Contemplative Play

Last week sat with C during chemotherapy infusion for facilitation of a guided meditation session. : Dx: Apprehension and Anxiety before, during and after with post-treatment stress-induced nausea refractory to Ondansetron and other pharmacologicals. —C said she would like to be able to take home practice for following day.

5.1.13. C stopped by my office on way to treatment today. Reported practice as helpful with lessened apprehension. Probable setting timing of therapy later in day to not disrupt morning regimen at home also had influence. Considering meditation, whether beneficial due to physiological response, or, designated time for gaining clarity of mind to declare her needs without anxious thought — probably a synergistic effect. Anxiety is highly exhaustive as well, so it is likely her energy resources improved as possible associated anxiety decreased. C uses wheelchair with post-polio syndrome. She was interested in discussion of how weightliftimg may be accomplished without weights but rather intentional internal message of tensing aka in place of lb per tension applied in order to support her maintaining physical strength through therapy.

6.10.13. This week C used our time during treatment planning to discuss a phenomenon she discovered. This past Cycle 4 of Bendamustin and Rituximab she experienced very mild post chemo-adverse effect that she referred to as, “somewhat quesey, less than mild nausea.” She attributed her mild upset to an anxiety related, this time, not to apprehension or side effects of treatment, but something else that she calls paradoxical insight:  C had good news this past week. Her CT scan showed a positive response to treatment with a significant reduction in her tumor. During the course of the week, she began to worry about how her life would be if she didn’t die. All that she needed to take care of, how she would care for herself, if her husband, who was 90 and her primary caretaker, was to get sick before her. “Before, when I thought I was sure to die soon,” she described, “I gave myself full permission to live in the moment. Now looking back, I recognize a certain freedom I felt,” she said. “I have practiced meditation for 35 years. There was never a time in my practice as effective in honing living in the present, as the overriding thought, that I could could die within the next month.” C was interested in exploring how she might take what she learned from that imposed period of perceptual impermanence in order to calm, once again, what she described as her overactive mind that tended toward worry and projection. I listened, and asked questions as the many lightbulbs went off in her expressions and dialogue on the true practice of mindfulness and what it means to be present. What an honor, to be in the intimacy of this exploration.

As a developmental segue to a new set of parameters in defining health, Erikson, in the 9th Developmental Stage, refers to Gerotranscendence, or the “shift to a meta-perspective, from a materialistic and rational vision to a more cosmic and transcendent one, normally followed by an increase in life-satisfaction” (E & E, 1997. p.124). Margaret Newman, one of nursing’s foremost theorists, defines health as “Expanding consciousness” (Newman, 2002).  Vollman (2008), describes existential wellbeing as a powerful determinant in health, and Bandura refers to the experience of self-efficacy in older adulthood as, “a larger set of human attributes that provide the capacity for becoming a spiritual being” (Bandura, 2003. p 167).

Aging in our culture has largely carried with it the stigma of degeneration and loss of self-efficacy (vs. other cultures, eg. the role of the elder). The question of, “why am I here, with a body that does not work as it did, with a mind that is not as sharp as it was, but with a spirit that is still searching for understanding, connection and meaning?” (Nell, Drew, Klugman & Jones, 2010) – is a universal theme, especially prevalent in Western culture, in which aging is often seen as either a reflective process or one of loss.

Perceptions of effective coping have a significant influence on wellbeing and health outcomes (Vollman, 2008 & Plante, Bandura, Thoresen, 2007). With the introduction of the palliative precepts declared by the National Coalition of the Palliative and End of Life Care, that convened in 1997, we are still standing before the threshold, asking the question of how we may best promote our patients’ experience of comprehensive care, aka, self-determination, in order to uphold our intention, that wishes are to be  valued and respected. How we, as health practitioners, utilize cost effective resources to facilitate patient’s self-efficacy when faced with complex symptoms and decisions regarding goals for care – how we address loss, and transition, as an opportunity to promote self-recognition and self-efficacy, is determinant upon our ability to utilize our most valuable resource:  the patient and their families.

The article, “Intersection between Geriatrics and Palliative Care: A Call for New Research Agenda” (Goldstein & Morrison, 2005), calls for interventional research that promotes, “psychological wellbeing, spiritual wellbeing, and quality of life” (p.1594). In a report by the National Consensus Project: Improving the quality of spiritual care as a dimension of palliative care (2009), concepts defined are, “Assessing the relief of suffering, forgiveness, and meaning in life.” How clinicians assist patients in navigating self-awareness and/or peace when faced with suffering and paradoxical meaning in life, provides implications for intervention-outcome metrics. Said another way, how we may promote psychological and emotional wellness during challenging transitions in acute care settings, longterm care, hospice, and community aging, requires creative approaches to measuring outcomes for the mainstream integration of compassionate and medical care.

CONTEMPLATIVE PLAY AS MEDITATION: PROMOTING RESILIENCE IN AGING

Self Active Play Pilot: Nine students/Clinical/Geriatrics/LTC/Palliative. Contemplative Play. Using open-ended materials. Two angles: 1)  PRN medication as instrument (may address pain, anxiety, insomnia, depression, i.e.).  Methodology: resident participants are their own controls – indicated by reduction in usage from baseline before palliative QOL intervention and end of 12 weeks – or possibly each session at baseline to measurable outcome following session. Use horizontal graph to show hypothesized plateau with prior trend, or decrease in usage;  2) QOL statements.  Could be data collected for theme building, as well as photographs (Action Research methodology).

