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

Module #5
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Body Language, Facial Expression and Eye Contact

Questions 1-15 found on this page
CE Test | Table of Contents | Geriatric & Aging
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

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This is Learning Module #5. It provides you with the Six How-To's of Non-Verbal Prompts or communications to increase the residents' ADL independence. As you learned in module four on verbal prompts, the effective use of verbal and nonverbal prompts can go a long way in creating an environment of success for your residents.

The last staff training module, five, gave you techniques for using verbal prompts (to include choice, single word, getting attention, orientation, and voice tone prompts). In this module, you will learn the six how-to's of using non-verbal prompts. What exactly is a prompt? You learned in the last module, a prompt is a "cue, a signal, or a suggestion you use to assist your resident in becoming more independent in performing their ADLs."

Non-Verbal Prompt #1 - Facial Expression
First, let's look at some how-to's regarding your facial expression as a tool to increase ADL independence. Your whole emotional tone is reflected in your face. Consider a day that you were late for work, and you have a headache. The brow ridge of your forehead is furrowed, or creases. You are helping Mary to wash her face. Upon looking at your face as you speak, Mary may interpret the intense creases in your forehead as indicating that you are dissatisfied with her. What do you feel that this does to her motivation to trying ADL independence?

Question #1: Your whole emotional tone is reflected where?
To select and enter your answer go to CE Test Question #1.

Your facial expression really goes a long way to create or not create an environment of success for your resident. You reflect to your resident feelings that are positive, neutral, or negative. Your facial expression goes a long way to encourage and support your resident's ADL independence, or discourage it.

Make it a habit to glance at your expression in the resident's dresser or bathroom mirror. You be the judge. Ask yourself, "What am I reflecting to this resident as they perform this ADL?" "What am I reflecting to the rest of the world, as far as that goes?" What do you see as you glance at your face?

So what can you do, if you feel that you need to change?

Here is technique, or how-to, number one. As you look in the mirror, divide your face into the upper brow region and the lower half, your mouth and cheeks. As you look at yourself in the mirror, first look at your upper face, your brow. Is it furrowed, perhaps indicating to your resident stress or displeasure? Or is it smooth? With age, unless we are movie stars who have had face lifts, we all have wrinkles, lines, and creases. I am not talking about natural aging or character lines. I am talking about the lines that you create yourself by tensing your brow ridge. Experiment with this, and note the dramatic difference in what you project by tensing up and pulling together your eyebrows.

Now, relax your eyebrows and concentrate on flattening or relaxing your brow ridge. Raise your eyebrows slightly. It almost feels like smiling with your forehead, because it reflects calmness in those muscles.

Furrowed, tense brows to your resident reflect an unfriendly, stressed person who seems unapproachable and unwilling to really help, no matter what their words say.

Question #2: To reflect calm in the upper portion of your face, concentrate on doing what with your brow ridge? See above

Now, let's look at the lower half of your face, your mouth and cheeks. Have you ever received an insincere smile from someone? Yes, unfortunately we all have. Like the fast food clerk that hates his or her job and hands you your bag of food through the drive up window, smiling with an all too toothy smile, while blurting out, "Have a nice day!!" What's wrong with their smile? The corners of his or her mouth are turned up, so doesn't that qualify as a smile? Why does it come across as painfully insincere? Well, it's because the smile is not reflected in their eyes.

Try another experiment with a mirror. Lower your lids to one-quarter or one-half of the way closed. Then smile. You look something like Bugs Bunny, don't you? The top half of your face doesn't match the bottom half. Think about how receiving this insincere Bugs Bunny-type smile feels to your resident as they are doing their best to put the button through the hole as they dress. If your eyes don't match your smile, they know in their heart that you don't really mean what you are saying.

Now look in the mirror and think of something wonderful, maybe a rainbow or a beautiful summer day. Or, think of someone or something that you really care about, maybe a car, a dog, or a significant other. Look in the mirror. Look straight into your eyes and smile. Do you see what your eyes are doing? They are open naturally, with a warm energy coming out. They match your smile.

That sincerity is what creates the kind of bonding relationship between a care giver and a resident. This helps the resident to see that you respect their efforts to risk trying and failing. They see that you really care. It's easy to have someone do something for you, because you don't have to risk failure. Obviously, none of us want to fail. We all want to succeed and have the feeling of being accepted just as much as our residents do.

