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Behavioral Interventions to Facilitate Growth
Geriatric Long-Term Care continuing education counselor CEUs

Module #4
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Verbal Prompts

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| Geriatric & Aging
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This is Learning Module #4. It provides you with key types of verbal prompts to increase your residents' ADL independence. What if you were living in a world where you could not fail, and you felt loved and cared about? Would you define that as heaven? Well, I may be going to an extreme to get your attention and to make a point about verbal and non-verbal prompts, which will be covered in the next Module. But you can go a long way to making that "heaven" for your residents by providing them with an environment of success. This Module deals with six key types of verbal prompts you can give your ALF resident or tenant to increase and maintain their ADL indpendence.

Types of Verbal Prompts
Well, what exactly is a prompt, anyway? A prompt is assistance provided to the resident, a cue, a signal, or a suggestion. You can create an environment for ADL success by using the right prompts. The first type of prompt to be discussed is the "choice" prompt. This assists your resident in making a choice by being stated in such a way as to maximize his or her independence. There are three kinds of choice prompts that can assist your resident in making a choice.

Choice Prompt 1 - Open Ended Questions
The first type of prompt is the open ended question, which you would reserve for your most capable and alert residents. Open ended questions cannot be answered by yes or no. An open ended question that prompts your resident to make a choice sounds something like these questions: "What would you like to wear today?" "Where would you like me to take you?" "Who was your company?"

Notice, open ended questions usually start with who, what, when, or where. They give the resident no clue or direction regarding their answer. So, if you have a resident, Joe, for example, who is becoming the slightest bit forgetful, he will have to create an answer or say, "I don't know."

However, as you are aware, if Joe has Alzheimer's, he may try to hide his lack of understanding and create an answer. Now in the case of dressing, if you use the open ended question by asking, "What would you like to wear today?" he may end up with so many layers of clothes on you will think he is going on an Alaskan vacation. However, for a resident who can make choices, you are doing them an injustice by limiting their choices and not asking open ended questions.

Question #1: Open ended questions cannot be answered by what?
To select and enter your answer go to CE Test Question #1.

How do you know whether to ask an open ended question or not with Joe? You need to observe two areas; Joe's facial expression and his behavior. In observing Joe's facial expression, note his eyes. Does Joe look blank or confused when you ask him a who, what, when, or where type question? Then observe Joe's behavior. Obviously, if Joe ends up with five layers of clothes on, his choices should be limited.

Question #2:
How do you know whether to ask an open ended question or not? You observe what two things about your resident? See above

Choice Prompt 2 - Multiple Choice Questions
The second type of choice prompt is the multiple choice question. Often times in a fast food restaurant, the clerk will use a multiple choice prompt to get you to buy more. They ask, "Would you like fries or a drink with your hamburger?" As you can see, you are offered a choice

Here are some examples with your residents. "Would you like to wear the red dress or the blue one today?" "Do you want your hair parted on the left or right side?" "Did you want more or less water on the cloth to rinse your face?"

Multiple choice questions are easier for your resident to answer than the open ended questions because, unlike the open ended prompt, you are giving them a clue to the answer as part of your question.

Question #3: Why are multiple choice questions easier than open ended questions to answer? Because you get what in the question? CE Test Question #2.

Choice Prompt 3 - Yes of No Questions
However, if Joe is still having problems, your third choice prompt is the yes or no question. You structure your question so that it can be answered by either yes or no. For example, "Do you want more toothpaste on your brush?" "Did you want more soap on the cloth?" "Do you want me to walk more slowly?" "Would you like some crackers from the store again this week?" "Did you want me to schedule your beauty shop appointment?"

Obviously, some tasks lend themselves more readily to open ended questions, some to multiple choice, and some to yes and no questions. But, it is important that you are aware that open ended questions such as, "Where do you want me to take you?" have an infinite number of answers, and may set your less alert resident up to feel failure and frustrations. Remember, the goal of this section on verbal prompts is to create an environment that does two things, provides your resident with feelings of success, and maximizes the use of the ability he or she has.

So, with a resident like Joe, how can you provide an environment of success? Look at his reaction. If he seems puzzled, hesitant, fearful, or confused, rephrase your ADL choice from an open ended, who, what, when, where, type of question, to a multiple choice, such as, "Do you want to do this or that?"

If your resident or tenant still seems stumped on what you want them to do, try making your request a yes or no question. Offering residents in your Assisted Living Facility (ALF) a choice is crucial to the dignity of the resident. So give a choice, then watch your resident's facial expression, eyes, and body movement to see if you need to rephrase. Open ended? Multiple choice? Or yes and no?

Question #4: Select the answer that numbers the following questions-types in order from the most difficult to the least difficult. Number one being the most difficult and number three being the least difficult .
open ended_____ multiple choice_____ yes and no_____
See above

Single Word Prompts
The second type of verbal prompt to increase ADL independence and create an environment of success is the single word prompt. This single word prompt can take two forms, both of which have been covered in previous learning modules. But, because they are prompts this is a good opportunity for a review.

