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I, Colleen Rae Bennett, do grant permission for my professional contribution to be
copied.
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EXPLORING ALTERNATIVE AND RECREATIONAL THERAPIES WITH
NURSING HOME RESIDENTS
by
Colleen Rae Bennett
A Professional Contribution
Submitted to the faculty of
Marywood University
in Partial Fulfillment of the Requirements for the Degree of
Master of Science in Gerontology
Department of Nursing and Public Administration
College of Health and Human Services
Approved ____________________________________
Mentor
____________________________________
Review Committee Member
____________________________________
Review Committee Member
____________________________________
Review Committee Member
____________________________________
Review Committee Member
______________________
(Date: Month and Year)
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Acknowledgments
This professional contribution was made possible by the support of the many
people; I would like to thank Dr. Alice McDonnell for giving me the opportunity to
complete this at my own pace, for allowing me to work so closely with her, and for
sharing her vast knowledge and resources with me. I would like to thank Dr. Barbara
Parker-Bell for sharing her passion for Art Therapy with me, and for allowing me to find
my own way in her class. Lastly, I would like to thank the staff and residents at Green
Ridge Health Care Center, especially Louanne Giles, Geri Gardner, and Ellen Craven, for
welcoming me into their family.
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Table of Contents
Acknowledgements………………………………………………………………………..4
List of Tables……………………………………………………………………………...6
Abstract……………………………………………………………………………………7
Chapter 1
Introduction to the Problem……………………………………………………….8
Purpose of the Proposal…………………………………………………………...8
Chapter 2
Brief History of Activities in Skilled Nursing Homes…………………………….9
Review of Literature……………………………………………………………..10
Introduction to Alternative and Recreational Therapies…………………11
Art Therapy………………………………………………………………12
Quilting…………………………………………………………………..15
Therapeutic Literary Expression…………………………………………16
Music Therapy…………………………………………………………...17
Intergenerational Programming………………………………………….19
Reminiscence and Life Review………………………………………….20
Holistic and Spiritual Therapies………………………………………….23
Summary of Literature…………………………………………………………...24
Chapter 3
Brief History of Green Ridge Health Care Center……………………………….25
Introduction to the Activities Department…………………………….....27
Description of Existing Small Group and One-on-One Activities………27
Chapter 4
Theoretical Base………………………………………………………………….29
Chapter 5
Methodology……………………………………………………………………..37
Discussion of Nurse Aide Survey Results……………………………………….38
Chapter 6
Brief History of Culture Change in Skilled Nursing…………………………….42
Models of Culture Change……………………….………………………46
Chapter 7
Intended Use of the Professional Contribution…………………………………..50
Description of the Administrative Impact of the Professional Contribution…….52
Conclusions………………………………………………………………………53
References………………………………………………………………………………..55
Appendix A
Nurse Aide Activities Opinion Survey…………………………………………..63
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List of Tables
Table 1
Nurse Aide Opinion Survey Results Questions 1-11…………………………….39
Table 2
Nurse Aide Opinion Survey Results Questions 12-13…………………………...41
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Abstract
Traditional and common activities available in skilled nursing home settings are
often stereotypical and generic. Activities such as “Bingo!” are popular, but may not be
appropriate for all residents. Because activities are not funded, but mandated, most are
chosen for mass appeal and relative low expense and ease. There are several alternative
therapies from which activity department planners can draw inspiration. Recreational
therapy seeks to meet basic human needs, safety needs, love and affiliation as well as
esteem needs, and the need for self-actualization; recreation therapy explores the value of
recreation as a means of satisfying personal needs, personality development, physical
well-being, emotional release, and social interaction (O‟Marrow, 1976). Activities may
range from arts and crafts, dance, drama, entertainment, hobbies, special interests, literary
activities, music, nature and outdoor recreation, outings and visits, physical, social and
community services activities, as well as special events.
This Professional Contribution will address the potential of applying non-
traditional and alternative therapies, such as art therapy, creative arts expression such as
quilting, therapeutic literary expression, music therapy, intergenerational arts
programming, reminiscence and life review, and holistic and spiritual therapies including
yoga and Tai Chi, to small group and one-on-one sessions at Green Ridge Health Care
Center (GRHCC) in Scranton, Pennsylvania. The author will evaluate the existing
programs, using literature review and philosophical basis, as well as results from an
opinion survey conducted at GRHCC
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Chapter 1
Introduction to the Problem
Traditional and common activities available in skilled nursing home settings are
often stereotypical and generic. Activities such as “Bingo!” are popular, but may not be
appropriate for all residents. Because activities are not funded, but mandated, most are
chosen for mass appeal and relative low expense and ease. There are several alternative
therapies from which activity department planners can draw inspiration. However, with
lack of funding and planning activities utilizing art, music, reminiscence and spiritual
therapies may not seem realistic or feasible.
