Examination of a Nursing Home Environment: Are Residents Engaged in Recreation Activities?
Voelkl, Judith E
The Omnibus Budget Reconciliation Act of 1987 mandates that nursing homes support residents’ engagement in preferred activities (Martin & Smith, 1993; U.S. Congress, 1987). Little is known, however, about the ways in which the environment affords or diminishes residents’ engagement in independent and group recreation. Therefore, a case study on a nursing home unit was conducted to examine (a) the use of the nursing home environment by residents and staff and (b) staff perceptions as to the predictors, barriers and affordances of resident engagement in activities when in the public environments of the nursing home. Findings revealed that residents were most frequently engaged in either eating/drinking or in no observable behavior. In contrast, staff most frequently were observed to be talking, traveling, or cleaning. Focus group data indicated that resident characteristics and the facility schedule predicted whether or not residents spent time in the nursing home’s public environments. Barriers to engagement included management, physical environment, resident characteristics, staff philosophy, and resident perceptions.
KEY WORDS: Nursing Home Environment, Older Adults, Staff, Time Use, Recreation Activities
Early studies examining nursing home residents’ time use documented that a majority of each day was spent in no observable engagement in activities or “null” activities (Brent, Brent, & Mauksch, 1984; Gottesman & Bourestrom, 1974). In response to early research findings, as well as documentaries on the lack of quality of life in nursing homes (e.g., Moss & Halamandaris, 1977; Vladeck, 1980), legislation was enacted to regulate the nursing home industry and ensure that environments were designed to foster positive experiences for residents (Martin & Smith, 1993). More specifically, the Omnibus Budget Reconciliation Act (OBRA) of 1987 (U.S. Congress, 1987) mandates that all facilities provide “. . . activities designed to meet the interests and physical, mental, and psychosocial well-being of each resident. . .”.
Although OBRA clearly mandates the provision of activity groups to enhance quality of life, recent studies have documented that residents of nursing homes spend little time in structured activity programs (Voelkl, Fries, & Galecki, 1995; Voelkl, Galecki, & Fries, 1996). These findings, therefore, suggest that a majority of residents’ time is unstructured in nature. Given the important role recreation activities may play in promoting free choice and responding to residents’ individual needs (Martin & Smith, 1993; U.S. Congress, 1987), it is important to understand whether or not the nursing home environment supports both group and independent engagement in recreation activities. Many questions remain as to how residents respond to the nursing home environment as they seek meaningful engagement. Are they continuing to engage in “null behaviors” as was found in studies conducted over 20 years ago (e.g., Gottesman & Bourestrom, 1974)? Or because of the changes implemented due to OBRA ’87 and the role of the therapeutic recreation (TR) specialist in creating meaningful opportunities in the nursing home environment (e.g., Buettner & Martin, 1995; Mannell & Kleiber, 1997; Shank & Coyle, 2002), are we more likely to find residents talking with one another or engaging in independent recreation pursuits?
As TR specialists take an active role in designing environments to foster residents’ positive interactions and engagements, understanding of the behaviors that naturally occur in the nursing home environment is essential. For instance, if little active engagement occurs other than in activity groups, this information may direct TR specialists’ attention toward making changes in the environment to increase residents’ active engagement in independent pursuits (Lawton, 1985).
In order to understand residents’ use of the nursing home environment, as well as make recommendations as to the role and responsibilities of TR specialists in designing areas to afford recreation participation, we conducted a case study on a 48 bed nursing home unit housed in a continuing care retirement community. The purpose of the case study was to examine: (1) the use of the nursing home environment by residents and staff and (2) staff perceptions as to the predictors, barriers and affordances of residents’ engagement in activities when in the public environments of the nursing home.
