average gain for the second was
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attitudinal change all trainees were given the Attitudes Toward Old People Scale (Kogan, 1961) upon entering the project. Those who went through all three courses were administered the same test as a post-testing instrument. The time lapse between pre- and post-testing was approximately 6 months. Trainees' positive attitudes toward the aged increased; p < .05. The results support the hypothesis that significant positive changes in attitude, as measured, would result from training in the program. All tested / values were well over the critical level. To measure cognitive change, the evaluation team and the trainees constructed pre- postknowledge tests which were congruent with the desired areas of knowledge of the project. Two equivalent form tests were constructed by the faculty with help from the evaluators and were used as a pre- post-design; r > .90. All trainees were administered the pre-test at the initial training session and were administered the posttest at the last session of the first course. The intervening time was 8 weeks. It was hypothesized that knowledge would increase to a significant degree. Trainees' cognitive knowledge in the realm of the aged increased; p < .05. These results support the hypothesis that significant positive cognitive learning would occur as a result of the training. This was the case for all groups included in the project. The project was able to bring about desired change, as specified, on the part of the trainees. However, the important results of the evaluation deal with the following: How were the institutions and the residents of those institutions affected by those trained? What was the measurable "impact" of the project? Impact Evaluation In order to assess the trainees' effect within their nursing home settings, trained observers conducted structured observations and interviews within a pre- post-design. These evaluative measures were of two general types: those that examined the nursing home environment through interviews with administrators and observations of the entire facility, and those that interviewed residents within the homes. The instrument selected to evaluate the total environment was a modification of that used by Slover (1969). This instrument examines 12 constructs and hypothesizes that the higher the score per construct the better the home is in meeting the physical and psychosocial needs of residents. Modifications were made in order to accommodate dimensions not originally in the instrument but specifically germane to the
Summary This paper described the first year of the Mental Health in Nursing Homes Training Project, including both the evaluation process and the results. Additional support from NIMH to continue the training program for 1973-1974 was received. A fourth course was added to enable those trainees who completed the 19721973 series and who are currently leading groups to receive further supervision. Modifications for the second year of training included: ( I ) That all trainees had an opportunity to complete the series of three courses,
(2) A 5 mos.1 lag time between pre- and post-testing, (3) A glossary of terms relevant to the reading materials, (4) On-site consultations, (5) Planned interagency visitations among trainees as an integral experience within the first course.
As a result of these modifications, the positive findings were again replicated and, in most cases, found to be greater. We have become especially conscious of our responsibility to help shape the institutional environment in which so many aged make their lives. Our experience in this project has been a confrontation with ourselves, our pretentions, our myths, our prejudices, and our value conflicts. It also has been a confrontation with the essential humanity in all of us. References Curtin, S. Nobody ever died of old age. Little. Brown, Boston, 1974. Dinnerstein, A., & Lowenthal, M. Teaching demonstrations of simulated disability. Archives of Physical Medicine & Rehabilitation, 1968, 49, 167-169. Euster, S . A system of groups in institutions for the aged. Social Casework, 1971, 523-529. Goldman, E. B. An educational model in continuing education for mental health in long-term skilled care for the elderly. In Mental health: Principles and training techniques in nursing home care, DHEW Pub. No. (HSM) 73-9046, 1972. Goldman, E. B. Mental health continuing education: The long-term care administrator as a key member of an interdisciplinary trainee team. In M. J. Stotts (Ed.), Education for administration in long-term care facilities. Assn. of Univ. Programs in Hospital Admin., Washington, 1973. Kahn, R. L, Goldfarb, A. I., Pollack, M., & Peck, A. Brief objective measures for the determination of mental status in the aged. American Journal of Psychiatry, 1960, 117, 326-328. Klein, W., LeShan, E., & Furman, S. Promoting mental health of older people through group methods. Mental Health Materials Center, New York, 1965. Kogan, N. Attitudes toward old' people: Development of a scale and examination of correlates, Journal of Abnormal & Social Psychology, 1961, 62, 4-54. Kramer, C , & Kramer, J . Establishing a therapeutic community in the nursing home. Professional Nursing Home, Sept., Oct., Nov., 1966, and Jan., Feb., April, 1967. Reprints available from the Kramer Foundation, 2 W. Johnson St., Palatine, IL 60067. Miller, M. Synthesis of a therapeutic community for the aged ill, Geriatrics, 1966, 21, 151-163. Neugarten, B. L, Havighurst, R. J., & Tobin, S. S. The measure of life satisfaction, Journal of Gerontology, 1961, 16, 134-143. Shore, H. Content of the group experience in a home for the aged, Social Group Work with Older People. Proceedings of the seminar on Social Group Work with Older People, Lake Mohonk, New Paltz, NY, June, 1961. Slover, D. Relocation of long-term geriatric patients. PhD dissertation, Univ. of Chicago, 1969.
