As a RA, I assist or direct residents who need physical or cognitive help with range of motion, ambulation, or per oscam (PO) intake. Difficulties with range of motion are usually sequelae of cerebral vascular accident, but could also result from traumatic brain injury. Difficulties with ambulation can result from cerebral vascular accident, but can also arise from lower extremity arthroplasty, fracture repair, bone or muscular disease, weakness from heart disease, or pulmonary disorders. Difficulties with eating and swallowing, can arise from cerebral vascular accident, but can also be a post-surgical complication from intubation (irritation or inflammation) cognitive deficits, such as dementia or merely a disorder of nearly any of the cranial nerves. I have even helped retrain eating modalities in an individual, who, having been originally admitted and assigned to restorative dining and speech therapy for throat irritation relating to surgery concomitant intubation, presented symptoms of germophobic obsessive compulsive disorder that manifested in rituals that were so intricate and time consuming that this person was at risk for failure to thrive from inadequate caloric intake. As an intake and swallowing coach in restorative dining, I engage residents in conversation, 1) in order to check for unswallowed food by attending to vocal tonal quality and resonance, 2) for cognitive and orientation practice, on occasion these skills need development before they can be deployed upon the task of adequate P.O. intake and nutrition with good swallowing techniques without choking. As a result, mealtime in restorative dining often acts as an analogue to group counseling as is normally seen with mutual sharing, educational, discussion and growth groups.In restorative dining, positive attending is necessary because the action of facial and throat musculature must be observed to identify specific swallowing problems such as pocketing, (the retention of food within the cheeks). Listening is essential because solids and liquids affect the sound of the voice in different manners in different parts of the mouth and throat, and the potential for choking or aspiration can be predicted by listening. Reflecting is also necessary as members can find ways to answer open-ended questions in responses too short to hear specific risk tones of voice. In addition, sometimes one must discuss not only the that of the necessity for chin tucking, small bites and sips, but also the why. On one occasion, a client's therapy regimen completion was dependent on the restoration of his short-term memory, (the etiology is irrelevant) this was expressed more readily in seeming innocuous dinner conversations than in more formal therapy sessions. Newspaper reading and discussion of current events as a part of dinner conversation assists residents to develop orientation skills that have been degraded by cranial surgery. This sort of orientation therapy helped another client to develop the ability to remember my name during the length of a dinner conversation and thus move from inpatient to outpatient therapy. On another occasion all restorative diners were either diabetic or were experiencing post-surgical complications resulting in either temporary episodic or permanent hyperglycemia, in this case, restorative dining therapy became a diabetes survivor's support group, and members benefited from the leader's sharing of experiences surviving and adapting to diabetes.In restorative dining, the ST or the RCM usually does screening by their own criteria, but sometimes it becomes necessary to remove a member from the group either because of disruptive behavior or because of other concerns such as a dementia or other disease process removing the ability to swallow altogether. In the case of restorative dining a screening interview often takes the form of a resident's first meal and as is often the case screening is irrelevant because inclusion in the group is the result of a physician's orders for a speech therapy assessment and new admits often move in at the conclusion of mealtime so that that first meal is often one-on-one between the new resident and the restorative aide.

What is a group? A group is an assemblage of persons pursuing goals through common interactions. (Jacobs, Harvill, & Masson 1988) These interactions may be prescribed or non-prescribed. In restorative dining the modalities of goal achievement is simultaneous individual practice under the auspices of a restorative aide who, in addition to making observations of and reporting eating patterns to the Speech Pathologist. The restorative aide also cues residents to practice safe swallowing techniques, not only giving attention to a group member who has the floor, but also reassuring other members that they still have the leader's attention.Groups whose members are confronted with a common stressor, such as CVA and choking and aspiration risk develop solidarity. (Janis 1972) This is also true of restorative dining. When due to infarctial dementia, a resident presents disruptive behavior, the other diners will act to discourage that behavior, if only by withdrawing into their own task of eating. The member violating the group's norms is not so much sent to Coventry as much as the others may tend to lose their appetite, or concentrate their attention exclusively on eating that they may finish and escape the disruptive behavior. Choking can be a frightful experience as falling can also be. It is required of me by my position that I inspire confidence in those that I help, confidence both in myself and in themselves. Inspiring confidence implies leadership skills even if leadership is not actually part of the restorative process. The effectiveness traits are much the same and compare favorably to self-actualization traits, and Jungian archetypes such as sage or hero. To inspire the trust necessary to stimulate a resident's progress amidst challenges, a swallowing coach, like a leader must be perceived by the residents as being with and for them. This implies openness and awareness.

