Journal of Communifu Psycholonu. 1976, 4. 281-268.

TRAINING FOR A SUPPORTIVE GERIATRIC ENVIRONMENT: A PRELIMINARY REPORT*

TOM HICKEY**

?‘he Penmylvariiu Stale I;iiiversily

(ieront ~il~igical manpower development is the goal of an ongoing project where vnrious training modules are designed, tested, and evaluated within the i~is~itiitional or community context where the service is delivered. This paper reports initial data on program effectiveness and attitudinal and work :iwissnient vhanges resulting from staff training iii environmental therapy.

Community psychology has, in large part, evolved from two conceptualizations for treating mental illness. One emphasizes social process and psychological forces in the development of illness, as contrasted with an individual disease entity frame- work. In the second, there is recognition of the artificiality of institutionally centered, custodial treatment which tends to prolong readjustment to the real world. These concepts have been operationalized into treatment modalities struc- tured in terms of the individual’s immediate social environment.

Although there are many unanswered questions about milieu therapy and its assumptions, there is general agreement about the therapeutic value of care which stimulates positive social interaction and which promotes independence by de- veloping a sense of individual choice in life style. Research and demonstration efforts, such as the University of Michigan’s program a t Ypsilanti State Hospital, indicate that milieu therapy techniques can be generalized to the institutionalized aged population (Gottesman, 1965, 19G7). The Ypsilanti research suggested that traditional geriatric staff behaviors can be modified to provide a therapeutic milieu for the elderly. Such behaviors take into account personalized interactions with the older patient, as well as individual needs and desires within the environment.

Staff-patient interactions are vital to the success of a milieu therapy prograin. Therefore, the Gerontology Manpower Project a t the Pennsylvania State Uni- versity developed a series of intensive short-term training experiences for the pro- viders of health care and social services to the elderly residing in various environ- ments. Although these programs promoted growth in the number and level of trained personnel in this field, a more substantive goal of the project was to translate the current research for practitioner use.

METHOD Two geriatric facilities were selected from among eight sites which the research

team visited. Site selection was largely determined by the willingness a t all staff levels to participate. I n the three-month pretraining period, the instructor and one other meniber of the research team visited weekly and participated in routine activities with patients and staff members, including treatment sessions and staff meetings.

*Based on the (ieronlology Man ower Development Project, sup orted in part by the Center for Human Servic.e-- Development o f the Institute for the Study o?Human Development, The Pennsylvania State University.

**Associate Professor of Human Development ; and Associate Chairman, Gerontology Center, College of Human I)evelopment, The Pennsylvania State University, University Park, Pennsylvania.

261

262 TOM HICKEY

Site A is located in a state-operated facility for psychiatric inpatient care-a large institution in numerous buildings and on extensive acreage, accommodating 2,000 patients, and providing a full range of medical services. The 350 geriatric residents were long-term patients originally admitted for psychiatric treatment who grew old in the institution. The programmatic emphasis in this institution was on custodial maintenance and general patient welfare, rather than on re- habilitation.

Site B is a former state-operated custodial care facility converted to a resto- ration and rehabilitation center for 100 older adults. Treatment is provided with emphasis on diagnosis and assessment for subsequent return home or placement in nursing and boarding residences. The average patient stay is less than six months.

Sixty participants a t each site were selected by the institutional directors balancing between estimated utility of the training program and possible inter- ference of the program with ongoing treatment. Participants were matched within sites in pairs for training and control groups. There were few demographic dif- ferences in age, sex, race, and education between sites, and among training and control groups. The most notable difference, in terms of possible program effects, was the greater percentage of Site A trainees who were involved in direct patient care. Of the 30 trainees at Site A, 22 were either nurses, aides, social workers, or activity therapists; five were maintenance and support personnel; and three were

TABLE 1. ENVIRONMENTAL THERAPY PROGRAM CONTENT AND SITE RATINGS OF EACH SESSION

Session Ratings A B Session Content

- + + +

- -

+ + + + + +

+ - + - + + +

0 0

0 + 0 +

+ +

0 + +

+ +

-

- -

- -

-

1. 2. 3.