Background Literature
Ecological Model
A number of models depicting the interaction between older adults and the environment have emerged from the environmental psychology and gerontology literature (e.g., Carp, 1987; Kahana, 1982; Lawton & Nahemow, 1973; Moos & Lemke, 1985). These models have been developed in an attempt to provide a theoretical framework from which to understand the behavior patterns of older adults. Lawton’s ecological model (Lawton & Nahemow; Lawton, 1980), in particular, provides TR specialists with a useful basis for understanding the activity engagement of older adults residing in nursing homes.
According to Lawton’s ecological model, the outcome of positive behavior and affect among older adults is dependent on the relationship between individuals’ competence and the demands or press of the environment (Lawton & Nahemow, 1973) (see Figure 1). Physical abilities, cognitive abilities, and mental health indices are a few of the variables that may be examined in regards to competence. The “press of the environment” refers to social and physical environmental demands. A delicate balance is needed between an older adult’s capabilities and environmental demands for positive behavior and affect to result. A mild increase in environmental press may be perceived as challenging and demand an individual’s attention (i.e., maximum performance potential). A mild decrease in environmental press may be experienced as comfortable and relaxing (i.e., maximum comfort).
The environmental docility hypothesis, a basic tenet of the model, suggests that the environment is seen as “. . . a more potent determinant of behavioral outcomes as personal competence decreases” (Lawton, 1990, p. 639). For example, Tom, an 82-year old man residing in the community who recently had a stroke that limited his mobility and opportunities to leave his home may display a drop in his level of social interaction and accompanying daily affect (i.e., negative affect and maladaptive behavior). Conversely, Lawton has also proposed an environmental proactivity hypothesis, suggesting that when an individual’s competence is commensurate with the demands of the environment “the variety of environmental resources that can be used in satisfaction of the person’s needs increases” (Lawton, 1990, p. 639). Tom exemplifies environmental proactivity when he displays an increase in his social interaction and positive affect upon moving into a nursing home that provides morning coffee socials and afternoon activities.
Lawton’s proactivity hypothesis is similar to tenets of Gibson’s environmental model. Gibson hypothesizes that when an individual perceives the resources and unique characteristics of an environment, he or she will be afforded the opportunity to act in response to these resources (Greeno, 1994). Mannell and Kleiber directly link Gibson’s model to the role of leisure service professionals: “Creating leisure affordances is often a matter of helping people to see the possibilities that are available to them, or in fact arranging such possibilities” (1997, p. 346).
Perhaps the most useful conceptualization of these models by TR specialists is to consider the ecological model as placing an older adult in an environment that is responsive to his or her competence level and fosters “proactivity” or affords active engagement in meaningful activities. Lawton (1985) has likened the environmental proactivity hypothesis to flow (Csikszentmihalyi, 1990), further establishing the link of the ecological model to therapeutic recreation practice. An environment designed to promote proactivity and flow would provide a variety of resources that may foster activity choice and participation.
Federal Policy
In 1987 the U.S. Congress passed the first federal guidelines, the Omnibus Budget Reconciliation Act (OBRA) of 1987, to outline quality of care standards for nursing homes. The impetus behind this legislation was to shift the mission of nursing homes from general provision of care to a broader focus that examined quality of care in terms of resident outcomes (Martin & Smith, 1993; Vladeck, 1996). As stated in OBRA 1987, the overriding goal of a nursing home is to “provide an environment in which each resident could achieve and maintain the highest practical level of physical, mental, and psychosocial well-being” (U.S. Congress, 1987).
Following the enactment of OBRA ’87, the Health Care Financing Administration provided guidelines for evaluating a facility’s compliance with OBRA ’87 (Department of Health and Human Services, 1992). These guidelines, which are used by surveyors, illuminate the impact of OBRA ’87 on nursing home care. Surveyors are instructed to assess how well a facility promotes residents’ (1) dignity, (2) self determination and participation, (3) participation in resident and family groups, (4) participation in other activities, (5) accommodation of needs, (6) activities, and (7) social services. As surveyors evaluate a nursing home, they address issues surrounding residents’ opportunities to participate in structured and unstructured recreation activities. Residents are asked questions regarding their ability to spend time the way they would like, visit with friends (including other residents), and access recreation and lounge areas. Surveyors are also instructed to evaluate whether or not there is a fit between the residents’ needs and the environment.
