Copyright © eContent Management Pty Ltd. Contemporary Nurse (2013) 45(2): 244–254.
Residents’ perceptions and experiences of social interaction and participation in leisure activities in residential aged care JESSICA E THOMAS, BEVERLY O’CONNELL*,+ AND CADEYRN J GASKIN* School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia; *Faculty of Health, Deakin University, Melbourne, VIC, Australia; +Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada
Abstract: Social interaction and participation in leisure activities are positively related to the health and well-being of elderly people. The main focus of this exploratory study was to investigate elderly peoples’ perceptions and experiences of social interaction and leisure activities living in a residential aged care (RAC) facility. Six residents were interviewed. Themes emerging from discussions about their social interactions included: importance of family, fostering friendships with fellow residents, placement at dining room tables, multiple communication methods, and minimal social isolation and boredom. Excursions away from the RAC facility were favourite activities. Participants commonly were involved in leisure activities to be socially connected. Poor health, family, the RAC facility, staffing, transportation, and geography influenced their social interaction and participation in leisure activities. The use of new technologies and creative problem solving with staff are ways in which residents could enhance their social lives and remain engaged in leisure activities.
Keywords: residential aged care, nursing homes, leisure, recreation, social interaction, social inclusion, older persons, nursing
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ust under 200,000 Australians live in residential aged care (RAC) facilities (Australian Institute of Health and Welfare, 2011). With the number of people aged 85 and over set to quadruple between 2007–2047 (Costello, 2007), demand for RAC places is set to increase into the future. Although questions regarding how this increase in demand will be met require answering, we also need to ensure that quality care is maintained in RAC facilities. In Australia, the Federal Government is the principal funder of RAC, providing an estimated $7.1 billion to support 182,850 RAC places in the year to 30 June 2010 (Australian Institute of Health and Welfare, 2011). Government policies that enable people to receive support in their own homes mean that people with low-care needs, and who used to be placed in RAC facilities, now stay living at home. The consequences of these policies for RAC facilities is that they now mainly accommodate people with high care needs, rather than people with a broad range of needs. In 2009–2010, 71% of permanent RAC residents were assessed as having high care needs, with the remaining 29% having low care needs. The Government provided RAC places and community aged care packages for 111 per 1000 people aged 70 or over in 2010,
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with current policy focused toward improving this ratio in coming years. Despite the amounts of funding provided to the RAC sector, the provision of care to many residents and the state of Australian facilities are suboptimal (de Bellis, 2010; Moore et al., 2011). Many residents report having negative experiences in RAC facilities (Jilek, 2006). The findings of research undertaken in one Australian RAC facility suggested that the care provided was frequently rushed and untimely, with residents put at risk of being exposed to unsafe practices and negligence (de Bellis, 2010). Furthermore, residents social and activity needs were not being addressed. This apparent neglect of residents’ social and activity needs is particularly concerning, because researchers have consistently identified a relationship between social interaction and participation in leisure activities in the health and well-being of elderly people (e.g., Bergman-Evens, 2004; Drageset, 2004; Victor, Scambler, Bond, & Bowling, 2000). In regards to social interaction, higher levels of social engagement have been linked to lower mortality rates, greater physical health (e.g., preserved physical function), and better cognitive functioning and affective
Social interaction and participation in leisure activities in residential aged care mental health (Street, Burge, Quadagno, & Barrett, 2007). Consistent with these findings, review evidence suggests that social isolation is associated with an increased risk of all-cause mortality, re-hospitalisation, cardiac heart disease, cancer, poor nutrition, negative health behaviours, and the common cold (Nicholson, 2012). With respect to participation in leisure activities, the findings from a review suggest that activity I positively associated with psychosocial well-being, health, and survival (Adams, Leibbrandt, & Moon, 2011). Although evidence suggests that both social engagement and participation in leisure activities are important for health (Wang, Karp, Winblad, & Fratiglioni, 2002), the former (social engagement) may matter to older adults more than the latter (Litwin & Shiovitz-Ezra, 2006). There is limited, but growing, amount of research in the area of aged care, however, that focuses on identifying residents’ perceptions and experiences of social interaction and participation in leisure activities (Andersson, Pettersson, & Sidenvall, 2006; Bergland & Kirkevold, 2006; Harper, 2002). In a Norwegian study, researchers found that positive peer relationships and participating in meaningful activities were two of a small number of factors contributing to thriving in RAC facilities (Bergland & Kirkevold, 2006). The findings of a fairly recent study showed that there was a general dissatisfaction with the level of activity and socialisation that occurred within RAC facilities (Andersson et al., 2006). The participants in this study regarded communication with residents, family, friends, and staff as the most important activity they performed, yet they reported that there were insufficient opportunities for this communication to occur. This finding is similar to those of previous studies (e.g., Tate, Lah, & Cuddy, 2003), which show that communication with family and friends are a high priority of many residents. Nevertheless, one in three elderly residents may not receive a visitor in a given 12-month period (Findlay & Cartwright, 2002). Although maintaining relationships with family and friends is of high priority for
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residents, evidence suggests that their capacities to form new social relationships upon moving into assisted care have a more positive effect on well-being than the continuation of existing relationships (Street et al., 2007). Understanding the experiences and perceptions of social interaction and leisure activity of residents in RAC facilities seems a prerequisite for developing interventions that have the potential for enhancing the quality of their lives through improving their social and leisure activity experiences. The purpose of this exploratory study was to investigate elderly persons’ experiences and perceptions of social interaction and participation in leisure activities in a RAC facility. Specifically, we aimed to: (a) understand residents’ perceptions and experiences of (i) social interaction and (ii) leisure activities in their RAC facility; (b) identify factors affecting social interaction and participation in leisure activities; and (c) gain residents’ impressions on how opportunities for social interaction and leisure activities could be improved in their RAC facility. METHOD Design In this study, a reality-oriented approach was adopted (Patton, 2002), with semi-structured interviews as the means of data collection. A reality-oriented approach was particularly suited for this study, because of its large focus on concrete events (e.g., whether participants took part in leisure activities). Although acknowledging that knowledge is historically and socially constructed, realists seek to transcend such processes to describe the real world (Patton, 2002). Based on the study aims, the main topics of the interviews were: (1) Perceptions and experiences of social interaction and leisure activities in their RAC facilities, including: (a) the range and types of social interaction and leisure activities residents prefer to and not prefer to be involved in and what they would like to see offered by their RAC facility; and (b) residents’ perceptions and experiences of social isolation and boredom. (2) Factors affecting social interaction and participation in leisure activities.
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(3) How opportunities for social interaction and leisure activities could be improved in their RAC facility. Setting The setting for this study was an Australian, private sector, metropolitan RAC facility, which accommodates 90 high and low care residents. The residents have individual rooms with their own bathrooms, furniture, and windows providing views of established gardens. Adjoining rooms are also available to accommodate couples wishing to live together. The facility has television and activities rooms, dining areas, working bars and pool tables, hairdressers, chapels, numerous private sitting areas, and garden areas accessible via patio doors. Respite care is available for various lengths of time as agreed with caregivers. The facility has a high level of security, with residents and visitors requiring staff assistance for entry and exit. Staff practise the philosophy of ageing in place, which allows for continuity of care to support the changing care needs of residents without having to displace them from their friends, their spouses, and familiar surroundings. Participants The participants were one male and five female residents with an average age of 84 years. The female participants (but not the male participant) were widowed. All participants experienced multiple co-morbidities and were dependent on staff and family to provide both physical and psychosocial care. The participants met the following inclusion criteria: (a) were not cognitively impaired; (b) could understand and speak conversational English; (c) were aged 65 years or older, because in many developed countries, including Australia, 65 years of age marks the beginning of retirement and older age (World Health Organization, 2012); and (d) had lived in the RAC for at least 6 months, thus having time to adjust to living in an RAC facility. Interview schedule The interview schedule reflected the topics of the interview (listed in the Design section), but phrased in the form of open-ended requests for
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information. Examples of these requests are: ‘Please tell me about the type/s of social activities you participate in here in the nursing home’ and ‘Please tell me about the leisure activities you participate in, here in the nursing home’. Follow up questions and probes were based on the participants’ responses. Procedures Follow approval from Deakin University’s Human Research Ethics Committee and from senior management of the RAC facility, nursing staff were briefed about the project and asked to be involved in the recruitment of participants. These staff identified potential participants who met the selection criteria, gave them flyers about the research, and invited them to return a completed slip to nursing staff if they wished to learn more about the project. The first author contacted the residents who returned slips, briefed them further about the research, and, if they were still interested in being interviewed, obtained their informed consent to participate. The first author then conducted the interviews at times and in places that were convenient for participants. The interviews were audio-recorded and transcribed verbatim. The transcripts were used as the material for the analysis. Data analysis Using the procedures of Braun and Clarke (2006), thematic analysis of the interview material was undertaken. Braun and Clarke have described a six-phase process of thematic analysis: (1) familiarising yourself with the data (transcribing, reading, and re-reading the interview material); (2) generating initial codes (coding interesting features of the material in a systematic fashion); (3) searching for themes (collating codes into themes); (4) reviewing themes (checking that the themes are consistent with the initial codes and the interview material); (5) defining and naming themes (generating clear names for each theme); and (6) producing the report (selecting extracts for report and ensuring they relate to both the analysis and the research questions and the literature. The first author was principally involved in this process, with the other two authors reviewing
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Social interaction and participation in leisure activities in residential aged care her work at the end of each phase, with particular attention to reviewing, defining, and naming the themes, and producing this paper. Rigour was assessed using strategies that Sandelowski (1986) recommends for qualitative research in nursing. Fittingness was enhanced through incorporating material from several participants in this study, and was demonstrated through discussing the findings of the study in the light of previous work in the area. Rigour in the analysis was achieved through: (i) all authors discussing interpretations during various phases of analysis; and (ii) the use of computer software to track all coding. FINDINGS Perceptions and experiences of social interaction During discussions about residents’ perceptions and experiences of social interaction within their RAC facility, five themes emerged: importance of family; fostering friendships with fellow residents; placement at dining room tables; multiple communication methods; and minimal social isolation and boredom. Importance of family A consistent theme in the interviews was that maintaining close contact with family was the most important form of social interaction that occurred on a regular basis. Family members provided opportunities for social interaction through driving participants to social outings, celebrations, and visits to friends who may not otherwise be able to visit themselves. Oh yes … all the kids still come and see me all the time … they all mean a lot. I still write to them all (MG02).