Day 1: We had our first day, on Saturday, for 30 minute “relationship building”, aka., self-active play with residents. Afterward, spoke with the students about neuroplasticity and Resilience and wellbeing.  We took a few minutes in post-conference to go around in circle quickly to state 1 word or phrase from the afternoon experience. A common theme was students expressed a deeper connection with their residents: “Saw another side of my patient.”  “At the start my resident said she couldn’t do it. At the end she was smiling saying she was going to give what she made to her best-friend. I didn’t know she grew up on an Indian Reservation.” “My resident who isolates, was talking, sitting in a circle and asked, When are we going to do this again?” It seems the short term experiment was a powerful wellbeing exercise. In the future we’ll take 30 minutes/Saturdays-with a focused exercise of what it means to promote deeper understanding and life-affirming recognition for residents. Students are wakened to, “health as expanded consciousness” (M.Newman), and participate as researchers in a quality of life intervention to address physical, emotional, cognitive, social and spiritual (aka. palliative) gerontological health. Day 1 was a hit. A lot of fun, and inspiring.

Preface to Day 2:

Within the activity, is also student opportunity for observing themselves as researchers and participants. An understanding of “spiritually-emotional intelligence”, or capacity for presence, is experientially understood. The opportunity to be researchers who also collect data and form themes from their facilitated intervention, may encourage enhanced perspective, or capacity for empathy and engagement, aka. S-EI. The idea being, that once students experience the potential for “relationship building”, they can see its value – in (Discuss in post-conference) critical thinking, narration, and story-telling. Out of an i.e.., joyful, nostalgic, or self-identifying encounter for the resident, the students, as observers and participants, gain an awareness of what is both opened and constrained; or, medically speaking, what may surface may be helpful in goals for care. Once experienced by students, when they are professionals in the rut of routine tasks that dictate only 3 minutes to visit, or assess, or assist, those 3 minutes have a reference point, or place of association that knows the meaning of empathic and caring presence.  There was reticence in one student bystander, I imagine her to be surprisingly adventurous Day 2.

Post-conferences, have covered: Day 1 orientation): Broken Heart Syndrome, or Takotsubo: its implication in health as a concept. Students have since been fascinated, and they really get it., Week 2): Neuroplasticity and resilience; introduction as river and riverbed. (These are visual learners for the most part).  Week 3): They identify story-telling, CSAP, narration in wellbeing-intervention with critical thinking connections…open discussion to how case examples may be formed as relevant to symptoms of psychological or physical discomfort. (These students are strongly motivated to fully grasp measurable outcomes – they are a dynamite team to define MO’s).

– Day 2.2.23.13

Day 2:  The context of this photograph is Nina is transcending from words in dementia to a song in a low deep gentle voice that transfixed the room. Nelli is a student who two years ago moved from Armenia. She is listening to Nina begin the anthem rooted in the old country, or Croatia. The surrounding students and residents in interactive play all became quiet, and moved into an inner-reflective, or contemplative self-active play (CSAP) that soaked in this wonderful woman’s spirit.  I too participated. And felt my soul being touched.

Neuroplasticity, Resilience and Contemplative Self-Active Play (CSAP) in Aging: Pilot by 9 Students and a Teacher in Long-Term Care Community College Nursing Program.

METHODOLOGY

Students ask all of their randomly assigned residents if they would like to participate in a 30 minute creative activity in the afternoon, an hour after lunch, in one of the facility’s activity rooms. Some students have 2-3 accompanying residents, some 1, and other students, generally 1 or 2, have treatments or extenuating circumstances that necessitate them being on the floor. Their resident engages with one of the groups or solo play, whichever she/he prefers.

Although we may use many colored open-ended materials, including paint and brushes, each resident has a box of blocks (30 pine wood blocks/box 5 x 5). Data is photographic action research, and includes statements made by students (both researchers and observers of their own experience in CSAP) and residents. The benefit for the students is enhanced experience of “relationship building” and increased cultural awareness of diversity and the marvelous complexity of aging.  The benefit for the residents is creative expression. And an hypothesized avenue to participatory meditation, self-reflection, engaged presence and wellbeing.

The research community worldwide has begun to acquire a plethora of experimental research with implications for increased resiliency, or mindful neuroplasticity, using meditation as a component of contemplative care (CITE). For many persons with depression, or anxiety, or agitation, or boredom, or loneliness, or propensity for isolation, or pain, or insomnia, or restlessness, the entrance to meditation as an activity that promotes resilience, is an impossible challenge to stay still.

Contemplative self active play, in solo and interactive milleu, is observed as a seque for inner exploration within the context of one’s environment. Allowing oneself to just play, without repercussion, judgement, fear or agenda was experientially understood by the students. Students also noted that statements and themes of wellbeing, gathered in data and made by resident participants, opened their eyes to the real people they were caring for.

When the last week of participatory research is complete, students do a secondary data assessment, by looking back into the medpass to see if any difference in prn medication afternoon or evening until following 12pm – 12am – 12 hour chart check (quantitative aspect).

Common themes : statements made by students and residents during and after.

Photographs both alone and with narrative.

Statements made by students: