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Module #1
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Reinforcement

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This is Learning Module #1. It provides you with the P-R-I-D-E Method of positive reinforcement to increase your residents' independence. A note here about terminology: for the sake of brevity, I will use the term resident; however, you may use the word tenant, client, consumer, customer, or a similar term. So don't let the difference in terminology side-track you from hearing the content of the learning module.

♦ Activities of Daily Living
The abbreviation ADL stands for Activities of Daily Living. If you have never had a job in health care before, the term ADL is probably foreign to you. Actually, the term itself says it all: Activities... of Daily... Living...

Directed Self-Reflection #1: What does ADL stand for? To select and enter your answer go to Test Question #1.

Some examples of activities of daily living are... bathing,. showering, eating, washing your face and hands, brushing your teeth, and combing or brushing your hair.

Directed Self-Reflection #2: Give three examples of ADLs? See above

Why is Activities of Daily Living independence important? You may be thinking "here is an entire course that focuses on increasing ADL independence... why is independence so important?" The three basic goals of an Assisted Living Facility are to maintain a resident's independence, dignity and choice.

Directed Self-Reflection #3: The three basic goals of an Assisted Living Facility are to maintain a resident's what? See above

Think about independence and what it means to you. Think about how your life would be if you had to depend on someone to wash your face, brush your hair, or even to eat. When you got ready for work this morning, you did all of the these on your own. However, say you had fallen the day before, your arm is stiff, and you can't move it above your shoulder. Now you have to go to work. How are you going to get your hair brushed? Who is going to do it? How would you ask them? What would be their attitude? Don't they have responsibilities and tasks to do in the morning as well?

If you live alone, would you have to ask a neighbor to brush your hair? Now, your lack of independence to do this one simple Activity of Daily Living, brush your hair, suddenly affects the start of your whole day. How do you feel? Frustrated? Angry? Sad? Depressed? You probably wouldn't feel much like going to work. Maybe you'd

Now place yourself in one of your resident's shoes for a minute. Let's say you have a resident, Effie, down the hall in room 201. She's had a stroke and she cannot raise her hand above her shoulder. She cannot brush her hair. How do you think Effie feels? Frustrated? Angry? Sad? Depressed? Maybe she feels like staying in her room and withdrawing, sulking, and feeling sorry for herself, and doing less and less...

Directed Self-Reflection #4: What are two common reactions to loss of ADL independence? Test Question #2.

If there were something you could do to help Effie not only use, but increase the use of the abilities she has, how do you think that would make her feel? Well, just think back a minute about your sore arm... lets say you move your arm a certain way and the soreness is magically gone. Now you're able to brush your hair independently and are no longer dependent upon others. How do you feel? Happy? Elated? Confident? Competent? Good about yourself? Successful?

Well, the same applies to Effie. The more she is able to do for herself independently, the better she feels about herself, and the more things she feels like doing for herself. So, increasing ADL independence becomes an upward spiral of independence resulting in a general positive outlook on life. That is one reason why your Assisted Living facility focuses so much on staff not doing for residents, but helping residents do for themselves. They want to create this upward spiral of independence.

Now that you understand what ADLs are and why independence is so important, let's spend the remainder of this tape giving you a tool to increase resident independence. This tool is called positive reinforcement. What is positive reinforcement? Well, a simple definition of positive reinforcement is something that you say or do to get a certain behavior to increase.

Directed Self-Reflection #5: Positive reinforcement is something that you say or do to get a certain behavior to do what? See above

♦ The PRIDE Method of Positive Reinforcement
Now let's get back to Effie. If she has mentioned to you that the doctor wants her to try to use her arm as much as possible, you might encourage her to brush her hair. You might use what I am going to outline for you, the pride (PRIDE) method of positive reinforcement.

In this particular module, you're not only learning a technique for on-the-job, but a technique to use at home too. If you have children or a significant other at home, and you want them to continue doing something that they are doing right, washing the dish or picking up after themselves, this technique works here too.

The essence of the technique is, when someone is doing something that you want them to continue doing, whether it be a resident in the facility, or someone at home, to encourage or reinforce that behavior, you say something like "good, great, good job, or thank you." Of course, I know you've done this in the past, but sometimes your positive reinforcement backfires, and the receiver ends up doing less, rather than more. Why? Well, you're about to find out. Here's part of the answer:

Let's go back to Effie's hair brushing for a minute. How do you think she would feel if she had been brushing her hair for the last month independently, and you walk into her room this afternoon and say, "I'm glad to see you are brushing your hair without any trouble." Or, what if Effie never has had a problem brushing her hair since being admitted to your facility?