Few participants had remained in contact with life-long friends living outside the RAC facility due to distance and limited availability of adequate transport. It appeared as though participants relied on the social interaction they receive from their family and from the social interactions they receive at the RAC facility. Fostering friendships with fellow residents In general, residents perceived that they could socialise with other residents in the facility,
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because most were friendly and willing to say, ‘Hello.’ Participants reported receiving regular visits from other residents to their rooms. They come in every night and visit me and we sit and watch the television from 6pm to 8.30pm. And we sit, the 3 of us together. We have supper in here also. It is so lovely having friends close by and at hand (sic). (MG05)
Often the participants talked about leaving their doors open for residents to come wandering in if they wish. These participants encouraged this behaviour in other residents by leaving their doors open and providing opportunities to sit, talk, and listen. Placement at dining room tables A common theme that participants talked about was socialising with other residents around the dining room table. Residents reported regularly sitting at the same tables every day, which gave them the opportunity to develop friendships with others. The participants reported experiencing difficulties, however, when attempting to socialise with residents who had dementia. Participants generally felt that residents with dementia were difficult to chat with, because the conversations would be one sided. She has dementia so she can’t talk but she is nice. She mumbles. I find it very hard to talk with her. (MG02)
Despite this challenge, there appeared to be a general consensus among the participants that certain topics that invoked mumbling from the residents with dementia could be avoided and an enjoyable meal could be had. Participants perceived that residents with dementia were just people wishing for social interaction themselves despite finding conversation challenging at times. Multiple communication methods The importance of contacting family and friends appeared as a common theme throughout the interviews. Telephones, letters, and computers were common methods of communication that participants used. In general, participants perceived that staying in contact with family and friends was extremely important. All
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participants had access to telephones in their rooms and would often call family and friends as they wished. Having access to these telephones provided opportunities for residents to socially interact with those living outside of the facility. I have my phone here, which I use a lot. I can call anybody whenever I want…I try to keep in touch as much as possible because I like knowing how they are doing. Friends and family are very important to me. (MG04)
With regard to sending letters to family and friends, in most cases residents felt that they could not write to family or friends because their health (e.g., macular degeneration) prevented them from doing so. Minimal social isolation and boredom Overall, most participants stated that they never felt socially isolated or bored. I am happy here. I have my friends and staff close by here to offer me a hand if I wish. I can ring up on the phone if I want to talk to someone. But I am content here (sic). (MG05)
In general, participants said that they were never lonely or bored because of the level of social interaction that occurred throughout the day. Participants socially interacted with staff (including doctors and allied health), other residents, family, and friends (living outside of the RAC facility). One participant stated that if she ever became lonely or bored then she would simply walk down to the dining room and there would always be other residents or staff around for a chat. I can just make a short walk to the dining room and there are always people sitting around in the dining room. I just go and talk to them (sic). (MG05)
One participant talked about the numerous people who attended to her on a daily basis in her room, thus preventing loneliness. Of interest, it was mentioned that the doctor who regularly visited this participant provided a form of social interaction that was often looked forward to and enjoyed. This participant also enjoyed visits from other health practitioners, including the physiotherapist, dieticians, and podiatrists.
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Perceptions and experiences of leisure activities Types of leisure activities available The participants reported that various types of leisure activities were pursued within their RAC facility. These activities can be divided into the following categories: solitary and social. Solitary activities were those activities that participants enjoyed on a daily basis, but that did not involve the participation of others. Such activities included reading newspapers and novels borrowed from the library, reminiscing by oneself, contemplation, and listening to the radio (wireless). Although these activities were not social, the participants generally perceived that they provided a means to feel connected with their local community and the world in general, as well as providing them with a sense of calm in an often hectic world. My comfort is my wireless. I cannot live without my wireless. (MG04) I like reading the paper, especially the local paper, with all the scandal. Keeping up to date with the world is important (sic). (MG03)
Numerous activities offered within the RAC facility required participants to be more physically involved and socially connected. Such activities included attending weekly exercise groups, walks, playing carpet boules and hookey, and weekly bus trips. Other, less physical, activities were also offered including: card games such as bingo and hoy, men’s group, and a weekly crossword group. These activities were run on a weekly basis and were regularly attended by participants. On a fortnightly basis, a gift shop was set up in the main dining room and residents could come and explore what was on offer. They also have a shop that comes here very often. I go to the shop a lot because I like looking at the stuff that they are selling. (MG04)
The gift shop provided opportunities for those less mobile residents to purchase items without having to leave the facility. Other creative social activities such as cooking, knitting, and craft groups were also offered. Participants also participated in informal craft groups within their own time and among other residents. Knitting was
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Social interaction and participation in leisure activities in residential aged care considered a common creative pastime and was often enjoyed in the company of friends. Leisure activities enjoyed The participants indicated that weekly bus outings were the most enjoyed activity offered at the RAC facility, because it provided opportunities for changes in the daily routines of residents. Such outings involved small bus trips to surrounding heritage sites, cafes, parks, and shopping centres. Participants often noted, however, that the bus trips were extremely popular and would become full very quickly, which often meant that some residents missed out on trips. Due to staffing constraints, the bus trips were restricted to one or two trips a week allowing for seven residents to travel each time. The bus trip, everyone likes it so we have to take in turns and it often gets full up. (MG02)
The participants commonly reported that reading newspapers and listening to the radio were enjoyable activities that they undertook. Often participants would enjoy retiring to their rooms in the afternoon and listening to their radios. I also rest in the afternoon and I listen to my radio. It is actually very calming down here in my room. I have it just the way I like it. Comfortable. I sit in the chair and I nap. (MG05)
On special occasions, which participants perceived occurred too infrequently, entertainment groups would attend the RAC facility to give performances. The participants commonly indicated that they greatly enjoyed these occasions. If they were unable to attend one of these occasions, then the doors to their rooms would be left open so that they could hear the music. Leisure activities disliked The participants reported that hoy and bingo were two of their least enjoyed activities. Often these activities weren’t enjoyed because poor health prevented participants from reading and holding the cards. Several participants indicated having a dislike for attending a lot of the craft groups. Some participants did not attend knitting groups, despite having an interest in knitting, because their health conditions
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(e.g., poor eyesight) prevented them from undertaking an activity they had previously enjoyed. One of the participants also perceived the cooking group to be boring. Residents were required to be involved in making a particular food item but were only allowed to help with part of the process (e.g., mixing or adding ingredients). As a result, the activity was perceived as boring. One participant also expressed a dislike for reminiscing groups. Participation in leisure activities facilitated social interaction Participation in leisure activities was found to facilitate social interaction. Participants indicated that they often attended activities for social reasons rather than for the enjoyment of the activity. I don’t like bingo and cards. You got to have two hands to play cards and I don’t. But I try to go to a lot of activities because it allows me to talk with other residents here. (MG06)
Numerous activities were perceived by participants to offer a form of social interaction. Such activities were attended on a weekly basis and were used as a way to stay in touch with other residents. Weekly hairdressing and manicures, while offering relaxation, allowed for participants to sit and chat while being pampered. … I have my hair done every week. I went last week and had it done. It is a real luxury. When I go to the hairdressers I can talk to the other ladies sitting beside me in the room. (MG04)
Participants interviewed also commonly talked about attending informal activities organised amongst themselves. A common pastime of participants was to enjoy a game of cards at the dining table, after meals. After, lunch, we stay around the dining table and we talk and play cards. (MG02)
Factors affecting social interaction and participation in leisure activities The participants identified six factors that affected their social interactions and participation in leisure activities, including poor health, family, the RAC facility, staffing, transportation, and geography.
