We are in the above article for a second post. We discussed the first part of this section on Monday– Failure is Not Fatal. We talked there about why it is important to allow our patients to constructively fail. Today we’ll talk about how to artfully provide cues that foster problem solving skills.
The author discusses two steps: 1) problem recognition and 2) problem-solving attempts. In problem recognition, remember to give the client enough time to see that there is a problem. Also remember that what we see as a problem, may not be big enough of a problem to get on your client’s radar, so chose a problem to work on that is OBVIOUS. For example, I was working on car transfers with one of my clients today that has an awareness problem. He had to make 2 significant errors in his transfer before he recognized that what he was doing was causing himself to lose his balance. BUT this is an improvement for him, because he did recognize that a problem existed. “If the patient is repeatedly unable to recognize a problem, […. t]herapists should intervene at this time with an indirect cue….. [b]eginning with the most subtle for that circumstance (often visual, followed by tactile, then verbal.)”
So back to my car transfer situation this afternoon. Picture this, the client has begun to get out of the truck. The first error he makes is remaining in a somewhat squatted position, and not fully extending his trunk in standing. Then error two: he proceeds to attempt turning his feet, but crosses one foot over the other. My first cue was for him to stop and pay attention to what he was doing. With that cue, he stopped talking and stopped his momentum BEFORE it got away from him (thank goodness.) He was able to recognize himself that his feet didn’t need to be crossed without further cuing. He still didn’t recognize that his trunk was flexed and leaning on the car frame, so I gave him a little faciliatory tactile cue at this trunk extensors. So then we got him upright. He just stood there for a second, so then I verbally cued to him to turn around and sit down on the waiting wheelchair. I think that was a perfect example of the progression of the cuing. Gave myself a pat on the back for that one! Mind, all that happened in about 8-10 seconds, so these things move quickly. Which is where the therapeutic arts come into play. We are artists after all, molding our charges into functioning humans.
On to step two: problem solving attempts. A client must be provided with enough time to think of possible solutions to the problem. BE PATIENT, THERAPIST! Then the client must be allowed to implement their solution, EVEN IF IT IS NOT CORRECT, so long as it does not endanger themselves or others or lead to the client becoming overly agitated (this is where knowing your client and his or her personality is important.) Here’s an example. Had a client not too long ago that decided that he didn’t want toilet paper to cleanse himself after using the toilet, he preferred to reach into the toilet bowl and splash himself with the water. Ok, not sanitary, nor achieving the cleansing goal. Not harming anyone or anything though. But the patient was able to recognize this action was not meeting his goals, as he got his clothes wet doing this and got a little frustrated with himself. So he asked for a towel to dry himself up and then to wash his hands. So he tried out his solution and found it wasn’t the best idea. Hasn’t done that since. Problem solved. He’s clean, and not doing something socially unacceptable.
“Therapists should guide patients to the correct solution if they need help because their actions will lead to unsafe behavior or agitation.” Another example: the patient who has a severe neglect and hasn’t noticed their flaccid effected arm is dangling down by the big wheel as they’re pushing their wheelchair. I always run up and grab that arm before it gets stuck in the spokes and injured. But before I just place it back on a tray or trough, I’ll wave the effected hand at the person and tell them what happened (they’re arm nearly got stuck in the spokes), why this is bad (possible injury) and what they– the patient– need to do to change that possibility (scan to check on the arm.)
Cuing is hard. This is one of those areas that I need to fine tune myself. I’m training a new-to-the-unit nurse tomorrow and I’m always instructing the new nurses to put their caregiver inner voice away and allow the patient to do as much as they can. After all, that’s what therapy is all about– improving the clients’ independence with motor tasks. But we’re all caregiving people at heart, so it’s hard to step back and LET them struggle. A touch of tough love goes a long way. They’re much more likely to remember solutions to problems they come up with on their own than solutions we spoon feed to them. Which makes them that much more independent. Yeah!