Scandinavian Journal of Occupational Therapy. 2015; 22: 435–441

ORIGINAL ARTICLE

Everyday doings in a nursing home – described by residents and staff

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MARTHA GUSTAVSSON1,2, GUNILLA M LIEDBERG2 & ÅSA LARSSON RANADA2 1

Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden, and Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden

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Abstract Objective: For many groups of elderly people it is important to be active, which can be hindered by disabilities that come with age. Research has progressed in this area but mostly concerns the elderly living at home. The aim of this study was to examine how residents and staff at a nursing home described the residents’ everyday doings. Methods: A nursing home was selected in which 15 of the residents and six of the staff were interviewed about the residents’ activities during an ordinary day and week. Results: The material was analysed using qualitative content analysis in which two categories emerged: shared doings and individual doings. The shared doings were important for supporting the residents in their social and physical activities, but participation in these was often hampered by reduced functions. The individual doings, where the residents’ own interests can be promoted, were also hampered by their disabilities. Being able to be active and having something to do were emphasized, either continuing with previous activities or participating in shared activities at the nursing home. Conclusions: Receiving care and being forced to adjust to the context at the nursing home had a significant impact on the residents’ daily doings. Most of the residents needed help to be able to continue performing their activities or to find new ones. The social environment consisting of other residents and staff also influenced the residents’ activities.

Key words: qualitative method, participation, occupational therapy, aged, activity

Introduction To continue to perform activities is described as promoting active ageing and increasing health for older people (1-3). One advantage of being active described by older people is that it can help them to forget about their ailments for a while, and gives them a feeling that time passes more quickly (4). To stay active when getting older can be challenging due to impaired mobility as a result of diseases and various types of disabilities, illnesses, and the lack of energy that older people experience (1,4,5). The most common activities among older people are tranquil ones such as watching TV and conversation (6-10). The Public Health Institute (11) suggests four cornerstones for the promotion of good health for

older people: physical activity, healthy eating habits, social relations, and a meaningful life. Physical activity has been shown to have positive effects on health even among the oldest old, but in advanced age (over 90 years) physical activities are not as common as among those who are younger (6,11). To have the ability to continue to perform social activities in old age can also be important and have a positive effect on a person’s health (1,12). Many older people express the view that to interact with others and talk about their lives makes them feel good (13). Social visits may have an even better effect on reduction of depressive symptoms and improvement of quality of life than physical activity (12). A meaningful life includes having meaningful activities and to be able to continue performing everyday doings is described as important by elderly people. The term

Correspondence: Martha Johanna Gustavsson, MSc, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Division of Occupational Therapy, Alfred Nobels Allé 23, 141 83 Huddinge, Sweden. E-mail: [email protected] (Received 16 July 2014; accepted 21 April 2015) ISSN 1103-8128 print/ISSN 1651-2014 online Ó 2015 Informa Healthcare DOI: 10.3109/11038128.2015.1044907

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“doings” is used since it is a wider concept than activities and includes actions such as thinking and relaxing (4). For many older people it is important to be as independent as possible (4,14,15). This is so even if it takes longer to perform tasks than when they were younger (4). Many older people who still live and manage by themselves are afraid of being abandoned, isolated, and without friends, and of being fully dependent on nursing staff if they should need advanced care (14). To live in a nursing home can be a factor that reduces life satisfaction (16), although for nursing home residents factors like having acceptable functions in daily activities/life, a pleasant environment, and relief of pain and concerns can enhance their comfort and well-being (15). Many who live in nursing homes are satisfied with the quality of care in terms of food, shower routines, and the possibility to watch television and to feel secure (17). To increase the well-being of the residents there are different factors to consider. The physical environment should be as home-like as possible, with familiar objects and smells (18). To be involved in kitchen activities is considered by professionals to be something that makes the accommodation more homely and is useful for stimulating the residents (19). To offer opportunities for older people to tell their life stories, or to write, draw, meditate etc. may reinforce residents’ inner strength (10). For those who live in a nursing home, the staff represent an important social component, whether to confide in or to have as a conversation partner (17). It has been shown that it is the staff that control the topics of conversation when communicating with the residents, which can be used to remove the focus on disease (20). Using humour can also have good effects on the quality of life (21). Research regarding older people and their activities or doings has progressed in recent years, as the everyday lives and activities of older people have been studied amongst the oldest old (4) and participants at day care centres (8). The research available on elderly care is usually connected to home help services and the care of the elderly in their own homes and leaves out nursing homes due to the residents’ age and disabilities (22). Therefore, research is still sparse regarding older people living in nursing homes and their daily life and doings. To investigate the residents’ daily doings can lead to a better understanding of how they perceive their situation and what support is needed for them to continue to be active in their daily lives. Thus, the aim of this study is to examine how residents and staff at a nursing home describe the residents’ everyday doings.