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Poor health Participants commonly reported that their health significantly influenced their participation in leisure activities and social interaction. They stated that particular health issues (e.g., loss of eyesight and hearing, arthritis, movement disorders such as Parkinson’s disease and strokes) were deterrents to social interaction and participation in leisure activities, because they affected their moods and their ability to participate. Because I have so much trouble with feeling dizzy and I fall and I can’t get up by myself so I find it hard to do the active groups (sic). (MG02)
Participants commonly referred to the impact of dementia on social interaction. Often friendships were taxed due to the decreasing cognitive states of friends and thus their ability to communicate. I get along with a lot of people here like [name removed]. But I am sad that he is going downhill at the moment…last night, at the dining table, he thought we were all sitting in a boat. We were in the dining room and he thought we were on a boat! He must be getting dementia pretty bad. (MG06)
In one interview, a participant talked about the death of her husband providing her with the opportunity to interact with family, friends and staff. Particular residents and staff had approached the participant to provide emotional support and friendship throughout her loss, creating friendships that had not previously existed. Family The impact of family on social interaction and participation in leisure activities of residents was a prominent theme in the interview material. Ways in which families assisted residents included providing transportation to social outings and activities, assistance and encouragement for their participation in activities and social interactions within the facility, items for activities, and emotional support and encouragement. Several participants talked about family being necessary for encouraging social interaction and participation in leisure activities by being supportive. The families provided a foundational support for when the resident moved from home
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into an RAC facility and encouraged opportunities for social interaction with other residents. One particular participant noted that when her family visited, which was on a regular basis, other residents would often come for a chat too. Last week, my daughter came to visit and my friend and I, we all went down to the lounge and had a cup of tea. That often happens that when family come over a few of my friends come as well to talk because I think they like the company of other people. That doesn’t bother me at all because I think it is important to have something to do during the day (sic). (MG05)
Several participants reported relying on family members for transportation to social outings and activities that were outside the facility. Often access to public transport or taxis were impossible due to health and financial constraints resulting in an inability for participants to visit friends, family, and organised activity groups. Therefore, participants relied on their family to drive them to places as required. Participants indicated that their families encouraged their participation in leisure activities. My daughter made me a giant card with really big letters on them so that I can see which numbers there are (sic). (MG05)
The facility A consistent theme in the interview material was that the facility, in which the participants lived, both assisted and hindered social interaction and participation in leisure activities. The participants remarked that the facility was warm and bright with big rooms and sitting rooms for entertaining family and friends. Having sitting rooms for family and friends to sit was perceived as encouraging social interactions. They have some lovely places to go and sit here. They have a sitting place at the end of my corridor that has couches and television and a tea and coffee station. I sometimes go and sit there. Occasionally there are other residents there to talk with but not very often, which I like because sometimes I just like to sit and think about things. (MG04)
Participants commented on how big the bedrooms were, which allowed for loved furniture and other chattels to be kept as well as room for
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Social interaction and participation in leisure activities in residential aged care family and friends to sit in private, making the participants feel at home. In contrast, some participants also felt that if family or friends wished to stay for dinner, there was poor availability of chairs and dining tables at the facility, which was discouraging of social interaction. The size of the facility also impacted on social interaction and participation in leisure activities. A particular resident had a negative experience with the size of the facility. Upon first moving into the facility, the resident became lost looking for the dining room in the many corridors. Furthermore, due to poor health this participant felt that it was too hard to attend leisure activities due to the distance required to walk to the activities room. For the safety of residents within the facility, a security system involving a swipe card for access in and out of the building was initiated. A particular participant had a negative experience with this security system when the participant was denied a swipe card by management preventing access to surrounding gardens. All the doors are locked now. It’s restricting. We have never had them locked before…recently they have been giving out swaps so people can go out the doors. But I have been trying to get mine and when I went down this morning they said I am just going to do your assessment but that was a week ago. So when I went down today, she said I will not give it to you. Most of the others have theirs already. (MG01)
Staffing Staff appeared to play a common role in impacting on social interaction and participation in leisure activities. Participants reported that staffing levels affected the availability of activities and opportunities for social interaction. Participant: There is craft but we are short staffed for that type of thing. Researcher: Do you mean the people who run the activities? Participant: Yes, you see we could have four activity ladies because we have high and low care. We really only have one activities person. (sic). (MG01)
Participants reported that staff availability greatly influenced the number of bus outings that
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occurred, and trips were cancelled if the bus driver was ill. Due to the high demand for bus trips, participants reported that some residents missed out on these excursions. Numerous residents felt that if there were more staff appointed to organise activities with participants there would be more opportunities for them to participate in leisure activities. Due to the staffing levels, participants perceived that social interaction with staff was rushed, because staff were over worked and had no time available. Often participants felt that social interactions with staff were limited to times in which the staff were assisting with activities of daily living. A common perspective of the participants was that staff helped residents to feel at home and comfortable in their environment. Participants appeared to value kindness from staff including helping with daily care, cleaning rooms, and changing sheets. I have a special chair that is comfortable. There was the maintenance man who said one day, “I have a comfortable chair you can have because you always sit here. I thought he was joking…but then one day, it was there…it looked new….when I saw the man again I told him thank you. (MG02)
Transportation Issues with transportation to social events with family and friends and access to leisure activities were commonly mentioned during the interviews. Not all participants had access to a personal car for transportation and relied on other methods. One participant stated that she missed her car most of all since moving into RAC, because she was not as social as she used to be. Other participants, however, stated that they do not miss their cars, because their health had impacted on their ability to drive. Well, my eyesight got really bad a couple of years ago, so I had to stop driving then. But I never really took the car anywhere unless I had my husband with me. But my husband passed away 3 years ago (MG05).
Poor health appeared to be a major factor preventing participants from accessing transportation to social outings and activities. Several participants stated that their health had a substantial impact on their ability to drive or catch a taxi.
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Jessica E Thomas, Beverly O’Connell and Cadeyrn J Gaskin You can catch a taxi, yes. When I am down the street I couldn’t walk so it makes it harder even though the taxis take your walker (sic). (MG01)
A number of participants stated that they relied on family to drive them to social outings and activities. Often their families were too busy with their own lives, however, and they were not always available to assist. Geography In a small number of interviews, geography (e.g., family and friends living too far away to visit) appeared to influence negatively social interaction and participation in leisure activities outside of the facility. In most cases, friends living outside the facility were too ill to be able to drive and visit the participants. When I moved into here it has become too hard to see them because none of them can drive to come and see me because it’s too hard (sic). (MG06)
As well as access to friends, sometimes participants’ family members lived to far away to visit often. My daughter visits me every week and my son, once a fortnight because he lives in Mentone and it’s is a bit of a drive to see me more often. My other daughter lives in Queensland….I rarely see her. (MG05)
Participants appeared to be resigned to the fact that geography impacted on their level of social interaction and participation in leisure activities with family and friends. Most participants used other methods to communicate with significant others in their lives, especially the telephone. How opportunities for social interaction and leisure activities could be improved Opportunities for social interaction The participants generally seemed satisfied with their social lives. When discussing methods of communicating with family and friends, however, one participant suggested she would like to have access to a computer within the facility. The participant perceived that it would be valuable to be able to contact family and friends via email. Participant: I went to see my sister yesterday who is in another nursing home…I think they are better equipped over there. You know, they have computers! Researcher: Were those computers for residents use?