Question #3: A Bugs Bunny insincere smile occurs when your what does not match your what? See above

In your ALF, it's up to you to provide that feeling of acceptance and support for your resident. You have to encourage them to try, to cheer and root them on with a warm caring expression of support on your face.

Non-Verbal Prompt #2 - Eye Contact
This brings us to our second nonverbal how-to, eye contact. Note that there are two ways which you can use eye contact You can use it to gain your resident's attention, and you can also use it as a prompt or a hint as to the next step to be taken in the ADL.

In learning module three on demonstration, you learned that maintaining eye contact is an excellent way to keep your resident's attention. Here is how it works. Using the how to just described, you have a natural smile on your face, smiling with your mouth and your eyes. By looking at your resident, you gain, or hook, their attention. All too often we are busy preparing equipment or supplies for the ADL and are talking to the resident, telling him or her what you are about to do, but having very little eye contact with the resident. If the resident is in the early stage of Alzheimer's, they may have a hard time paying attention to your ADL explanation unless you are looking directly at them.

Question #4: Eye contact is a way to get, or keep your resident's what? See above

In addition to gaining attention, eye contact can be used as a prompting device. Let's say that you have a resident, Loretta, in the early stages of Alzheimer's. She is becoming forgetful. You are talking to her in your facility living room. Her purse is on the couch next to her. You tell Loretta it's time for lunch. She stands up to leave and it looks like she is going to forget her purse. So you could say, "Loretta, don't forget your purse."

But, you notice that after she stands up, she has direct eye contact with you. Use this opportunity to break eye contact and look at her purse. It is fairly natural, if the resident is alert enough, to look in the direction that someone else is looking to see what is going on.

For example, if you were walking along a crowded street and most of the people are looking up at the sky, what would you do? Look up, of course. It's human nature.

Here's another example. Let's say that a resident gets forgetful regarding the steps to getting dressed. You would like for her to put on her own socks. She has put on one sock, but stares off into space, seeming not to know what to do next . So, catch her glance and look down at the sock in your hand. In both of the examples with the purse and with the sock, your breaking eye contact and looking at the object draws attention to the object. This serves as a nonverbal prompt to assist in maintaining a certain level of the resident's ADL independence. Of course, many residents have poor sight, and will never notice the subtle shifts in your eye movement. But, experiment and see with which residents this is an effective technique.

Question #5: A way to minimize assistance, but to prompt the resident to the next step in an ADL is to look at what?
CE Test Question #2.

Non-Verbal Prompt #3 - Use of your Head
The third area of nonverbal prompting is the use of your head. Yes, I said your head... the most common and obvious is the head nod for "yes." What a wonderful atmosphere for success your resident is surrounded with. As they put soap on the cloth to wash their face, shave their right cheek while you hold the skin taunt, or comb a portion of their hair, they receive a warm genuine smile. A smile where your whole face is smiling. You are nodding your head up and down to show your support and approval. No words are really needed, are they?

Obviously, the head shaking back and forth is a subtle way of correcting an error. But remember with the head shake, to maintain an adult attitude and relationship with the resident. The head shake and nod are so subtle they might be reserved for your more alert residents, who have clear vision.

Question #6: A head nod up and down is a good way to show what? See above

The advantage of using a slight head shake, rather than verbally pointing out your resident's error, is that less attention is drawn to the error. The resident has more of an opportunity to save face, or in other words, save their feeling of personal dignity. Think of a time when you have made an error. Maybe you didn't give the check-out clerk enough money. Or, maybe you have had a bounced check, and you had to go to the store to straighten out the problem. Were you a little nervous, anxious, or embarrassed? In each case, if you had a choice of having a lot of attention drawn to your error, or a small amount of attention drawn, your choice is obvious. No one likes to be wrong.

The same is true for your resident. When he turns the wrong way to go to lunch, or she forgets her purse, remember, if they happen to have eye contact with you, perhaps a slight head shake accompanied by a friendly smile, will get the message across to your more alert residents. Thus, your actions are upholding the philosophy of providing the least amount of assistance in order to maintain the maximum level of your resident's ADL independence.

Question #7: The advantage of using a slight head shake to indicate an error is that it does what?
CE Test Question #3.