The Resident Assessment Instrument (RAI) (Morris et al., 1990), an assessment tool mandated for use in all nursing home facilities receiving federal funding, also highlights the importance of resident engagement in activities. For example, upon admission, a resident’s “Customary Routine” is assessed via items pertaining to his or her daily cycle (e.g., “stays busy with hobbies, reading, or fixed daily routine,” “spends most time alone or watching TV”) and patterns of involvement (e.g., “daily contact with relatives/close friends,” “daily animal companion/presence”). Annually the resident’s activity pursuit patterns are assessed via items pertaining to preferred activity settings and pursuits.
In general, it seems likely that OBRA ’87 has had an impact on how well nursing homes support resident engagement in recreation activities. This legislation, however, goes beyond the provision of group activities to provide TR specialists with a rationale for designing the environment to afford residents’ active engagement in a variety of recreation pursuits at both the independent and group level.
Resident Time Use
Over the past 30 years, gerontologists have conducted a series of observational studies to document resident time use. For example, Gottesman and Bourestom (1974) conducted one of the first systematic studies investigating the activity involvement of 1,144 residents of nursing homes. Each resident was observed at 24 random times over the course of two days. Residents were observed to spend 39% of their time in no observable activity, 17% in passive activity, 23% in personal care, and 20% watching television or socializing. Level of social activity was found to be positively related to level of independence in activities of daily living and mental status.
Brent and colleagues (1984) were specifically interested in residents’ activity engagement in three public areas of a 54-bed nursing home, including the dining room, lounge, and corridors connecting public areas to residents’ rooms. Behaviors in public areas were thought to have an important influence on one’s self-expression and self-esteem. The authors noted that:
. . . there are important differences between an elderly resident who spends considerable time in the semi-public areas in a nursing home actively engaged in activities with others and conversing with them and a resident whose time in those areas consists exclusively of passive observations, normally private backstage behaviors such as sleeping. . . [such behaviors] are likely to reflect qualitatively different levels of functioning and adjustment in the nursing home setting . . . (p. 186)
Using cluster analysis, the authors reported ten groups of people who displayed unique patterns of use of public areas. Groups of residents ranged from “observers,” “socialites,” “infrequent active observers,” “low users,” to “active observers,” to name several groups. Subsequent analyses found that level of mobility and mental status were significantly related to patterns of use of public areas, with “greater diversity of spatial organization of behavior . . . displayed by residents with better health status than by those with poorer health status” (p. 192).
In order to examine the quality of care in one nursing home, following the enactment of OBRA ’87, Shore, Lerman, Smith, Iwata, and DeLeon (1995) observed resident and staff time use on four units. They observed residents to be most frequently engaged in no activity (51.4%), followed by engagement in appropriate non-social activities (e.g., ambulation, TV, eating) (34%), and appropriate social activities (e.g., conversation, receiving care or instruction) (12.1%). Staff were observed most frequently to be engaged in non-resident work (42.5%), followed by staff-other interactions (25.1%), positive interactions with residents (21.2%), resident care (19.7%), off-task activities (5.4%), and negative interactions with residents (.8%). When comparing time use on weekends to that on weekdays, no significant differences were found in staff’s time use. Residents, however, were found to spend significantly more time in no-activity on weekends and significantly less time in appropriate social and non-social activities on weekends.