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Participant: Yes, yes Researcher: Do you think having computers here would be beneficial? Participant: Oh yes, it will help me to stay in contact with friends. (MG03)
Computers could also be used to communicate with family and friends via email but also provide the chance to play online games and keep up to date with the news. Leisure activities The participants reported that, in general, there was a good range of activities offered at their facility. Participants perceived that there should be some changes made to the current activities offered, however, to make them more user friendly. Several participants mentioned that they enjoyed reading novels but were restricted in doing so by the availability and access to books and limitations regarding size of the text (and thus ability to read). Most people here have difficulty reading. So we really do need larger print books. We have a library here that has a small collection of books. But they are all small print of course. (MG01)
A few participants mentioned that gardening was an enjoyable activity; it was generally perceived that gardening was too difficult to undertake, however, due to poor health. Through developing interventions to improve access to garden beds (i.e., raised garden beds and improved access via paths), participants would be able to actively participate. DISCUSSION The findings of this research form are sharply juxtaposed with recent work (e.g., de Bellis, 2010; Moore et al., 2011), in which unflattering accounts of Australian RAC settings have been presented. In contrast with previous studies (e.g., Andersson et al., 2006; Harper, 2002), the participants in the present study appeared generally satisfied with their social lives and participation in leisure activities. One reason for this contrasting evidence is that the present study was conducted in a private RAC facility, which had better amenities that many other facilities. Even so, the findings of this research could hold value for other facilities wishing to improve their practices. © eContent Management Pty Ltd
Social interaction and participation in leisure activities in residential aged care Consistent with previous research (e.g., Tate et al., 2003), regular communication and being with family and friends outside the RAC facility was a high priority for residents. In the Tate et al. study, participants were asked to define successful ageing, and ‘having a loving spouse, family, and friends’ was the sixth most common component of individual definitions. Unfortunately, in the present study several participants reported having difficulties maintaining contact with life-long friends due to limited transport options. One participants’ suggestion that having access to a computer would have allowed her to email friends and family may have broader implications. The increasing popularity of voice over Internet protocol service and software applications (e.g., Skype, GoogleTalk) makes it possible to communicate via video, voice, and instant messaging with a computer and adequate Internet bandwidth. Using this technology, residents of RAC facilities may be able to keep in contact with friends and family more easily. One implication of the ageing in place philosophy that had been adopted at this RAC facility is that some residents found it increasingly difficult to communicate with others who had developed dementia. Progressive memory impairments make it increasingly difficult for people with dementia to comprehend and use language (Azuma & Bayles, 1997). Even so, evidence suggests that people with mild and severe forms of dementia are able to maintain friendships and have conversations with others (Saunders, de Medeiros, Doyle, & Mosby, 2012). The conversations of people with dementia are similar in structure to non-impaired people, but tend to focus on mundane or personal topics. Although the participants seemed compassionate towards these friends, the presence of residents with a wide range of cognitive abilities has clear implications for policies in aged care. Staff should engage in socially inclusive practices and promote friendships among like-minded individuals. The participants in the present study had a clear preference for activities outside of their RAC facility, with more demand for seats on the bus than could be met. This finding differs from that of a recent study (in which watching television was the most preferred activity; Kracker, Kearns, Kier, & Christensen, 2011), and suggests that it may be important to survey residents periodically to maintain awareness of their leisure activity © eContent Management Pty Ltd
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preferences. Although excursions have clear cost implications, RAC facilities should consider how they could enable residents to have experiences outside their facilities on a tighter budget. Residents were more likely to report disliking activities because they found participation difficult, rather than indifference towards the activities themselves. There were stories from residents of how family members facilitated their inclusion in activities through, for example, increasing the size of numbers on bingo cards. Staff in RAC facilities should take such stories as instructive about how they could modify activities to enable maximum participation. Residents could also be made aware of e-book readers and tablets, on which text can be magnified. Although the sample of residents in this exploratory study was reasonably small, their demographic characteristics compare well with those of the broader population of Australians living in RAC. In 2010, 56% of residents living in RAC were aged 85 years or older, 70% were women, 66% lived in major cities, and 65% of permanent female residents were widowed at the time of admission (AIHW, 2011). The participants in the present study, however, seemed to be more highly functioning (e.g., they could go on bus trips and make meaningful contributions to this research) than the wider population of people in RAC. Approximately half of permanent residents in RAC facilities have been diagnosed with dementia and require medium or high levels of assistance with activities of daily living (AIHW, 2011). The findings of this study indicated that residents enjoyed their social activities and their social interactions with others. To encourage RAC facilities to promote these activities, Government funding formulas should reward RAC facilities that have good social programs for residents. There is a need for further research to be conducted across a few RAC settings to determine the types of activities residents enjoy so appropriate social programs can be designed and adequately resourced. The present study demonstrates that RAC facilities can assist residents to fulfil their social and leisure needs. Although maintaining contact with family and friends was of prime importance to the participants in this study, they also appeared to form meaningful relationships with fellow residents, which highlights the need to place low-care
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residents in close proximity in RAC facilities. There was a clear preference for going on excursions over participating in activities at the RAC facility. New technologies and creative problem-solving with facility staff may be key to enhancing the social worlds and leisure pursuits of older persons in RAC facilities. Supporting residents to remain socially connected is an important goal of good care. This paper recommends a number of strategies that support this goal. It may be useful for RAC managers and policy makers to take cognisance of the points raised in this paper and review ways these activities can be implemented and adequately funded. REFERENCES Adams, K. B., Leibbrandt, S., & Moon, H. (2011). A critical review of the literature on social and leisure activity and wellbeing in later life. Ageing & Society, 31, 683–712. Andersson, I., Pettersson, E., & Sidenvall, B. (2006). Daily life after moving into a care home – Experiences from older people, relatives and contact persons. Journal of Clinical Nursing, 16, 1712–1718. Australian Institute of Health and Welfare. (2011). Residential aged care in Australia 2009-10: A statistical overview. Aged care statistics series no. 35 (Cat. no. AGE 66). Canberra, ACT: Author. Azuma, T., & Bayles, K. A. (1997). Memory impairments underlying language difficulties in dementia. Topics in Language Disorders, 18, 58–71. Bergland, A., & Kirkevold, M. (2006). Thriving in nursing homes in Norway: Contributing aspects described by residents. International Journal of Nursing Studies, 43, 681–691. Bergman-Evens, B. (2004). Beyond the basics: Effects of the Eden alternative model on quality of life issues. Journal of Gerontological Nursing, 30, 27–34. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Costello, P. (2007). Intergenerational report 2007. Canberra, ACT: Commonwealth of Australia. de Bellis, A. (2010). Australian residential aged care and the quality of nursing care provision. Contemporary Nurse, 35(1), 100–113. Drageset, J. (2004). The importance of activities of daily living and social contact for loneliness: A survey among residents in nursing homes. Scandinavian Journal of Caring Science, 18, 65–71. Findlay, R., & Cartwright, C. (2002). Social isolation and older people: A literature review. Paper at Australasian Centre on Ageing, The University of Queensland, Brisbane, QLD.
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Harper, G. (2002). Daily life in a nursing home: Has it changed in 25 years? Journal of Aging Studies, 16, 345–359. Jilek, R. (2006). The lived experience of men entering residential aged care. Geriaction, 24(2), 5–13. Kracker, J., Kearns, K., Kier, F. J., & Christensen, K. A. (2011). Activity preferences and satisfaction among older adults in a veterans administration long-term care facility. Clinical Gerontologist, 34, 103–116. Litwin, H., & Shiovitz-Ezra, S. (2006). The association between activity and wellbeing in later life: What really matters? Ageing & Society, 26, 225–242. Moore, K. J., Hill, K. D., Robinson, A. L., Haines, T. P., Haralambous, B., & Nitz, J. C. (2011). The state of physical environments in Australian residential aged care facilities. Australian Health Review, 35, 412–417. Nicholson, N. R. (2012). A review of social isolation: An important but underassessed condition in older adults. The Journal of Primary Prevention, 33, 137–152. doi:10.1007/s10935-012-0271-2 Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science, 8(3), 27–37. Saunders, P. A., de Medeiros, K., Doyle, P., & Mosby, A. (2012). The discourse of friendship: Mediators of communication among dementia residents in long-term care. Dementia, 11, 347–361. Street, D., Burge, S., Quadagno, J., & Barrett, A. (2007). The salience of social relationships for resident wellbeing in assisted living. The Journals of Gerontology: Series B, Psychological Sciences and Social Sciences, 62, S129–S134. Tate, R. B., Lah, L., & Cuddy, T. E. (2003). Definition of successful aging by elderly Canadian males: The Manitoba follow-up study. The Gerontologist, 43, 735–744. Victor, C., Scambler, S., Bond, J., & Bowling, A. (2000). Being alone in later life: Loneliness, social isolation and living alone. Reviews in Clinical Gerontology, 10, 407–417. Wang, H., Karp, A., Winblad, B., & Fratiglioni, L. (2002). Late-life engagement in social and leisure activities is associated with a decreased risk of dementia: A longitudinal study from the Kungsholmen Project. American Journal of Epidemiology, 155, 1081–1087. World Health Organization. (2012). Definition of an older or elderly person. Retrieved from http://www. who.int/healthinfo/survey/ageingdefnolder/en/ Received 24 February 2012
Accepted 16 May 2013
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Residents’ perceptions and experiences of social interaction and participation in leisure activities in residential aged care JESSICA E THOMAS, BEVERLY O’CONNELL*,+ AND CADEYRN J GASKIN* School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia; *Faculty of Health, Deakin University, Melbourne, VIC, Australia; +Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada
Abstract: Social interaction and participation in leisure activities are positively related to the health and well-being of elderly people. The main focus of this exploratory study was to investigate elderly peoples’ perceptions and experiences of social interaction and leisure activities living in a residential aged care (RAC) facility. Six residents were interviewed. Themes emerging from discussions about their social interactions included: importance of family, fostering friendships with fellow residents, placement at dining room tables, multiple communication methods, and minimal social isolation and boredom. Excursions away from the RAC facility were favourite activities. Participants commonly were involved in leisure activities to be socially connected. Poor health, family, the RAC facility, staffing, transportation, and geography influenced their social interaction and participation in leisure activities. The use of new technologies and creative problem solving with staff are ways in which residents could enhance their social lives and remain engaged in leisure activities.
