Transforming Personal Care Through Ritual

Article Outline

• Abstract
• Background
• Framing
  • Framing Exercise
• Rituals
  • Symbols
  • Types and Benefits of Ritual
  • Transitions
• The Environment for Ritual in Everyday Care
• The Ritual Tool-Kit
  • Bell or Gong
  • Ritual of the Stones
  • Soap Bubbles
• Self-Care
• Conclusion
• Resource
• Appendix A
  • Ritual: Relinquishing a Driver's License3
  • Intention
  • Leader
  • Resources Needed
  • Preparation
  • Crossing the Threshold Into the Ritual Space
  • The Activity
  • Ceremonial Closing
• Appendix B
  • Ritual: Blessing of the Room3
  • Resources Needed
  • Preparation
  • The Activity
    • Crossing the Threshold
  • Celebratory Conclusion
• References
• Biography
• Copyright

The philosophical and theoretical framework of transforming personal care through ritual is based on 5 assumptions: 1) routinization is not necessarily a good thing; 2) individuals who are deprived of “other ways” of knowing, of experiencing the everyday, will have a felt sense of helplessness and hopelessness; 3) personhood relies on memory and on the frames we construct to interpret and explain the world; 4) having a sense of purpose affects health and well-being; and 5) caregiver self-care increases productivity and well-being. The approach discussed in this article suggests that the opportunity for other ways of “doing” should be injected into the daily routine of care giving and care receiving. In fact, the American Nurses Association Code of Ethics for Nurses holds that a nurse is as morally obligated to care for his or her self as for others; this would certainly apply as well to the personal care staff in assisted living. This article discusses the key concepts that support the introduction of ritual into long-term care practice, champions, a ritual “toolkit,“ self-care rituals, and 2 rituals for assisted living residents: moving into their new homes/rooms and relinquishing their driver's licenses.

• 
  • View Large Image
  • Download to PowerPoint

• Ethel Mitty

• 
  • View Large Image
  • Download to PowerPoint

• Sandi Flores

Thinking about personal and supportive care of older adults living in an assisted living residence (or community) has to go beyond the notion that it is a social model of care, or an emerging medical model. It is a way of caring that must include rites and rituals of passage, of transitions that include all the players and activities that are still important in old age and part of the social fabric. This article is somewhat different from previous articles in this series. It has a clinical message, as did the other articles, but it is less obvious. Instead, the clinical indicators are embedded in the rituals. The article discusses the background, definitions, and key concepts that support the introduction of ritual into long-term care practice, as well as champions, a ritual “toolkit,” and self-care rituals.

Back to Article Outline

Background 

Transforming personal care through ritual is based on a program that was developed, tested, and implemented in traditional long-term care, that is, nursing homes and home care: Transforming LTC Through Ritual (TLTC-R). The philosophical and theoretical framework of TLTC-R is based on 5 assumptions:

We suggest that many older adults feel helpless with regard to creating other or new ways of knowing and experiencing everyday life (that is, the “mundane”). It has been argued that older adults like a stable routine, that this helps them feel safe. Yet studies have also shown that unvarying routine is associated with negative affect (depression). Thus, the opportunity for other ways of “doing”—for change—should be injected into the daily routine of caregiving and care receiving. It bears noting that the caregiver can also feel helpless because of a dearth of creativity in caregiving. The fifth provision of the American Nurses Association (ANA) Code of Ethics for Nurses holds that a nurse is as morally obligated to care for self as she or he is to care for others.¹ This would certainly apply to the personal care staff as well.

Back to Article Outline

Framing 

Human beings constantly use their sensory antennae and cognitive skills to project an interpretive frame into the world and thus make sense of it. As such, frames are a way of explaining the world (i.e., a phenomenon) to others. Frames can exist on a preconscious level, before information processing and decision making occurs. For example, let's imagine being younger and observing one's own parents at age 65; they seemed ”worn out,” maybe even a little forgetful. We take with us this paradigm of what being old is that admits of no other interpretation. That is, being old is “losses.” Hence, a meaning is at hand before even consciously thinking about it or sifting through information.