As openness is often touted as an element of group leader effectiveness, openness to models of group leader behavior from Industrial/Organizational psychology should be accepted as helpful even though the groups in question are working groups instead of therapy groups. Modalities of task achievement and goal orientation should not be that much different despite the pragmatic and/or practical nature of working groups. Indeed, T-groups, systematic human relations training groups, task groups, and learning groups should be fundamentally the same irrespective of the operative personality theory.Individual intrinsicities in work motivation are determined by the individual’s pattern of needs; a need for achievement involves pride in workmanship, sense of accomplishment, and appreciation of challenge. The need for power resembles the controlling impulse of those who, either from self-centeredness, or lack of self-confidence, or feelings of powerlessness are compelled to take matters into their own hands to enhance their sense of security, or to compensate for their inherent smallness of soul, or to compensate for a perceived external locus of control. In a non-pathological sense, a need for power may be a means to the end of accomplishment and achieving goals. A need for affiliation is self-explanatory. (Riggio 2003) Concerning motivation in-group counseling, goal achievement is a factor especially in managed care and rehabilitation. Without motivation, goal accomplishment is problematic at best; in some managed care and therapy settings, some demonstration of progress is essential for continuation of therapy. Ergo an understanding of motivation allows flexibility in therapy modalities in order to navigate obstacles to progress. Alterations in approach can sometimes restore progress when it has become stalled.In health care growth is of primary concern, therefore, growth need strength is a moderator of the job characteristics model in a therapeutic setting; this reflects the aspect that only a client with a desire for change will achieve progress. In other words, a client still attached to their pathology will not work effectively towards health or a stroke victim who does not wish the costs of their recovery to detract from the resources of their progeny might not be motivated towards recovery. The job enrichment strategy can be useful, in some respects, while ineffective in persuading a client to choose life, if that is even a goal, it is routine to give a client some voice in the determination of treatment in respect to rehabilitation. The Equity theory of motivation is generally not applicable to rehabilitation therapy, (as clients more often pay than get paid) but as emotional equity economics applies to relationships, a therapist’s charm may squeeze an extra drop of effort from a client if a client sees an emotional return on their investment in therapy. Expectancy theory presupposes motivation as a complex of variables. (Riggio 2003) Expectancy theory assumes that people are rational. Reasons for therapy, loss, pain, etc. are also reasons for irrationality.Intragroup mutual support can enhance individual achievement. An individual group member, out of their own personality, may act to encourage other members in their achievement. Group interaction can also supply individual social needs.

Restorative dining requires a variety of leadership styles. Addressing an immediate severe risk of choking may require determination of textures, bite sizes and liquid thickness from an authoritarian perspective, but choices of menu content, or beverage types is usually democratic when not laissez faire. While issues of texture and thickness are under the direction of the speech therapist, and cueing to small bites is usually effective, sometimes it is necessary to remove excess bite size from a client's spoon as it travels from plate to mouth, but if self feeding is deficient and a resident needs to be fed with assistance then leadership perforce moves from laissez-faire towards authoritarianism. Since restorative dining is learning and skills building group, it is necessarily leader centered. Group polarization is the tendencies of groups to be more extreme than individuals are. This is especially so where risk is involved, so groupthink might be avoided by introducing individual accountability into group decisions, but again, how is this to be done? What individual is willing to accept responsibility without authority? Groups are more adventurous than individuals are simply because just as a burden shared is a burden halved, a risk shared is a risk halved. Group polarization shows that enthusiasm is additive even if the result of group polarization are an increase in protecting against risk. Group discussion deploys the additive nature of enthusiasm. In group polarization, individual members may fill in the holes in each other's arguments. (Riggio 2003) The types of groups that may present as analogues to restorative dining are mutual sharing groups, educational groups, discussion groups (as in orientation cognitive training, speech training, and attending to vocal cues to choking risks). Mutual sharing groups are like restorative dining because a group of individuals has come together to achieve the same end, and although it is not structured, mutual sharing and encouragement naturally occurs as residents are oriented to and trained in safe swallowing techniques. Sharing one’s feelings about dining and listening to others do so provides a variety of viewpoints, which in their turn provide a baseline of data and a feeling of commonality, even if these feelings discussed are on the relative merits of oatmeal versus cream of wheat or tea versus coffee. The important point is that the group is assembled for the promotion of physical healing, and the commonality of the social atmosphere facilitates that.Education groups are like restorative dining in that