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— 6.38. This further finding strongly suggests that the positive impact of the program showed tremendous gains as trainees took more courses and time was available to put into practice their new knowledge, skills, and attitudes. A significant increase in residents' mental status was found for the Face-Hand test; no significant increase was found for either the Mental Status Questionnaire or the Life Satisfaction Index. There are three possible explanations for this mixed finding, although it should be strongly noted that this is not a negative finding. First, it could be hypothesized that the measuring instrumental were not precise enough to measure significant positive change that did, in fact, occur. This is possible, but dubious, for all three instruments have an enviable record of being valid enough to pick up such change. However, they may not have been in this project. The second possible explanation could be that the project has just not had time enough to affect this type of change and that given further staff training and time, significant positive change in residents' mental status will result. This is certainly possible. The third possible explanation may be found in the nature of the population. Two facts emerge. First, the aged population in a nursing home is highly heterogeneous in terms of mental status and is highly changeable. Second, general deterioration is a fact, although it is most difficult to deal with. Most simply stated, numerous residents die or are in a state of dying between any time lapse. A t the risk of sounding inhumane it must be said that given these facts, a researcher's task is made more difficult when he hypothesizes positive change through systematic intervention in a well-controlled design within the context of general personal deterioration. Thus, the expectation of significant positive change may be unrealistic. It just may be that the lack of negative findings is, in fact, positive.
Elaine B. Goldman, MS, RN,2 and Pierre Woog, PhD3 The design, methodology, and faculty of the Mental Health in Nursing Homes Training Project provided an opportunity for trainees to increase their knowledge, skills, and resources in order to create a structure and a climate conducive to improving the mental health status of nursing home residents. Sponsored jointly by the Schools of Nursing and Social Work of Adelphi University, Garden City, NY, this interdisciplinary, continuing education program consisted of three sequential courses: Mental Health and Gerontological Practice, Group Process and Group Dynamics, and Training Group Leaders. This series was repeated at different geographical locations on Long Island. To determine the efficacy of the Mental Health in Nursing Homes Training Project, the Bureau of Educational Evaluation of Hofstra University, an agency totally independent from that of the project, constructed an evaluation design prior to the project's implementation. The success of this NIMH Project, as reported in this paper, was a result of a blend of planning, hard work, and maximum cooperation. Two schools, the School of Nursing and the School of Social Work within one University, Adelphi, jointly conceived, wrote, and implemented the project. A third school, School of Education from another University, Hofstra, conducted the evaluation. In addition, selected faculty, consultants, and a Steering Council from community mental health centers, long-term care institutions, 1. This project has been supported by NIMH, Health Services and Mental Health Administration. DHEW, Contract No. HSM42-72-218. Paper presented at the annual meeting of Gerontological Society, Nov., 1973, Miami Beach. 2. Director of Training Project, Mental Health in Nursing Homes, and Assistant Professor, School of Nursing, Adelphi Univ., Garden City, NY 11530. 3. Director of Evaluation Project Mental Health in Nursing Homes, and Assistant Professor, Bureau of Educational Evaluation, Dept. of Educational Psychology, Hofstra Univ., Hempstead, NY 11550.