At the same time, many nursing home residents may be low-functioning and
therefore require stimulation or activities in a small group or one-on-one format.
Although small group activities or one-on-ones can be difficult to orchestrate due to
staffing and financial constraints, these activities should not be overlooked. There is the
potential in smaller group and one-on-one settings to implement art and music therapies,
for example.
Purpose of the Proposal
The author intends to address the potential of applying non-traditional and
alternative therapies to small group and one-on-one sessions at Green Ridge Health Care
Center (GRHCC) in Scranton, Pennsylvania. The author will assess successes or
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shortcomings of the existing programs, using literature review and philosophical basis, as
well as results from an opinion survey conducted at GRHCC. The author will formulate
recommendations for application by the Activities Director at GRHCC.
Chapter 2
Brief History of Activities in Skilled Nursing Homes
O‟Marrow (1976) provided a historical perspective of the growth of therapeutic
recreation, which first appeared in the late 1950s; prior to this terms such as hospital or
medical recreation were used, as well as recreation for the ill and handicapped
(O‟Marrow, 1976). These terms are rarely used today lest they are merely identifying the
department or services in a particular setting.
Historically, hospital recreation referred to the limited recreation services within
acute care settings, whereas medical recreation suggested recreational activities were
under medical supervision or guidance. Recreational therapy or therapeutic recreation as
general terms may refer to any of these types of activities; in skilled nursing settings
today, the terms therapeutic recreation, recreational therapy, and activities are used
interchangeably.
Broadly, therapeutic recreation services include activities programming,
leadership and instruction, administration and counseling, equipment and supplies,
education, training and research (O‟Marrow, 1976). Recreational therapy seeks to meet
basic human needs, safety needs, love and affiliation as well as esteem needs, and the
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need for self-actualization (O‟Marrow, 1976). Recreation therapy explores the value of
recreation as a means of satisfying personal needs, personality development, physical
well-being, emotional release, and social interaction (O‟Marrow, 1976).
The basic tenets or values of Activities departments include: assisting in diagnosis
and evaluation, assisting individuals in adjustment to the facility settings, increasing
growth and development, increasing socialization and fostering interpersonal
relationships, providing opportunities for creativity, providing outlets for emotional
expression, and promoting healthy personal habits and improvement in activities of daily
living (ADLs) (O‟Marrow, 1976). Activities may range from arts and crafts, dance,
drama, entertainment, hobbies, special interests, literary activities, music, nature and
outdoor recreation, outings and visits, physical, social and community services activities,
as well as special events. Although the Activities profession provides unlimited
opportunities and challenges to energetic, able, imaginative and dynamic individuals,
activities departments are mandated facets of long-term care, they are largely unfunded.
Review of Literature
The purpose of this Professional Contribution is to explore alternative and
recreational therapies for long-term care or nursing home residents. The goal of this
chapter is to examine various therapies including art therapy, creative arts expression
such as quilting, therapeutic literary expression, music therapy, intergenerational arts
programming, reminiscence and life review, and holistic and spiritual therapies including
yoga and Tai Chi.
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EBSCO, PUBMed, the Marywood University Library, and Wilson‟s Web were
used during the discovery and research period of literature review. Much research was
reviewed and preference was given to studies with specific applications or case studies
involving elders, as well as seminal works. The author will use the literature review and
theoretical base to formulate recommendations of intended use for the Activities
department at Green Ridge Health Care Center (GRHCC).
Introduction to Alternative and Recreational Therapies
Beyond traditional activities, some alternative and recreational therapies are now
being used in long-term care settings. Various arts programming, including music and
dance, poetry, and Tai Chi for example, have all been shown to elevate overall mood and
relieve depression without pharmacological intervention. Skills used in integrating life
changes and loss, reminiscence and social interaction are keys to successful aging. In
addition to older adults‟ enjoyment, physiological and mental health benefits of various
creative expression therapies are overwhelming. Research suggests that as one‟s overall
health declines with age, there may be limitations on one‟s activity but creativity is still a
viable outlet for self-expression, and that coping with these limitations may be an
additional facet of creative processes (Fisher & Specht, 1999, Kates, 2008, and Cohen,
2006).