Cautions Regarding Head-Shaking
However, to repeat once again, it is important not to take a parental, one up, or superior attitude while nodding or shaking your head. One way that this attitude can be conveyed or shown is by tilting your head back. Try it. Take out your mirror again. Shake your head from side to side, as if something is not okay. Then tilt your head back. You've heard the expression looking down your nose at someone? This is where that comes from. So, maintain an adult attitude with dignity.

Share on Facebook Non-Verbal Prompt #4 - Use of your Hands
The fourth area of nonverbal prompting to create an atmosphere of success for your residents is the use of your hands. Let's talk once again about your resident, Loretta, who gets up from the couch and leaves her purse. You look at her purse, but she does not pick up on your cue. So, you casually point to it.

Now of course you could say, as mentioned earlier, "Loretta, you forgot your purse." Some residents need that very direct approach. But in creating an atmosphere of ADL success, we want the resident to maintain as high of a level of dignity as possible and as high of a level of self- esteem as possible. So if an error is made, you need to think of the least obtrusive or noticeable way to assist the resident to correct the error.

After you provide the prompt, you then need to follow this with a few seconds of observation. This is done to decide whether your pointing needs to be repeated, or some other form of cueing, prompting, or assistance needs to be provided. In this case, since eye contact did not work, try a gesture. If that does not work, you might state, "Loretta, your purse."

Question #8: After you provide the prompt, you then need to follow this with what to see if your prompt was effective? See above

Now let's look at hygiene assistance and how non-verbal prompts work. Let's say you want to assist Loretta in her goal of washing her own face. You give Loretta the washcloth, adjust the water temperature and the flow, dampen the cloth and wring it out. You hand the cloth to Loretta to put the soap on. However, she seems not to know what to do next. So, with a gentle smile on your face, you raise your index finger and point to the bottle of soap next to the sink. No words are exchanged, and she proceeds to put soap on the cloth.

Now let's say that Loretta doesn't get the message. She is sitting, staring off into space. You might point again, but Loretta's lack of eye focus tells you that your gesture of pointing is not effective. Then, add a verbal cue, via a yes or no prompt, which you learned in the previous learning module. Ask, "Loretta, are you ready to put soap on your cloth now?" If she still does not respond, you could repeat your question, or change your question into a statement, "Loretta it's time for the soap now."

Progression from Independence to Dependence
Note that with any ADL, whether it's hygiene, grooming, dressing, ambulation, toileting, or medication assistance, there is a progression from independence to dependence, determined by the amount of assistance you give. For Loretta, the first step is to provide the least amount of assistance, such as non-verbally looking at, and then pointing to the bottle of soap. The second step is verbally asking, "Did you want soap on your cloth?" And lastly, if the non-verbal and verbal fail to create an ADL action on Loretta's part, is a passive dependent stage. You place the soap on the cloth for Loretta. These are the kind of dependence-versus-independence decisions you make daily step by step as you assist your resident with ADLs, whether you are aware of them or not.

Question #9: There is a progression from independence to dependence, depending upon what? See above

Another non-verbal prompt is the use of a hand gesture, and saying her name to gain Loretta's attention. A non-verbal prompt to pull Loretta back into focus, and regain her attention, would be to touch Loretta on her arm, shoulder, hand, or knee. Thus, after you point to the soap bottle to draw her attention to it, if she doesn't move her hand to pump the soap, you might touch Loretta's hand and say her name to regain her focus.

Question #10: To gain a resident's attention touch his or her what? CE Test Question #4.

A word of warning here: any time that you touch a resident, you are entering his or her personal space. So, be aware of "Loretta's" preference. As you know, there are some residents that you just don't touch, and others that seem to crave it. You will usually know which residents to touch, and which it is not okay to, by their facial expression and what they say. However, if you are not sure, ask. For example, "I just touched your arm right now, Loretta, is that okay?" To touch a resident to dress them or perform an ADL, may be okay. However, touching their arm, shoulder, or hand in order to gain their attention, may not.

Question #11: Any time that you touch a resident, you are entering what? See above

Non-Verbal Prompt #5 - Body Language
The fifth how-to for non-verbal prompts is body language. The way that you move your arms and stand gives a message to your resident. If your arms are folded across your chest while explaining an ADL to Loretta, this may send a message of uncaring, as opposed to arms at your sides, or slight forward ready to provide assistance. If you have a mirror close by, the best way to understand this non-verbal language is to try it.