April 1975
and concerned governmental agencies were instrumental in the planning and implementation of the project. This cooperation cannot be minimized. It was from this premise, maximizing interpersonal relations in cooperation, in order to have a direct beneficial effect upon nursing homes as institutions and residents of those homes as people, that made this project possible. Problem
As of 1970, there were 289,609 persons in the Long Island, New York, region over 60 years old. The number of institutionalized aged is rising at a rapid rate as population patterns change. For the most part, institutionalized aged are crowded into both proprietary and public nursing homes, with proportionately fewer hospitalized in State Dept. of Mental Hygiene facilities. The increasing numbers of institutionalized aging, coupled with the shifts caused by overcrowded facilities, have added to a stressful experience for the aged and have affected the nature and quality of their care (Curtin, 1974). In order that persons residing in long-term care facilities can be supported toward the maintenance and retention of levels of healthy functioning, they must be approached, like people at other stages of life, as individuals, and their problems dealt with accordingly. These residents include mentally impaired individuals for whom practitioners need to assume the role of patient advocate on behalf of his needs and rights as a human being as well as the alert and/or ambulatory resident whose needs go beyond physical security, watching television and "busy work" activities. The usual caretakers and decision makers at all levels need to become aware of their own attitudes, feelings, and behavior toward residents and their families. They
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Theoretical Base Having identified the problems and needs for mental health training, it was necessary to develop a working definition of mental health and an approach to facilitate change. The mental health practitioners on our team suggested careful attention to the therapeutic community model at least to explore the social system of the longterm care institution and at best to bring about positive change. Much has been written about the therapeutic community in psychiatric institutions and of the utilization of the therapeutic community model in long-term care institutions (Kramer, Kramer, 1967; Miller, 1966). Concomitantly, mental health has been written about prolifically and defined in a variety of ways. This suggests that mental health does not mean the same thing to all people; it is at best a phenomenon difficult to conceptualize and more difficult to put into a few words. For the purposes of this training program, one needs to associate mental health with three words: mastery, fulfillment, and people. In order for an individual to be "mentally healthy," he or she needs to have: (I) a sense of mastery over what he or she is doing, thinking, and feeling; (2) a sense of being fulfilled or satisfied with what he or she is doing, thinking, and feeling; and (3) meaningful contact with people. We all know someone who is never satisfied with their accomplishments; we also know those who "master" or accomplish their goals and are satisfied but are unable to relate to another person in a meaningful way. Therefore, neither of these persons would be considered mentally healthy. With this description of three components necessary for mental health, one better understands the need for, and the benefit of meaningful contact in a therapeutic com-
munity in long-term care institutions, not only to residents and their families but also to all those who work with the aged and disabled. The Project Planning For 4 months, the Project Director was involved in planning and organizing the following: faculty selection and training, curriculum development, content and methodology, public relations, publicity, and selection of and collaboration with the Bureau of Educational Evaluation of Hofstra University. The director sought advice from the Nassau County Mental Health Board, the Older American Volunteer Committee, nursing home administrators, and other concerned practitioners. The above efforts culminated in the formation of a 40-member Community Steering Council, which represents the community relevant to this particular program and includes representatives of concerned governmental and voluntary mental health agencies, voluntary and proprietary nursing homes, several faculty of the training program, and older persons residing in nursing homes. While the over-all task was to examine ways to continue the linkage between mental health, continuing education and nursing homes, the immediate task of this council meeting was to help publicize and recruit those teams of trainees who would fulfill, in fact, the aims of the program.4 Recruitment and Enrollment A 6-page brochure publicizing the program, including the year's schedule, was mailed 5 weeks before the first section of courses began to every director of nursing and to every nursing home administrator on Long Island. All personnel in nursing homes and extended care facilities were invited to participate as members of an "agency team." A minimum of 3 trainees were encouraged to attend together as a team in order for them to implement the program's objectives in their own facility. Knowing that any change in an institution requires the involvement and commitment of the top administrator, the nursing home administrator was encouraged to become a team member.5 Teams varied in member's discipline, role, and function, but in each training section there were representatives from 4. Some of the content of this paper, e.g., Planning, Framework, Course Descriptions, etc., has appeared in two earlier articles by Goldman (I972, I973). 5. Nursing home administrators were recruited as team members with ease, since the training program received approval by the Board of Examiners of Nursing Home Administration of the New York State Dept. of Health for I04 continuation credits. One hundred credits are required every 2 years for nursing home administrators' relicensure.