Keywords: residential aged care, nursing homes, leisure, recreation, social interaction, social inclusion, older persons, nursing
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ust under 200,000 Australians live in residential aged care (RAC) facilities (Australian Institute of Health and Welfare, 2011). With the number of people aged 85 and over set to quadruple between 2007–2047 (Costello, 2007), demand for RAC places is set to increase into the future. Although questions regarding how this increase in demand will be met require answering, we also need to ensure that quality care is maintained in RAC facilities. In Australia, the Federal Government is the principal funder of RAC, providing an estimated $7.1 billion to support 182,850 RAC places in the year to 30 June 2010 (Australian Institute of Health and Welfare, 2011). Government policies that enable people to receive support in their own homes mean that people with low-care needs, and who used to be placed in RAC facilities, now stay living at home. The consequences of these policies for RAC facilities is that they now mainly accommodate people with high care needs, rather than people with a broad range of needs. In 2009–2010, 71% of permanent RAC residents were assessed as having high care needs, with the remaining 29% having low care needs. The Government provided RAC places and community aged care packages for 111 per 1000 people aged 70 or over in 2010,
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with current policy focused toward improving this ratio in coming years. Despite the amounts of funding provided to the RAC sector, the provision of care to many residents and the state of Australian facilities are suboptimal (de Bellis, 2010; Moore et al., 2011). Many residents report having negative experiences in RAC facilities (Jilek, 2006). The findings of research undertaken in one Australian RAC facility suggested that the care provided was frequently rushed and untimely, with residents put at risk of being exposed to unsafe practices and negligence (de Bellis, 2010). Furthermore, residents social and activity needs were not being addressed. This apparent neglect of residents’ social and activity needs is particularly concerning, because researchers have consistently identified a relationship between social interaction and participation in leisure activities in the health and well-being of elderly people (e.g., Bergman-Evens, 2004; Drageset, 2004; Victor, Scambler, Bond, & Bowling, 2000). In regards to social interaction, higher levels of social engagement have been linked to lower mortality rates, greater physical health (e.g., preserved physical function), and better cognitive functioning and affective
Social interaction and participation in leisure activities in residential aged care mental health (Street, Burge, Quadagno, & Barrett, 2007). Consistent with these findings, review evidence suggests that social isolation is associated with an increased risk of all-cause mortality, re-hospitalisation, cardiac heart disease, cancer, poor nutrition, negative health behaviours, and the common cold (Nicholson, 2012). With respect to participation in leisure activities, the findings from a review suggest that activity I positively associated with psychosocial well-being, health, and survival (Adams, Leibbrandt, & Moon, 2011). Although evidence suggests that both social engagement and participation in leisure activities are important for health (Wang, Karp, Winblad, & Fratiglioni, 2002), the former (social engagement) may matter to older adults more than the latter (Litwin & Shiovitz-Ezra, 2006). There is limited, but growing, amount of research in the area of aged care, however, that focuses on identifying residents’ perceptions and experiences of social interaction and participation in leisure activities (Andersson, Pettersson, & Sidenvall, 2006; Bergland & Kirkevold, 2006; Harper, 2002). In a Norwegian study, researchers found that positive peer relationships and participating in meaningful activities were two of a small number of factors contributing to thriving in RAC facilities (Bergland & Kirkevold, 2006). The findings of a fairly recent study showed that there was a general dissatisfaction with the level of activity and socialisation that occurred within RAC facilities (Andersson et al., 2006). The participants in this study regarded communication with residents, family, friends, and staff as the most important activity they performed, yet they reported that there were insufficient opportunities for this communication to occur. This finding is similar to those of previous studies (e.g., Tate, Lah, & Cuddy, 2003), which show that communication with family and friends are a high priority of many residents. Nevertheless, one in three elderly residents may not receive a visitor in a given 12-month period (Findlay & Cartwright, 2002). Although maintaining relationships with family and friends is of high priority for
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residents, evidence suggests that their capacities to form new social relationships upon moving into assisted care have a more positive effect on well-being than the continuation of existing relationships (Street et al., 2007). Understanding the experiences and perceptions of social interaction and leisure activity of residents in RAC facilities seems a prerequisite for developing interventions that have the potential for enhancing the quality of their lives through improving their social and leisure activity experiences. The purpose of this exploratory study was to investigate elderly persons’ experiences and perceptions of social interaction and participation in leisure activities in a RAC facility. Specifically, we aimed to: (a) understand residents’ perceptions and experiences of (i) social interaction and (ii) leisure activities in their RAC facility; (b) identify factors affecting social interaction and participation in leisure activities; and (c) gain residents’ impressions on how opportunities for social interaction and leisure activities could be improved in their RAC facility. METHOD Design In this study, a reality-oriented approach was adopted (Patton, 2002), with semi-structured interviews as the means of data collection. A reality-oriented approach was particularly suited for this study, because of its large focus on concrete events (e.g., whether participants took part in leisure activities). Although acknowledging that knowledge is historically and socially constructed, realists seek to transcend such processes to describe the real world (Patton, 2002). Based on the study aims, the main topics of the interviews were: (1) Perceptions and experiences of social interaction and leisure activities in their RAC facilities, including: (a) the range and types of social interaction and leisure activities residents prefer to and not prefer to be involved in and what they would like to see offered by their RAC facility; and (b) residents’ perceptions and experiences of social isolation and boredom. (2) Factors affecting social interaction and participation in leisure activities.
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(3) How opportunities for social interaction and leisure activities could be improved in their RAC facility. Setting The setting for this study was an Australian, private sector, metropolitan RAC facility, which accommodates 90 high and low care residents. The residents have individual rooms with their own bathrooms, furniture, and windows providing views of established gardens. Adjoining rooms are also available to accommodate couples wishing to live together. The facility has television and activities rooms, dining areas, working bars and pool tables, hairdressers, chapels, numerous private sitting areas, and garden areas accessible via patio doors. Respite care is available for various lengths of time as agreed with caregivers. The facility has a high level of security, with residents and visitors requiring staff assistance for entry and exit. Staff practise the philosophy of ageing in place, which allows for continuity of care to support the changing care needs of residents without having to displace them from their friends, their spouses, and familiar surroundings. Participants The participants were one male and five female residents with an average age of 84 years. The female participants (but not the male participant) were widowed. All participants experienced multiple co-morbidities and were dependent on staff and family to provide both physical and psychosocial care. The participants met the following inclusion criteria: (a) were not cognitively impaired; (b) could understand and speak conversational English; (c) were aged 65 years or older, because in many developed countries, including Australia, 65 years of age marks the beginning of retirement and older age (World Health Organization, 2012); and (d) had lived in the RAC for at least 6 months, thus having time to adjust to living in an RAC facility. Interview schedule The interview schedule reflected the topics of the interview (listed in the Design section), but phrased in the form of open-ended requests for
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information. Examples of these requests are: ‘Please tell me about the type/s of social activities you participate in here in the nursing home’ and ‘Please tell me about the leisure activities you participate in, here in the nursing home’. Follow up questions and probes were based on the participants’ responses. Procedures Follow approval from Deakin University’s Human Research Ethics Committee and from senior management of the RAC facility, nursing staff were briefed about the project and asked to be involved in the recruitment of participants. These staff identified potential participants who met the selection criteria, gave them flyers about the research, and invited them to return a completed slip to nursing staff if they wished to learn more about the project. The first author contacted the residents who returned slips, briefed them further about the research, and, if they were still interested in being interviewed, obtained their informed consent to participate. The first author then conducted the interviews at times and in places that were convenient for participants. The interviews were audio-recorded and transcribed verbatim. The transcripts were used as the material for the analysis. Data analysis Using the procedures of Braun and Clarke (2006), thematic analysis of the interview material was undertaken. Braun and Clarke have described a six-phase process of thematic analysis: (1) familiarising yourself with the data (transcribing, reading, and re-reading the interview material); (2) generating initial codes (coding interesting features of the material in a systematic fashion); (3) searching for themes (collating codes into themes); (4) reviewing themes (checking that the themes are consistent with the initial codes and the interview material); (5) defining and naming themes (generating clear names for each theme); and (6) producing the report (selecting extracts for report and ensuring they relate to both the analysis and the research questions and the literature. The first author was principally involved in this process, with the other two authors reviewing
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Social interaction and participation in leisure activities in residential aged care her work at the end of each phase, with particular attention to reviewing, defining, and naming the themes, and producing this paper. Rigour was assessed using strategies that Sandelowski (1986) recommends for qualitative research in nursing. Fittingness was enhanced through incorporating material from several participants in this study, and was demonstrated through discussing the findings of the study in the light of previous work in the area. Rigour in the analysis was achieved through: (i) all authors discussing interpretations during various phases of analysis; and (ii) the use of computer software to track all coding. FINDINGS Perceptions and experiences of social interaction During discussions about residents’ perceptions and experiences of social interaction within their RAC facility, five themes emerged: importance of family; fostering friendships with fellow residents; placement at dining room tables; multiple communication methods; and minimal social isolation and boredom. Importance of family A consistent theme in the interviews was that maintaining close contact with family was the most important form of social interaction that occurred on a regular basis. Family members provided opportunities for social interaction through driving participants to social outings, celebrations, and visits to friends who may not otherwise be able to visit themselves. Oh yes … all the kids still come and see me all the time … they all mean a lot. I still write to them all (MG02).