Material and methods Research design A qualitative design with a content analysis approach (23) was used in order to describe the participants’ perceptions of daily life activities. To be able to understand and explore people’s experiences interviews were chosen as a method. This was regarded as appropriate as it also has been suggested that older persons may have difficulties with completing questionnaires (24,25). Participants and procedure Participants were recruited from a nursing home in the south-east of Sweden. The accommodation contained 104 apartments distributed in four divisions. The inclusion criteria were that the participating residents should be permanent residents at the nursing home, be able to describe what they had done during a day or week, and be physically fit to cope with an interview situation. Thus residents with for example cognitive or speech impairments were excluded. One of the four heads of division at the accommodation acted as a gatekeeper (26) and mediated contact with the appropriate participants among the residents via the nursing staff. There were 17 residents who were judged to be eligible for interviewing and asked by the staff to participate. At that time, they received a letter in which they were informed about the study’s purpose, that participation was voluntary, and that the material would be treated confidentially (27). Of these 17 possible residents there were 15 who agreed to participate when asked again. The study thus included 15 of the 104 residents, interviewed individually in their apartments. The average age of the participating residents was 88 years, ranging from 69 to 97 years, and comprised four men and 11 women. The residents had lived in the current accommodation for between three months and two-and-ahalf years. A further six staff members from one division who were selected by the gatekeeper were asked to participate; this division had been reorganized to have extra focus on activities for the residents. There were two individual interviews and one group interview consisting of four staff members. A group interview can be used to capture that group’s common experiences (28) and, in this case, to validate previous results (29). The staff participating had been working for between 15 and 22 years in elderly care and between six months and seven years at this specific nursing home. All the participants were informed both in writing and orally about the purpose of the study and informed consent was retrieved and recorded

Everyday doings in a nursing home at the beginning of the interviews. In the text the participants’ names have been altered to ensure confidentiality.

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Data collection Data were collected by semi-structured interviews, with an interview guide. The interview guide with question areas had been outlined to ensure that certain topics were discussed during the interview, and was used for both residents and staff. The questions concerned the residents’ daily activities in the accommodation during an ordinary week, the possibility for them to influence their daily activities, and what activities they wished to engage in. Follow-up questions were used to further explore the participants’ experience in the different areas. The same interview guide was used when interviewing the staff to ensure that it would confirm and complement the resident’s stories. As an introduction to the interviews with the residents’ background information on their age, family situation, and how long they had lived at the nursing home was gathered. The staff were asked about how long they had worked in their profession and at the current nursing home. Each interview was audiotaped and varied in length from 15 to 50 minutes. All interviews were conducted and transcribed verbatim by the first author (MG). Data analysis A qualitative content analysis was used (23). After a first read through of the interviews the analysis started by identifying meaning units significant for the purpose of the study. Finding these meaning units is an important part of the analysis, as the result of this forms the basis for further analysis (29). The meaning units were condensed to concentrate the material, still keeping the core of the meaning (23). The condensed text was abstracted by dividing the material into categories and subcategories. The categories describe both the manifest and latent content of the material. This means that both the direct descriptions and the underlying meanings are included. In this case the residents’ actual doings are described as well as what hinders and facilitates the performance through the residents’ and staff’s descriptions. Finally, the category system was tested for its consistency within categories and made sure the categories created a complete picture (28). Trustworthiness It is important that an interviewer achieves and maintains a good relationship with the participants (28), which was facilitated by the author’s previous

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experience working as an occupational therapist at nursing homes for the elderly. In order to ensure the quality of this study, it is important to determine its relevance. The residents’ everyday activities were described based on their own perspective. Triangulation can strengthen the results of a study by highlighting the same phenomenon from different sources (30). In this case the residents’ descriptions of their day-to-day activities were analysed together with the staff’s descriptions to elucidate the similarities and differences.