Let's take dressing for example. If you are standing, ready to hand Loretta the next item of clothing, or ready to help put her put her arm through the sleeve as she needs assistance, this is a posture to convey or show helpfulness, rather than standing with your arms folded across your chest.

Question #12:
When your arms are at your sides or slightly forward, they can convey or show a message of what? See above

Here's how you can use your body movement to facilitate your resident's ambulation independence. For example, walk in cadence, or in time, with the resident's steps. When the resident steps, you step. Also, take small, smooth, slow steps that match your resident's.

If your body movements are sudden or jerky, this may startle your resident. They may feel less secure and less willing to try further ambulation. In summary, when assisting with ambulation, slow, smooth movements with steps or a gait that match your resident's are the best to maximize ambulation skills.

Question #13: What kind of movements are best when assisting with ambulation? See above

Non-Verbal Prompt #6 - Provide an Independence Environment
Non-verbal prompt number six is to provide an environment that increases ADL independence. Here are several techniques to create an environment for your resident that enhance ADL success. To facilitate dressing, if Loretta has problems remembering which clothes are in what drawer, discuss with her her feelings about labeling drawers to help her find her clothes.

For example, if Loretta needs assistance to locate her underwear drawer, you might talk to her about putting a red piece of yarn or ribbon around the handle of that one drawer. If she has problems locating her room, a special decoration might be placed on her door.

Also, reminder notes might be used if Loretta forgets to set her clock at night. Notes, labels, and prompts, like pieces of yarn or ribbon and door decorations, are effective tools to assist your resident in having a feeling of success and maintaining ADL independence.

Another way to create an environment of success is to provide your resident with a calendar and a list of facility and community events and activities.

But remember, don't overdo with environmental aids. If Loretta has a small clock, but still can read the numbers, uses the calendar from her checkbook for the date, and has no problem locating clothes, no environmental aids are needed. In short, one size or one approach does not fit all. Observe, evaluate, then decide what action would encourage and support the most resident independence.

Question #14: List environmental aids to assist resident ADL independence. See above

2 Rules for ADL Setup
The last environmental aid in ADL setup includes two rules. First, only place in view the items needed for that ADL. Secondly, position the ADL equipment or supplies to help guarantee success.

Here's a list of positioning and setups that assist stiff, shaky hands, as well as forgetful residents. This is a general list and would need to be adapted for each resident's abilities and capabilities. If the resident is right handed, place the toothbrush and paste to their right with the handle of the brush towards the resident.

The same holds true of a hair brush. If the resident is right handed, place it to the right, ready to picked up. If denture cleaning tablets are used in packets, partially tear the pack open. If a resident has a hard time getting the top off of the the mouth wash, remove it for her.

The list could go on forever, but I think you get the idea. Observe, then ask yourself, "What can I do regarding setup of the ADL to facilitate the greatest amount of independence for my resident?"

Question #15: Two rules related to ADL setup are what?
CE Test Question #5.

In summary, the six non-verbal how-to's in this learning module are:
#1. Facial expression. Note your brow, eyes, and smile.
#2. Use eye contact with your resident to gain their attention, or eye contact with an object to facilitate completion of an ADL.
#3. Use head nods for approval, and shakes to replace telling a resident he or she has made a mistake.
#4. Hand gestures include: pointing to tell the resident the next step in the ADL, and touching the hand, arm, or leg to regain attention, if appropriate.
#5. Regarding body language, you give messages with your arms. Reaching forward indicates ready to assist, if needed, rather than folded across the chest.
#6. Use environmental aids and set up ADL supplies to facilitate independence and success.

In this learning module, number five, you've just learned about the Six How-To's of a Non-Verbal Prompt to effectively increase your resident's ADL independence and create an environment of success. In the last Module, number six, you will learn about Motivation.

Peer-Reviewed Journal Article References:
Abramson, L., Petranker, R., Marom, I., & Aviezer, H. (2020). Social interaction context shapes emotion recognition through body language, not facial expressions. Emotion. Advance online publication.

Hietanen, J. K., Myllyneva, A., Helminen, T. M., & Lyyra, P. (2016). The effects of genuine eye contact on visuospatial and selective attention. Journal of Experimental Psychology: General, 145(9), 1102–1106.

Scherer, K. R., Dieckmann, A., Unfried, M., Ellgring, H., & Mortillaro, M. (2019). Investigating appraisal-driven facial expression and inference in emotion communication. Emotion. Advance online publication..

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