Behar Rcs & Therapy. 197’1. Vol. IS. pp. 429434 Pergamon Press. Printed m Great Britain

INCREASING ENGAGEMENT IN ACTIVITY OF RESIDENTS IN OLD PEOPLE’S HOMES BY PROVIDING RECREATIONAL MATERIALS

JUIXTH JENKINS, DAVID FELCE, BARRY LUNT and LIZ POWELL

Health Care Evaluation Research Team, Dawn House, Sleeper’s Hill, Winchester SO22 4NG, England

Summary-This project investigated whether the level of engagement in two special Homes for the elderly could be increased by providing a regular recreational session, where the residents had the opportunity to use various extra recreational materials and to interact with the organiser of the session. The residents’ level of engagement during the sessions was consistently higher than under baseline conditions. This indicates that the low engagement of the residents is at least partly due to lack of opportunity to engage, rather than to the specific disabilities of the residents. The methodological approach used in this study is suggested as a useful. objective way of evaluating the effects of, and preferences for, various types of recreatio~dl activities that might be oRered to elderly people in residential care.

Low levels of purposeful activity are frequently observed with elderly people living in residential environments. Admission to an old people’s home or a long-stay ward reduces the need to engage in many practical activities of daily living; all too often it also fails to provide the chance to engage in them at all, or in alternative recreational activities. For example, Kurasik (1965) found that only 33% of the private hospitals and 202, of the nursing homes in New York provided an active recreation programme. Low levels of observed activity may be as much a function of very limited opportunitjes to engage in activities as of the characteristics or disabilities of the residents.

Besides contributing to the bleak and depressing situations described by a number of authors (e.g. Jaeger, 1963; Kurasik and O’Connor, 1966; Robb, 1968) a high degree of inactivity may lead to undesirable physical consequences. Comstock, Mayers and Folsom (1969) and Bonner (1969) describe a range of dysfunctions and problems that may occur as a result of low rates of motor movement. Havens (1968) also suggests that reduction of activities following admission to a home is associated with poor adjust-

ment. Other authors (e.g. Jeffers and Nichols, 1961; Routh, 1970) believe that pro- grammes which increase activities can help maintain the skills of elderly people, thereby retarding the degenerative process.

These are powerful reasons for providing activities in which elderly residents partici- pate. Their importance is recognised to the extent that activity programmes are now considered to be one criterion for high-quality care (Incani, Seward and Sigler, 1975). It is only recently, however, that researchers have begun to assess empirically the sorts of materials and activities that engage the interest of elderly people in reside~ltial environ- ments.

Quilitch (1974) found that the regular provision of a planned group activity (bingo) considerably increased the engagement of residents in a geriatric ward. McClannahan and Risley (1975) increased the engagement of nursing-home residents from ZOO/;, to 7496 by providing manipulative puzzles and games and prompting their use. A substan- tial improvement was obtained even with extremely debilitated, ‘gerry chair’ residents, by placing manipulative materials on their trays (McClann~an and Risley, 1974).

The project reported here aimed to improve the level of activity in two speciai Homes for the elderly, catering for the physically and mentally frail respectively. It was the first in a series of projects to identify popular activities which could then be successfully run by the staff of the Homes.

The choice of Homes for the research was made by the local Social Services Depart- ment, on the grounds that the residents displayed a wide variety of behavioural deficits

429

430 JUDITH JENKINS el d.

and problems which constituted considerable management and care difficulties. The specific research setting in each Home was selected jointly by the Home supervisors and the researchers, using the supervisors’ judgements of places and times where activity was low, and some preliminary observational data collected by the researchers. The choice of activities was governed by practical considerations such as the limited staff time available to maintain the activities, restricted space and lack of tables, and the limited mobility of the physically frail residents. All activities could be carried out by residents seated in armchairs.

