12/27/11

ST. CHARLES, MO. – Getting elderly patients to talk about their illnesses, their feelings, and their care preferences can be challenging, especially when these people come from a culture where open communication is considered inappropriate or even disgraceful, Diane Heliker, PhD, told her audience at the Pioneer Network annual conference. However, she said that her experience with a communication model used originally in occupational therapy may help long-term care practitioners establish more meaningful connections with their patients.

The Kawa (Japanese for river) model uses the image of flowing water to represent life from beginning to end. Well-being is portrayed as a smooth, unobstructed flow down the river.

Users are asked to draw rocks, walls, bottom features, and driftwood in their river, determined by whether the features impede or enable the flow. The Kawa model thus lets users show how environmental factors and circumstances affect their lives. Rocks are barriers to accomplishing goals or having a satisfying life, walls and river-bottom features are environmental factors affecting the person, and pieces of driftwood are assets or liabilities.

Each individual is then engaged in conversation about these items and what they mean. "The model’s goal is to move or erode some of the rocks and increase the flow of the water to create an optimal state of being," said Dr. Heliker, who is director of education and training for China Senior Care in Bartlett, Ill.

In her experience, Kawa "goes beyond story sharing," she said. "It is a structural way of gathering the individual’s story." It is especially useful for individuals from Chinese and other cultures in which sharing personal feelings with a virtual stranger is considered inappropriate.

"I can’t ask a Chinese elder, ‘Tell me about your life,’ and expect a candid reply," Dr. Heliker said. In fact, that approach actually can cause the person to withdraw. "But this model is something he or she is likely to be comfortable with, and it will tell you much more," Dr. Heliker said.

She offered an example of how the Kawa model works. An elder draws rocks in her river related to her arthritis and the fact that she can’t play with her grandchildren anymore. Now that the occupational therapist understands the problem, he or she is able to find new ways for the woman and her grandkids to play together. By removing "rocks" related to the issues and problems that individuals see as disrupting or inhibiting their lives, practitioners can identify interventions and activities that can improve residents’ quality of life, reduce pain or discomfort, and maximize functioning, said Dr. Heliker.

A New LTC Tool?

While use of this model in long-term care isn’t widespread, Dr. Heliker asserted that it’s a good fit. "The team approach comes naturally with this model. This is a way to provide truly holistic care," she said. "This model may be just what we need to deliver culturally sensitive care."

The model is "a very interesting construct for a holistic, person-first view of care," Al Power, MD, a geriatrician and Eden mentor at St. John’s Living in New York, said in an interview. "The metaphor of the river and its constituents gives a framework for looking at the person’s condition within the larger context of the social realm, personality, relationships, and other factors that can impede medical progress," he added.

Asked to review the outlines of the Kawa model, National Association of Directors of Nursing Administration in Long-Term Care (NADONA) President Sherrie Dornberger, RNC, said she has hope for the tool in long-term care. "When I first started reading about this model, I thought, ‘No way would this work.’ But the more I read and researched, the more I thought that it would be ideal for the direct care staff," she said. "If a hands-on staff member did this Kawa drawing with their own life to see what is blocking their personal flow, they would better understand why their residents are acting a certain way."

Texas-based medical director Dr. David Smith, CMD, stressed that Kawa can’t be used with every elder. "The model requires the elder to have a pretty intact ability to think in the abstract – a cognitive skill that may be lacking in those with life-long low IQ, with minimal education, or with cognitive impairment or dementia," he said. "A caregiver using this model will want to know the elder’s ability to think in the abstract, or you may be fooled into believing you are getting profound self-disclosure when you’re really just getting drivel."

For more information about the Kawa model, see www.kawamodel.com.

Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, Pa., and a communications consultant for AMDA and other organizations.