education groups meet in order for the leader to impart information; and restorative dining meets that a restorative aide might impart information concerning safe swallowing techniques. Restorative dining resembles educational groups more closely than it does discussional groups. While discussions are an important part of restorative dining, the discussions are more often than not several separate one-on-one discussions between the leader and the different members. Rarely does it happen that one member discusses their problems with a member, other than encouraging someone with less developed skills. Oftentimes due to multi-infarct dementia, members may be barely cognizant of the presence of other members, or they may be aware of others, but incapable of seeing that information as significant, indeed they may need to have their plate rotated in order to recognize the existence of food on one side of the plate as significant.With the possible exception of therapy groups, growth groups resemble restorative dining the most. The purpose of growth groups is honest sharing and listening towards exploring and developing personal goals. Group members address changes in lifestyles such as adapting to post-surgical complications or recovering from a CVA. Even though the personal goals might be as simple as, “advance to thin liquids without signs or symptoms of aspiration’, the exploration, development and achievement are the same or at least an analogous process. Growth groups overlap with therapy groups for prevention issues. Prevention of choking, aspiration, and failure to thrive is the raison d’etre of restorative dining. Counseling and therapy groups come together for solutions to life’s problems. Except that the problems are more specific, restorative dining is a group that comes together to solve specific problems relating to activities of daily living. Therapy groups are similar to both growth and support groups. I contend that restorative is, in effect, a therapy group. In therapy groups, goals are achieved by sharing concerns, both those of one’s own and those of others. In restorative dining, goals are achieved by individual simultaneous practice.The leadership style may depend not only on the intrincisity of individual members but also on the character or characteristics of the group. Educational, discussion, and task groups need a facilitative role for the leader and may actually require directional and focus from the leader while therapy, growth, and sharing could alternatively need either support or confrontation and caring or structure from the leaders.

As in Yoga meditation, wherein one does not fight to control random thoughts, rather allowing them to flow past without fascination or repulsion, accepting emotional reactions without either indulging them or repressing them demonstrates openness and honesty. One must deny prior teachings to deny feelings; this would be equivalent to not indulging the nattering of the one thousand wrathful demons of the Bardo Thotrol. Feelings usually considered negative act like flypaper when fought, attention and energy are diverted from the goals of the group. Ironically, control is achieved by not controlling. It is as the uncarved block of the Tao or as Heraclitus once said, “By changing, it rests.” Awareness allows choice of action; ignorance is swept away with the current.Group leaders who are afraid of their own negative feelings will either be too distracted, detached, or, dare I say it, disassociated to be of any use in helping others. Sympathy and empathy are both derived from pathos, that is to say there must be a foundation of feeling upon which a structure of helping is to be built. Group leaders who are aware of their own values are more likely to tolerate values that are different and are more cognizant of the extent to which their own value system will affect the group.Genuineness is not wearing a mask; genuineness is without pretenses. Genuineness is the result of a stable self-image and estimation of self worth. If one's self-worth is not dependent upon the opinions and words of others then one can self-disclose without apprehension. A leader with genuine self worth can share feelings and reactions as they result from group interactions. Such a leader has no need to choose between repertoires of masks, but genuineness can dispel the masks of the false interpretations of all but the most disassociated. Genuineness does not imply a lack of privacy but merely involves the existential actualization of making purposeful, deliberate choices to share. Leaders who are genuine are free to be spontaneous because they do not need to ride herd on their reactions because they arise from a center that is genuine. A genuine foundation supports the independent development of a stable superstructure. The genuine leader knows when to express negative feelings in order to prevent them from interfering with helping or to discover why they are not transitory. (George, & Dustin 1988)

Genuineness in a group-counseling leader is a reflection of the “authentic existence” of Martin Heidegger. While the inauthentic therapist would merely respond to the current situation, the genuine group leader would proceed out in front of the situation to unconceal a modus of operation that would not only respond to the current problem but also expand to resolve difficulties before they occur. In restorative dining, both approaches are appropriate even if J. P. Sartre would label one as not being in good faith, even if “inauthentic” by Heideggerian standards, for example if a group member is choking, restoring their breathing takes precedence over teaching the mechanics of not choking in the future. Whereas spoon-feeding does not promote the development of good self-feeding ability, in some cases, it may be necessary to avoid failure to thrive long enough for long-term survival to promote the development of self-feeding.