The word “frame” is a noun and a verb. A frame both provides and is the context. As a noun, it denotes the boundary of the event, activity, or phenomenon; think of a picture frame. As a verb, and this is its importance in ritual to create remeaning, framing is a systematic, analytic process of learning other ways of knowing. A frame is a “cognitive shortcut” that draws from memory to guide interpretation, organize information, and figure out what is important or not important.

A frame can be thought of as a bias; it exerts influence. Framing is inevitable; it encourages or supports certain interpretations and discourages other. Frames are constructed from beliefs, values, and experiences. As such, 2 individuals can look at the same event or activity (phenomenon) but have diametrically opposite interpretations or meaning. However, frames can be replaced or shifted when an interpretation seems incongruous or it has a poor fit with what is perceived.

Framing Exercise 

Try this by yourself or with your staff: make a “frame” using your arms and hands. You are setting up a boundary, a perimeter, that allows certain information in and keeps certain information out. Turn slowly in all 4 directions; what do you see? Now place your hands around your eyes to “frame” the field of vision, like goggles or looking through binoculars. Turn slowly in all 4 directions. Now what do you see? With which frame do you want to understand or know the room? The landscape?

Picture one of your residents on a locked dementia unit who keeps pulling at the locked door. What is the frame that comes to mind? Dementia means wandering. Now change the frame; expand the perimeter. You open the door and go for a walk with the resident. But what else happened? You didn't stick with the typical interpretation of dementia behavior. You allowed in the possibility that this lady wanted a change of scenery!

Back to Article Outline

Rituals 

The most important thing about ritual is that it functions as a frame.² Ritual takes a piece of reality and gives it character and definition; it endows the everyday with special meaning. The “special task” of ritual is to persuade; it carries recognition and respect. The word “ritual,” often used synonymously with the word “ceremony,” evokes a variety of images, ideas, and associations. There are many types of ritual: religious, secular, everyday, social, and civic. Examples of religious ritual include the celebration of Shabbat in Judaism or a baptism in Christianity. Celebrating Thanksgiving and Halloween, putting baby teeth under a pillow for the tooth fairy, or having a tailgate party at a sports stadium are examples of secular rituals. Everyday rituals include sitting and enjoying your morning coffee (tea) along with a moment of reflection or a daily walk. Social rituals might include saying, “Hi, how are you?” when meeting someone or brushing dirt off your shoes when entering someone's home. Civic rituals include saluting the flag, a parade, and political campaigns. The various forms of ritual address both individual and collective needs.

Ritual differs from “habit” because ritual is an act that has value added; it is imbued with special meaning. It is informed by conscious intention; consequently, it is deliberate and is elevated above the “habitual.” Because it requires consciousness, ritual is imbued with special meaning that can ground and ennoble the present, the everyday, and the mundane. Thus, ritual can help give meaning to our world by linking the past to the present, and the present to the future. Ritual can address both individual and collective needs. Reminiscence, life review, and stories can help build selfhood, community, and embed meaningfulness in ritual. In the appendices of this article are 2 rituals that may be of interest to an assisted living resident. The first relates to relinquishing one's driver's license (see Appendix A); the second relates to moving into an assisted living residence or community: Blessing of the Room (see Appendix B).³

Derived from the Indo-European root meaning of “to fit together,” ritual is an activity of joining the metaphysical and the physical to bring meaningfulness into one's life. It is one of the oldest forms of human activity and integrates storytelling, dance, music, performance, and theatre. The arts and crafts of ritual are the senses and symbols. Ritual is a sensory and a symbolic experience.

Symbols 

Symbols carry and convey meaning and are an important element of ritual. They stimulate memory and associations that help in recalling events, feelings, and experiences. They may range from symbols of spirituality such as skullcaps, chalices, and candelabra to everyday symbols such as a ticket stub from a first date, a pillbox hat from a certain era, or the hat of a firefighter or police officer. Some symbols, such as the nurse's cap, have disappeared over time. Certain foods take on symbolic importance during particular rituals: eating an apple for a sweet new year or a round bread to represent the life cycle, or a wafer and wine for the sacrament. Symbolic action is connected to activities such as ripping your garment to represent a recent loss or cleaning your home to symbolically represent a new beginning or springtime.