Alternative and recreational therapies include art therapy and various creative-arts
expressions such as quilting, therapeutic literary expression such as poetry and short-
story writing, music therapy, various forms of intergenerational programming,
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reminiscence and life review, and holistic and spiritual therapies. These therapies provide
opportunity for self-expression and introspection, engages the mind, senses, emotions,
body and soul.
Art Therapy
Art therapy is holistic and allows group participants to get to know one another in
a safe, controlled environment, and to explore metaphor imagery, and symbolism. Arts
expression can liberate an older adult. Creative expression can provide a “looking glass”
within which depression can be targeted head-on (Larson, 2006; Layton, 2006; Whalen,
2004). Treatment goals vary according to individual needs; for example, a goal for an
older adult client may be reducing anxiety and depressive symptoms resulting from
chronic illness (Peterson, 2006). Art therapy is not verbally dependent, and thus can be
highly successful with older adult clients; persons with impaired language skills, limited
cognitive abilities, or suffering debilitating illnesses which inhibit verbal expression can
participate in creative expression (Peterson, 2006; Mosher-Ashley & Barrett, 1997;
Nolta, 2006; Stafford, 1997). Communication can be verbal or non-verbal, just as
dialogue may be conscious or unconscious with the older adult (Peterson, 2006), thus art
therapy does not demand a high level of cognitive ability. Art therapy also promotes a
holistic view of the mind-body connection in health aging (Peterson, 2006).
Doric-Hendry‟s (1997) research found that using art therapy with elderly nursing
home residents improved self-esteem, depression, and anxiety. Magniant (2004) found
that art therapy could be used in a variety of diverse settings and sub-populations of
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elderly to integrate biopsychosocial and spiritual engagement; art therapy was used as an
adjunctive therapy to support traditional “medical” goals (Peterson, 2006). Art-making
supports expressiveness that is often muted by depression. It also provides opportunities
for satisfaction and goal fulfillment which improves self-esteem (Doric-Hendry, 1997;
Johnson & Sullivan-Marx, 2006; McGuire, 1982).
Older adults may be more receptive to creative endeavors that provide an
opportunity for social interaction than to medications or psychotherapy. Flood and
Phillips (2007) found that older adults who might otherwise not accept treatment, due to
social stigma, could find art-making and art therapy therapeutic and socially stimulating,
which may in turn reduce emotional distress or depressive symptoms. Doric-Hendry
(2004) found that art-making with pottery and clay improved psychological well-being
and self-esteem, and relieved depressive and anxious symptoms. Older adults face many
life changes, many associated with loss – loss of family, friends, homes, independence, as
well as physical and cognitive abilities. Stephenson (2006) argued that art therapy
provides a way for the older adult to cope with and adjust to these losses.
Elderly people who experiences changes in functional or physical condition often
have difficulty managing or coping with these changes. Art therapy enables verbal and
nonverbal communication for expression of desires and feelings related to these changes.
As a participant becomes aware of new communication techniques through the art
therapy, the elder is able to assume a more active role in the rehabilitation process. Art
therapy is empowering and provides a richness of experiences, resources, knowledge, and
accomplishments (Yaretzky, Levinson, & Kimchi, 1996).
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Mosher-Ashley and Barrett (1997) found that art therapy minimizes verbal
demands for elderly patients suffering cognitive disorders; the art therapy environment
can serve as an alternative outlet for negative feelings and can lead to favorable
personality changes. The researchers encouraged patients to title art pieces as closure to
the largely non-verbal process; this empowerment facilitated further discussion and
served as a starting point to explore feelings with others in the group. Nonverbal art
therapy exercises such as painting, drawing, sculpture, or music and movement therapies
are keys to encouraging relaxation. Creative expression provides opportunity for personal
accomplishments and independence. Specific art exercises also highlight fine motor
coordination, vision and other abilities, rather than stressing overall weakness and
disability such as frailty or depression (Madori, 2007). Art therapy can encourage
channels of communication otherwise unavailable while facilitating much needed
socialization. (Kates, 2008)
Cohen (2006) found that various art processes could help elders to focus on the
potentials of aging and look past the limitations and problems. Shore (1997), Fisher and
Specht (1999), and Cohen (2006) all found that creative activity contributes to successful
aging by fostering feelings of competence, purpose and growth. Artistic expression also
encouraged development of problem-solving skills, motivation, and perceptions.
