is Learning Module #6. It provides you with motivational approaches for ADL refusals and adminstering to increase your residents'
ADL indpendence. Remember, as mentioned in the other Modules,
you are trying to create an atmosphere of ADL success for your
residents. This module deals with motivating your resident to
do his or her ADLs. However, now we are dealing with the topic
of motivation in brief, only as it relates to a resident's performance
of Activities of Daily Living. There are residents in most every
ALF that have the abilities and capabilities to do portions of
their own ADLs, but they just choose not to do them.
#1: Think about a resident in your facility that fits into this
category and write his or her first name after question one. If
this question does not apply to your situation, write "N." To select and enter your answer go to .
Question #2: Write the ADL or ADLs he or she is refusing to perform.
If this question does not apply to your situation write "not
9 Categories of Refusal
the person whose name you just wrote, and decide if they could
fit into any the following categories:
Maybe he or she has never been a real go-getter or a self-starter
all of their life.
They may be the type of person that, if they can get someone else
to do something for them, they will.
They are manipulative, and like to feel the power of getting others
to do for them.
They have had a physical disability for a long time, and are used
to having others at their beck and call.
They may refuse to do ADLs related to hygiene because they never
have valued cleanliness as being important.
They still hold the emotional scars of the Depression Era, and
don't want to waste the water to wash themselves, or to have their
7. None of these could be true, and they may be in the early stage
of Alzheimer's. Because they feel that they are losing their grip
on their memory, they mask their fear by being overly demanding,
or overly dependent. They may have an attitude of, "If I
don't try, I won't fail."
They may be disoriented and get a sense of comfort from wearing
the same clothes over and over.
9. Or they may be disoriented and are unaware of wearing the same
soiled clothes over and over.
Question #3: Decide if your resident is oriented enough to
know that he or she is refusing or being demanding. If this question
does not apply to your situation write "not apply."
this Module, we are not talking about the forgetful Alzheimer's
resident, or the frail resident who truly cannot do for themselves.
We are talking about the person who decided that they don't want
to perform an ADL for a reason other than health reasons. In motivating
a resident to do an ADL and creating an environment of success,
here are three approaches that are most commonly used.
talk about the resident who may take a commanding voice tone and demands your
assistance to put on her shoe, comb her hair, or wash her hands even though she
is capable of doing all three. We'll call her Helen.
1. The Soft Line Approach
first approach to try is a soft line approach. What you say is,
"Helen. There's an old saying that states, what you don't
use, you lose." If you feel she needs more information, continue,
"And what that means is, physically, if you don't use a muscle,
you gradually lose the use of that muscle."
If needed, continue
further, "Now I am interested in helping you keep the hand
and arm movement that you have." Pause for a moment for her
to reply, then say, if it seems appropriate, "Here's your
brush." You then hand Helen her hair brush with a friendly,
We talked about facial expression in Learning
Module Five, on non-verbal communication. It goes without saying
-- always treat the resident or tenant with dignity and respect
in order to foster success.
Question #4: A soft line approach with a demanding resident
is to state what?
2. Simple, Technical Explanations Approach
Here's a second
approach if you feel that a simple, but more technical explanation
may be useful. If Hester says, "What are you talking about?"
or "I don't believe you," state in a factual, but friendly
tone, "Hester, when your hands and arms are held immobile,
the blood supply to your muscles is slowed, thus causing your
muscles to become stiff. Over time with this decreased blood supply,
muscles become more and more stiff, and less and less able to
Question #5: When a resident's hands and arms sit (what) and
do not move, the blood supply to their muscles is (what). This
causes the resident's muscles to become(what).
3. Motivate behind her Action Approach
third approach for Helen, who refuses to perform an ADL which
she is capable of performing, is to motivate behind her action.
In short, why should she be assisted with her ADLs? With a kind,
gentle, but professional manner, inform her that your Assisted
Living Facility is only able to provide a certain level of care
for residents, and when care increases beyond a certain level,
Helen is no longer an appropriate placement in your ALF.
a major word of caution here: Be aware of the tone of voice that you use when
presenting these facts. Be sure to present them in a factual manner, and not as
a threat. Here's what I mean:
Three Negative Qualities in Voice Tone
qualities in a voice make it sound negative, unprofessional, and
threatening. First, emphasizing certain words by saying them louder. Secondly, clipping off or ending quickly some words. And thirdly,
using several pauses which have the effect of adding a certain
emotional drama, and raises emotional intensity.
