Members Article – DIV THERAPY 2016 STARTING POINTS by April-Kaye Ikinci

FACILITATING Bonding of family & friends visiting with People in Assisted Care

I know experienced Diversional Therapy staff would know much of this, but we all need support to stay aware of it in the face of dealing with everything else  daily. It is also a celebration of joint efforts and successes.

The following essay/discussion is with the proviso that where there are problematic situations, conflict in families or estrangements, it is not the responsibility of staff to intervene or fix relationships, though duty of care due to the resident may mean some social intervention.

PRINCIPLE: Placement out of the family home doesn’t have to mean placement out of family…

Having visitors and family can still be an important part of an assisted facility resident’s life even where they are unable to participate in family/social events elsewhere that ordinarily they are included in.

 Days can seem long if people are bored, under stimulated or lonely, despite activities offered, and nights that come after 5 o’clock evening meals can seem long if one doesn’t sleep well.

 The most important thing people can give is time and attention.

The second most important thing is to give people time and attention with a sense of no rush.

VISITING

Facilitating optimized VISITING in GROUP HOUSING/Aged Care Facility

Visiting can take many forms, all valuable when matched to circumstances, depending on visitors’ life and the relationship with the resident.

Situations to be considered:

*Where possible the State of resident needs to be settled/readied in a desirable space, as people are often loath to move to a better space because of complex issues of mobility, social acumen, inertia, unsureness of what is permissible/appropriate.

*Places: Choice/allocation public or private

In shared spaces, extending socializing with other visitors and residents can be pleasant but can cut down on chances for intimate or personal conversations or sense of attention given.

*Possibility of interruptions can abound with doctor’s visits (shifting times),

toileting/accidents, noises, other people’s dramas, domestic details followed up, common room TV distractions.

*The state of people that come to visit, from the previous situation, from the pressure on their timetable, their feelings about the complex situation they’re coming into can all affect the visit.

If they are able to settle quickly and to slow down to the workings of the “world” of their resident, all benefit.

The structure, rules and timetables sometimes need explaining to the visitor to help make sense and for them to feel welcomed and comfortable, and to allow them “manoeuvre” to advantage within these.

Planning ahead may or may not be possible or useful.

Residents sometimes need time to focus, to settle to a visit, sometimes being in states that require time and patience of the visitor, possibly more used to different forms and levels of daily sociability.

 Where some residents are not very responsive (due to health, deteriation, and condition) to visitors, their visitors sometimes have social needs, unconsciously “competing” with residents for staff attention in chatting. Staff may need to redirect attention, include resident in conversations.

Sometimes if communication is not easye.g. little known shared interests, different worlds, health and communication difficulties, shynesses or unresolved conflicts, excitement at new contacts, conversations can happen among the visitors that don’t include her, making the resident a passive presence.

Sometimes social facilitation by staff can help this, opening conversations relevant to the resident, encouraging their “news”.

Blank moments and boredom can arise in visiting, sometimes a little sitting it out can allow a new topic to arise. People have varying limits and ability to deal with it, some people chattering constantly, sadly some people leaving early trying to avoid this.

Updating of residents’ news by staff and encouragement also for healthy “passive” companionship can be fulfilling (eg knitting quietly beside the resident).

Simple hand holding can be very satisfying for sharing, physically comfortable placement of chair and sides of bed etc to be taken into account.  

STYLES of VISITING TIME

Times:

A/brief

E.g. brief and regular

 T was frail and ambulant and her conversation skills had diminished yet she was responsive to familiar faces. Her nearby busy family learnt the facility evening meal timetable (earlier than most families’ meals), and would call in briefly 10-minutes before to sit with her before tea.

It meant 2 things

a/they could enjoy each others company and then say a brief farewell as T was  helped to the meal table with other social contact to look forward to.

 b/ if no one could make that time then there was only 10 minutes of  “waiting”, before the “next activity” (group meal /food). Sometimes a paper message was given to her if a phone message was sent, maybe to apologize for not coming that night, which after being read to her was put in her hand by staff.

B/longer/ “hang-ins”

Some visitors who have previously shared daily interspersed social time with resident like to  “hang-in”, sitting with the resident in some of their usual activities and  in private time and space (if appropriate), making desultory conversation and enjoying times of passive company with no sense of time pressure or being trapped. Some are included in meals; some come back after meals or local messages.

For a lot of people past retirement this was a more normal pattern in daily living before entering residential care.

C/Regular/timetabled VISITORS time

Hopefully this is in Lifestyle Care Plan and DV and other staff can facilitate that this is not “double booked” as some visitors only have a limited and time-controlled slot in their lives, and whether weekly/fortnightly/monthly it is important that it gets as little cut into as possible by bed changes and other care needs/services.