Results Two main categories emerged in the analysis process: shared doings and individual doings. The shared doings consisted of what the residents did together with other residents and staff in the nursing home. The individual doings consisted of what the residents did in their own time. Each category contained subcategories (Table I). Perspectives from both the residents and staff are intertwined in the following description.

Shared doings Ruled by the contexts. The context of the nursing home, including times for meals and arranged activities on set days and times during the week, influenced how the residents and staff described the resident’s daily doings at the division. Many of the residents could state the times for each meal and activity, even if some declared that the staff reminded them when something was about to happen. The residents also described their other activities in relation to the mealtimes and arranged activities. For example Karin said, “After lunch I rest for a while, until 14.30 when the coffee is served”. As three main meals (breakfast, lunch, and dinner) and coffee/snack in between these were served each day, these recurring elements influenced the possibilities for performing one’s own activities and doings but also helped to structure the day.

Table I. Overview of categories and subcategories appearing from the interviews. Shared doings

Individual doings

Ruled by contexts

Managing daily routines

A social gathering point

Doings for pleasure

Doing things together

Maintaining close relationships with family and friends Receiving nursing care

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A social gathering point. Social companionship was deemed important by the residents, and was often the reason why they had moved into the nursing home. The shared meals and activities created a natural opportunity for the residents to gather. Coming together for a meal in the dining room enabled interaction with the other residents as they talked to each other during the meals. However, several of the residents reported problems in communicating with each other due to different impairments. “It’s a bit dull, we sit ten people at a table, and no one says anything. They can’t hear, so it’s not like there will be any debates”, said Sonja. The most common impairments described by the residents were impaired hearing or vision and decreased cognitive ability, which hampered the social exchange. Some of the residents said that they had found really good friends on the division with whom they socialized; this was also confirmed by the staff. Some took walks together, participated together in the arranged activities, and sat at the same table in the dining room, which was appreciated. Anna said, “We sit at the table talking to each other from time to time. It’s just enough.” Two of the residents had a special friendship. Both they and the staff described how they cared for each other, for example by reminding each other of different activities and worrying about their friend if he/she did not come to dinner. Others had more superficial acquaintances at the division, for example they described that they sat with each other at meals, drank coffee together, or conversed when the opportunity arose. The staff emphasized that an important part of promoting social companionship among the residents was that the staff themselves participated in the activities. Lena, one of the nurses, said, “We sit there with them (the residents) to have coffee. When we are there, they stay, but if we leave, everybody leaves.” Doing things together. In conjunction with the meals and snacks, the staff initiated and performed different activities with the residents: reading the newspaper aloud, watching TV, or listening to music or having conversations. At one division the staff and the residents baked cakes every Friday, something that was much appreciated by everybody. Sara, one of the nurses, describes it thus: “And licking the bowls! Yes they do, when we bake, they want to taste the batter, they like it! Often that’s enough as well . . . they have memories from when they did this themselves.” Each week, activities were organized such as gymnastics, bingo, or quizzes. The activities that were arranged throughout the week were mentioned by almost all the residents, as Karin explained: “Every day there’s always something. And sometimes