4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18. -

Acceptance of milieu therapy as a desirable training outcome Therapeutic and nontherapeutic features of geriatric institutions Behavioral expectations of patients when functioning in different social

The effects of physical environments on patients Staff structure and roles in an institutional setting Simulation of new roles and collaborative techniques for staff memben Communication patterns within the environment Communicating to effect positive patient motivations The sequence for reinvolving the patient in social roles Case histories of patient role development Therapeutic and nontherapeutic factors in the work role Structuring work roles to match patient capabilities Analyzing treatment modalities progressing from simple to complex tasks Structuring group activities as social therapy Adapting the patient to a noninstitutional environment Facilitating the actual return to the community Planning models for changing the hospital environment Implementing the training program objectives TOTAL PROGRAM

roles

+ - 0

&signed when number of trainees who rates session favorably was 2 20; Assigned when number of trainees who rated session favorably was 5 10; and &signed when there were a t least 10 positive and 10 negative, or 10 neutral ratings

TRAINING FOR A SUPPORTIVE GERIATRIC ENVIRONMENT 263

in administration. For the most part, trainees and controls worked in adjacent buildings in the Site A geriatrics unit. The training group at Site B was composed of 18 direct service personnel, eight support staff, and four administrators who, for the most part, worked on different days and shifts than did the controls during the training period.

TABLE 2. NEGATIVE STEREOTYPES TOWARDS OLD hw.

1.

2.

3 .

4. They have poor coordination. 5. 6. 7. 8. 9. They are insecure.

They are out of step with the times. They have too much power in business and politics. They are tight in money matters.

They die soon after retirement. They feel sorry for themselves. They are suspicious of others. They are f w y about food.

10. They cannot reinember names.

The training program was based on the previously described Ypsilanti re- search project and the resulting training materials (Coons et al., 1972). Extensive adaptations in technique and emphasis were made in the use of these materials based on an earlier study (Hickey, 1974). The training program was the same for each site, and it was directed and taught by the same instructor in overlapping eight-week periods. The program involved environmental therapy principles presented to trainees in 18 two-hour sessions, through a variety of didactic methods including lecture, discussion, role play, audiovisual materials, and small group problem-solving sessions (Table 1).

Before and after measures of age stereotypes were administered to the partici- pants (Table 2); and attitudes toward hospital work were measured (Table 3). Also, mid-program data were gathered to monitor the controls; and attitude data

TABLE 3. HOSPITAL ASSEMMENT FACTOF~S

1. This hospital has a homey feeling. 2. A good patient behaves himself 3. Our patients look nice. 4. Our patients could not learn to take care of

themselves. 5. Seeing atients improve over time makes me feel

I’ve acgieved something. 6. I t does no good for patients to work on the wards. 7. I have special tricks I’ve learned to get patients

to do thmgs. 8. Patients really can’t offer suggestions-the staff

knows what’s good for them. 9. I sometimes set certain goals for my patients 10. Working in groups is not good for patients-they

do better with staff.

264 TOM HICKEY

were compared with staff job satisfaction ratings collected periodically by the institution. Specific course evaluation by trainees was obtained during the pro- gram and at its conclusion (Table 1).

RESULTS AND DISCUSSION Age Stereotypes

There is an assumption in milieu therapy training that better understanding of the patient’s role, and emphasis on the patient as a fellow human being, will lead to more positive attitudes toward dependent, chronically ill patients. In the case of a geriatric milieu therapy training program, negative stereotypes toward old age should decline following the training.