D/Specific activity time sharing

It can be distressing visiting with someone one knows/loves who can no longer converse and thus some shared activities e.g. bingo, carpet bowls, quizzes, radio, CD players, even TV program watching, can have benefit for both the resident and the visitor.

Some visitors occasionally need assistance to recognise the fuller needs of the situation e.g. some quizzes geared to residents’ ability level may seem simple or inviting to them but need visitor to be tactful and non-competitive.

E/ Late night visits

A pattern became clear that some visitors, based at a distance on regular routes, often were forced to call in late, after evening meals or even when everyone was in bed for the night (some places as early as 8 o’clock).

As part of a Lifestyle Care Plan, and relevant staff informing Care staff on those shifts, can make these visits, possible and easy. Encouraging visitors to phone ahead can also prevent conflict of needs.

This can be great, broadening the visitor base and also with individual benefits. E.g. one resident, B, who was used to busy, loud or TV Saturday nights. If without visitors, staff tended to make her comfortable, switch off the TV, lights out, etc at staff changeover at 9pm in making all ready for night shift.

With her late night visitors, she got to see a different TV choice schedule, ends of movies, special events e.g. Edinburgh Tattoo, Olympics, etc and a sense of a night different from all the others in the week.  And a hot-chocolate supper was possible, made by visitor (using tiny kitchen provided by facility), a warm washer hand wash, and then lights out mostly by 12 (at end of movie, etc).

This also allowed the family member to visit the split aged-couple, one still at home up the road and one in Care.

F/Call-ins with coffee, cakes (if appropriate) etc

With so many takeaways now, visitors are able to bring treats of drinks and/or food that are not available and is a glimpse of the outside world and resident’s past experiences and tastes.

 Staff may need to facilitate with assistance or passing on knowledge of diet (including diabetes), safety and assistance with handling and drinking of hot/cold drinks, and eating re ability, heat, size, pace of sips or chewing, cutting to bite-size or smaller, texture/ consistency, swallowing difficulties, napkins/bibs etc to minimize accidents, hurt or damage or mess, which aside from pain experienced, “cuts” into visiting/shared time.

G/Sharing meals/feeding meals

Some facilities make it possible for visitors to share a meal with the resident, often at a group table. Bringing this to the notice of the visitors and being clear about planning and costs can be of benefit: the resident can have her visitor as part her daily routine and meet her fellow residents, and the visitor is sharing a normal everyday activity.

A high-needs resident, dependent on being fed can benefit from a competent visitor who can feed her with pace/time, slow and patient and chat geared only to her needs, not as part of a larger group serviced by/with Care staff.

H/Feast and famine

Most visitors are appreciated by the residents, but there is a phenomenon that sometimes needs some maneuvering around, especially if the resident is bedbound.

Sometimes there are no visitors for a while and then all of a sudden there are several/many and sometimes at the same time. The resident can feel overwhelmed and tired prematurely. Without trying to control or manage people, sometimes intervention by staff can help.

Drinks facilities and areas including garden space shown, timetables explained especially meals and hygiene /care times can smooth interactions.

 My experience as a Diversional Therapist is that generally Care staff are very supportive of resident & their visitors and intrude their timetables only as much as is necessary.

Extra chairs can be found, seating and standing positions can be important to include the resident: with the sharing of the knowledge of the special needs of the resident (e.g. left ear the less deaf ear) with the visitor and allowance for shifting and rotating of places so many of the visitors can make personal contact with the resident within the visit.

Communication Book

Set up In the residents room, for diarising/notations/cross-communications by Family &/or staff, regarding resident and her life and contacts especially noting Visitors names.  This helps connections as resident may have find it hard to remember them all.

Gaps in Visiting

Encouragement of family members and other visitors to send Postcards. Physical mail etc, the making of contact in visitor’s absence also is excellent for deaf or memory-limited people as reminders of dates, messages, thoughts, wishes especially as phone contact and messages can go astray or be forgotten.

Anecdotal reporting on the benefits of facilitating visitors for RESIDENTS

RESIDENT Y: with condition of Alzheimer’s

Y. was a tall, slim, conservatively dressed woman, generally nicely spoken, courteous and friendly. She’d had children, had run the household, with her husband preferring her not to work outside the home during their post-war marriage. At its end, she had had to recreate her life for independence and security for herself and half-grown children.

She had managed well and had kept some friendships going and had continuing relationships with her children.

When she came into the assisted hostel, it was with the beginnings of Alzheimer’s. Several friends visited still, and a man friend took her out regularly for meals and concerts which was a core part of her social life.