Have you thought about the meaning of plastic versus real flowers on the dining room table? What message are we conveying? If you had a choice, which would you choose?

Neuroscience reveals that human beings are “hardwired” to do or engage in ritual. Neurobiologists D'Aquili and Laughlin⁴ explained the connection between myth and ritual, arguing that given the structure of the brain, human beings construct myths to explain their world through ceremonial ritual. Ritual provides a framework, a container, and is a way to symbolically mark events and changes. As such, rituals have specific stated intentions. Ritual space and time are extraordinary and are set apart from ordinary space and time. Ritual acknowledges cultural and religious practices and beliefs; these are the starting point for discussing and planning ritual. To have the fullest possible meaning, a ritual must be culturally sensitive, relevant, and appropriate.

Types and Benefits of Ritual 

Rituals can be celebratory, like when reaching an age milestone, a birth, a marriage, a graduation, or going back to school. They can mark a turning point, like moving to an assisted living residence, completing a divorce, or adapting to new technology (such as a pacemaker, hearing aid, etc.). And they can mark loss, such as the death of a roommate, loss of mobility, loss of vision or hearing, or loss of cognitive skills.

The benefits of ritual can be categorized and described as follows:

Transitions 

The rituals that mark transitions are denoting transformations in the individual's status and age.² Characteristics of rites of passage are crystal clear with regard to being young or old, male or female, living or dead. They are imbued with culture, biology, and values. The notion of “old age” has been expanded and lengthened as a result of medical technology and economic necessity. Yet there is an irrevocable point of “social irrelevance” that confronts older adults and that requires almost heroic creativity to reinvent meaning and usefulness.

As poignantly noted by Myerhoff,² Western culture acknowledges certain transitions unique to older adults: 50 years of marriage, becoming a grand or great grandparent, birthday milestones (and some Olympiad-like medaling).² Given that these celebrate achievements, it is noted that some losses have no rites to mark them: needing to use a wheelchair, selling or giving up one's home and moving to an assisted living residence, estate management to protect assets for the children, or letting the driver's license renewal lapse. Ritual has great value in those transitions that are fraught with anxiety and uncertainty, with being betwixt and between.

Back to Article Outline

The Environment for Ritual in Everyday Care 

The environment for conducting a ritual activity is, essentially, a change in the routine use of a space. This creates an atmosphere that contributes to the reframing and remeaning of the everyday care. The changes can be small yet dramatic, and as simple as changing the lighting upon entering or exiting a resident's rooms, opening the shades or curtains, or playing music. Each approach is an attempt to change the ordinary routine environment into one with special, personal meaning for the resident and, it is hoped, the caregiver as well. Objects from nature can also be used to stimulate the senses and reconnect older adults with their surroundings through touch and smell.

The dining-room table can become a focal point for beauty and source of stimulation. A centerpiece photo display can use the images for conversation and communication between and among residents and staff. These visual objects can be changed with the seasons or for specific events (e.g., staff member wedding; a resident's new grandchild), holidays, and celebrations. Re-creating the dining-room table itself restores the notion of family; it creates a special space within the larger dining space. Staff, residents, and visitors can participate in changing the images, providing different images for each table (ask residents at each table what images they would like) and simultaneously engage in meaningful conversation.

Back to Article Outline

The Ritual Tool-Kit 

The ritual toolkit consists of objects selected with the intention of stimulating the senses, memory and recall, and conversation; they open a door to remeaning. The items in the ritual toolkit are ordinary, but they become special because they (re)endow a simple activity with new meaning and importance or value. Some of the objects will have more resonance for some residents than others, and this is as it should be because we are seeking the personalized experience.