METHOD Szhjects umi srttiiy

The research was conducted with a group of residents in each of two purpose-built special Homes for the elderly run by the local Social Services department. Home A contains 55 beds, and caters for people categorised as pllysically frail; Home B (36 beds) is for people categorised as mentally infirm. A lounge area in each Home provided the research setting, and all the residents in those lounges at any time during the project were included as subjects. In Home A, 19 residents were involved in all, 17 of whom were women. Average age was 8.5 years (range 71-100). Only three residents moved around the Home without aids; 13 walked with the help of Zimmer frames or sticks, and three were usually moved in wheelchairs. Six of the residents were registered as partiall~~-sigllted or blind, and three used hearing aids. In Home B, a total of 19 female residents participated, with an average age of 80 years (range 71-91). In all cases diag- noses of senility or progressive senile dementia had been made, and 7 were receiving antidepressant or major tranquillizing drugs in connection with their diagnoses. Thirteen of these residents were mobile without aid, four used Zimmer frames or sticks. and two were moved mainly in wheelchairs. Two residents were registered as partially

sighted; none wore hearing aids. The subjects spent much of their ‘free time’ (i.e. time between meals, health care

activities and occasional special events) in the lounges observed during the project. Both lounges were furnished with armchairs and one or two small tables. Home A lounge also had books and jigsaws in a bookcase; Home B had a radio and a piano. Residents were free to receive visitors there, and to bring their own recreational activities (e.g. books or magazines, knitting, letter-writing). Staff were rarely present in the lounges except to collect individual residents for meals, baths, toileting or medical care.

~atcri~~ls for 9 different types of activity were used. The materials were packed and presented so they could easily be used by residents sitting in armchairs, in quantities sufficient for several people to use them at the same time. The materials were:

Beads and laces for threading, Pictures. scissors, glue and card for cutting out, Jigsaws of varying difficulty, Magazines. Wool and cardboard for making pompoms, Coins. polish and varnish for shining up old currency, Colorpegs for making patterns on pegboards, Octons for constructing models, Fuzzy Felt for making felt pictures.

The activities were made available to the residents in the lounge from 2 to 2.45 p.m. (Home .4), and 1 1 to 11.45 a.m. (Home B). In each Home, one experimenter pro- vided a choice of four out of the 9 activities at each session. Each type of material was presented at four sessions, allocated randomly in advance. The experimenter offered the choice to each resident who was awake. Residents were encouraged to accept mater-

Engagement of residents in old people’s homes 431

ials and assisted to begin as necessary. When residents hesitated over the choice, the experimenter made specific suggestions. If a resident firmly refused the materials he or she was not pressed to accept. After handing out materials to all residents agreeing to participate, the experimenter continued to interact with them, praising, assisting and replenishing or changing materials where necessary. About half-way through the session, the experimenter re-offered materials to residents who were not engaged in an activity (thus including those who had woken up or entered the lounge during the session).

Response dtlfinitions

The primary dependent measure was the residents’ level of engagement in activity. A resident was defined as engaged if, at the time of observation, he or she was interacting with another person, using recreational materials (provided by the experimenter, by the Home or by him or herself), using materials connected with daily living activities (e.g. using a comb or nail file, eating fruit or sweets), or moving around the lounge area with the aid of equipment designed to aid mobility.

The second dependent measure was the residents’ use of the different types of activity provided by the experimenter. An activity was defined as being in use if at the time of observation a resident was attending to and actively manipulating the materials in- volved.

Observation procedures

The observer stood in the lounge area as unobtrusively as possible and made observa- tions every three minutes during each session. To count engagement, the observer looked in a prescribed order at each resident, at the rate of about one per second, and decided whether the resident was engaged or not at the start of each second. The observer recorded the total number of residents engaged and immediately afterwards counted and recorded the number of residents present. The results obtained over the whole session were summarized to provide average numbers of residents engaged and present in the lounge that day.

To count the use of different activities provided, the same observation procedure was conducted immediately following each measure of engagement, but this time the observer tallied the number of residents using each type of activity provided that day. The results were summarized to provide the percentage of time (based on the three- minute observation intervals) during which each activity was used, and the number of residents using it.

Reliability

Reliability checks on resident engagement were made on 6 sessions in each Home. three in each experimental condition, by a second observer recording simultaneously but independently throughout the sessions. During the project, neither observer received any information on the level of agreement between their records. Inter-observer agree- ment was obtained by calculating the difference in the number of residents recorded as engaged by the two observers, dividing this by the number recorded present, multiply- ing by 100, and subtracting the result from 100%. In the case of a disagreement in the number of residents recorded present, the smaller number was taken as the denomi- nator. Inter-observer agreement averaged 98% in Home A (range 97-100:/g) and 97% in Home B (range 91-99%). Inter-observer agreement on how many residents were present was obtained in a similar way. Any difference between the two observers’ records was expressed as a percentage of the number recorded present (using the smaller number in the case of a disagreement) and subtracted from 100%. Over the 6 sessions reliability on residents present averaged 99% (range 92-100%) in Home A and 997: (90-100’~) in Home B.