Single Word Prompt 1 - Instructions
The first form was discussed in Staff Training Module three on demonstration. You learned about transferring a resident from a bed to a wheelchair, and the use of single word instruction prompts, such as, stand, grab chair arm, turn, and so on. So, to increase ADL independence for one resident, you need to decide what part of the ADL needs verbal prompting. For some residents, you may need to do prompting beyond the word "turn," as they pivot to sit in their wheelchair. Too many prompts, especially if not needed, can be confusing and may be degrading to the resident.

Single Word Prompt 2 - Positive Reinforcement
The second type of single word prompt was discussed in the first learning module on positive reinforcement. If you recall, one of the basics from that module was to give positive reinforcement frequently. Some one word prompts that encourage are "good, great, good job, terrific" and so on. These single word prompts go a long way to creating the environment of success, which is our goal.

However, a word of warning here. If single word instruction prompts are used with a resident that does not need them for ADL assistance, they may end up feeling incompetent. Or if your positive reinforcements or compliments are insincere, they will definitely have a negative impact on the resident, perhaps making them feel unimportant and uncared about.

Question #5: Single word prompts are for what?
CE Test Question #3.

Attention-Getting Prompts
The third type of verbal prompt is used to get your resident's attention. Think about how you feel right after Thanksgiving dinner, or right before your head hits the pillow. I bet you may feel out of focus and have difficulty concentrating. Here's an example of a way to get your resident's attention.

"Mary, Sue, Bill, Jane, Kathy, John, Bobbie, Sharon!" What am I doing? Well, let's say that one of the names you just read was your name. Do you think I would have gotten your attention? You bet I would have.

The point of this exercise is, how do you feel when someone uses your name in a friendly conversation? Do you feel closer to that person and a little more important? Maybe you feel even a little better about yourself, sort of like you count.

Now let's take an opposite example. When you run into an old acquaintance that you haven't seen for years, they avoid using your name, and you know that they really don't remember your name. Do you feel just a little sad inside? I think that by now you know where I am headed for with this personal example.

When doing ADLs, use your resident's name. Use it often. Also, use the name that your resident prefers to be called by. If you aren't sure, start off by calling the resident Mr. or Mrs. or Miss, then their last name, Mr. Smith, Mrs. Jones, or Miss Phillips. Be sure if you use a nick name like "granny" that it is the definite preference of the resident. Document this preference in your service or care plan notes.

Just listen to what a difference the use of your resident's name makes while doing the ADL of shaving. Incidentally, in this example I will point out several other techniques which you have learned from this, and previous modules, for purposes of review. "Bill, are you ready for your shave?" (sample of a yes or no choice prompt). "Did you want to put the shaving cream on yourself this morning, Bill?" (sample of another yes or no choice prompt). "Good job!" (sample of positive reinforcement). "Bill, can you puff out your cheek slightly while I shave your left cheek?" (example of maximizing your residents ADL involvement). "Good job Bill! Thanks!" (positive reinforcement). "Did you want to shave your right cheek yourself today, like you did yesterday, Bill?" (maximize resident ADL involvement).

Maintaining Dignity in Prompts
The warning label comes with the use, or should I say misuse, of the terms "hon, honey, or dear." If you are used to addressing all others in your life by slipping in two or three "hons," you may have a major challenge eliminating this term. However, with the philosophy of your ALF, to maintain resident dignity, the use of a familiar term like "hon, honey, or dear" can be viewed as condescending or a put down. This may place you in a position superior to your resident and thus be viewed as a violation of your resident's dignity.

Question #6:
A good general rule, to maintain dignity when addressing a resident for the first time, you should address them how, until they tell you otherwise? See above

Voice Volume
A second verbal prompting technique to use in getting your resident's attention is to increase the volume of your voice. Obviously, you need to be careful with this technique, to make sure that you do not violate your resident's dignity. However, if a resident seems hesitant to do an ADL, try repeating a portion of the instruction in a slightly louder tone, especially if records indicate your resident has a possible hearing loss.

Also, it's human nature to vary the volume of your voice depending upon your own mood and energy level. If it's Monday morning, a cold gray day, and you have a headache, you might be speaking in a low volume. If your resident looks at you with a puzzled expression, increase your self awareness of your own voice volume. You might repeat your instruction more loudly. However, a warning here is, too loud of a volume will have a negative effect upon your resident, and may leave them feeling like they are being spoken down to, like a child.

In summary, two ways to get your resident's attention is to use their name, and to slightly increase the volume of your voice. The use of one or both of these techniques may be an essential key to getting your resident to wash her face or comb a portion of his or her hair independently.

Question #7: Two ways to get your resident's attention are to do what? CE Test Question #4.

Reality Orientation
The next key type of verbal prompt to use in order to create an environment of success is to use reminders to orient your resident to time, place, and person as needed. Since orientation and mental alertness definitely affect ADL independence, let's first talk about how easy it is to become disoriented to time and place.

