ADVERTISEMENT
Engaging Nursing Home Residents in Meaningful Activities
The quality-of-life model that we subscribe to recognizes that having opportunities to choose, especially from among meaningful options, can significantly influence a person’s sense of well-being.1,2 Correspondingly, cultural and regulatory changes in recent years have sought to make nursing home life more akin to the life residents enjoyed while living independently in the community.3,4 Attention to relationships, resident preferences, and lifestyle patterns now often predominate over safety, management, and treatment issues.5 This shift in the philosophy of care for nursing home residents is commonly referred to as culture change. To individualize the nursing home experience for residents—an important pathway to a better quality of life—it is crucial to offer meaningful activities that reflect their preferences6-8 and to encourage them to explore and choose from among those options.9 Many individuals transitioning to long-term care (LTC), however, experience a narrowing of choices for meaningful activities,10 especially in facilities where care staff lack information about residents’ preferences.11,12
_______________________________________________________________________________________________________________________________________________________
Related Content
The Use of Commercial Health Video Games to Promote Physical Activity in Older Adults
DOES MENTAL AND PHYSICAL ACTIVITY PROMOTE COGNITIVE VITALITY IN LATE LIFE?
______________________________________________________________________________________________________________________________________________________
A study of 135 LTC residents found that they were generally dissatisfied with the level of control they had over important choices in daily routines, in their ability to make purchases or use the telphone, and in excursions.13 To assess the quality of nursing home care, a national panel of nine experts identified quality indicators from focus groups, interviews with residents and families, and a literature review, and they rated these indicators using a modified-Delphi panel process.14 Inadequate choice and lack of control over daily activities were consistently noted as concerns. Instituting preferred daily life activities was among the recommended indicators rated as feasible to implement and measurable by direct observations of care, with participation in specific activities identified as a potential indicator as to whether preferences have been met. A grounded analysis of focus groups for caregivers and dementia subjects in eight countries reported that “choices” was the most common suggestion for improving quality of life.15 Thus, residents’ quality of life can be improved if care staff are able to discern residents’ preferences and offer them a selection of personally meaningful activities.
Currently, residents’ choices with regard to mealtimes receive the most attention.16,17 Reimer and Keller16 identified choices regarding food service as one of three areas residents considered meaningful,leading to a recommendation that direct care workers be trained to improve person-centered mealtime care. Expanding the range of syntonic choices well beyond activities and meals, even as far as end-of-life directives,18 can preserve residents’ sense of autonomy and preserve quality of life. A sense of autonomy promotes health and well-being at all ages,19 and residents can and will benefit from feeling their input can change their surroundings in a meaningful way.20
One way to identify residents’ activity preferences might be to take a systematic narrative history of activities that the resident enjoyed prior to admission. Gathering information about residents’ desired activities can facilitate the ideal goal of recreating those opportunities or a reasonable goal of devising comparable options. The attainment of either goal represents successful re-engagement in prior activity preferences (PAPs). In this article, we discuss our approach, which involved (1) directly interviewing residents about their PAPs and available choices; (2) identifying health-related or contextual obstacles to engaging in PAPs; and (3) working with residents and staff to develop novel interventions to re-engage residents in PAPs.
The Interview Questionnaire
To assess residents’ PAPs and identify obstacles preventing them from engaging in desired activities, we developed a structured interview questionnaire (Table). The questionnaire, which is divided into four sections and takes approximately 30 minutes to administer, incorporates validated items from the CLIN-CARE assessment12,13 and original items generated by our team. The objectives are to identify residents’ interests, the ways in which health impedes their activities, and any resident-specific goals or desires.
The first portion of the interview addresses nine categories of health-related obstacles—health in general, memory, energy, pain, mobility, fear of falling, hearing, sight, and shortness of breath—as they relate to a resident’s ability to “do the things he/she wants to do.” One point was assessed for each positive response, with the total points indicating the “restriction score” (ie, a “yes” response to five of the nine restriction questions produces a score of 5/9).