In order to test this, a negative attitude toward old age score was derived by asking respondents to indicate on five-point Likert scales the extent to which they agreed or disagreed with each statement (Table 2). These statements, originally drawn from Tuckman and Lorge’s work (1953), have been modified for geronto- logical research in a variety of ways. Summing over ratings by the same subject, mean scores were derived for trainees and controls in each institution. Nonpara- metric statistics were used to compare ratings of groups. A summary of site by subject data is presented in Table 4. Lower scores mean greater negativity. TABLE 4. MEANS, MEAN DIFFERENCES, AND AVER.\GE C H I N G E S IN NEGATIVE STEREOTYPES OF

OLD AGE

Site A Site B Trainees Controls Trainees Controls

Differences - (30) (30) (30) (30)

Pretest Means 33.07 36.31 3.24; 31.83 34.26 2.43

Posttest Means 32.57 31.94 0.93 30.86 33.45 2.59

Average Changes 1.20 0.45 4.87* 0.76

* p < .05

Pretest Comparisons. At the outset, trainees a t Site B had a more positive image of old age than did Site A trainees ( p < .05, Mann Whitney U test). This was somewhat predictable given that Site A was custodial, while Site B was re- habilitative in treatment orientation. The magnitude of difference, however, was surprising-especially to others outside these institutions. The appropriate state level bureaucratic unit with responsibility for geriatric institutions typically ignored the differing treatment orientations at these sites, and dealt with the two facilities similarly in the policy formation and resource allocation processes. The magnitude of this site difference and how it potentially affected staff attitudes, had never been previously considered.

There were no significant differences between trainees and controls on the pre- test of negative stereotypes about aging. Therefore, trainees and controls were combined for further analysis by level of education, age, length of employment, and job classification as an index of contact level with patients, and ratings of job satisfaction. None of these additional demographic comparisons yielded significant differences.

TRAINING FOR A SUPPORTIVE GERIATRIC ENVIRONMENT 265

Pre-Post Comparisons. There was little change in negative stereotype scores of trainees a t Site A as a result of training. Their descriptive evaluations of the courses after each session were consistent with this finding (Table 1 ) . They indi- cated that the examples used were familiar to them in representing a range of the best to most dysfunctional patients. Positive responses declined noticeably a t Site A after the later sessions in which patients were presented as fellow human beings and where participants were challenged to implement the environmental therapy concepts.

A lack of understanding of this more positive concept of the patient is a pos- sible explanation for both the decline in content score and the absence of overall change in attitudes. This is a reasonable interpretation given the daily work ex- periences and t! pe of patient contact present a t Site A. On the other hand, Site A trainees may have been unwilling to accept the basic philosophical approach of the training program-as especially exemplified in the later sessions which presented the patient as a fellow human being. A third interpretation is that Site A trainees both understood and accepted the training program, but did not see themselves as capable of implementing the program’s concepts, or of effecting positive environ- mental changes within their institution.

Before and after comparisons of Site B trainees on the negative stereotype measure yielded significant c h a n g e b u t in a negative direction. It would seem that, contrary to expectations, the environmental therapy program fostered the development of negative attitudes towards the elderly. This is difficult to interpret, considering that Site B trainees were, for the most part, favorably impressed with the content (Table 1). As a matter of fact, much of their class discussion, as well as responses following each session, focused on implementation of program principles. No differences were found when analyzing the results from either site by subgroups of direct service and support personnel.

From these data it would seem that exposure to knowledge about aging and the aged does not lead to more positive attitudes. I n fact, a possible interpretation for the negative stereotypes a t both sites following the program might be that the program increased their personal dissatisfaction or guilt in being unable to meet their own personal expectations to work well with all geriatric patients. For Site A, the training program may have appeared as an idealistic and unattainable model, which could accentuate the trainees’ negative feelings about working successfully with the elderly. On the other hand, Site B trainees may have been reminded by the program of some of their own failures (possibly emanating from individual negative attitudes) in working with a few, more difficult patients who were sub- sequently placed in nursing homes or in more custodially oriented institutions.