Think about your residents' lives. For many, Monday is like Saturday, is like Sunday. They don't have a job. They lose that Monday through Friday, weekend grasp of reality. So just like your resident's arms and legs need to exercise, so do their minds. To assist them with the ADL of being oriented to time, place, and person, use verbal prompts or reminders. If a holiday is coming up, mention it. Also, occasionally mention the name of your ALF, as well as the city and state in which it is located.

The warning label, so to speak, with Reality Orientation is that you may have some residents that are slipping from the earlier stages of Alzheimer's into the mid stages, but they are still an appropriate placement for your ALF. If a resident honestly believes that he has children to get off to school, and any amount of correcting is not going to change his mind, a Validation Technique might be used, if it seems appropriate and of value to your resident.

In summary, in speaking to a resident, to help to keep them oriented, you might mention your name, the name of the facility, the city in which it is located, the next holiday, the season, and so on.

Question #8: Do you orient all residents to reality? (Yes or no) See above

Tone of Voice
Voice tone is the fifth and last verbal prompt to be discussed. There are two areas to be covered here. First, if you sound supportive, empathetic, and warm with a low tone to your voice, there is a greater chance that the resident will trust you and perhaps risk trying to do an additional portion of their ADLs which they had stopped doing.

The warning label here is, if you have a bad day, make it a habit to listen to and be aware of the tone of voice you use. It may have a dramatic effect on your resident's ADL independence.

Question #9: To encourage maximum ADL independence, your voice ideally should have what three qualities?
See above

3 Types of Baby-Talk
The second area regarding voice tone is the topic of the baby talk. What is it? And, how can it be avoided? For some staff, it may be all too easy to fall into using baby talk unconsciously, especially if you have small children at home. If you do not have a clear awareness of what constitutes baby talk, you may slip into using it unintentionally. To heighten your awareness of this type of inappropriate speech, here are three characteristics that distinguish baby talk from normal adult communication.

In one type of baby talk, the speaker draws out certain letter sounds like, "F-i-i-i-i-ne job Mary-y-y, " rather than, "Fine job, Mary." The words are exactly the same, but the meaning and character of the talk is totally different, with little dignity found in the first example.

A second type of baby talk is the exaggerated up and down voice tone or modulation. There is a roller coaster voice tone change, "Good ^ job using^ that cane, Henry^," rather than, "Good job using that cane great, Henry!"

A third type of baby talk is one that uses over emphasizing, or speaking certain words more loudly. Here's an example, "Let me SHOW you HOW to transfer from your BED to your WHEELchair," rather than, "Let me show you how to transfer from your bed to your wheelchair."

The warning label is obvious. Know what baby talk is, recognize it, and eliminate it totally from your work environment. If you have small children and are unsure whether you slip unconsciously into using baby talk, ask another staff member. Then, listen to yourself.

Question #10: What are the three types of baby talk to be avoided?
CE Test Question #5.

Here is a summary of the key concepts in this Module. The five key types of verbal prompts taught are:
1. Choice prompts. Evaluate the most effective use of open ended, multiple choice, or yes and no ADL questions.
2. Use singe word prompts as a tool for frequent positive reinforcement, and ADL task reminders, such as when transferring say, "turn, turn turn."
3. Attention getting verbal prompts used to increase ADL individual can include the use of your resident's name, and increasing voice volume.
4. Use frequent verbal prompts to orient the resident to time, place, and person when appropriate for the resident's mental ability.
5. Regarding voice tone, have a voice that conveys caring and warmth. Recognize, and avoid the use of baby talk.

When these verbal prompts are combined with the nonverbal prompts instructed in the next module, number five, you are going a long way to create an environment of ADL success for your resident.

You need to follow through to do and get what is necessary to make this information work for you. Have verbal prompts become a tool that you use with your residents daily. Remember, take action! In learning module five, you will learn about nonverbal prompts to increase ADL independence.

Peer-Reviewed Journal Article References:
Barnett, M. R., Jowett Hirst, E. S., & Boydston, P. S. (2020). A comparison of simple versus elaborative verbal prompts on acquisition of picture associations. Behavior Analysis: Research and Practice, 20(1), 24–35.

Bordne, S., Rietz, C., Schulz, R.-J., & Zank, S. (2020). Behavioral and emotional quality of life of patients undergoing inpatient geriatric rehabilitation. Rehabilitation Psychology, 65(3), 299–310.

Harris, J. A., Kwok, D. W. S., & Gottlieb, D. A. (2019). The partial reinforcement extinction effect depends on learning about nonreinforced trials rather than reinforcement rate. Journal of Experimental Psychology: Animal Learning and Cognition, 45(4), 485–501.

Yin, S., Zhu, X., He, R., Li, R., & Li, J. (2015). Spontaneous activity in the precuneus predicts individual differences in verbal fluency in cognitively normal elderly. Neuropsychology, 29(6), 961–970.

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