Reliability on residents’ use of activity materials was checked during three sessions in each Home. An agreement in the use of an activity was defined as every observation where two observers’ records had the same number of tally marks for that activity.

The percentage agreement was computed by dividing total agreements by the total observations, x 1000;. Average agreement. across all activities and sessions. was 97”,, (range 79-1OOY’:;) for Home A, and 91”$; (71 -lOOl,,) for Home B.

E.xprrinierztcrl design

Data were collected for four days on the residents’ engagement in the lounge during a baseline condition where the extra activities were not available. In order to demon- strate the effect of making activities available the experimental procedures were then alternated randomly with the baseline condition for the next 10 days, for a total of 5 days in each condition. From day 15 to day 18. activities were available each da).

RESULTS

Figure 1 shows, for rhe two Homes, the average number of residents prcscnt. ;tnd

the average number engaged during each session of the project. In Home A. the average number of residents engaged during the sessions WZIS 1.4

(range 1.7-3.8) when no activities were provided. and increased to an average of 6.1 (range 4.6-7.7) when the experimenter made activities available. In Home B the avcragc number of residents engaged was 0.7 with no activities (range 0.4 1.3). and incrcascd to 4.1 when activities were available (range 3.1. 4.9). There was no overlap bctbvcen the ranges of scores for the two conditions in either Home.

In each Home the number of residents present in the lounge was very similiir for the two conditions. At Home A 13 residents were present on nvcragc when activities were not available (range 11.9-15.9), and 13 when activities were available (rnngc I3.2-- 15.5 residents). At Home B the average was 1 1 residents present under both condi- tions. (ranges 9.1-13.2 when activities were not available, and 9.G 12.1 when activities

were availa blc). t+?gure 2 shows . the percentage of time (observation intervals) for which each t)pc

of activity was used by a minimum of one, two. three or four residents. The data for the two Homes have been combined. There were considerable diffcrcnces in the time during which each type of activity was used at all (i.e. by at least one rcsidenti. ranging from 94’>,, of the time (making pompoms) to 20”$ (Octons). All activities cxccpt

Home A

3456769lC

r

1 2 3 4 5 6 7 6 9 10 11 12 13 14 15 16 17 16

cl Resldenls present

Fig. 1. Awrage numbers oi’ residents present and engaged in the two Homes under ‘xtivhcc available’ and ‘activities not availablc’ conditions.

Pompoms Beads JIgSaWS cutting out Magaz,nes coiorpegs Fuzzy Felt C0il-S OCtOnS

1234 1234 ,234 1234 1234 1234 t 234 12 34 12 34

Mms?um Number of Residents usmg mater&s

Fig. 2. Percentage of time for which different numbers of residents were engaged with each type of material (both Homes).

Engagement of residents in old people’s homes 433

Octons engaged one person or more for at least 257;; of the time available, (the equivalent of one whole session). However, only three activities (making pompoms, bead threading and jigsaws) engaged at least two people at once for 2.57: of the time. Four activities (pompoms, beads, magazines and coin polishing) succeeded in engaging up to four resi- dents at once but only for a very small proportion of the total time they were used.

DISCUSSION

The results indicate that when the experimenter provided simple recreational mater- ials. and interacted with the two sets of residents while they used them, the level of observed engagement in activity increased. The levels of engagement were consistently different across the 18 days of the project, depending on whether the experimen~l procedures or baseline conditions were in effect. This demonstrates that the experimental procedures were responsible for producing the change.

The baseline levels of engagement show that in Home A an average of between two and three residents only were pLlrposefully occupied at any one observation interval. In Home B, less than one resident was occupied, on average. These very low levels of engagement indicate that lack of self-initiated occupation is a problem with these two groups. This therefore places an onus on residential care staff to find ways to encourage and initiate activity. This project showed that providing a variety of simple recreational materials and prolnpting residents to use them is one way to increase en- gagement in activities to a noticeable extent. The immediate, and consistent increase in engagement produced by the recreation sessions suggests that the low baseline levels are, at least in part, due to lack of opportunities to engage in the setting of the residential Homes, rather than due to particular disabilities or characteristics of the residents.