Hospital Assessment The hospital assessment measure dealt with those aspects of institutions which

are generally viewed as having a particular importance in the therapeutic use of the environment. It was derived from the principal environmental change factors outlined in the training program itself, and pretested in an earlier study in a similar geriatric setting (Hickey, 1974). The hospital assessment score was determined by summing over Likert ratings on those 10 factors which had the highest degree of validity in terms of work assessment and the patient’s environment (Table 3).

266 TOM HICKEY

High ratings indicated a favorable assessment of the institutional environment and of working with patients.

Since trainees varied in degree of direct service to patients, the results are also presented separately for direct service and support staff. Pretest comparisons between the two sites indicated little difference.

Pre-Post Comparisons. The results of pre-post comparisons on this measure demonstrated the effectiveness of the program in changing trainees’ assessments of their patients’ care, and of their hospital environment in general. Using the Wil- coxon matched-pairs test for pre and post scores, significant change was evidenced by trainees a t both institutions ( p < .OOl). The postscores a t Site A tended to be higher, reflecting perhaps the slightly larger representation of direct service stafT members in the training group.

At Site B a halo effect was demonstrated; controls made approximately the same changes on the hospital assessment scores. During both mid- and post- program interviewing and observation periods, it was apparent that program con- tent waa being discussed widely (despite work shift variations), and the enthusiasm engendered in some of the trainees was transmitted to other st& members. At Site A, this effect was only slightly discernible among nursing controls who worked in the same buildings with the trainees, and with whom program content was often discussed.

Table 5 summarizes before and after training assessments.

TABLE 5. MEANS AND CHANGE SCORES ON HOSPITAL ASSESSMENT MEASURES ~ ~~

Pretest Posttest Average n Means Means Change

SITE A: Trainees 30 16.06 24.81 9.15* Controls 30 16.71 17.86 1.61 Direct Service Staff 22 15.57 25.00 9.60* Support St& 8 16.44 24.36 8.56*

SITE B: Trainees 30 16.63 23.44 7.10* Controls 30 17.17 24.15 6.91* Direct Service Staff 18 1.5.33 23.17 9.50* Support Staff 12 17.40 23.60 7.40*

* p < .001

Content Assessment The content measures were largely descriptive in an effort to gather as much

data as possible after each session, for the subsequent modification and refinement of the program c,,qtent and format. To provide some basis for comparing the two sites, the trainees were asked to rate each session as positive, negative, or neutral. Median ratings appear in Table 1, where it is evident that the training program had quite different effects a t each geriatric institution.

It would seem that trainees a t Site A liked the program until it called for change and action. They also seemed to like the opportunity for self-improvement,

TRAINING FOR A SUPPORTIVE GERIATRIC ENVIRONMENT 267

which the program provided, (or at least the time away from work). However, their generally negative reactions to the second half of the course (further sub- stantiated by their written and verbal comments), seemed to indicate that there was a degree of threat implied by, or substantial resistance to, the notion of patient improvement, or at least resistance to their perception of it from the training pro- gram. The presence of a custodial or maintenance model of care a t Site A became more obvious from the content assessments.

Trainees at Site B, who worked with a rapidly shifting patient population, ranged more broadly in their evaluations. In this setting, the initial three sessions were not :ts effective as had been anticipated; and it was not until the fourth session that responses t o the program became enthusiastic. Other written and verbal comments seemed to indicate some confusion about what the program was trying to accomplish, and a lack of familiarity with some of the terminology and con- trasting custodial examples. During the remainder of the program, trainees at Site B were generally very positive about the program, finding it consistent with their institution’s rehabilitative goals. This was especially evident in the final sessions which dealt with program planning and implementation. However, this positive attitude toward their clients was not reflected in the poststereotype data.

The only part of the course which did not elicit much favorable response at either site were sessions 11 and 12 which dealt with therapeutic work roles. They were generally considered to be impractical or idealistic. It is also possible that some trainees at both sites did not perceive themselves as having the requisite skills for implementing these roles.