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need to realize that (I) by not being in touch with their own feelings, or (2) due to lack of knowledge about the aging process and/or failure to apply knowledge, they inadvertently have increased the patient's dependency, psychosocial decline, and physical impairment, and (3) interdisciplinary cooperation is necessary in order to deliver quality care. One needs little experience in a long-term care setting to become aware that, although residents live together, they have little meaningful contact. This is not surprising when one considers that many people live a lifetime without experiencing tenderness, closeness, and intimacy. In order to rectify these deficiencies, both in residents and staff, a whole new approach was obviously indicated.
administration, nursing, social work, recreation, and their respective assistants. The number of trainees from nursing homes ranged from I to 10 with a median of 4. The total number of trainees was 128, representing 32 nursing homes with more than 6,000 residents. About half of the trainees were nurses. One-fourth of the trainees were administrators and the other fourth of the trainees included almost all conceivable nonresident adults who could be found in a home.
of the group. This 24-week training program model was offered four times during the I-year training period in various long-term care institutions in different locations on Long Island. This enabled participation by nursing home personnel who live and work as far as 90 miles from the university.
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Experiential Learning Consideration was given in the experiential design of the courses to make it possible for The Training Program Model each participant to become more effective in The training program consisted of three se- what he or she is doing and happier in underquential courses: Mental Health and Gerontologi- standing the why as well as the how of human cal Practice in Nursing Homes (one day a week behavior. The process of the training program for 8 weeks), Group Process and Group Dy- focused on the experience of the resident in namics (one-half day for 8 weeks), and Training order to initiate and maintain meaningful contact. Trainees became sensitive to the experiGroup Leaders (one-half day for 8 weeks). The first course, Mental Health and Geron- ence of an older person, that is, what he pertological Practice in Nursing Homes, offered ceives, interprets, and responds to by talking to trainees an opportunity to grasp the relation- an older person about himself and his experiships among sociological, psychological, and ences or by reading personal accounts of how physiological phenomena of aging. Emphasis older persons see themselves and their life situawas placed on maintaining optimal functioning tion. The program utilized techniques that simuof residents through a guided theoretical assess- lated the experiences of the older person. An ment of, and intervention into, the psychosocial, example of simulation equipment used is as folphysiological, and environmental aspects of lows: By means of a specialized tape recorder aging. The intervention included effective utili- (Lomask Engineering, Sharon, CT), which prozation of internal and external resources. Struc- vides delayed feedback of speech and a pair of tured exercises were utilized to promote clinical goggles (Pentagon Device Corp., Syosset, NY), which rotate the axis of the visual field, trainees and interpersonal competence. The second course, Group Process and Group were able to experience a simulated view of Dynamics, was an experiential group course de- neuromuscular disability. When the tape resigned to increase the trainee's effectiveness as corder delays the trainee's speech sounds a fraca group member and as a group leader. Learn- tion of a second, it caused the trainee to retard ing was achieved through the examination of the his rate of speech, increase his pitch and loudactual experience of the group. Trainees had an ness, to falter his vocal rhythm, and to misarticopportunity to: (I) increase their awareness of ulate frequently. This is similar to the speech their feeling experiences and of their reactions patterns of a person who is hemiplegic. When to and impact on others, (2) become more effec- the trainee wore the goggles, which contain an tive in expressing what is going on with them- arrangement of mirrors that rotate the entire selves, (3) become acquainted with processes visual field 5° to 20° to the left or right, he common to a variety of groups, (4) experience walked slowly with hesitation. He also had diffithose forces which influence group behavior, and culty in maintaining his balance and would reach out for someone or something to hold on to, or (5) practice intervention. The third course, Training Group Leaders, was would grasp the wall if it was within reach. a continuation of Group Process and Group DyThis exercise created increased sensitivity and namics. Trainees who were not leading a group more constructive attitudes toward the disabled needed to select a group to work with on a older person. The demonstration helped to imweekly basis. The groups selected were com- part certain facts about the nature of disability prised of either residents, family, staff, or a mix- and how this type of disability produces the ture of these. The purpose of each group was illusion that the subject is suddenly confused or decided by the group leader and/or the group stupid. Trainees were to become aware of resimembers. In this experiential group course, there dents' behavioral changes due to sensory diswas discussion of the trainee's group work as turbances and neurological and neuromuscular well as an examination of the actual experience dysfunctions. As anticipated, these teaching
42-72-218.