Few participants had remained in contact with life-long friends living outside the RAC facility due to distance and limited availability of adequate transport. It appeared as though participants relied on the social interaction they receive from their family and from the social interactions they receive at the RAC facility. Fostering friendships with fellow residents In general, residents perceived that they could socialise with other residents in the facility,
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because most were friendly and willing to say, ‘Hello.’ Participants reported receiving regular visits from other residents to their rooms. They come in every night and visit me and we sit and watch the television from 6pm to 8.30pm. And we sit, the 3 of us together. We have supper in here also. It is so lovely having friends close by and at hand (sic). (MG05)
Often the participants talked about leaving their doors open for residents to come wandering in if they wish. These participants encouraged this behaviour in other residents by leaving their doors open and providing opportunities to sit, talk, and listen. Placement at dining room tables A common theme that participants talked about was socialising with other residents around the dining room table. Residents reported regularly sitting at the same tables every day, which gave them the opportunity to develop friendships with others. The participants reported experiencing difficulties, however, when attempting to socialise with residents who had dementia. Participants generally felt that residents with dementia were difficult to chat with, because the conversations would be one sided. She has dementia so she can’t talk but she is nice. She mumbles. I find it very hard to talk with her. (MG02)
Despite this challenge, there appeared to be a general consensus among the participants that certain topics that invoked mumbling from the residents with dementia could be avoided and an enjoyable meal could be had. Participants perceived that residents with dementia were just people wishing for social interaction themselves despite finding conversation challenging at times. Multiple communication methods The importance of contacting family and friends appeared as a common theme throughout the interviews. Telephones, letters, and computers were common methods of communication that participants used. In general, participants perceived that staying in contact with family and friends was extremely important. All
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participants had access to telephones in their rooms and would often call family and friends as they wished. Having access to these telephones provided opportunities for residents to socially interact with those living outside of the facility. I have my phone here, which I use a lot. I can call anybody whenever I want…I try to keep in touch as much as possible because I like knowing how they are doing. Friends and family are very important to me. (MG04)
With regard to sending letters to family and friends, in most cases residents felt that they could not write to family or friends because their health (e.g., macular degeneration) prevented them from doing so. Minimal social isolation and boredom Overall, most participants stated that they never felt socially isolated or bored. I am happy here. I have my friends and staff close by here to offer me a hand if I wish. I can ring up on the phone if I want to talk to someone. But I am content here (sic). (MG05)
In general, participants said that they were never lonely or bored because of the level of social interaction that occurred throughout the day. Participants socially interacted with staff (including doctors and allied health), other residents, family, and friends (living outside of the RAC facility). One participant stated that if she ever became lonely or bored then she would simply walk down to the dining room and there would always be other residents or staff around for a chat. I can just make a short walk to the dining room and there are always people sitting around in the dining room. I just go and talk to them (sic). (MG05)
One participant talked about the numerous people who attended to her on a daily basis in her room, thus preventing loneliness. Of interest, it was mentioned that the doctor who regularly visited this participant provided a form of social interaction that was often looked forward to and enjoyed. This participant also enjoyed visits from other health practitioners, including the physiotherapist, dieticians, and podiatrists.
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Perceptions and experiences of leisure activities Types of leisure activities available The participants reported that various types of leisure activities were pursued within their RAC facility. These activities can be divided into the following categories: solitary and social. Solitary activities were those activities that participants enjoyed on a daily basis, but that did not involve the participation of others. Such activities included reading newspapers and novels borrowed from the library, reminiscing by oneself, contemplation, and listening to the radio (wireless). Although these activities were not social, the participants generally perceived that they provided a means to feel connected with their local community and the world in general, as well as providing them with a sense of calm in an often hectic world. My comfort is my wireless. I cannot live without my wireless. (MG04) I like reading the paper, especially the local paper, with all the scandal. Keeping up to date with the world is important (sic). (MG03)
Numerous activities offered within the RAC facility required participants to be more physically involved and socially connected. Such activities included attending weekly exercise groups, walks, playing carpet boules and hookey, and weekly bus trips. Other, less physical, activities were also offered including: card games such as bingo and hoy, men’s group, and a weekly crossword group. These activities were run on a weekly basis and were regularly attended by participants. On a fortnightly basis, a gift shop was set up in the main dining room and residents could come and explore what was on offer. They also have a shop that comes here very often. I go to the shop a lot because I like looking at the stuff that they are selling. (MG04)
The gift shop provided opportunities for those less mobile residents to purchase items without having to leave the facility. Other creative social activities such as cooking, knitting, and craft groups were also offered. Participants also participated in informal craft groups within their own time and among other residents. Knitting was
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Social interaction and participation in leisure activities in residential aged care considered a common creative pastime and was often enjoyed in the company of friends. Leisure activities enjoyed The participants indicated that weekly bus outings were the most enjoyed activity offered at the RAC facility, because it provided opportunities for changes in the daily routines of residents. Such outings involved small bus trips to surrounding heritage sites, cafes, parks, and shopping centres. Participants often noted, however, that the bus trips were extremely popular and would become full very quickly, which often meant that some residents missed out on trips. Due to staffing constraints, the bus trips were restricted to one or two trips a week allowing for seven residents to travel each time. The bus trip, everyone likes it so we have to take in turns and it often gets full up. (MG02)
The participants commonly reported that reading newspapers and listening to the radio were enjoyable activities that they undertook. Often participants would enjoy retiring to their rooms in the afternoon and listening to their radios. I also rest in the afternoon and I listen to my radio. It is actually very calming down here in my room. I have it just the way I like it. Comfortable. I sit in the chair and I nap. (MG05)
On special occasions, which participants perceived occurred too infrequently, entertainment groups would attend the RAC facility to give performances. The participants commonly indicated that they greatly enjoyed these occasions. If they were unable to attend one of these occasions, then the doors to their rooms would be left open so that they could hear the music. Leisure activities disliked The participants reported that hoy and bingo were two of their least enjoyed activities. Often these activities weren’t enjoyed because poor health prevented participants from reading and holding the cards. Several participants indicated having a dislike for attending a lot of the craft groups. Some participants did not attend knitting groups, despite having an interest in knitting, because their health conditions
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(e.g., poor eyesight) prevented them from undertaking an activity they had previously enjoyed. One of the participants also perceived the cooking group to be boring. Residents were required to be involved in making a particular food item but were only allowed to help with part of the process (e.g., mixing or adding ingredients). As a result, the activity was perceived as boring. One participant also expressed a dislike for reminiscing groups. Participation in leisure activities facilitated social interaction Participation in leisure activities was found to facilitate social interaction. Participants indicated that they often attended activities for social reasons rather than for the enjoyment of the activity. I don’t like bingo and cards. You got to have two hands to play cards and I don’t. But I try to go to a lot of activities because it allows me to talk with other residents here. (MG06)
Numerous activities were perceived by participants to offer a form of social interaction. Such activities were attended on a weekly basis and were used as a way to stay in touch with other residents. Weekly hairdressing and manicures, while offering relaxation, allowed for participants to sit and chat while being pampered. … I have my hair done every week. I went last week and had it done. It is a real luxury. When I go to the hairdressers I can talk to the other ladies sitting beside me in the room. (MG04)
Participants interviewed also commonly talked about attending informal activities organised amongst themselves. A common pastime of participants was to enjoy a game of cards at the dining table, after meals. After, lunch, we stay around the dining table and we talk and play cards. (MG02)
Factors affecting social interaction and participation in leisure activities The participants identified six factors that affected their social interactions and participation in leisure activities, including poor health, family, the RAC facility, staffing, transportation, and geography.