The second section seeks to identify activities with personal significance to the resident before and after institutionalization. Residents are asked about activities they “enjoyed the most” in recent weeks, those they enjoyed the most shortly before becoming an LTC resident, and those they enjoyed the most 5 to 10 years before entering the nursing home.
In the third part of the interview, residents are asked about a comprehensive range of activities, to help them identify activities previously enjoyed in which they are no longer able to participate. Activity categories included are games, reading, arts and crafts, gardening, culinary arts, religious activities, cultural activities, new technology, communications, shopping, music, pets, exercise, television/movies, sports, travel/excursions, driving, socializing, dancing, photography, volunteering, and classes.
The final section attempts to elicit goals or activities the patient finds meaningful, using an open-ended prompt: “If your health was not an issue, is there anything special that you would want to do in the next 6 months?”
In March 2009, our team approached residents of our 125-bed skilled LTC facility in the Bronx, NY, who were identified by nursing home staff as cognitively intact and able to indicate their preferred activities. We administered the questionnaire to 11 residents (age range, 57-95 years) who expressed interest and provided informed consent; five respondents were men. Each interview took 25 to 45 minutes. In every case, the interviewer was able to identify one or more PAPs and direct obstacles that hindered the resident’s ability to engage in PAPs. The obstacles most frequently cited were lack of energy, limited mobility, pain, memory or health problems, worry about falling or injury, lack of materials, and lack of opportunity.
Continued on next page
Generating Interventions
To generate interventions that would be effective at re-engaging the residents and feasible for the LTC facility to implement, we assembled an interdisciplinary team that included the facility’s executive director, activities coordinator, nursing staff (registered nurses or certified nursing assistants), and physical therapists. A member of the research team would present a summary of each resident’s interview, detailing his or her PAPs, obstacles, and any significant preferences the resident had expressed. The interdisciplinary team would consider the resident’s responses, the staff member’s knowledge of the facility, and the resident’s limitations in generating an individualized plan for engaging the resident in meaningful PAPs.
Guidelines required proposed interventions to be safe for the resident and others and reasonable to implement and support at the facility. The team often had to be creative in finding solutions that would enable a resident to circumvent health or contextual impediments and re-engage in an activity that had personal significance. For example, many residents expressed a desire to travel but were unable to do so. The facility arranged a video travelogue series with themes like “a trip to Ireland,” which the residents could watch and discuss, attempting to simulate as closely as possible the experience of traveling abroad. The nursing home staff assumed clinical responsibility for implementing the interventions and documented steps taken to facilitate re-engagement in PAPs.
Follow-up was set for 6 months, at which point efforts had been made to engage each resident in PAPs according to his or her specific plan. At the 6-month mark, one resident had passed away; the remaining residents were re-interviewed to assess the effectiveness of the interventions in facilitating residents’ engagement in PAPs. The majority of residents (8 of 10) indicated that they were re-engaged in the targeted activity. Efforts to re-engage the remaining residents continued, with the staff expressing interest in expanding the program to include additional residents.
Case Reviews
The following contains a synopsis of the interview, plan, and 6-month outcomes for each resident who took part in the study.
Case 1
Prior to institutionalization, this 95-year-old woman enjoyed playing cards and bingo with friends, “talking politics,” reading books, listening to operas, playing golf and ping-pong, and drinking beer. She wants to learn new things about politics.
Obstacles: Restriction score 9/9. She indicates that marked visual and auditory impairment, a lack of energy, and “health problems” interfere with her ability to pursue desired activities.
Plan: Enable her to participate in familiar games by partnering her with a volunteer or another resident. Encourage her to participate in social singing events, supply music and listening books on tape for in-room use, and provide passive physical therapy to improve function.
Follow-up: She now participates in games and social activities with a new friend. With staff encouragement, she takes part in discussions of current affairs with student volunteers from local schools. She is not interested in accessing music and books on tape in her room and was found not to be a candidate for passive physical therapy.
Case 2
This 81-year-old man had previously enjoyed travel and would like to drive to Florida. He also enjoyed seeing plays at the theater and listening to live and recorded jazz music.