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tools engendered many thoughts and feelings design of this program was for all participants on the part of trainees. Some trainees related to lead some group in their agency. For exwhat they experienced to residents whom they ample, participants, in working with groups of know and care about. Some trainees spoke about residents, help them become more expressive, their own process of aging and of their own feel- increase their interactions, reexperience closeings of loneliness. Some of the lessons learned ness, and increase positive group feelings. These from these exercises were: (I) individuals differ in behavioral changes should enable the resident their response to imposed sensory distortions; (2) to come to terms with himself, i.e., with his a perceptual disability affects the total person strengths and limitations, with his fears and longand his effect on others; (3) handicapped persons ings, with his anger and his joy. A t this stage, parhave an inordinate need for personal contact with ticipants would be able to develop program resomeone who is aware of his experience; and (4) lated to the resident's real life situations (Euster, recovery of normal function is facilitated on the 1971; Klein, LeShan, & Furman, 1965; Shore, part of the trainee by active movement (Dinner- 1961). Some participants led staff groups, family groups, and mixed groups of all descriptions. stein & Lowenthal, 1968). Specific objectives.—Specific program objecTraining was carried out predominantly in small group work with a mixture of trainees in each tives help participants: (1) Increase their knowledge of the psychosocialsmall group. These group experiences helped physiological process of aging with emphasis on how participants to deal with interpersonal and the aged experience themselves and their problems. group-living problems with depressed, regressed, (2) Increase interpersonal competence enabling them confused patients and their families. In addition, to establish and maintain meaningful contact with residents and staff. A . Understand: ( I ) the way one sends these experiences helped in exploring and resolva n d / o r responds to messages; (2) different life styles ing intergroup conflict caused by the racial, and value systems: (3) how feelings influence behavior. ethnic, and socioeconomic composition of staff B. Develop skill in: ( I ) listening; (2) sharing emotional and patients. In order to accomplish all this, relereactions to planned or spontaneous behavior; (3) practicing communicating one's feelings and ideas in vant findings were utilized from sociology, social helpful ways. work, physiology, psychology, psychiatric nursing, (3) Increase ability t o assess physiological, psygroup work, and adult education. Participants chological, and sociological needs. received a bibliography and a workirfg library of (4) Become skilled in detecting and preventing the maladaptive patterns of the institutionalized aged. reprints and reports selected for relevance and (5) Develop an awareness of the special needs of clarity. Participants also purchased several paperthose residents presenting problems in institutions and back books which were required reading (list of provide skilled intervention to maintain optimal funcreading materials available upon request). tioning. This model of mental health continuing edu(6) Increase their knowledge and utilization of available internal and external resources. cation included structured and unstructured ex(7) Develop group leadership skills. A. Sensitivity periences which facilitated personal growth and to group process and dynamics; B. Techniques for the transfer of learning to the long-term care group leaders. setting. An important goal was to affect change Evaluation Design in the trainee's behavior at work. The ripple The evaluation design included trainee evalueffect built into the program also helped change ation and impact evaluation.6 Impact evaluation the behavior of personnel who were not in the training program. Ultimately, all those who refers to that area of evaluation which is concame into contact with residents, including rela- ducted on-site and deals specifically with the tives, became part of the therapeutic commu- clients-residents, of the training rather than the nity and helped rehumanize the lives of residents. trainees. The size of the nursing homes had great The training staff reinforced the idea that resi- variability. The range of possible residents was dents are a source of meaningful human contact from 16-1000, with a media n of 150 a nd a tota I of to each other when the structure, climate, and 6,058. The range of possibly affected residents was 10-83, with a median of 55 and a total of 1,185. personnel foster this kind of relatedness. Trainee Evaluation In order to foster this planned change, the In order to assess the effect of the project training program provided participants with the opportunity to: (I) become aware of their atti- training upon those directly trained, two formal tudes toward themselves and toward older per- pre- post-strategies were employed; attitudesons, (2) develop authentic relationships; (3) affective and knowledge-cognitive. To measure deal openly with conflict; and (4) organize and 6. For a complete report of the Project Evaluation, see NIMH lead groups of residents. A major thrust of the Health Services & Mental Health Admin., Contract No. HSM-