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Poor health Participants commonly reported that their health significantly influenced their participation in leisure activities and social interaction. They stated that particular health issues (e.g., loss of eyesight and hearing, arthritis, movement disorders such as Parkinson’s disease and strokes) were deterrents to social interaction and participation in leisure activities, because they affected their moods and their ability to participate. Because I have so much trouble with feeling dizzy and I fall and I can’t get up by myself so I find it hard to do the active groups (sic). (MG02)
Participants commonly referred to the impact of dementia on social interaction. Often friendships were taxed due to the decreasing cognitive states of friends and thus their ability to communicate. I get along with a lot of people here like [name removed]. But I am sad that he is going downhill at the moment…last night, at the dining table, he thought we were all sitting in a boat. We were in the dining room and he thought we were on a boat! He must be getting dementia pretty bad. (MG06)
In one interview, a participant talked about the death of her husband providing her with the opportunity to interact with family, friends and staff. Particular residents and staff had approached the participant to provide emotional support and friendship throughout her loss, creating friendships that had not previously existed. Family The impact of family on social interaction and participation in leisure activities of residents was a prominent theme in the interview material. Ways in which families assisted residents included providing transportation to social outings and activities, assistance and encouragement for their participation in activities and social interactions within the facility, items for activities, and emotional support and encouragement. Several participants talked about family being necessary for encouraging social interaction and participation in leisure activities by being supportive. The families provided a foundational support for when the resident moved from home
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into an RAC facility and encouraged opportunities for social interaction with other residents. One particular participant noted that when her family visited, which was on a regular basis, other residents would often come for a chat too. Last week, my daughter came to visit and my friend and I, we all went down to the lounge and had a cup of tea. That often happens that when family come over a few of my friends come as well to talk because I think they like the company of other people. That doesn’t bother me at all because I think it is important to have something to do during the day (sic). (MG05)
Several participants reported relying on family members for transportation to social outings and activities that were outside the facility. Often access to public transport or taxis were impossible due to health and financial constraints resulting in an inability for participants to visit friends, family, and organised activity groups. Therefore, participants relied on their family to drive them to places as required. Participants indicated that their families encouraged their participation in leisure activities. My daughter made me a giant card with really big letters on them so that I can see which numbers there are (sic). (MG05)
The facility A consistent theme in the interview material was that the facility, in which the participants lived, both assisted and hindered social interaction and participation in leisure activities. The participants remarked that the facility was warm and bright with big rooms and sitting rooms for entertaining family and friends. Having sitting rooms for family and friends to sit was perceived as encouraging social interactions. They have some lovely places to go and sit here. They have a sitting place at the end of my corridor that has couches and television and a tea and coffee station. I sometimes go and sit there. Occasionally there are other residents there to talk with but not very often, which I like because sometimes I just like to sit and think about things. (MG04)
Participants commented on how big the bedrooms were, which allowed for loved furniture and other chattels to be kept as well as room for
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Social interaction and participation in leisure activities in residential aged care family and friends to sit in private, making the participants feel at home. In contrast, some participants also felt that if family or friends wished to stay for dinner, there was poor availability of chairs and dining tables at the facility, which was discouraging of social interaction. The size of the facility also impacted on social interaction and participation in leisure activities. A particular resident had a negative experience with the size of the facility. Upon first moving into the facility, the resident became lost looking for the dining room in the many corridors. Furthermore, due to poor health this participant felt that it was too hard to attend leisure activities due to the distance required to walk to the activities room. For the safety of residents within the facility, a security system involving a swipe card for access in and out of the building was initiated. A particular participant had a negative experience with this security system when the participant was denied a swipe card by management preventing access to surrounding gardens. All the doors are locked now. It’s restricting. We have never had them locked before…recently they have been giving out swaps so people can go out the doors. But I have been trying to get mine and when I went down this morning they said I am just going to do your assessment but that was a week ago. So when I went down today, she said I will not give it to you. Most of the others have theirs already. (MG01)
Staffing Staff appeared to play a common role in impacting on social interaction and participation in leisure activities. Participants reported that staffing levels affected the availability of activities and opportunities for social interaction. Participant: There is craft but we are short staffed for that type of thing. Researcher: Do you mean the people who run the activities? Participant: Yes, you see we could have four activity ladies because we have high and low care. We really only have one activities person. (sic). (MG01)
Participants reported that staff availability greatly influenced the number of bus outings that
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occurred, and trips were cancelled if the bus driver was ill. Due to the high demand for bus trips, participants reported that some residents missed out on these excursions. Numerous residents felt that if there were more staff appointed to organise activities with participants there would be more opportunities for them to participate in leisure activities. Due to the staffing levels, participants perceived that social interaction with staff was rushed, because staff were over worked and had no time available. Often participants felt that social interactions with staff were limited to times in which the staff were assisting with activities of daily living. A common perspective of the participants was that staff helped residents to feel at home and comfortable in their environment. Participants appeared to value kindness from staff including helping with daily care, cleaning rooms, and changing sheets. I have a special chair that is comfortable. There was the maintenance man who said one day, “I have a comfortable chair you can have because you always sit here. I thought he was joking…but then one day, it was there…it looked new….when I saw the man again I told him thank you. (MG02)
Transportation Issues with transportation to social events with family and friends and access to leisure activities were commonly mentioned during the interviews. Not all participants had access to a personal car for transportation and relied on other methods. One participant stated that she missed her car most of all since moving into RAC, because she was not as social as she used to be. Other participants, however, stated that they do not miss their cars, because their health had impacted on their ability to drive. Well, my eyesight got really bad a couple of years ago, so I had to stop driving then. But I never really took the car anywhere unless I had my husband with me. But my husband passed away 3 years ago (MG05).
Poor health appeared to be a major factor preventing participants from accessing transportation to social outings and activities. Several participants stated that their health had a substantial impact on their ability to drive or catch a taxi.
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Jessica E Thomas, Beverly O’Connell and Cadeyrn J Gaskin You can catch a taxi, yes. When I am down the street I couldn’t walk so it makes it harder even though the taxis take your walker (sic). (MG01)
A number of participants stated that they relied on family to drive them to social outings and activities. Often their families were too busy with their own lives, however, and they were not always available to assist. Geography In a small number of interviews, geography (e.g., family and friends living too far away to visit) appeared to influence negatively social interaction and participation in leisure activities outside of the facility. In most cases, friends living outside the facility were too ill to be able to drive and visit the participants. When I moved into here it has become too hard to see them because none of them can drive to come and see me because it’s too hard (sic). (MG06)
As well as access to friends, sometimes participants’ family members lived to far away to visit often. My daughter visits me every week and my son, once a fortnight because he lives in Mentone and it’s is a bit of a drive to see me more often. My other daughter lives in Queensland….I rarely see her. (MG05)
Participants appeared to be resigned to the fact that geography impacted on their level of social interaction and participation in leisure activities with family and friends. Most participants used other methods to communicate with significant others in their lives, especially the telephone. How opportunities for social interaction and leisure activities could be improved Opportunities for social interaction The participants generally seemed satisfied with their social lives. When discussing methods of communicating with family and friends, however, one participant suggested she would like to have access to a computer within the facility. The participant perceived that it would be valuable to be able to contact family and friends via email. Participant: I went to see my sister yesterday who is in another nursing home…I think they are better equipped over there. You know, they have computers! Researcher: Were those computers for residents use?