Efforts have also been undertaken to describe the characteristics of those residents who participate in group activities. Based on a sample of 3008 nursing home residents, Voelkl and colleagues (1995) reported that residents’ mean time in activities was 217 minutes per week. In terms of characteristics that predict time in activities, the results indicated that resource use, cognitive abilities, depression, activity preferences, sense of initiative/involvement, location preferences, gender, and a facility indicator, were each statistically significant. More specifically, those residents receiving high levels of resources (i.e., nursing care) spent little time in activities. Those residents with moderately-severe or severe cognitive impairments had high levels of time in activities and residents with very-severe cognitive impairments had the lowest mean time in activities. Residents who were non-depressed and those with a high sense of involvement in the facility had high levels of time in activities in comparison to those residents who were depressed and those with a low sense of involvement. Residents with a preference for the day area had high levels of time in activities in comparison to residents with preferences for their own room or no preference. Lastly, women were found to spend a greater amount of time in activities than men.
Although these studies span more than twenty years, the findings are consistent in their reports on residents’ low level of engagement in activities (e.g., Gottesman & Bourestrom, 1974; Shore et al., 1995; Voelkl et al., 1995). Many questions remain as to the relationship between specific areas of the nursing home environment and residents’ time use, as well as to how staffs use of the environment may impact residents’ time use.
Method
Nursing Home Environment
The nursing home environment in this study was one unit housed within a continuing care community. This particular unit was selected because it was the only nursing home unit in the area that employed certified therapeutic recreation specialists. Given that one aspect of the study was to understand the role therapeutic recreation specialists may have in creating environments that promote recreation engagement, it was necessary to collect data in a facility that employed therapeutic recreation specialists.
The nursing home unit contained one large dining room, two smaller dining rooms for residents in need of staff assistance with eating, a large sun room (i.e., day room), two long hallways that were connected via a nurse’s station, a small sitting area with a large fish tank, and a physical therapy room (see Figure 2). Full time staff included nurses, nurses’ aides, and two certified therapeutic recreation specialists. Part time staff included a physical therapist, an occupational therapist, a speech therapist, and a therapeutic recreation assistant. The ratio of nursing staff to residents was one staff to five residents between 7:00 am and 3:00 pm and one staff to six residents between 3:00 pm and 7:00 am.
At the time of the study, 42 of the 48 beds were occupied. Of the 42 residents, 90% were female and 10% were male. The average age of the residents was 90 years (SD = 6) and their average length of stay on the unit was two years and four months (SD = 2 years). Individualized assessment data came from the Resident Assessment Instrument (RAI). The Cognitive Performance Scale, based on select items from the RAI, was used to assess residents’ cognitive abilities (Morris et al., 1994). Twenty-one percent (N = 9) of the residents had ‘intact’ or ‘borderline intact’ cognitive abilities, 55% (N = 23) had ‘mild’ or ‘moderate’ impairments, 5% (N = 2) had ‘moderate-severe’ impairment, and 19% (N = 8) had ‘severe’ or ‘very severe’ impairments. Residents’ level of independence in six activities of daily living (ADL) was assessed (i.e., bed mobility, transferring, walking, dressing, eating, toileting) (Morris et al., 1990). Each ADL was rated from O to 4 with higher scores indicating more dependence. Residents’ total ADL scores ranged from zero to 20 with a mean of 5.9 (SD = 6). Assessment data also indicated that 26% of the residents (N = 11) displayed depressive symptoms. Assessment data on residents’ room preference for activity involvement indicated that 19% (N = 8) of the residents preferred their own rooms, 78% (N = 33) preferred both their own room and the day room, and 1 % (N = 1) mentioned the day room as the only preferred activity setting.
Data Collection
Observational Data Collection. At random times over the course of one week, trained observers recorded residents’ and staff’s observable behaviors in the nursing home environment. As stated previously, the nursing home environment contained one large dining room, two small dining rooms, a large sun room (i.e., day room), two long hallways that were connected via a nurse’s station, a small sitting area with a large fish tank, and a physical therapy room. Observations were not conducted in residents’ private rooms out of respect for the privacy of each resident and because the focus of the study was on the public spaces within the nursing home, which is similar to previously conducted observational studies (e.g., Brent et al., 1984; Shore et al., 1995).