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project's specified objectives; namely, Group Functioning and Interagency Communication. It was hypothesized that nursing homes would have a significantly positive change in their total score as measured by the Impact Evaluation Instrument of Agencies (IEl). Random selections of residents were interviewed in order to determine whether, as a result of the project, there was significant positive change in their mental status. Mental status was operationally defined as the scores from three well-established measures of mental status: Life Satisfaction Index (Neugarten, Havighurst, & Tobin, 1961) (LSI) long form, Mental Status Questionnaire (Kahn, Goldfarb, Pollach, & Peck, I960) (MSQ), short form and Face-Hand test (Kahn et al., I960). Once the impact evaluation was designed and instruments were selected, modified, and collated, observers were obtained and trained in the use of the instruments. Observers were carefully selected. All had previous experience in the field of collection of data. All were professionals in an area that dealt in human service. All had previous formal training in interpersonal relations. Because the impact evaluation was conditioned by the specific entry point of an agency's participation in a project, the time between preand post-impact evaluation varied. For the first course cycle, the elapsed time between pre- and post- was 7 mo., for the second, 6 mo., for the third, 3 mo., and for the fourth, 2 mo. Only for the first two cycles did trainees go through all three courses. These two constraints of the project, when added to expected deterioration of residents in nursing homes, mitigated against any positive findings. The results show that, over-all, there was a significant positive change, as measured, in the nursing homes, although this change could not be isolated in the dimensions. This is probably a function of the impreciseness of each dimension in isolation. The finding does demonstrate that within a very short time, with the constraints already mentioned, institutional change did occur. To gain more insight into this finding, agencies were dichotomized into: (I) those agencies for which trainees attended more than one course and at least 5 months lapsed between pre- and post-testing; 19 agencies, and (2) those agencies for which trainees attended but one course and less than 3 mo. lapsed between pre- and posttesting; 8 agencies. On the average the mean total gain for the first group was 43.63, while the mean average gain for the second was
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attitudinal change all trainees were given the Attitudes Toward Old People Scale (Kogan, 1961) upon entering the project. Those who went through all three courses were administered the same test as a post-testing instrument. The time lapse between pre- and post-testing was approximately 6 months. Trainees' positive attitudes toward the aged increased; p < .05. The results support the hypothesis that significant positive changes in attitude, as measured, would result from training in the program. All tested / values were well over the critical level. To measure cognitive change, the evaluation team and the trainees constructed pre- postknowledge tests which were congruent with the desired areas of knowledge of the project. Two equivalent form tests were constructed by the faculty with help from the evaluators and were used as a pre- post-design; r > .90. All trainees were administered the pre-test at the initial training session and were administered the posttest at the last session of the first course. The intervening time was 8 weeks. It was hypothesized that knowledge would increase to a significant degree. Trainees' cognitive knowledge in the realm of the aged increased; p < .05. These results support the hypothesis that significant positive cognitive learning would occur as a result of the training. This was the case for all groups included in the project. The project was able to bring about desired change, as specified, on the part of the trainees. However, the important results of the evaluation deal with the following: How were the institutions and the residents of those institutions affected by those trained? What was the measurable "impact" of the project? Impact Evaluation In order to assess the trainees' effect within their nursing home settings, trained observers conducted structured observations and interviews within a pre- post-design. These evaluative measures were of two general types: those that examined the nursing home environment through interviews with administrators and observations of the entire facility, and those that interviewed residents within the homes. The instrument selected to evaluate the total environment was a modification of that used by Slover (1969). This instrument examines 12 constructs and hypothesizes that the higher the score per construct the better the home is in meeting the physical and psychosocial needs of residents. Modifications were made in order to accommodate dimensions not originally in the instrument but specifically germane to the
Summary This paper described the first year of the Mental Health in Nursing Homes Training Project, including both the evaluation process and the results. Additional support from NIMH to continue the training program for 1973-1974 was received. A fourth course was added to enable those trainees who completed the 19721973 series and who are currently leading groups to receive further supervision. Modifications for the second year of training included: ( I ) That all trainees had an opportunity to complete the series of three courses,
(2) A 5 mos.1 lag time between pre- and post-testing, (3) A glossary of terms relevant to the reading materials, (4) On-site consultations, (5) Planned interagency visitations among trainees as an integral experience within the first course.