Different rituals use different objects or symbols. Some are universal, and others vary with culture, such as a bell or gong, incense or other odoriferous sensation, stones, colored cloth, water, bread, a vase with flowers, flags, candles, oils, and shells. Each symbol listed here is explained by the type of ritual it represents, the sense(s) that the object was intended to stimulate, the rationale for the object (i.e., the symbolism or meaning attributed to the object for the way it is used in a ritual), the activity itself, and reported outcome(s) among participants with that symbol.

Bell or Gong 

Ritual: Community; coming together

Sense: Hearing (tinkling sound)

Rationale: The bell or gong sound evokes a special time or experience—ergo, special meaning. [Note: There was no verbalization of the bell sound being associated with a bad experience or event.]

Activity: Use the bell to set aside or recognize that a special time is about to begin, such as, eating (whether alone or with others).

Outcome: Laughter, joyfulness; spontaneous expressions of meaning based on experience and recall

Ritual of the Stones 

Use small, opaque or translucent stones; those from a lake, the seashore, and so on; they may be placed in bowl or other container.

Ritual: Community (group memory)

Sense: Touch

Rationale: The stones are an expression of good wishes without seeming maudlin, patronizing, or uninvolved.

Activity:

Outcome (from past events): Participants were objectively involved in creating a “good wish”; they were surprised, pleased—and almost shy—when they each received a stone “impregnated” with the wishes that all had contributed.

Note: In conducting this activity with those who have dementia, select an object that cannot be swallowed or that can induce choking.

Soap Bubbles 

Ritual: Community

Sense: Sight; Touch

Rationale:

Activity: Assist older adult use; show them how to wave the bubble wand or gently blow through the round aperture.

Note: The bubble mixture should be a nonslippery, “floor-surface preserving” for inside use.

Outcome: Pure, unmitigated joy.

Back to Article Outline

Self-Care 

Daily stressors, staff turnover, workload, and coping with difficult residents can be a factor in an assistant's sense of helplessness that, in combination with a dearth of creative choices in caregiving, can engender a sense of hopelessness. Self-care for the caregiver is a fundamental and integrated component of the TLTC-R philosophy.

The TLTC-R approach to self-care for the caregiver consists of experiential activities and simple nurturing rituals for the mind, body, and spirit. In a sense, these rituals are “collaborators” in practice because the body is an instrument and needs tuning in the same way that musicians care for their instruments. Care of the self is key to maintaining and nourishing the caregiver and his or her relationship with the care receiver.

Ritual reminds the caregiver to take time to replenish—for example, by consciously washing one's hands and saying “I wash away stress,” taking a walk, stating an affirmation at the beginning or end of the day, or by simply breathing deeply and slowly.

Affirmations are positive statements that caregivers can use to improve the quality of their everyday lives. These statements can be thought of as a tool for health and well-being. A classic affirmation is the book “The Little Engine That Could”; think of how the train engine keeps saying, “I think I can, I think I can, I know I can, I know I can.” These words can be used at the beginning of the day with a resident and again at the end of the day. Affirmations are restorative and can be transcendental when offered to someone.

This part of the toolkit can be introduced with a general discussion about whether—and which—affirmations staff use throughout the day, in both their working and personal lives, to get through the day. Affirmations can be copied out of the Bible or from poetry; they can be comedy lines or any other words that offer inspiration. Phrase books can be used. Two of our favorites are “Don't just do something. Sit there!” “The only thing we have to fear is fear itself.” We recommend preparing and having twice as many affirmations as the number of staff members who will be participating in the exercise. Introduced as part of a staff meeting, or just as the conclusion of a change-of-shift report, each person can read his or her affirmation silently, to a co-worker, or to the group. Every person has options. Participants can say their affirmation is for everyone, they can trade their affirmation with another person, or select a new affirmation from the (small) pile.

In recalling the several affirmation rituals we have done, a key component was gathering pinecones; their odor, shape, and sensory elements were a part of the process. Participants seemed to appreciate that someone went to the trouble to find, collect, and clean them for the ritual. The affirmation, written on a 1 × 3–inch card (colored or white) would then be wedged into a crevice of the pinecone and then placed on a desk, by the bedside, on a bathroom shelf—wherever it would be easily visible.