On one occasion, as part and parcel of the nursing process, a resident’s charge nurse wanted information about a restorative diner’s speaking, specifically if the resident’s speech was slurred or tongue was swollen. This resident in particular, was very laconic and would rarely answer an open-ended question with more than three words. I was able to relate incidental details of the resident’s life history to my personal memories of harvesting filberts with my mother as a child. The connection was so tenuous as to be laughable, but I was able to parley that connection into a twenty-minute conversation and acquire the needed information. Later, my colleague ascribed the success to my genuineness. Openness, self-awareness, and genuineness imply an ability to form warm, caring relationships. This ability involves sensitivity and understanding. Sensitivity is both cognitive and emotional. Sensitivity is a normal part of emotional intelligence; it is a more efficient response to group issues. The ability to form caring relationships is essential for instilling confidence in group members. Carl Rodgers made empathy preeminent amongst the triumvirate of prerequisites for effective relationships. (George, & Dustin 1988) In restorative dining, one outcome is that the group leader models empathy in understanding responses for the group and also empathetic responses help clarify communication.This ability arises out of a positive valuation of other individuals. This is also unconditional positive regard. The effective group leader need not fear caring. The effective leader knows that being a caring person does not tattoo them with the label "easy mark". The effective group leader knows that vulnerability is not gullibility; that lack of reciprocity in caring need not be wounding. The effective leader knows that vulnerability engenders trust. The celebration of a group member's progress, no matter how small, not only engenders an enhanced self-image on the part of group members but it also reassures them of the prosocial motivations of the group leader. Self-confidence is awareness of one’s own skills and knowledge helps members attain their goals. Self-confidence is absolutely required for rehabilitation ambulation; a client who is at risk for falling must feel the therapist’s confidence. A group leader’s self-confidence must be felt by the group members in order that order be established and maintained. Awareness of one’s abilities implies awareness of one’s limitations. (George, & Dustin 1988) In that awareness of abilities, awareness of the extent of those abilities is required. When inspiring another to push past obstacles to a new horizon of abilities one must be careful not to tear that envelope by exceeding one’s capacity as a coach. A good leader does not abuse the power of influence, but uses it to channel the focus of members on their tasks. Raising someone up to the pinnacle of their abilities is mutually exclusive with keeping them suppressed in an inferior position of dependency. The therapeutic nature of humor has been established. Indeed, it is a truism and is proverbial, "Laughter is the best medicine." Nevertheless, a too serious view of one's own self-importance disengenders trust as well. People who are pompous are just as proverbially seen as fools. Humor allows a therapist to employ paradox and reductio ad absurdum to facilitate enlightenment. Therapeutic humor is not derisive, but it is positive, upbeat, and grows naturally from empathetic listening. Therapeutic humor forges closer social bonds amongst the group rather than having divisive effects. Laughter allows someone whose disease process has made breathing a conscious process to develop better wind for speech. Flexibility allows the leader to respond to changing conditions within the group instead of forcing the group to conform to a rigid format. (George, & Dustin 1988) Flexibility works hand-in-hand with spontaneousness to allow adaptability both to changing conditions within a group as well as changing from one group to another. Adaptability absorbs new ideas, and develops new modalities from new ideas. Adaptability allows a leader to accept group members taking up elements of direction as their growth progresses. Allowing the group to self-direct enhances the leader’s need to achieve in a way in which a leader’s need to control could never enhance a group’s growth or potential thereto. When a group is trusted, this sense of being trusted facilitates their ability to recognize and move beyond negativity.Self-awareness and self-confidence imply evaluating one’s own effectiveness; security in one's self allows the group leader to criticize their own effectiveness without fear of losing power, control or self worth. A self-actualized leader can objectively assess their own contribution to the group process without needing to paint a good picture or put on a game face. In restorative dining, this translates out as knowing when one's efforts are not as effective as one's colleagues and dropping back to second place for the greater good of the resident. A theoretical approach can apply blinders to a counselor's appraisement of a group-counseling situation, but it can also serve as a map to a group's particular destination of success. In restorative dining, cognitive deficits play a larger but not exclusive role over that of unconscious motives and conflicts. The past experiences that account for behaviors in restorative dining are the sequelae of the event, accident, surgery, or disease process that brought a resident to restorative dining in the first place. (Phares 1982) Rational Emotive Theory has been the most effective guideline in this endeavor. Every aspect of progress is celebrated, providing not only a rational emotive reason for recognizing progress, but also reinforcement for positive progress from the behaviorist perspective. Nevertheless, the primary purpose of these celebrations is to give the resident a sound, logical rational reason to continue hope, rather than to reward progress in a strictly behaviorist sense. In long-term care, a resident's dignity is a primary priority. Ergo, when a resident has already lost some functionality and independence, the feeling of being treated as some sort of lab rat is not only contraindicated, it is definitely counter-productive. (Goffman 1965) However, the discussion, education, and task orientation groups tend away from a theoretical perspective, if only from the focus on getting things done, as in, no one starves, and no one chokes. One on one theories, such as Rational Emotive theory has been adapted to groups. Groups without a theoretical perspective tend to be shallow; however, discussion, education and task groups normally do not require a counseling theory point of view. Albeit, some members are incapable of progressing without extensive cueing and thus doubly unable to help others. Every aspect of progress is celebrated providing not only a rational emotive reason for recognizing progress, but also reinforcement for positive progress, however, the discussion, education and task orientation aspects of restorative dining tend away from a theoretical perspective. Social or vicarious learning theory as a perspective for therapy is wherein; individuals can listen to the recounted experiences of others that are similar to their own. Thusly they can compare modalitiesWhile some informality is inevitable, due to choking and aspiration risk, there must be a limit on informality. The informal nature of synanon groups is inappropriate for restorative dining. (Yablonsky 1988) Should members help each other? Should individual therapy be observed by the group? In a restorative dining setting, this is sometimes necessary and some members are naturally sociable and supportive and underscore the leader’s encouragement. Should rational emotional therapy be strictly followed or should social learning theory be integrated into therapy? Irrespective of theoretical basis, these theories of personality and therapy often come into play, in order to break a lifetime’s eating habits, the mere punishment of choking on a bite too large is sufficient. Thus, a behaviorist perspective can be useful for purely physiological reasons.Restorative dining requires a variety of leadership styles. Addressing an immediate severe risk of choking may require determination of textures, bite sizes and liquid thickness from an authoritarian perspective, but choices of menu content, or beverage types is usually democratic when not laissez faire. While issues of texture and thickness are under the direction of the speech therapist, and cueing to small bites is usually effective, sometimes it is necessary to remove excess bite size from a client's spoon as it travels from plate to mouth, but if self feeding is deficient and a resident needs to be fed with assistance then leadership perforce moves from laissez-faire towards authoritarianism. Since restorative dining is learning and skills building group, it is necessarily leader centered.In restorative dining, avoidant coping strategies manifest as a loss of appetite. Whether the loss of appetite is the physiological result of depression generated by the loss of functionality, or the loss of appetite is the result of avoiding the physiological challenge of eating is irrelevant to addressing failure to thrive. With voluntary loss of appetite, hunger will eventually ameliorate the condition, but if a resident is determined, or the particular disease process has completely degraded the ability to swallow, (except in the case of the insertion of a PEG tube), starvation will result. In restorative dining, avoidance behavior is most often passive experiential avoidance. Active avoidance in this context would more likely be a refusal to come to the dining therapy room altogether than a refusal to eat or otherwise participate once having arrived. Avoidance is negatively correlated with rehabilitation success and positively correlated with depression and anxiety. (Kortte, Veiel, Batten, and Wegener 2009) Dementia and other forms of altered cognition could well be confounding variables as I have observed residents refusing to eat due to a mistaken impression that they have just eaten, whether this is the faulty perception or the result of a faulty apprehension of time, the consequences are the same. Group ambiance and individual member's emotional states change from moment to moment. Member's responses to stimuli are reactions to both internal states and the external environmental gestalt of the group. A layered web of interactions occurs between the individuals and their own selves, between individuals, between individuals and the group, between the group and the leader, and between the group leader and individuals. These interactions occur both verbally and sub-verbally as well as supra-verbally. (George, & Dustin 1988) The group leader must be aware of all these interactions on all levels to channel effectively these interactions to the benefit of the members. Admittedly, this web may well be to large for one mind to hold, but an apprehension of the gestalt of what is going on is possible and occurs nearly every day, else group therapy would have been given up as a bad idea long ago. To observe these interactions, the group leader must live in the member's mental worlds as a participant observer. Empathy is not only required to enter the internal worlds but the limitations of empathy must be recognized in order to maintain the detachment required for objectivity. Ordinarily, people enlist the assistance of groups by delegation in order to circumvent the limitations of the mental function of a single individual. However, the group normative process can work for or against group or individual goals. (Janis 1972) In restorative dining, group members might encourage each other to learn safe swallowing techniques, or they might just as easily compete with each other for the special attention of the RA, thus degrading the efficiency of the dining process for all involved. Short-term affiliation seeking behavior must be redirected to the social process of the group as a whole without allowing the dining process to be subverted by the discussion process.There are advantages of group counseling: 1) sheer convenience, doing several residents’ meals separately means that some one has to wait while being hungry and their food is cooling. 2) The individual learns that they are not alone. A feeling of commonality is therapeutic; groups allow sharing and a format and forum for safely risking openness. Often one group member will be an upbeat attitude person who encourages positive affect in the group. Exposure to people who are succeeding at the same tasks will encourage some people to push ahead. Inability is a contributing factor in negative affect. Groups can provide positive affect support until limitations upon activities can be reduced through training. Belongingness and mutual identification allows the experience of being accepted, groups provide for role-playing. Groups can be analogous to a front wheeled walker or a four-point cane rather than crutches or a wheelchair. Groups are an arena for skills practice and/or the initial practice of new skills. Groups can provide feedback; interaction with a group allows a resident to gain the advantage of a different vantage point. Group feedback is more difficult to dismiss than the advice of a mere individual.

In my career as a CNA, I have measured and documented vital signs, and collected urine and stool samples as needed. As a CNA 2, I have also performed “dipstick” urinalysis and guiac tests. I have monitored, directed, and/or assisted residents with their activities of daily living. These activities include bathing, feeding, grooming, dressing, oral care, and toileting. In conjunction with these duties, I would give such personal and perineal care as needed. I would also assist with lifting, repositioning and walking. I would enter data describing these activities into resident’s records. I also attended to resident’s basic physical, emotional, and social needs by assuring that residents have such personal items such as soap, toothbrushes, and shampoo and denture cleanser as needed. This is an adjunct to insuring that they are bathed, groomed, properly clothed, and fed. These duties could involve escorting residents off ward when assigned, for instance, to beauty appointments, or to pick up by medical transport to off-site appointments.

As a CNA 2, I have also regularly cleaned and cared for peg tube (percutaneous endoscopic gastrostomy) sites, defining that as within my scope of practice as the changing of a non-sterile dressing. While not acting unsupervised, I have performed the discontinuance of Foley catheters as assisting the charge nurse with the change of such. As a CNA 2 restorative, or in everyday parlance, restorative aide, (RA) I employ additional training that I have received in the area of rehabilitation. I work directly with residents in a one-on-one basis to restore or maintain functional skills. I implement restorative programs written by Residential Care Managers, (RCM's) and Occupational, Physical, and Speech Therapists. (OT, PT, ST) These programs include passive and active range of motion, splint or brace assistance, training and skill practice, eating and swallowing, memory and cognition and orientation practice. I assist with O2 therapy. I give treatments, perform tests, carry out procedures, and collect specimens as instructed within my scope of practice. I report and record observations, results of treatments, tests, procedures, and specimens when indicated. I coordinate and cooperate with other staff specifically RCMs, charge nurses and therapists concerning the care of residents.

Notes