Each day was divided into ten-minute blocks between 6:00 am and 9:00 pm. One third of the 630 ten-minute blocks were randomly selected for observation. Of the 210 randomly selected time blocks, data were collected during 209 of the ten-minute time blocks. The trained observers entered the unit and moved through the unit recording observed behavior (i.e., each individual, his or her activity engagement, and location) in a consistent manner. The data entry sheet for each ten-minute block consisted of a map of the nursing home (see Figure 2). For each individual observed the researcher would write in a number representing the ‘type’ of individual (i.e., 1 = resident, 2 = visitor, 3 = nursing staff, 4 = other staff) and a letter representing his or her activity (i.e., a = eating/drinking, b = no observable activity, c = solitary recreation, d = recreation group activity, e = talking, f = traveling, g = passing medications, h = charting, I = cleaning, j = other). The number representing the ‘type’ of individual and letter representing his or her activity would be placed on the map in the exact location the researcher observed him or her on the unit.
Focus Groups. The authors conducted three focus groups: one with residents, one with nursing staff, and one with recreation staff. The format of each group was similar and included open-ended questions focusing on the three broad areas of (1) predictors, (2) barriers, and (3) affordances of residents’ engagement in the nursing home environment. Two investigators ran each focus group. Each group was audio-taped and the audio-tapes were then transcribed by one of the investigators.
Data Analyses
The observational data collection resulted in 3428 observations in the nursing home environment. Prior to conducting analyses, the data were cleaned and coded into individual, activity, location, and time of day categories. Observation data on individuals were coded into four categories: resident, visitor, nursing staff, and other staff. Each observation of activity was placed into one of the following ten activity categories: eating/drinking, no observable behavior, solitary recreation (i.e., reading, knitting, playing with pets), recreation group activities, talking, traveling (e.g., walking, wheeling), passing medications, charting, cleaning, and other. Categories for location included: hallways, nurses’ stations, sun room/ fish tank, dining rooms, and physical therapy room. Time of day was divided into 2.5 hour time slots: 6 am to 8:30 am, 8:31 am to 11:00 am, 11:01 am to 1:30 pm, 1:31 pm to 4:00 pm, 4:01 pm to 6:30 pm, and 6:31 pm to 9:00 pm.
Inter-rater agreement was examined for 125 observations (i.e., 21 time blocks). Agreement on categorization of observations was 96% for activity engagement. Frequencies were run on the types of individuals, activity, and location, and time of the observational data (see Table 1). Due to the low frequency of observations of visitors (N = 164) and observations in the physical therapy room (N = 35), these categories were excluded from subsequent analyses. Therefore, subsequent analyses were conducted using 3231 observations. Chi-square analyses were conducted to test the significance of the relationships between activity engagement and individuals (i.e., residents, nursing staff, other staff), activity engagement and location, and time of day and individuals.
Focus group data were analyzed using constant comparative method. Data from the resident group, however, were not included in the analyses. The sensory impairments of the participants made it difficult for the interaction and sharing that is a central ingredient of a focus group, thereby leading to questions about the validity of that data.
Results
Observational Data
The type of activity engaged in varied significantly by type of individual observed, [chi]^sup 2^(18, N = 3231) = 2454.4, p
The type of activity engaged in also varied significantly by location, /(18, N = 3231) = 2023.85, p
The use of the nursing home environment was also found to vary significantly by individual and time of day, [chi]^sup 2^(10, N = 3231) = 568.47, p
Focus Group Data
Three therapeutic recreation staff members and one therapeutic recreation volunteer participated in one focus group and eight nursing staff participated in the second focus group. Analyses of the focus group data resulted in several distinct themes emerging from the perceptions and thoughts of the nursing and recreation staff. Themes emerged in regards to what factors predicted residents’ time use in the nursing home environment, barriers to and affordances of their engagement in the nursing home environment (see Table 5).