Question #6: If a resident continues to be demanding, staff
may need to point out factually that the resident's level of care
may increase to the point of being too (what) for the ALF?
Question #7: What are three tones to avoid in your voice that
can make it sound threatening?
Changing Voice Tone
First, lower the tone
of your voice. Remember, you learned about the importance of voice
tone in Learning Module number four on verbal prompts. Secondly,
keep the volume level the same for all words. Thirdly,
phrase the words with a smoother, sincere, caring pace and feeling.
You have that intangible underlying quality to let Helen know
that you care about her. This is not only reflected in my voice,
but also in my facial expression, as described in Learning module
five nonverbal prompts.
Question #8: What are three ways to change your voice tone
with a resident to sound professional and caring?
last word about giving your uncooperative resident the facts.
Keep in mind, as you know, what you are telling her really is
the truth. If Helen is disrupting your facility by being very
vocal and demanding, as well as demanding more ADL care, then,
initially agreed upon when entering your facility, she will end
up having to move to a more appropriate setting. However, if you
are unsure about using approach three of presenting the facts
in a factual manner, it is best to check with your director or
review the first motivation approach to do an ADL is, "What you don't use,
you lose." The second approach is, provide a more detailed explanation. Approach
number three is reminding your resident of the terms or conditions of their level
of care at your Assisted Living Facility.
4. Approaching a Depression-Era Client
fourth motivational technique is used with a different kind of
resident . A resident, Joe, who refuses to change his clothes
because he remembers all too well, the Depression Era. He feels
that he may not want to waste the water that it takes to provide
him with clean clothes daily. It's not that he wants to be waited
on, as with Helen, but in addition to saving water, he simply
may have never valued or thought it to be important to be clean.
you feel that odor and hygiene are becoming a concern due to lack of cleanliness,
the time has come for a more firm stance regarding ADLs with resident Joe.
a. Statement, not Question
Learning Module One on instruction, you learned about the importance of giving
your resident a choice. But, in this case, the best approach takes place in four
steps. The first step is to make a statement, not ask a question. Say something
like, "Joe we need to change your shirt now."
Step two, if he states a refusal like, "I don't want to,"
or "No, it doesn't," then go back to step one, repeat,
"Joe we need to change your shirt now." Make sure that
the volume and tone of your voice is low. Do not increase volume
on certain words. Do not clip off the ends of your words, or your
statements may escalate and get an emotional reaction.
c. Judge Level of Refusal
Step three requires a judgment call on your part as to how emphatic
Joe is in his refusal. If you feel he is on the fence, so to speak,
you might unbutton one button of his shirt. But, how do you tell
if Joe is on the fence and that it's okay to approach him? Look
at his face and listen to volume and emphasis in his words. This
reflects how determined he is not to comply. Just listen, he may
say, "I don't want...no" or "I don't! want... no!"
Question #9: What are two ways to tell if it is OK to approach
a resident who refuses ADLs? (look at his face, listen to the
volume and emphasis in his words).
d. Inform the Resident You Will Return
will give in at the point when you start to unbutton the shirt.
However, you definitely do not want this to escalate into a full
blown confrontation. So, if he still remains negative to create
an environment for success, go to step four and say, "Well,
I'll leave now, but I'll be back in a little while. And we do
need to change your shirt."
you don't return, and someone on the shift after you approaches
him, that just makes it much harder tomorrow for you to get Joe
to comply. So, if you state that you are going to be back in a
little while, do so. If it's at the end of your shift, state this
by saying, "Well
Joe, that shirt needs to be changed. I'm going off shift now,
maybe Alice will have better luck."
you'll win no popularity contest if this becomes a standard ploy
on your part, when the next shift has to do your work. So, plan
better. The next day, approach Joe toward the beginning of your
shift to allow you an opportunity to revisit, and request several
times the shirt change.
Question #10: It's best to approach a resident who refuses
ADLs (blank) in the day to allow time to reapproach them several
times later during your shift.
summary, there are four steps with someone who is at the point
of lack of ADL performance which affects others, due to odor,
and also affects their health. The first step is to make a statement,
"We need to change your clothes now." You do not request,
because you've tried, and requesting has not worked. Step two,
calmly repeat your statement, "We need to change your clothes
now." Step three, judge the level of refusal. If he seems
to be close to complying, physically start the clothing change.