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Participant: Yes, yes Researcher: Do you think having computers here would be beneficial? Participant: Oh yes, it will help me to stay in contact with friends. (MG03)
Computers could also be used to communicate with family and friends via email but also provide the chance to play online games and keep up to date with the news. Leisure activities The participants reported that, in general, there was a good range of activities offered at their facility. Participants perceived that there should be some changes made to the current activities offered, however, to make them more user friendly. Several participants mentioned that they enjoyed reading novels but were restricted in doing so by the availability and access to books and limitations regarding size of the text (and thus ability to read). Most people here have difficulty reading. So we really do need larger print books. We have a library here that has a small collection of books. But they are all small print of course. (MG01)
A few participants mentioned that gardening was an enjoyable activity; it was generally perceived that gardening was too difficult to undertake, however, due to poor health. Through developing interventions to improve access to garden beds (i.e., raised garden beds and improved access via paths), participants would be able to actively participate. DISCUSSION The findings of this research form are sharply juxtaposed with recent work (e.g., de Bellis, 2010; Moore et al., 2011), in which unflattering accounts of Australian RAC settings have been presented. In contrast with previous studies (e.g., Andersson et al., 2006; Harper, 2002), the participants in the present study appeared generally satisfied with their social lives and participation in leisure activities. One reason for this contrasting evidence is that the present study was conducted in a private RAC facility, which had better amenities that many other facilities. Even so, the findings of this research could hold value for other facilities wishing to improve their practices. © eContent Management Pty Ltd
Social interaction and participation in leisure activities in residential aged care Consistent with previous research (e.g., Tate et al., 2003), regular communication and being with family and friends outside the RAC facility was a high priority for residents. In the Tate et al. study, participants were asked to define successful ageing, and ‘having a loving spouse, family, and friends’ was the sixth most common component of individual definitions. Unfortunately, in the present study several participants reported having difficulties maintaining contact with life-long friends due to limited transport options. One participants’ suggestion that having access to a computer would have allowed her to email friends and family may have broader implications. The increasing popularity of voice over Internet protocol service and software applications (e.g., Skype, GoogleTalk) makes it possible to communicate via video, voice, and instant messaging with a computer and adequate Internet bandwidth. Using this technology, residents of RAC facilities may be able to keep in contact with friends and family more easily. One implication of the ageing in place philosophy that had been adopted at this RAC facility is that some residents found it increasingly difficult to communicate with others who had developed dementia. Progressive memory impairments make it increasingly difficult for people with dementia to comprehend and use language (Azuma & Bayles, 1997). Even so, evidence suggests that people with mild and severe forms of dementia are able to maintain friendships and have conversations with others (Saunders, de Medeiros, Doyle, & Mosby, 2012). The conversations of people with dementia are similar in structure to non-impaired people, but tend to focus on mundane or personal topics. Although the participants seemed compassionate towards these friends, the presence of residents with a wide range of cognitive abilities has clear implications for policies in aged care. Staff should engage in socially inclusive practices and promote friendships among like-minded individuals. The participants in the present study had a clear preference for activities outside of their RAC facility, with more demand for seats on the bus than could be met. This finding differs from that of a recent study (in which watching television was the most preferred activity; Kracker, Kearns, Kier, & Christensen, 2011), and suggests that it may be important to survey residents periodically to maintain awareness of their leisure activity © eContent Management Pty Ltd
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preferences. Although excursions have clear cost implications, RAC facilities should consider how they could enable residents to have experiences outside their facilities on a tighter budget. Residents were more likely to report disliking activities because they found participation difficult, rather than indifference towards the activities themselves. There were stories from residents of how family members facilitated their inclusion in activities through, for example, increasing the size of numbers on bingo cards. Staff in RAC facilities should take such stories as instructive about how they could modify activities to enable maximum participation. Residents could also be made aware of e-book readers and tablets, on which text can be magnified. Although the sample of residents in this exploratory study was reasonably small, their demographic characteristics compare well with those of the broader population of Australians living in RAC. In 2010, 56% of residents living in RAC were aged 85 years or older, 70% were women, 66% lived in major cities, and 65% of permanent female residents were widowed at the time of admission (AIHW, 2011). The participants in the present study, however, seemed to be more highly functioning (e.g., they could go on bus trips and make meaningful contributions to this research) than the wider population of people in RAC. Approximately half of permanent residents in RAC facilities have been diagnosed with dementia and require medium or high levels of assistance with activities of daily living (AIHW, 2011). The findings of this study indicated that residents enjoyed their social activities and their social interactions with others. To encourage RAC facilities to promote these activities, Government funding formulas should reward RAC facilities that have good social programs for residents. There is a need for further research to be conducted across a few RAC settings to determine the types of activities residents enjoy so appropriate social programs can be designed and adequately resourced. The present study demonstrates that RAC facilities can assist residents to fulfil their social and leisure needs. Although maintaining contact with family and friends was of prime importance to the participants in this study, they also appeared to form meaningful relationships with fellow residents, which highlights the need to place low-care
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residents in close proximity in RAC facilities. There was a clear preference for going on excursions over participating in activities at the RAC facility. New technologies and creative problem-solving with facility staff may be key to enhancing the social worlds and leisure pursuits of older persons in RAC facilities. Supporting residents to remain socially connected is an important goal of good care. This paper recommends a number of strategies that support this goal. It may be useful for RAC managers and policy makers to take cognisance of the points raised in this paper and review ways these activities can be implemented and adequately funded. REFERENCES Adams, K. B., Leibbrandt, S., & Moon, H. (2011). A critical review of the literature on social and leisure activity and wellbeing in later life. Ageing & Society, 31, 683–712. Andersson, I., Pettersson, E., & Sidenvall, B. (2006). Daily life after moving into a care home – Experiences from older people, relatives and contact persons. Journal of Clinical Nursing, 16, 1712–1718. Australian Institute of Health and Welfare. (2011). Residential aged care in Australia 2009-10: A statistical overview. Aged care statistics series no. 35 (Cat. no. AGE 66). Canberra, ACT: Author. Azuma, T., & Bayles, K. A. (1997). Memory impairments underlying language difficulties in dementia. Topics in Language Disorders, 18, 58–71. Bergland, A., & Kirkevold, M. (2006). Thriving in nursing homes in Norway: Contributing aspects described by residents. International Journal of Nursing Studies, 43, 681–691. Bergman-Evens, B. (2004). Beyond the basics: Effects of the Eden alternative model on quality of life issues. Journal of Gerontological Nursing, 30, 27–34. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Costello, P. (2007). Intergenerational report 2007. Canberra, ACT: Commonwealth of Australia. de Bellis, A. (2010). Australian residential aged care and the quality of nursing care provision. Contemporary Nurse, 35(1), 100–113. Drageset, J. (2004). The importance of activities of daily living and social contact for loneliness: A survey among residents in nursing homes. Scandinavian Journal of Caring Science, 18, 65–71. Findlay, R., & Cartwright, C. (2002). Social isolation and older people: A literature review. Paper at Australasian Centre on Ageing, The University of Queensland, Brisbane, QLD.
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Harper, G. (2002). Daily life in a nursing home: Has it changed in 25 years? Journal of Aging Studies, 16, 345–359. Jilek, R. (2006). The lived experience of men entering residential aged care. Geriaction, 24(2), 5–13. Kracker, J., Kearns, K., Kier, F. J., & Christensen, K. A. (2011). Activity preferences and satisfaction among older adults in a veterans administration long-term care facility. Clinical Gerontologist, 34, 103–116. Litwin, H., & Shiovitz-Ezra, S. (2006). The association between activity and wellbeing in later life: What really matters? Ageing & Society, 26, 225–242. Moore, K. J., Hill, K. D., Robinson, A. L., Haines, T. P., Haralambous, B., & Nitz, J. C. (2011). The state of physical environments in Australian residential aged care facilities. Australian Health Review, 35, 412–417. Nicholson, N. R. (2012). A review of social isolation: An important but underassessed condition in older adults. The Journal of Primary Prevention, 33, 137–152. doi:10.1007/s10935-012-0271-2 Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science, 8(3), 27–37. Saunders, P. A., de Medeiros, K., Doyle, P., & Mosby, A. (2012). The discourse of friendship: Mediators of communication among dementia residents in long-term care. Dementia, 11, 347–361. Street, D., Burge, S., Quadagno, J., & Barrett, A. (2007). The salience of social relationships for resident wellbeing in assisted living. The Journals of Gerontology: Series B, Psychological Sciences and Social Sciences, 62, S129–S134. Tate, R. B., Lah, L., & Cuddy, T. E. (2003). Definition of successful aging by elderly Canadian males: The Manitoba follow-up study. The Gerontologist, 43, 735–744. Victor, C., Scambler, S., Bond, J., & Bowling, A. (2000). Being alone in later life: Loneliness, social isolation and living alone. Reviews in Clinical Gerontology, 10, 407–417. Wang, H., Karp, A., Winblad, B., & Fratiglioni, L. (2002). Late-life engagement in social and leisure activities is associated with a decreased risk of dementia: A longitudinal study from the Kungsholmen Project. American Journal of Epidemiology, 155, 1081–1087. World Health Organization. (2012). Definition of an older or elderly person. Retrieved from http://www. who.int/healthinfo/survey/ageingdefnolder/en/ Received 24 February 2012
Accepted 16 May 2013
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