multiple times, like on Wednesday and Thursday, it’s both morning and afternoon.” These activities provided opportunities for residents to do things together. Maria said, “We play bingo on Thursdays” and Sven said, “The scavenger hunt is fun, and then you have to think hard”. However, some of the residents found it hard to participate, for example in gymnastics, due to reduced strength and mobility. “I’ve been a few times to the gymnastics, but I got a bit too tired”, says Inga. Several of the participants did not take part in the arranged activities due to impaired hearing, sight, or mobility needs or because they did not think that they gained any benefit from it. The staff were aware of this but tried to help everybody participate by reminding and motivating them and also helped those who needed practical help getting there, for example by bussing them in wheelchairs. The staff also emphasized that they encouraged all the residents to participate actively if possible. Individual doings Managing daily routines. Several of the residents said that they mostly managed their personal routines by themselves, but that they got help from the staff if needed. These personal routines during the day mostly involved basic activities like morning and evening routines such as dressing, personal hygiene, and care. These personal activities were described by both residents and staff as being carried out according to the individuals’ wishes and needs, but at the same time were adapted to match the staff’s working schedule if help was needed. Sonja described her own routine in the morning: “I sleep for a long time, but manage my morning chores by myself. After I have had my breakfast, drunk tea, and received my medicine, I can go back to sleep.” The staff described how they made sure that everybody woke up on time in the morning to get breakfast and receive prescribed medicine. The staff and most of the residents said that everybody went to bed at a time they chose themselves. But some of the residents chose to adapt to the staff’s schedule. Anna said, “I ring the alarm at 10 [22: 00]. Then they have the time to help me.” Not all residents were satisfied with the fact that their own activities had to be performed to suit the staff’s working hours. When talking about the time of going to bed Margareta said, “At nine o’clock [21: 00]. I think it’s early, but then the night staff come. When I take sleeping pills, I can fall asleep anyway.” Doings for pleasure. All the participating residents talked about doings they enjoyed performing.

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Everyday doings in a nursing home However, not all could perform these activities as they used to, so they adapted the doing if possible, for example listening to an audiobook instead of reading a book, or they stopped the activity altogether. The staff tried to encourage these activities if possible even if they were carried out in solitude. The most common activities performed in solitude were watching TV, reading, solitaire, or walking. Tony said, “I walk around the building, go to the restaurant on the bottom floor, and I play the harmonica”. These activities took place in between meals or in the evening after the last meal had been served. Those who had had to give up activities that they used to perform sometimes said they missed the activities: Sonja said: “I have nothing to do and I complain about it! Preferably, I would like to do something with my hands!” For many of the women, making handicrafts was an activity they could no longer perform due to impairments. The staff described that they wanted to create opportunities for individually adjusted activities but that they did not have the time and resources to do so. Maintaining close relations with family and friends. Being able to keep in touch with the next of kin was something that was highly regarded by most residents. Many said that they had good contact with relatives and close friends, but several also indicated that the contact was not as frequent as they would like. Most of them had lost their spouse but kept in contact with adult children and grandchildren and close friends. Some kept in contact by telephone; the others received visits more or less regularly. Sometimes the relatives or friends helped by doing errands and making sure that the residents had what they needed. Anna said: “I have a friend whom I have known since school, who lives here. She can run errands for me and I got a flower from her the other day.” Receiving nursing care. Most of the residents were satisfied with the care they received from the nursing staff. The health care initiative that was most commonly received, as described by the residents, was to get help with medication. Some also mentioned that they had help with dressing wounds. A few of the residents felt that the contact with the doctor and the nurse could have been better and were not satisfied with the care they received. Vera said, “Some are a bit rough, they don’t always understand that you are 97 and fragile” and “They don’t remember that I can’t see”. To get to know the staff, to have confidence in them, and to have the opportunity to talk with them was important for the residents. The residents wanted

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the staff to take the time to have individual conversations and hoped they would sit down with them for meals and activities. Some were happy with the contact they had. “We have an awfully good staff. They really take the time for us!”, says Anna. Others requested more contact, for example Vera who said: “I miss the contact. They do not have time.” The staff themselves wished they had more time to talk with the residents. The staff requested more resources from the occupational therapist; they felt that a lot of time was spent on administrative tasks instead of on the resident’s rehabilitation and activation. Discussion This study contributes with a different perspective not described earlier, namely describing activities and doings in the context of a nursing home from the perspective of both residents and staff. The findings show that doings, both shared and individual, are important for the residents, as the residents emphasize the importance of having something to do. This is something that has been expressed by other groups of older people, for example the oldest old living at home (4) and participants at day care centres (8). Being active and maintaining a positive development of occupation is vital for health and well-being among older people, regardless of accommodation (31). This is in line with both the cornerstones suggested by the Swedish public health institute (11) and the results presented by Dwyer et al. (13), which emphasize that older people want to be active and interact with others. Being able to perform meaningful activities when older should be fundamental; it is required for our survival and well-being (32). The shared doings at nursing homes create opportunities for social interaction, provide something to do, and contribute to a sense of security because the residents are surrounded by others. The main opportunities for social interaction were in conjunction with meals, which is common among older people (6). As these shared doings are ruled by the contexts at the nursing home they also govern the possibilities to choose when and what individual activity to perform. The environment can be a factor that is perceived to be either a hindrance or an enabler in terms of participation and social interaction in health and social care (18). In this study the lack of opportunities to interact in the social environment and the residents’ disabilities, rather than the physical environment itself, were described as factors that hindered participation in shared activities. The staff described their role as social facilitators, enabling and easing the social interaction among the residents.