Step four, if you feel the resident's refusal is too emphatic
or emotional, as reflected by his facial expression, voice volume,
etc. inform the resident that you will return. Then, plan your
care schedule accordingly, to accommodate revisiting the resident.
course, the very last step with Joe, as with Helen who demanded
care, is the "Why should I?" reply. You inform Joe that
he may become an inappropriate placement for your ALF, requiring
a level of care too high for your facility, and would need to
seek placement elsewhere.
Facility Policies on Clothing Changes
goes without saying, be very clear about your facility policy
on clothes changes. Obviously, one resident's rights end where
another one's begins. By that I mean, if the odor from Joe is
to a point of bothering other residents, or incontinence is presenting
a health hazard to Joe, the firm, three-step method stated above
needs to be considered. Depending upon your policy, distractions
might be used, like washing Joe's clothes while he is in the whirlpool,
or if he takes them off at night, while he sleeps.
Question #11: Especially where odor is involved, one resident's
rights end where another's what?
Question #12: Incontinence can present a (what) due to lack of
for some, only when the consequences occur do they feel a motivation
to change. Just like the confirmed smoker may not be motivated
to learn techniques to breaking the nicotine habit until he or
she has a sore throat that will not go away, or has trouble breathing.
Thus, your obstinate resident may not be motivated to cooperate
with ADL requirements until he or she is actually transferred
to another facility.
Two Principles of Motivation
to this point, we've talked about ADL refusals regarding residents
who are demanding, and your residents who do not value cleanliness.
Let's shift gears to talk about how two principles of motivation
can assist your teaching residents to self-administer medication,
and how to provide an environment of success.
times, stiff fingers and limbs, as well as shaky hands make it a challenge for
a resident to take medications or apply ointments independently. As you know,
performance of these tasks may be a criteria for placement in your ALF and the
use of a Home Health Agency.
Principle 1. Helping Your Resident "See the Need"
most basic motivators to learn, or in this case relearn, a skill is first for
your resident to see a need to do the task. So, as you are asking Mary or Maude
to stretch that extra inch to put the ointment on her foot, or raise a shaky hand
to her mouth to take a medication, she needs to be aware that independence in
taking medications is needed to maintain her current level of care.
the motivation comes from being aware that independence in taking medications
is part of a larger concept. The concept is their placement in your ALF, and the
level of service required, rather than just an isolated task.
say to Mary, "I know it's hard for you to reach your toe
to put on the ointment. I'll help you uncap the tube. Put some
on your finger, and guide your hand to your toes. But, I am not
qualified to apply the ointment for you."
Question #13: Independence in taking medications is explained
to your resident, as it related to what two areas?
Principle 2. Associate the Action with a Past Action
providing an environment of success in motivating your resident
to do the medication task that is a challenge for her, associate
it with something that she has done in the past, perhaps hundreds
of times before. Here are some examples: As the resident reaches
down to put the ointment on her foot, you might motivate her by
stating, "Mary, remember the garden you talked about yesterday?
Just pretend that you are reaching down to pull those weeds or
plant a seed."
if Mary is an extremely neat person, you might relate putting
on the ointment to picking up a piece of thread or lint off the
carpet. For a male resident who had played some sports, you might
down to your foot like you are picking up a golf ball, baseball,
or horse shoe." Use your imagination. This approach works
best if you know your resident and if the example applies closely
to something he or she can relate to.
the cap on a medicine bottle, you might ask, "Remember putting
the lids on jars when you did canning?" If you have the unit
dose blister cards, relate it to pushing a button for an elevator
or electric light. Some old-fashioned light switch wall plates
used to be push buttons. Or, if the resident sews, how about pushing
the bobbin into their machine?
Question #14: In motivating your resident to do the medication
task that is a challenge; associate it with what?
to provide an environment of success with residents demanding
ADL care, take a soft line approach of "what you don't use,
you lose," provide more details of what this means. Repeat
as needed, and inform residents of the level of care provided
by your ALF. Be aware of your voice volume, tone, and be sincere.
For residents refusing ADLs, try making a statement starting with,
"It's time to..." Repeat your statement, return later,
try physical assistance, inform the resident of the level of care
provided by your ALF, and use distractions. For medication administering,
provide assistance only. Inform resident of the level of care
provided by your ALF. Relate the task to one they have enjoyed
in the past.
this Learning Module, number six, you've just learned about motivation with residents
who refuse ADLs, or are demanding. We have also covered medication administration,
to effectively increase your resident's ADL independence, and create an environment
You have completed all six modules! You need to follow through
to do, and to get what is necessary to make this information work
for you. And, be a tool you use with your residents to provide
an environment of success. Remember, take action!