Predictors. Two themes, characteristics of the residents and the facility schedule, emerged regarding the factors that predict whether or not residents spent time in the nursing home environment. The observations of the nursing and TR staff contributed equally to our understanding of resident characteristics as a predictor. Residents’ cognitive abilities, physical abilities, and personal preferences were all thought to influence their engagement. For instance, a TR staff member stated:
Some people don’t have the cognitive ability to say whether or not they want to be in the hallways-some people are just set in the hallway for no reasonfor a lack of a better place to go, and they’ll just sit there.
A nursing staff member stated:
Those who have impaired mobility-we do the mobility for them and we have a tendency to bring them out into the hallways where the people are.
Both the TR and nursing staff also recognized the effect of personal preferences on time use. Nursing staff stated “they are just that type of person” and “we have several people who would much prefer to stay by themselves.”
The facility schedule and routine were also thought to predict residents’ time use in public areas. A variety of activities, such as games, birthday parties, and intergenerational activities, were identified as novelties in the schedule that motivated residents to leave their rooms and move into the general nursing home environment. The staff routine was also a factor effecting resident time use. For example, a nursing staff member stated: “Well, when we get them dressed, we put them in the hallways so that they can see us bobbing in and out.” A TR staff member indicated that residents developed a routine that influences their participation patterns: “And routine seems to be really important to them. Even the ones who don’t go to activities, they have their specific time when they come out… there are certain ones who come out and walk the halls . . . even when it is motivated on their own.”
Barriers. Five themes emerged regarding the barriers to residents’ use of the nursing home environment. These themes included (a) management, (b) physical environment, (c) resident characteristics, (d) staff philosophy, and (e) resident perceptions. Both nursing and recreation staff identified barriers pertaining to management. More specifically, staffing patterns were thought to limit staff’s ability to support residents’ engagement in the environment. One nurse viewed daily care responsibilities, “. . . as far as nurses and CNAs go there are designated assignments and then there are rounds and stuff. . .,” as preventing nursing staff from engaging residents in independent and group activities. Staff turnover was another factor seen as affecting whether or not residents spent time in the general nursing home environment. The working relationship between nursing and TR was also sited. For instance, one TR staff member stated:
And the residents trust the staff and once they have to start that all over again, they go back to where they were. One person may get someone to come to activity and then that person [staff] is gone . . . forget going to activities.
Both nursing and TR staff noted factors in the physical environment that negatively effected residents’ engagement. For instance, the sun room, which was the main public area, was accessible via a short corridor that served as a depository for used meal trays and contained a room that held the unit’s dirty laundry.
. . . this is unpleasant. . . you are walking past all of the dirty trays, you are also walking past the dirty linen room which isn’t a pleasant experience. all of that stuff is the leftover food . . . you know just to pass by it is not [inviting] . . . (TR staff member)
Nursing staff noted that the furniture in several of the sitting areas was not designed well for older adults. For instance, a nursing staff relayed the story of a resident’s difficulty using a love seat due to the depth of the seat, making it impossible for the resident to lean against the back of the seat and still be able to rise independently. Finally, staff noted that the lack of recreation resources (books, puzzles, storage for recreation activities) negatively effected residents’ active engagement. Residents inability to successfully interact with the physical environment, such as their inability to use remote controls for using the television and VCR, also limited engagement.
Although, as stated earlier, resident characteristics served as a predictor of their engagement in public areas, characteristics also served as a barrier to residents’ engagement. Staff discussed lack of communication abilities, cognitive abilities, and withdrawal as several of the resident characteristics that prevented their engagement. Nursing staff noted: “They can’t talk loud enough” and “Or they can’t hear what is being said-it frustrates them.” A TR staff member indicated that cognitive abilities served as a barrier: “. . . it is just hard if they don’t know where to look or where to go, or can’t remember.” Finally, withdrawal or a general level of depression was seen as a barrier: “Some people just kind of give up” (TR staff member).
The themes on barriers pertaining to staff philosophy and resident perceptions emerged solely based on the data from the TR staff. Staff voiced concern about the clash between whether the unit was a home environment or a health care environment. One staff viewed the recreation staff as being “. . . more respectful for the [individual! residents and the background that the nurses come from being more clinical and just get them their food, make sure they are dressed, make sure they get their medicine . . .”. The complexity of the environment was noted by another TR staff:
“Even the terms we use-residents versus patients. There are just such different clashes of people in one area that the barriers are definitely going to stay there, because in one room you have all of the dirty linens and then right next to it you have a bookshelf… it is such a collage of different views.”
The TR staff also noted that residents did not seem to perceive ownership for the general environment. A TR staff recalled an experience when she was talking with two other staff members in the sun room: “… even though we were up against a wall on one side . . . she [resident] came through, ‘Is it ok if I come through here, do you mind?’ Of course not, go ahead,’ but they perceive it that way . ..”. On the other hand, another TR staff member recognized that one way residents exercised control was to spend time in public spaces.
Affordances. Nursing and TR staff provided numerous suggestions as to how to promote residents’ use of the nursing home environment. Altering the physical environment was seen as one way to promote residents’ engagement. Many comments indicated a need to redesign the sun room to make it more accessible and to add on an outdoor patio that would encourage residents to leave their rooms. Another suggestion was to “. . . use the dining rooms [for charting] and then really try to make that [sun room] home like and really make it the residents’ lounge.” Other suggestions pertained to increasing resources, such as pictures of residents and events to look at and discuss, bookshelves to store resources in an accessible manner, and recreation resources for individual participation.
Finally, nursing staff also saw the need for staff to be more active in ensuring that residents were dressed appropriately and that the temperature of the environment was comfortable for residents. In contrast, TR staff focused on the need to meld the various perspectives on use and ownership of the nursing home environment:
There has to be some kind of approach met by both areas to take away the stress on the barriers because even with respect between the departments, the residents can pick up on that, and if they know that one of the departments is looked upon different from the other, then they are not going to [become actively involved! . . .
Discussion
Although OBRA ’87 mandates that nursing home facilities create environments that meet the needs of residents, our findings suggest that the nursing home environment in this case study was not fostering residents’ proactivity or engagement in meaningful pursuits. Residents were most frequently observed to be eating/drinking or engaged in no discernible behavior. Similar to the findings of Shore and colleagues (1995), less than 15% of observations of residents captured them engaged in social interactions, independent recreation, and group recreation. These findings, coupled with staff reports on the lack of recreation resources on the unit, suggest the need for environmental affordances that would result in higher levels of engagement.
Patterns of use by location also speak to the possibility that few leisure affordances exist in the environment. Most striking is the finding that less than 5% of observations in each of the three locations captured involvement in solitary recreation pursuits. Pairing that with approximately 20% of the observations to be of no observable behavior in both the hallways and the nurses’ station/fish tank/sun room, it appears that there are few opportunities for engagement and/or a general perception that these public environments are work spaces.
The profile of staff time furthers our concern that the environment was not effectively designed to foster residents’ engagement. It seems possible that the profile of staff time use may create an atmosphere in which residents feel little ownership of the public environments. Staff’s highest frequencies of engagement were talking, traveling, charting, cleaning, and passing medications, all of which may communicate responsibility, importance, and staff’s ownership of public space. Even the central location of the nurse’s station may communicate ownership. The placement of the used meal trays and dirty laundry near the sun room speak to the institutional nature of the environment; again lessening the odds that residents feel a sense of ownership or investment in the living environment.
The differences in care philosophies held by nursing and TR, as discussed by the recreation staff, speak to lhe complexity of shaping the nursing home environment to afford residents engagement in leisure experiences. Nursing staff discussed the difficulties in providing efficient direct care for numerous residents (i.e., Barrier: Management/Regulations). The demands placed on nursing staff make it understandable that they treat the environment as work space. TR staff, in direct contrast to the nursing staff, discuss the challenge of attempting to create a home-like environment that affords resident choice and meaningful engagement.