Obstacles: Restriction score 4/9. His knee pain and fear of falling limit mobility, and he lacks opportunities to attend live jazz or theatrical performances.
Plan: Foster participation in group travel outside the nursing home and/or group activities that simulate travel (ie, videos and discussions), and provide jazz music tapes and videos and opportunities to attend stage productions.
Follow-up: Jazz music tapes and a radio were provided. He has also become more involved in social activities and enjoyed a boat trip with a small group of residents. He is participating in the travelogue group at the nursing home.
Case 3
This 87-year-old male resident expressed a desire to go outside and enjoy fresh air; running outdoors was a favorite activity prior to admission.
Obstacles: Restriction score 1/9. His limited mobility (he uses a walker), cold weather, and no reason to go outside interfere with his pursuit of this activity.
Plan: Provide structured activities that encourage him to be outdoors (eg, yoga, stretching, drawing) and possibly an opportunity to be a spectator at a running event.
Follow-up: The facility arranged for a local student and track team member to visit the resident; the student visited several times, and the resident enjoyed their conversations. He also took part in a 5-month exercise program at the nursing home that was run by students from a local school.
Case 4
Case 4 is a 92-year-old woman who used to enjoy handicrafts, such as sewing and embroidery, and liked polishing silver, jewelry, and furniture. She also enjoyed singing in her church choir.
Obstacles: Restriction score 8/9. She reports shortness of breath, lack of energy, and vision problems. She lacks the materials to do craftwork, and vocal cord problems preclude singing. Diabetic peripheral neuropathy also limits her ability to participate in these desired activities.
Plan: Involve the resident in craft activities and have occupational therapy evaluate her ability to safely perform sewing and polishing activities.
Follow-up: Despite staff encouragement, she has not shown interest in resuming any of her previous handiwork activities. She has expressed interest in polishing activities, but does not pursue them when offered. She has started to attend music listening activities, and it was recommended that she be invited to attend choral recitals.
Case 5
This resident is an 85-year-old woman who would like to travel. She also expressed missing partaking in activities at her Catholic church.
Obstacles: Restriction score 4/9. Back pain, disinterest, lack of energy, and limited availability of Catholic religious programs limit her engagement.
Plan: Encourage her to participate in group activities that address specific interests (eg, books, Catholic-related activities, volunteering, and travel).
Follow-up: A new rosary group has been formed, which she attends regularly. She has resisted encouragement to participate in nursing home–sponsored trips, stating that she only wants to go places with her daughter. It was recommended that the nursing home staff continue encouraging her to participate in the travelogue group and
discussions.
Cases continue on next page
Case 6
This 83-year-old woman reported enjoying outdoor gardening, feeding birds, reading, and visiting with friends and family.
Obstacles: Restriction score 2/9. Lack of energy and difficulty navigating the grass on her wheelchair make outdoor activities difficult.
Plan: Provide an area of soil reachable by wheelchair and outdoor gardening supplies. Offer small group activities involving her areas of interest to enhance socialization.
Follow-up: She has been provided with books and is an avid reader. She enjoys caring for potted plants in her room. Although she has not shown any interest in wheelchair-height gardening outdoors, it was recommended that staff continue encouraging her to try this activity.
Case 7
The youngest participant in the study, this resident is a 57-year-old man who has always wanted to travel to India, South America, and Ireland. He previously enjoyed being a lecturer on religion.
Obstacles: Restriction score 4/9. Limited mobility, pain, and fear of falling due to his “difficulty getting around” hamper his ability to take part in desired activities.
Plan: Provide assistance in locating and using travel videos and Websites, and encourage social activities that address his interests.
Follow-up: He now has a computer, has received assistance with its operation, and uses it all day to visit travel Websites. He has set up a Hindu altar in his room, which has stimulated discussion (sometimes negative) with others, but it is a source of enjoyment for him. He attended a play at the local college, watches travelogues on television, and takes part in a television travelogue group activity at the nursing home.
Case 8
This 75-year-old woman previously enjoyed traveling, outdoor gardening, and participating in a book club.