During this ritual, as staff members read their affirmations out loud, one could hear different voices: “Oh, I could use that one!” “This surely gets me through my day, every day.” “So true, so true.” Staff members commented that they would use affirmations more if they posted where they could be seen, used throughout the day, and recalled later with family and friends.

Back to Article Outline

Conclusion 

Social engagement, reduced depression, and a feeling of mastery—outcomes of an ongoing creative arts community-based program for older adults—can reduce the risk factors for nursing home placement.⁵ Ritual is a form of expression that uses a variety of arts (e.g., music, poetry, dance and movement, art, drama) creatively. We suggest that the experience of ritual, for the care receiver and caregiver, is an expression of the concept of locus of control. This theory holds that there are 2 dimensions of control: internal and external. On a single continua of internal–external control, or 2 separate continua, internal control means that personal efforts make a difference; external control means that a person's efforts make no difference, and outcomes are due to fate or are in “God's hands.” Drawing on symbols of personal or universal meaning (and hence, worthiness), ritual restores control. And control is a key component of quality of life.

Back to Article Outline

Resource 

Transitional Keys Web site: www.Transitionalkeys.org

Back to Article Outline

Appendix A 

Ritual: Relinquishing a Driver's License³ 

An array of feelings accompany the psychological shift as an elder goes from independence to interdependence, acknowledging that some freedom and mobility that driving provides will be given up. The challenge is to help elders remain empowered by suggesting ways they can reciprocate with those who offer to fulfill their transportation needs. This is especially important if an elder is reluctant to ask for a ride, whether to the doctor, the store, or elsewhere.

For many older adults, giving up driving and their driver's license is especially traumatic. The driver's license was used for so many more things that just driving: identification when cashing a check, age identification to buy an alcoholic drink, and so on. Often it happens suddenly, with no warning or preparation. If at all possible, plan this ritual in cooperation with family, friends, or physicians so that the pain of loss can be mediated and humiliation is avoided.

Intention 

To prepare the resident (the “elder”) for her or his new status as a nondriver and to set up an alternative transportation plan with the support of family and friends.

Leader 

Staff person(s), family member, grandchild(ren), friend(s)

Resources Needed 

Preparation 

Crossing the Threshold Into the Ritual Space 

Some possibilities:

The Activity 

Some suggestions from Transitional Keys programs of how an elder can continue feeling empowered and valued after giving up driving:

Ceremonial Closing 

Back to Article Outline

Appendix B 

Ritual: Blessing of the Room³ 

Intention: To help the new resident feel comfortable, safe and at home in their new room/ home. Option: To celebrate the anniversary of the person moving into their new room/home.

Leader: Staff person, family member, another resident, a friend

Resources Needed 

Preparation 

The Activity 

Celebratory Conclusion 

At the end, all express good wishes, and refreshments are served.Blessing of the Room 1

Back to Article Outline

References 

1. American Nurses Association . Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Association; 2001;
   • View In Article
2. Myerhoff BG. We don't wrap herring in a printed page: fusion, fictions and continuity in secular ritual. In:  Moore SF,  Myerhoff BG editor. Secular ritual. 1977. Amsterdam: van Gorcum and Co.; 1977;p. 199–224
   • View In Article
3. Sherman A, Weiner M. Transitional Keys [TK]. A guidebook: rituals to improve quality of life for older adults. Dobbs Ferry, NY: Transitional Keys; 2004;
   • View In Article
4. D'Aquili R, Laughlin M. The neurobiology of myth and ritual. In:  Grimes R editors. Readings in ritual studies. Upper Saddle River, NJ: Prentice Hall; 1996;p. 22–28
   • View In Article
5. Cohen E. Executive summary. The creativity and aging study. The impact of professionally conducted cultural programs on older adults. Kensington, MD: The Center on Aging. George Washington University: Health & Humanities; 2006;
   • View In Article