As her condition deepened she became fractious, argumentative, monopolizing in conversations and conversationally obsessed on the war bravery of a relative. To her friend and her son she started to say insults and accusations that they found as unkind, unfair and felt hurt. It was unclear what the grounds of her complaints were. Though they did have an understanding that some of this may well be the condition, it still made it harder to visit, spend time with her, take her out or have long distance phone calls (as her son lived at a distance still, though no longer the other side of the country). Her friend was devastated, saying she had always been a kind, and gentle woman. She had told her son, in anger, not to visit. This scene was acted out in the shared group lounge. Her son had been nonplussed as he lived at a distance and had made special efforts to keep in touch. He withdrew his visits. It meant few visitors for her.

The staff was also recipients of this aggressive speech pattern and spiked anger.

I received a call from Y’s son, saying that they i.e. his family would be calling in that day, coming from the other end of the State and were checking that Y would be there, would it be worthwhile to visit?

 It had been nearly a year since he had come and he wanted to know how she was. Her loss of memory had increased, but she was still mobile, social and as the condition progressed less aggressive. I felt it was worthwhile for everyone’s sake. As he couldn’t give a fixed time, I negotiated with the kitchen if they arrived on meal time, to keep her food hot etc

When the family arrived, every one’s attitude became clear: that the mature 2nd wife wished to meet her husband’s mother, wanted to gain a sense of who she was, though she still knew that there would be little contact; that Y’s granddaughter wanted to show/share the baby and was happy to hang-in; the baby was happy and cheerful and confident to be held by anyone; Y’s  son wished to see her but was nervous of Y’s potential anger and wanting to protect his family from it.

His idea was to keep the visit brief and go on. Y was seated in the lounge when they came and was quite amicable when I brought them to her and set up chairs. She introduced herself as if to strangers saying, “I’m Y.” And “who’s the baby?”  I went through introductions: names and family roles, her son kissing her lightly on her face and sitting by her. She was very pleased to be in a social grouping though it soon became clear she had no idea who they were in regards to her. I would not normally stay, not wanting to intrude, but knowing the possibility of Y’s unprovoked anger and that it was a first visit with some of the visitors, I stayed and they welcomed me.

Her son was distressed at not being recognized, but the two women settled down, with Y. chatting freely to her, about babies, this baby, the weather, family. They told her, in simple evocative speech of their happiness, the new marriage, home, work, the baby etc. Y’s son made odd comments, smiling and sitting close to her.

She got up a few times and circled the room and come back (sometimes needing encouragement) and each time saying with a huge smile, “I’m Y., Whose the baby?” Calm and warm introductions were made again and she settled down again. It took a little while for the son to accept the pattern of interaction but was relieved that she was this courteous gentle creature he had known growing up and his wife and daughter were ok with it all. When confidence had been gained, the young mother asked if Y would like to hold the baby: which she did with great joy, competence and baby-chat to him.

I arranged tea and biscuits/cakes and the baby was handed around, several times, and everyone, relaxed and interested talked in-group. With permission I took a photo of the group, and later, after the event I put one in her room and one sent onto the family.

When the family left, the son thanked me saying he had been dreading the visit, as the angry period with his mother was still fresh in his mind, now thankfully overlaid with this, though her memory loss was saddening. It had been his wife’s idea to come, he had felt it might not be worth the while, but he was glad they had come as he realized with the time gap how much she had changed  and next time she may have even less memory or ability.

The wife was pleased, saying that he had worried about his mother, would probably still worry but they both now knew the score. Also though she guessed Y. wouldn’t remember her, she at least had met her and saw how she fitted in her husband’s life. Hopefully she would recognize the new happiness in her son even if she couldn’t remember his name.

The granddaughter was pleased and proud to be able to offer such delight that Y had taken in the baby and that it was nice to be part of the family if only for the afternoon.

Y graciously accompanied them to the front door, fare welling them cheerfully, then went off to her meal, proudly saying to a staff member who mentioned her visitors, “Yes, my baby”

EVALUATION

It was a success due to a number of factors: preparation ahead for limiting choices and conflicts of time and interruptions, staff support, the slowing down of time around Y’s state, goodwill on the part of the family and within the family, Y having a good day, the effect of the baby, and plain good luck of timing. Every way it was to everyone’s advantage.

Anecdotal reporting of continuing resident’s involvement with her large FAMILY: 

RESIDENT  N:  with left side paralysis, bedbound or Duchess Chair (with hoist required)                  

N, with severe paralysis from a stroke was placed needing high care nursing.  She was warm, sociable, and lucid, whilst managing pain and greatly liked by staff.

Hy, her husband also in his late 80’s and dependent, continued at home, with their eldest daughter bringing him to visit his wife most days at the ACF.

Many of her numerous children and descendents lived at a distance, upcountry or interstate but wanted to contribute to her quality of life and keep the bonds of family and visited when they could.