Obstacles: Restriction score 6/9. Poor health, limited finances, lack of gardening space, and limited availability of books inhibit her pursuit of desired activities.
Plan: Involve her in planning and participating in group activities of interest, including gardening, cooking, volunteering, using the computer, and attending lectures.
Follow-up: She has been enjoying outdoor gardening with other residents. She has also enjoyed taking part in a Girl Scouts reading group, which fits well with her teaching experience. She has been watching political activities on television and participates in the travelogue group. Staff will encourage her to help plan for an outside speaker to visit the nursing home and address current political health issues.
Case 9
Case 9 is a 76-year-old woman who wants to travel and participate in outdoor gardening, Catholic services, and volunteer activities.
Obstacles: Restriction score 4/9. Health problems and limited opportunities for involvement in Catholic activities limit her engagement.
Plan: Provide assistance with outdoor wheelchair-height gardening and encourage formation of a rosary group and book club to allow her to pursue Catholic activities.
Follow-up: Resident was deceased at 6-month follow-up.
Case 10
Before becoming an LTC resident, this 73-year-old man enjoyed watching baseball (especially the Yankees), Catholic activities, and group activities.
Obstacles: Restriction score 4/9. He has vision problems and uses a motorized wheelchair, which limit his mobility.
Plan: Involve him in baseball-related activities, such as attending games and lectures and watching games on television with others in a communal location. Encourage him to participate in planning group activities, including a rosary group and lectures.
Follow-up: The resident recently attended a Yankee game with his family. He regularly attends the newly formed rosary group and Catholic masses. He also participates in resident council meetings and is a floor representative, responsible for reporting and helping to resolve resident problems. He has expressed interest in political activity and will be encouraged to attend future lectures by visiting speakers.
Case 11
When this 90-year-old man lived in the community, he loved cooking, reading cookbooks, and shopping for cooking supplies. He also enjoyed keeping potted plants and using his computer.
Obstacles: Restriction score 4/9. He has mobility issues (wheelchair-bound) and lacks materials and opportunities to cook.
Plan: Provide potted plants for his room, bring his home computer to the nursing home, encourage wheelchair-height outdoor gardening, and involve him in group activities related to his interest in cooking.
Follow-up: He now has potted plants in his room that he enjoys tending. He declined an invitation to participate in outdoor gardening with other residents. He has been provided with cookbooks, which he enjoys. His computer is running, and he uses it regularly to e-mail his grandchildren. He will be invited to participate in a group cooking activity.
Discussion
Through a 30-minute interview process, we were able to efficiently and systematically identify residents’ PAPs and the obstacles limiting their engagement. All nursing home residents we interviewed identified activities they had previously enjoyed but from which they had become disengaged due to health-related obstacles or assumed limitations of the environment. Providing this information to the LTC facility’s interdisciplinary team allowed the team to develop and execute a plan specific to each resident, which resulted in the creation of several new structural innovations that increased choices for many residents, such as the formation of a rosary group and a travel-focused video and discussion group and the designation of space for group cooking activities. Nearly all of the study participants demonstrated re-engagement.
We also found that residents were able to exercise their autonomy in unexpected ways, such as by positively influencing changes in their environment. Suggestions and comments from the residents interviewed led to small but meaningful changes at the nursing home, such as the installation of a fish tank in the great room, the provision of more potted plants in residents’ rooms, and an evaluation of the physical therapy kitchen for use in group cooking activities. While these changes were small, the fact that they incorporate residents’ choices into nursing home life represents a fundamental change. The positive response from facility administrators tells residents that the staff and administrators truly value their input.
Initially, this unfunded project was designed to run for 6 months for each resident interviewed, which was the amount of time covered by the Institutional Review Board. Our experience demonstrates the intervention’s significant potential for achievement, and through extended collaboration with the nursing home, we hope to expand the intervention and observation period.