Both nursing and recreation staff voiced ideas as to how to improve the match between residents’ needs/abilities and environmental press/affordances, such as increasing the number and variety of recreation resources, providing resources in an accessible manner, and prompting resident engagement. Neither nursing or recreation staff, however, spoke of the role or involvement of residents in caring for and taking responsibility for public environments. It seems that if the environment is to afford residents’ engagement in meaningful leisure experiences, there needs to be a shift from a work environment to that of a familylike environment. An environment that espouses a family-like philosophy will view residents as equal members in creating space that allows for meaningful engagement among residents, family members, and care staff (Voelkl, Battisto, & Carson, 2003). Finally, as alluded to by one of the TR staff members, to make changes in the environment there would have to be a consensus among residents, nursing staff, and recreation staff as to the direction taken, as well as an understanding of each member’s role in the development and maintenance of the environment.
Although we advocate for the creation of nursing home environments that empower residents and promote their engagement and decision making, we recognize the difficulties in doing so. Even within our case study we were unsuccessful in involving residents in a focus group due to sensory impairments. Further, residents’ perceptions, as voiced by one resident who participated in the resident focus group: “. . . as long as there is permission to use the rooms . . .”, also speaks to the challenge inherent in empowering residents and shifting the dominate medical paradigm of nursing homes to a social or family paradigm.
Future Research
A strength of the present study was the case study design that included use of multiple methods to describe the nuances of the social processes on one nursing home unit (McCormick, 2000). Although the findings support the general tenets of Lawton’s ecological model, due to the case study design the findings can not be generalized to the population of nursing home facilities. Therefore, continued work is needed to document the time use of residents and staff across facilities, as well as further our understanding of the environmental affordances that enhance resident engagement in the environment. Future studies would also benefit from further consideration as to how to facilitate resident input. We found that the sensory impairments of residents precluded the implementation of an effective focus group. Perhaps, in the future, individual resident interviews could be conducted to give voice to residents and thereby, furthering our understanding of residents’ perceptions.
Research is needed to increase our understanding as to how recent innovations targeting the organizational culture and physical space of nursing homes may promote higher levels of engagement among residents than is found on traditional nursing home units. More specifically, research is needed to understand resident engagement on Eden Alternative facilities (Thomas, 1999) that espouse a social model, as well as in those facilities seeking culture change via the Pioneer Network philosophy (Pioneer Network, n.d.). Further study is also needed to document how units designed based on a household model, that creates living space for 9 to 12 residents with their own lounge, kitchen area, and access to a patio, may promote higher levels of engagement among residents, family members, and staff (Calkins, Meehan, & Lipstreuer, 1999).
Future studies may also benefit from broadening the involvement of staff other than nursing and TR. Given that our findings indicated a high frequency of cleaning occurring in the environment, it would be interesting to consider the perception and potential role of housekeeping staff in the development of recreation rich environments. The perceptions of family members would also enhance our understanding of the environment, as well as provide ideas as to how the environment may be designed to afford family leisure.
Finally, the present study was limited to public environments in the nursing home. It is possible that residents’ engagement in meaningful pursuits occurred in their rooms. Future studies may also be designed to address residents’ experiences and perceptions regarding private spaces. Such work, however, docs not preclude our need to continue to examine public environments. Only by continued exploration of the nursing home can residents and staff members come together to create environments that foster positive, meaningful experiences for all members of the community.
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Voelkl is an Associate Professor in the Department of Parks, Recreation, and Tourism Management at Clemson University. Winkelhake is a Program Associate in the Division of Interdisciplinary Programs at University of Iowa. Jeffries is a CTRS with United Action for Youth, Iowa City, Iowa. Yoshioka is an Associate Instructor in the Department of Physical Education and Recreation at Tokai University in Japan. The authors wish to thank Julie Bobitt-Thompson, CTRS and Angle Young, CTRS for their participation in the reported study and Jennifer Carson, CTRS for her critical review of the manuscript.
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