As a result of these modifications, the positive findings were again replicated and, in most cases, found to be greater. We have become especially conscious of our responsibility to help shape the institutional environment in which so many aged make their lives. Our experience in this project has been a confrontation with ourselves, our pretentions, our myths, our prejudices, and our value conflicts. It also has been a confrontation with the essential humanity in all of us. References Curtin, S. Nobody ever died of old age. Little. Brown, Boston, 1974. Dinnerstein, A., & Lowenthal, M. Teaching demonstrations of simulated disability. Archives of Physical Medicine & Rehabilitation, 1968, 49, 167-169. Euster, S . A system of groups in institutions for the aged. Social Casework, 1971, 523-529. Goldman, E. B. An educational model in continuing education for mental health in long-term skilled care for the elderly. In Mental health: Principles and training techniques in nursing home care, DHEW Pub. No. (HSM) 73-9046, 1972. Goldman, E. B. Mental health continuing education: The long-term care administrator as a key member of an interdisciplinary trainee team. In M. J. Stotts (Ed.), Education for administration in long-term care facilities. Assn. of Univ. Programs in Hospital Admin., Washington, 1973. Kahn, R. L, Goldfarb, A. I., Pollack, M., & Peck, A. Brief objective measures for the determination of mental status in the aged. American Journal of Psychiatry, 1960, 117, 326-328. Klein, W., LeShan, E., & Furman, S. Promoting mental health of older people through group methods. Mental Health Materials Center, New York, 1965. Kogan, N. Attitudes toward old' people: Development of a scale and examination of correlates, Journal of Abnormal & Social Psychology, 1961, 62, 4-54. Kramer, C , & Kramer, J . Establishing a therapeutic community in the nursing home. Professional Nursing Home, Sept., Oct., Nov., 1966, and Jan., Feb., April, 1967. Reprints available from the Kramer Foundation, 2 W. Johnson St., Palatine, IL 60067. Miller, M. Synthesis of a therapeutic community for the aged ill, Geriatrics, 1966, 21, 151-163. Neugarten, B. L, Havighurst, R. J., & Tobin, S. S. The measure of life satisfaction, Journal of Gerontology, 1961, 16, 134-143. Shore, H. Content of the group experience in a home for the aged, Social Group Work with Older People. Proceedings of the seminar on Social Group Work with Older People, Lake Mohonk, New Paltz, NY, June, 1961. Slover, D. Relocation of long-term geriatric patients. PhD dissertation, Univ. of Chicago, 1969.
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— 6.38. This further finding strongly suggests that the positive impact of the program showed tremendous gains as trainees took more courses and time was available to put into practice their new knowledge, skills, and attitudes. A significant increase in residents' mental status was found for the Face-Hand test; no significant increase was found for either the Mental Status Questionnaire or the Life Satisfaction Index. There are three possible explanations for this mixed finding, although it should be strongly noted that this is not a negative finding. First, it could be hypothesized that the measuring instrumental were not precise enough to measure significant positive change that did, in fact, occur. This is possible, but dubious, for all three instruments have an enviable record of being valid enough to pick up such change. However, they may not have been in this project. The second possible explanation could be that the project has just not had time enough to affect this type of change and that given further staff training and time, significant positive change in residents' mental status will result. This is certainly possible. The third possible explanation may be found in the nature of the population. Two facts emerge. First, the aged population in a nursing home is highly heterogeneous in terms of mental status and is highly changeable. Second, general deterioration is a fact, although it is most difficult to deal with. Most simply stated, numerous residents die or are in a state of dying between any time lapse. A t the risk of sounding inhumane it must be said that given these facts, a researcher's task is made more difficult when he hypothesizes positive change through systematic intervention in a well-controlled design within the context of general personal deterioration. Thus, the expectation of significant positive change may be unrealistic. It just may be that the lack of negative findings is, in fact, positive.