It was difficult logistically regarding transport and support mechanisms to take N off-site. Though one special day had been organized by the family to take her home to the nearby farm, which was a success.

Laptop skypeing had been raised several times but resources and skills were not/never solved so the swathe of weddings, birthdays, funerals etc of the gathering of “the clan” were held without N’s inclusion though photos and cards were shared afterwards.

PRINCIPLE: People, family and friends can contribute much to the resident if the ACF facilitates visiting and involvement.

Often the mother/grandmother/great grandmother is the one who remembers birthdays and is often still a pivotal point in the family through communication and visiting. This can change drastically upon ill-health of fragility and transfer to an Aged Care Facility.

But the last years can still be a time of further family connection and surprisingly, family and friends can learn new things about their loved one and their family and renew and/or strengthen relationships.

For some family members it had been a longtime since there had been space in N’s or their busy lives when they could settle down to spend real time together, and now could visit N without domestic or business responsibilities.

A Communication Book noting visits and commentary facilitated family connections and conversations. Diversional Therapy and other staff sometimes made notes, contributing some of the flow of information across days and non-access hours.

IN-HOUSE Family events

The Nursing Home was very supportive of visitors and family involvement and allowed certain group celebrations.

N and Hys’  60th Wedding Anniversary was held in a side room which meant that 40 plus family came, some quite long distances for whom this might well be their last contact with N, some with new rapprochement and a grand-daughter who came with her child which N had not previously met. These large extended family invitations ensured the family members knew their grandmother’s new address and hopefully encouraged individual visits when nearby.

A quieter, small 21th birthday of one of her grandsons was held there specifically to have her participate. He had also a big special one at his dad’s place upcountry which was out of reach.

Hy’s Funeral. 2 years after her entry into the Nursing Home, Hy died. After discussion, the family worked out a way to ensure N’s inclusion/attendance at her husband’s Funeral in the same country town. By arranging 3 of the son-in-laws and grandsons to safely, manually push her Duchess Chair ( with weather proofing and support), the 2 kilometers to the local Funeral Parlour, ensuring a pain-free attendance and inclusion with comfort, engagement in the farewell of the man she shared her adult life with,  surrounded by her family.

Some staff attended the funeral.

The ACF facilitated a small parlour for pre-funeral & after visits from the family with N, allowing normal drop-in/come-go pattern of socializing of the gathered extended family. Being part of this most significant event, the Funeral of her husband, the celebration of his life and the ritual of condolences was appreciated by N and by her family.

FAMILY Involvement

A son-in-law brought N a footy scarf in her chosen Team colours, some of the family had no idea she had a team. Sometimes this meant they asked if she would like the footy on the TV after they left. Sometimes she said yes, sometimes no. She was not able to use the remote so was dependent on staff or visitors for TV access/change/off. The Staff then ensured her inclusion in football related activities which she enjoyed.

Family members, children and adults drew in her drawing book, (with her permission) sometimes talking to her as they drew and left the images there to be looked at afterwards. Often surprising themselves and her, becoming aware of what is outside the window or drawing her. This triggered further conversations about the subjects and the person drawing and (hopefully) their dated visit.

A neighbor brought news of a death of farming neighbor, and leaving it in the communication book, allowing the opportunity for a family member to get a special card and help N write a message of condolence and appreciation of the deceased. Sometimes these deaths are of a much younger person, confounding a common assumption that the resident will die first.

Sometimes friendships or acquaintanceships within the facility, ended through death, create the need for sensitive response from the resident and the family.. Often this information is gained through staff.

A daughter-in-law gave a gift packet of writing cards, facilitating possibilities of other family members, as scribe, helping N, to write to distant family members.

A niece made a grand wraparound shawl in red velvet with gold braid for her, knowing her love of fine materials and the occasional dressing up in the Grand Manner, to counteract the mundane effects of  low-key white-background, small floral patterned, cotton jersey knit, practical nightgowns that so figured in her bed wardrobe and her image to others nowadays. Staff facilitated it being on a top surface/available and notified family when special washing of it was needed, to protect its life and beauty and effective use.

An up-country daughter brought her cattle dog which was a delight to N. (and other residents especially other retired farmers)  

Another daughter acted as “curator” of her possessions and gifts given,

 Pinning up postcards received (after reading several times to N), also these becoming a wonderful resource to access, from board or decorated shoe box, to remind her that X or Y had written, reinforcing a sense of connection. 

Rotating and reorganizing newly given or found photos or gifts to satisfy access by her and visiting family members for the competing (small display) space, with changing stimulations and ambience of her now home, that also was enjoyed by Care staff when servicing her needs. The several Diversional therapy staff  and Care Staff who ensured rotating seasonal motifs, decorations and events (in common and private rooms) made the resident and family feel part of the community of the ACF without diminishing the sense of family.

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