Because this was our first test of a new, semi-structured approach to eliciting residents’ activity preferences, we decided to interview residents identified through consultations with care staff as cognitively intact. Although the study is limited by the small sample size and the exclusion of cognitively impaired residents, we believe we have nevertheless adequately demonstrated the utility of our process and that it may be amenable for use in the broader population of nursing home residents, most of whom have cognitive impairment or communication difficulties. Kane21 has emphasized that “many nursing home residents, including those with substantial cognitive impairment or major communication difficulties, can report on their quality of life if the trouble is taken to ask them and listen to their answers,” a position supported by other researchers.22,23 Having demonstrated the utility of our instrument, we intend to broaden the scope of our research to include cognitively impaired persons.
Although we did not invite family participation in the interview portion of the pilot study, it may be highly important to do so in any expansion of the study that includes participants with difficulties in cognition and communication. Families could provide information about these residents’ past activities and current interests. We did find that family members helped provide materials, such as potted plants, music players, books, and personal computers, to facilitate the resident’s engagement in activities. Family involvement to facilitate communication and diminish provider burden should be encouraged as long as it does not infringe upon the resident’s autonomy.
Continued on next page
One of the most promising aspects of this study was the positive reception our objectives and suggestions received from the facility’s administration and nursing home staff. It was clear that the staff and administrators wanted to provide more personally relevant activities for their residents, yet lacked the information and resources to do so.
We considered full collaboration with nursing home staff a priority, anticipating that facility buy-in would be a powerful force for adopting and sustaining this innovative approach to re-engaging residents in their PAPs. Prior to beginning the study, we held several meetings with the executive director and the activities director to explain the study proposal and interview instrument and to clarify the study plan. It was agreed that if the study results were promising, volunteers or staff could then administer the interview under the direction of the activities director and that coordination of the activities would become the responsibility of the activities department once the study ended.
At the 6-month follow-up point, the facility staff reported having made efforts to engage all interviewees in the designated activities. Some initiatives were implemented and proved wholly successful; those that had not yet been implemented were placed in a continuing intervention category. However, several residents were no longer interested in activities for which they had previously expressed a desire, whereas others were interested in only one aspect of a particular intervention. For example, two residents who had expressed an interest in gardening were content to tend potted plants in their rooms and to watch outdoor gardening activities, but declined to participate in wheelchair-height gardening outdoors. This highlights the importance of individualizing re-engagement goals for each resident and maintaining flexibility. Some residents remained interested in an activity that was made available to them, but elected not to participate for other reasons. For example, one woman withdrew from the group shopping activity because she felt it would undermine her relationship with her daughter, who normally did her shopping.
Conclusion
Our study demonstrated that when provided with the right information about residents’ PAPs, nursing home staff and administration are highly capable of generating novel ways to use existing resources to address these preferences. This demonstrates that the absence of personalized activities available to residents is attributable not to a lack of resources, but rather to a lack of information. Our brief, easy-to-administer directed interview could help remedy this problem, offering an avenue for residents to express their desires without consuming excessive time on the part of the staff. The responses supply nursing home staff with a well-developed picture of the residents’ past and current activity preferences and guide them in providing access to previous or substitute activities, taking potential or actual resident limitations into account. In the aggregate, data can be used to restructure the menu of group activities, encompassing a wider range of residents’ preferences. The ability to provide residents with activities specific to their preferences and past experiences represents a vast improvement in personalization of care.
The authors report no relevant financial relationships.
Mr. Port is a medical student III at Weill Cornell Medical College, New York, NY. Dr. Barrett is professional geriatric care manager, and Dr. Gurland is Sidney Katz professor and director, Columbia University Stroud Center for Study of Quality of Life, New York, NY. Ms. Perez is executive director, and Mr. Riti is activities director, Methodist Home for Nursing and Rehabilitation, Riverdale, NY.
References
1. Gurland BJ, Gurland RV. The choices, choosing model of quality of life: description and rationale [published correction appears in Int J Geriatr Psychiatry. 2009;24(4):436]. Int J Geriatr Psychiatry. 2009;24(1):90-95.