The procedures also seemed to be generally fairly pleasant for the residents. in that as many remained present in the two lounges during experimental as during baseline sessions. Recording the number of people present, as well as those engaged, is clearly relevant in evaluating the popularity of different types of activity. Practical factors like staff time, money and space available will almost always restrict the number of different activities that can be provided, so the selection should be made on the basis of which are most preferred. Verbal comments, or stated preferences, often did not match the

residents’ observed behaviour in this project. While no objective measure was taken of this, many occasions were noted anecdotally of residents expressing interest but then failing to use the materials chosen. and also voicing strong negative comments yet participating consistently (and voluntarily) throughout the session. Therefore it seems that preferred activities can be identified more reliably by recording the numbers of people present and participatin g. than by responding to what they say.

The specific materials used in this project were selected to fit certain practical criteria, rather than for any intrinsic qualities. The criteria were that the activity could be carried out by a resident seated in an armchair, with no table available, that it would take little time to prepare, hand out, or clear away, and that residents should be able to engage in the activity without intensive staff assistance. Most of the activities met these

434 JUDITH JEUKINS er d.

criteria fairly well. Only two (coin polishing and cutting out) were found to need extra staff input or table space to assist residents in using them.

During the project it was found that some of the activities were clearly more popular than others in terms of engaging several residents for quite long periods of time. Others seemed popular in one Home but not both, or engaged quite a lot of residents for only a short time, or only a few residents at all. Both the length of time for which materials were used and the number of people using them, are relevant pieces of informa- tion for a Home supervisor faced with the task of setting up a successful progr~me of activities. In this project, the experimenter did not present the available daily choices in a totally controlled way, so no firm recommendations concerning the popularity of these particular materials can be made. However, the project does illustrate an objec- tive approach for identifying which materials are the most effective in engaging residents’ interest.

One reason for selecting the materials used in this project was to provide residents with activities in which they could participate when staff were only intermittently avail- able to prompt or assist. In the event, the experimenter spent a considerable time circu- lating among the residents after initially handing out materials. Although interaction between residents and staff is obviously to be encouraged, there is a need to have some activities requiring little staff input for times when staff are occupied with residents’ health care or treatment routines, or housekeeping duties. One strategy is to involve the more able residents, or volunteers, in running the activities. Another is to use activi- ties which depend mainly on providing materials, not on people to run them. In this case useful further research would identify the most suitable materials and the minimum staff intervention needed to maintain the residents’ engagement with them. With both strategies, written instructions on how to run the activities need to be experimentally tested by people who will be responsible for running them. Future projects will be concerned with this.

In conclusion, this project demonstrated that substantial increases in engagement in activity were obtained in two special Homes for the elderly by making activities available to the residents. This was seen as particularly important in showing that residents who did not initiate activities for themselves did readily participate when stimulated to do so. The research strategy used provides a model for evaluating residents’ preferences that can easily be carried out in residential Homes and thus provide an objective basis for the selection of different activities to be provided.

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Cornmun. Psychiat. 20, 377-380. HAVENS B. J. (1968) An investigation of activity patterns and adjustment in an aging population. Gerontofugisyist

8. 20 I-206. INCANI A. G., SEWARD B. L. and SIGLER J. E. (1975) C(~-u~fii~~~i~~~ dcriuiry Pro~~u~i?.~,~~~~ I& A@: A HOW-to-

do-it ,Munual. American Hospital Association, Chicago. 111. JAEGER P. (1963) Better nursing care for the indigent agid. J. Anz. yeriac. Sot. II. 797. JEFFERS F. and NICHOLS C. R. (1961) The relationship of activities and attitudes to physical well-being in

older people. .I. Gerontol. 18. 67.-?O. KURASIK S. (1965) The need for recreational therapy in hospitals, nursing homes, and homes for the aged.

.I. Am. geriat. Sot. 13. 556560. KURASIK S. and O’COXNOR R. (1966) Why recreation in hospitals. nursing homes and homes for the aged?

.J. Am. grriat. Sot. 14, 643-646. MCCLANNAHAN L. E. and RISLEY T. R. (1974) Activities and materials for severely disabled patients. Nursing

Homes. December 1974January 1975. MCCLANNAHAN L,. E. and RISLEY T. R. (1975) Design of living environments for nursing home residents:

increasing participation in recreation activities. J. qpl. Eehuc. And. 8, 261-268. QUILITCH H. R. (1974) Purposeful activity increased on a geriatric ward through programmed recreation.

J. Am. geriat. Sm. 22, 22&X9. ROBB B. (1968) Surzs ~~e~y~~zj~g. Nelson, London. ROUTH T. A. (1970) Realistic recreation in nursing homes. Thrrap. R~~~~~~ri~~~ J. 4, 23%25.