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All the participants also described individual doings that were important for them. To manage their personal affairs and routines was an important part of their individual doings, as was receiving nursing care. Doings for pleasure often included tranquil doings in their own apartment or taking walks outside. Maintaining close relations with family and friends was also mentioned as an individual doing that they appreciated, and it included visits, phone calls, and letters. The meaning of close relationships has also been described by Larsson (4) as important for older people living at home. Several of the residents described individual doings they missed, that they used to do but no longer were able to perform. Staff wanted to create opportunities for individually adjusted activities, but issues such as staff shortages and workload did not encourage them. When it comes to receiving nursing care, most of the residents were content with the care. But some had an opinion about how and when the care was given and wanted to receive care on their own terms, which is an important part of having selfdetermination and participation. This is confirmed by Hellström and Sarvimäki (33), who state that the major cause of reduced self-determination is poor health and increased need of assistance (33). Hellström and Sarvimäki (33) also conclude that residents at a nursing home can express self-determination by deciding what clothes they want to wear, how much help they want, or by deciding if they want to participate in common activities or take time for reflection. Many adapt to staff routines, sometimes because they do not want to be a nuisance to staff or take time from others who need more help. Adapting to the context is common among older people in nursing care (33,34). Living at a nursing home indicates that one needs care or assistance of some sort, but it is not only a matter of receiving care or assistance. Although the caring needs are a large part of everyday life, it is the social needs and talking about their life that have significance for the residents’ quality of life (1,12). Study limitations In the present study, which was based on interviews, it was not possible to include all residents at the nursing home due to their health and disabilities. Residents at nursing homes are frail and are mostly the oldest old people. The distribution of gender and age among the residents was consistent with the average for people living at nursing homes, although the residents were more active and alert than most elderly people living at nursing homes. Therefore, the results presented here are not a complete picture of activities in nursing homes in Sweden; however, qualitative studies aim to describe different pictures based on the informants’

experiences. Every life story is unique and every nursing home has its own context, so the results from this study are but one example of how doings at a nursing home can be experienced and described. In this study residents and staff from only one nursing home were interviewed and the division at the nursing home in which most of the interviewed residents and staff lived or worked had an extra focus on activities as it had one nursing staff member whose only responsibility was to arrange activities for the residents, which might have had an impact on the results.

Conclusion This study describes how residents can perceive living at a nursing home in Sweden. Several of the residents and the staff stressed the importance of having something meaningful to do, such as being able to continue performing activities that they had previously engaged in and being part of a social context. The result shows that both individual and shared doings are important and are performed by the residents as described by both residents and staff. Some individual activities can be hindered by the lack of resources and special contexts of the nursing home. Other activities such as social activities can be facilitated. The quality of the shared doings can be improved by extra resources. Since this study did not capture the everyday activities of all the residents it would be interesting to investigate the doings of those who have difficulty in participating in an interview. This could be studied through observation or interviews with relatives and staff.

Acknowledgements The authors would like to express their gratitude to all the participants who were willing to share their views of everyday life at a nursing home and who made this study possible. This article is based on revised and elaborated material from the first author’s master’s thesis. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Everyday doings in a nursing home - described by residents and staff.

For many groups of elderly people it is important to be active, which can be hindered by disabilities that come with age. Research has progressed in t...
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