2. Gurland BJ, Gurland RV. The choices, choosing model of quality of life: linkages to a science base. Int J Geriatr Psychiatry. 2009;24(1):84-89.
3. Buettner LL. Therapeutic recreation in the nursing home. Reinventing a good thing. J Gerontol Nurs. 2001;27(5):8-13.
4. Smith M, Kolanowski A, Buettner LL, Buckwalter KC. Beyond bingo: meaningful activities for persons with dementia in nursing homes. Annals of Long-Term Care: Clinical Care and Aging. 2009;17(7):22-30.
5. White-Chu EF, Graves WJ, Godfrey SM, Bonner A, Sloane P. Beyond the medical model: the culture change revolution in long-term care. J Am Med Dir Assoc. 2009;10(6):370-378.
6. Kane RA, Caplan AL, Urv-Wong EK, Freeman IC, Aroskar MA, Finch M. Everyday matters in lives of nursing home residents: wish for and perception of choice and control. J Am Geriatr Soc. 1997;45(9):1086-1093.
7. Crogan NL, Evans B, Severtsen B, Shultz JA. Improving nursing home food service: uncovering the meaning of food through residents’ stories. J Gerontol Nurs. 2004;30(2):29-36.
8. Meeks S, Young CM, Looney SW. Activity participation and affect among nursing home residents: support for a behavioural model of depression. Aging Ment Health. 2007;11(6):751-760.
9. Gurland BJ, Gurland RV, Mitty E, Toner J. The choices, choosing model of quality of life: clinical evaluation and intervention. J Interprof Care. 2009;23(2):110-120.
10. Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York, NY: Doubleday and Sons; 1961.
11. Kahn DL. Making the best of it: adapting to the ambivalence of a nursing home environment. Qual Health Res. 1999;9(1):119-132.
12. Ryvicker M. Preservation of self in the nursing home: contradictory practices within two models of care. J Aging Stud. 2009;23(1):12-23.
13. Kane RA, Caplan AL, Urv-Wong EK, Freeman IC, Aroskar MA, Finch M. Everyday matters in lives of nursing home residents: wish for and perception of choice and control. J Am Geriatr Soc. 1997;45(9):1086-1093.
14. Saliba D, Schnelle JF. Indicators of the quality of nursing home residential care. J Am Geriatr Soc. 2002;50(8):1458-1460.
15. Banerjee S, Willis R, Graham N, Gurland B. The Stroud/ADI dementia quality framework: a cross-national population-level framework for assessing the quality of life impacts of services and policies for people with dementia and their family carers. Int J Geriatr Psychiatry. 2010;25(3):249-257.
16. Reimer HD, Keller HH. Mealtimes in nursing homes: striving for person-centered care. J Nutr Elder. 2009;28(4):327-347.
17. Crogan NL, Evans B, Severtsen B, Shultz JA. Improving nursing home food service: uncovering the meaning of food through residents’ stories. J Gerontol Nurs. 2004;30(2):29-36.
18. Cai X, Cram P, Li Y. Origination of medical advance directives among nursing home residents with and without serious mental illness. Psychiatr Serv. 2011;62(1):
61-66.
19. Andresen M, Puggard L. Autonomy among physically frail older people in nursing home settings: a study protocol for an intervention study. BMC Geriatr. 2008;8:32.
20. Andresen M, Runge U, Hoff M, Puggard L. Perceived autonomy and activity choices among physically disabled older people in nursing home settings: a randomized trial. J Aging Health. 2009;21(8):1133-1158.
21. Kane RA. Definition, measurement, and correlates of quality of life in nursing homes: toward a reasonable practice, research, and policy agenda. Gerontologist. 2003;43(suppl 2):S28-S36.
22. Brod M, Stewart AL, Sands L, Walton P. Conceptualization and measurement of quality of life in dementia; the dementia quality of life instrument (DQoL). Gerontologist. 1999;39(1):25-35.
23. Logsdon R, Gibbons LE, McCurry SM, Terri L. Quality of life in Alzheimer’s disease: patient and caregiver reports. J Ment Health Aging. 1999;5(1):21-32.