In general, when comparing content data with hospital work assessments (Table Fj), it can be said that the participants reacted favorably to the program, although much less so a t Site A.

C o N c L u s I o N In discussing the relevance of this study for future training programs, a point

deserving emphasis is that the significant variation in outcomes between Sites A and B suggests the need for educational programs carefully tailored to the client population and its institutional goals. Although the primary goal at Sites A and B was similar-i.e. the care and treatment of the mentally ill older adult-it was opera- tionalized quite differently in each setting. The difference between custodial and rehabilitative care, for example, was clearly a marked one in the attitudes, orien- tations, and work environments of staff members a t each site at pretraining time. Other phases of the Gerontology hlanpower Project have emphasized the im- portance of the interaction of trainee, content, and context (Hickey, 1974, 1975). The present study once again supports the importance of the contextual variable, the environment within which the training principles must be implemented.

The second point is that such training programs may improve staff attitudes towards their work environment, at least temporarily. Whether this improvement stems from the program content itself, or is determined by the fact that an edu- cational program was conducted, is unclear. The latter interpretation is the parsi- monious one. However, some of the descriptive responses following each session would tend to support the view that the program emphasis on the therapeutic nature of the hospital environment had a favorable impact on most trainees. I n

268 TOM HICKEY

other words, one could cautiously interpret from their overall responses to the content of the training, as well as the general tenor of their descriptive comments to the instructor, that this was a good program. Whether it was an efective one remains to be demonstrated after an additional period of time. Effectiveness will be measured in terms of the degree to which environmental therapy principles become operationalized in the two geriatric facilities. Whether the implementation of these principles leads to lasting behavioral and attitudinal change must also be studied over time. Thus, the value of the present study is primarily in laying the groundwork for a long-range study of these two institutional environments.

A third, and related point, is the fact that, for varying reasons, the trainees generally seemed to enjoy their participation in the program. While trainees a t Sites A and B evaluated some sessions differently, the ratings for the total program were positive. Trainees at Site A liked the program for reasons of self-growth and interstaff cooperation; while those a t Site B also appreciated the training program for its emphasis on the patients themselves. The absence of a patient orientation in their satisfaction with the training is consistent with the more custodial approach at Site A; and the training program itself failed to change the negative stereotypes of the patients, held by this maintenance-oriented staff. It is difficult to explain, on the other hand, the development of negative stereotypes a t Site B, where there was a more dominant patient focus.

In conclusion, it would seem that the application of milieu therapy techniques to geriatric institutional settings warrants continued attention, despite conflicting theoretical views. The educative process, however, must be carefully matched with the participating institution. The long-range value of this type of educational program and the effectiveness of milieu therapy principles in the geriatric setting remain to be determined. The two institutions participating in this study will be looked at again after six-month and one year intervals, to determine the long-range implications of milieu therapy for patient benefit. Such a determination should provide additional guidance to the planning of educational interventions for a supportive geriatric environment, as well as some clarification of the foregoing tentative interpretations of negative stereotypes and work assessment scores in this preliminary study.

REFERENCES COONS, D., LIPPITT, M., GROSSMAN, E., SAH.LRA, P., & BROWN, C. Developing a therapeutic com-

University of Michgan, Ann Arbor: Audio-Visual Education

GOTTESMAN, L. Resocialization of the geriatric mental patient. American Journal of Public Heallh,

G~ITP:SMAN, L. The response of long hospitalized aged psychiatric patients to milieu treatment.

HICKLY, T. In-service training in gerontology: Toward the design of an effective educational process.

HICKEY, T. Continuing education in gerontology for allied health. Journal of Allied Health, in press.

munity (Training Manual). Center, 1972.

1965, 66, 1964-1970.

Gerontologist, 1967, 7, 4749.

Gerontologist, 1974, 14, 57-64.

TUCKMAN, J., & LORGE, I. Attitudes toward old people. Journal of Social Psychology, 1953, 37, 249-260.