What kind of message does your comment give to her? What do you think she would say to you out loud or to her self? Probably something like, "Gee, I've been brushing my hair all along. Why is it so special now? Didn't she notice before that I'm able to brush my hair myself? I guess this staff member has me confused with someone else and really doesn't know me." So, now how does Effie feel? Happy and confident to do more? Or sad, confused, and unimportant? As a result, your positive reinforcement, which was intended to increase independent behavior, may become a negative reinforcement and actually decrease the behavior.

The same holds true for your children or significant others. If for the past week, by some miracle, they've been doing an extra special job of washing the dishes or picking up their room, hoping you'll reward them. Then one day they decide to slough off and do a half-way job. Today when you get home, you decide to try positive reinforcement and say, "Gee, your room (or the dishes) look great." Chances are they, like Effie, will be confused, perhaps feel unimportant, and feel like you really don't know what is going on with them.

♦ P = Personalized
So let's establish some ground rules for your positive reinforcement. There will be five steps or rules to this method. To help you remember all five, just remember the word pride. PRIDE: Each letter will help you to recall one of 5 techniques to make positive reinforcement work for you. The "P" stands for personalized.

Your first rule is: Your reinforcement or compliment needs to be personal or individualized to the receiver, whether it is a resident in the facility, or a child or significant other at home.
Directed Self-Reflection #6: "P" in the PRIDE method stands for what? See above?

And incidentally, with your children you might say, "Wow, you even put the casserole dish to soak. Thank you. That makes it easier for me later on."

♦ R = Real
In summary, the P stands for personalize or individualize your comments or compliments. The second key to making the PRIDE method work for you is the R in Pride. The R stands for real. You have to be real or sincere. In other words, you have to believe that Effie is doing a better job of buttoning, Henry rising from the chair, or Maude washing her face. Or, as in the case of your children or significant other, doing the dish. If you don't really believe your compliment yourself, chances are it will be reflected in your tone of voice, your facial expression, and even in the way you stand or move your body.

Directed Self-Reflection #9: The "R" in the pride method stands for what? See above

Directed Self-Reflection #10: If you are not sincere, it will be reflected or show in what three areas? Test Question #4.

Regarding sincerity or being real, you'll know exactly what I am talking about when you watch a poorly produced TV commercial, usually the ones done by local businesses. A good example in my area are car and appliance sales ads. They say that their cars or appliances are great, and that they have the best prices in town, but there is just something about the way that they say it which makes it not believable. The whole commercial comes across like a bunch of phony, insincere, hype. So, in the past, if your compliments have backfired, maybe they were personalized, but you were not sincere.

Regarding your compliment as a means to increase your resident's ADL independence, find a piece or a part inside of you that really believes your comment.

If you can't feel good or right about what you are saying or if it just doesn't seem right to you, to provide and environment for resident success, keep looking and observing the resident until you find an ADL accomplishment that really strikes you as deserving. Then, make your comment genuinely enthusiastic because it's

♦ I = Immediate
The P stands for personalize or individualize, the R stands for being real or sincere, the I in our PRIDE method to increase ADL independence stands for immediate. I think this one is pretty self- explanatory. When you see a resident or your children doing something worthy of a compliment or positive comment, give it immediately. Can you think of a time in your childhood or adult life when you have really worked for something and the compliment came much later after the fact or not at all?

Directed Self-Reflection #11: The I in our PRIDE method to increase ADL independence stands for what? See Above

Now that you have your situation in mind when your accomplishment went unnoticed, how did you feel? Unhappy, unimportant, frustrated? Now let's think about the Effie, Henry, or Maude in your facility. Let's take Effie for example with her button. She really has been struggling with her stiff fingers lately. You walk into her room and just before this she figured out the knack of getting it through the hole. This time she pushes the button through with little effort. You observe this, and are aware that this is a major accomplishment for her.

So you say, "Wow, Effie, that's great! You did that button in nothing flat!" How does Effie feel? Well, she probably feels the way you would have felt if after making a special meal, someone would have said, "What a great meal! Thanks for the effort!" You feel on top of the world. Like a winner, good about yourself. So the "I" in PRIDE stands for immediate. When you compliment or reinforce immediately, it has much more impact at the time.

♦ D = Direct
"P" is for personalize, "R" is for real, and "I" is for immediate. The "D" in the PRIDE method of increasing ADL independence is the word "direct." Be very direct or specific with your comments, rather than being vague or general, rather than just saying, "good or great." It means much more if you use the person's name and state specifically what it is you are complimenting. The resident needs to know exactly why he or she is receiving the compliment. Here's how this works. Let's look at a different set of ADLs and how the "D" of being direct would apply.

For a resident that needs assistance in and out of the shower, you might say, "Mary, good job! I barely had to help steadying you at all getting into the shower." For a resident who needs hygiene assistance you might say, "Ernie, great, your hands seem much steadier brushing your dentures today." For a resident that needs structuring and setup help with dressing, you might say, "Elizabeth, oh great, you have already chosen the dress you want to wear today."

Directed Self-Reflection #12: The "D" in our pride method of increasing ADL independence stands for what? See above

Directed Self-Reflection #13: Your resident needs to know exactly what? Test Question #5.

♦ E = Express Frequently
"P" is for personalize; "R" is for real; "I" is for immediate; and "D" is for direct in our PRIDE method of using positive reinforcement to increase ADL independence. So what does the "E" stand for? Express frequently. Don't be stingy with your positive reinforcement. It doesn't cost anything. Think about how good you feel when you get recognized for your effort. There is a saying, "What goes around comes around." By putting a smile on one of your residents' faces, by expressing to him or her frequent compliments that are personalized, real, immediate and direct, you end up returning their smile with one of yours. As you interact with other residents and give more PRIDE positive reinforcements, it becomes kind of like a chain reaction. So the "E" stands for "express positive reinforcement frequently."

Directed Self-Reflection #14: What does the "E" stand for? See above

The question is "why don't we give positive reinforcement more often?" We become busy, and so focused upon doing things for our residents that we forget to notice what they do for themselves, and don't take time to compliment, encourage and reinforce the abilities they do have.

So, remember, in Assisted Living the goal is to maintain a resident's independence in as many areas as possible, for as long as possible. Don't do something for a resident that he or she could do for themselves. Yes, it is quicker to put the soap in their hand rather than stand there and wait while you watch them fumble. However, by doing this for them, you deprive the resident of the opportunity to experience a feeling of accomplishment, success, and raised self-esteem. When you say, "Great! You got the soap in the clothes yourself. I knew you could do it," this gives them confidence in their own independence.

Directed Self-Reflection #15: What is one reason that staff do not use positive reinforcement more? See above

So slow down, watch and see what the resident truly needs assistance with before helping.

When you see a behavior, whether it be a resident zipping a zipper independently or your child doing his school work without being told, positive reinforcement will increase the chance that the behavior will continue, especially if you use the method outlined here by thinking of the word "pride."

♦ Summary
In summary, "P" stands for personalize. Observe first, then make sure your compliment is given for a behavior which the receiver may view as worthy of a compliment. "R"stands for real. Be real. It's important that you mean what you say, and are sincere. "I" stands for immediate. Give the compliment at the time you observe the behavior. Better late than never is fine, but complimenting at the time is much better. "D" stands for direct. Be direct with the resident and very specific about what you are complimenting. Don't leave him or her guessing as to what you mean by "great job." "E" stands for express. Express praise and compliment frequently.

As stated at the beginning of this tape, you need to have a working knowledge of the techniques presented on positive reinforcement. This is necessary in order to take action on improving the quality of your residents' lives. That is what this Learning Module and entire series is all about --taking action. You now have what you need to be successful. You have just been provided with very concrete, specific examples of how to use positive reinforcement to increase your residents' ADL independence ... the rest is up to you. The next Staff Training Module, two, deals with instruction.

Update
Deep Learning, Reinforcement Learning,
and World Models

- Matsuo, Y., LeCun, Y., Sahani, M., Precup, D., Silver, D., Sugiyama, M., Uchibe, E., & Morimoto, J. (2022). Deep learning, reinforcement learning, and world models. Neural networks : the official journal of the International Neural Network Society, 152, 267–275.

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

Bordne, S., Rietz, C., Schulz, R.-J., & Zank, S. (2020). Behavioral and emotional quality of life of patients undergoing inpatient geriatric rehabilitation. Rehabilitation Psychology, 65(3), 299–310.

Harris, J. A., Kwok, D. W. S., & Gottlieb, D. A. (2019). The partial reinforcement extinction effect depends on learning about nonreinforced trials rather than reinforcement rate. Journal of Experimental Psychology: Animal Learning and Cognition, 45(4), 485–501.

van Haaren, F. (2015). Automatic negative reinforcement: Its possible role in problem behavior with treatment implications. Behavior Analysis: Research and Practice, 15(3-4), 161–170.

Differential versus differentiated reinforcement. Behavior Analysis: Research and Practice, 17(1), 98–100.

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Module 1 - Course Manual (Positive Reinforcement)
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