Art therapy processes can alleviate depression stemming from feelings of
uselessness and isolation (Landgarten, 1983; Marsden, Briller, Calkins & Proffitt, 2001;
Perez, Proffitt, & Calkins 2001). Personal creations help alleviate depressive symptoms.
Marsden et al. (2001) point out that in addition to art-making, art displays and collections
of memorabilia in the form of shadow boxes or wall collages can help stimulate positive
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affect in depressed patients. Positive memory stimulation can occur through formal art-
making or informal room décor. Perez et al. (2001) found that interactive art can
stimulate low-functioning patients and discourage disruptive behavior; by keeping these
patients engaged and stimulated, other group members are less disrupted and all can
enjoy full sensory experiences.
Art making can significantly affect an elder‟s mental health and self-esteem, thus
lowering aging-related depression (Greenberg, 1985; Miller, 2008; Stephenson, 2006).
Social engagement is another mechanism for promoting mental health in older adults;
through arts programming elders are able to interact socially while facilitating artistic
expression. Social health is a growing area of aging study which has been shown to have
a positive influence on general health while also reducing depression and mortality in the
elderly (Cohen, 2006). Art therapy provides social engagement and interaction for older
adults, relieving depressive symptoms stemming from isolation and withdrawal. Art
therapy can also help rehabilitate and strengthen individuals by improving coordination
and range of motion.
Quilting
Quilting is also common among older adults, and is often passed through familial
generations. Also, individuals may not even take up quilting until retirement or a
significant life or role change, such as becoming a grandparent (Kirshenblatt-Bimblett et
al., 2006). Individuals may have grown watching an elder family member quilt, but never
really start themselves until much later. Quilting is a creative expression both
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communally and individually, it can be done in a group or individually, or both. Quilting
is a creative expression that represents aspects of art therapy, but also reminiscence
therapy when conducted in a quilting circle, spiritual or holistic therapy, and can
intergenerational as well. Quilts may be sold to benefit charities, or donated to hospitals,
nursing homes or community centers (Kirshenblatt-Bimblett, Hufford, Hunt, & Zeitlin,
2006). Quilts may also be fashioned and hung as art in nursing homes or community
centers, for example; the pieces help foster a sense of warmth and community.
Therapeutic Literary Expression
McGarry and Prince (1998) facilitated creative expression through individual and
group poetry, storytelling, drawing, painting, and music in a noncompetitive and
supportive environment. The project allowed participants to verbalize positive statements
of self in relation to their creative experiences. Discussion was encouraged with simple
directives, such as probing „What color best describes you?‟ McGarry and Prince (1998)
found that poetry and storytelling were the favorite activities, promoting laughter and
camaraderie. Campbell (1984) facilitated life review writing in groups of seniors in a
long-term care facility. Short-story writing served as a form of growth over the thirty
week study, stimulating discussions that would last long outside the sessions (Campbell,
1984). The participants were encouraged to write simple stories based on themes such as
“something I never told anyone” or “marriage;” through discussion the participants found
shared values and a shared experience that bonded them.
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Bonhote, Romano-Egan, and Cornwell (1999) also used literature to facilitate
expression of feelings in group settings. Poetry, reading, writing, music, myths, folklore,
opera, humor, and art all provoke emotion, insight, and joy. Bonhote et al. (1999) found
that poetry could symbolically reflect extreme emotional states, such as anger, shame,
loneliness and fear, and discussion or sharing of poetry could bond participants through
shared emotions and experiences.
Music Therapy
Music therapy is the use of music or sounds to encourage desired changes in
behaviors, emotions, or physiological processes (Lowry, 2002). Music works as therapy
by influencing the area of the brain involved with emotions and feelings, stimulating the
release of endorphins which can change mood. These mental and emotional changes can
create physiological processes through the autonomic nervous system (Lowry, 2002).
Music therapy is many faceted, just as music itself is multi-dimensional. Popular
music may promote the urge to dance, and in later years a similar song may encourage
movement and emotions even when long-forgotten (Aldridge, 1999). Music therapy
emphasizes personal contact and fosters feelings of hope and purpose through melodic
undertones. Aldridge (1999) used music therapy in palliative care, concluding that music,
like hope, involves feelings, thoughts, and requires action; in other words, hope and
music and dynamic and susceptible to human influence. Songs can be a vehicle for this
means of expression, and may express the deepest of human feelings. Music, in this way,
may serve as an ultimate means of comfort (Aldridge, 1999; Weber, 1999).
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Clabby and Howarth (2007) used various therapies to help manage chronic heart
failure (CHF) and depression in elderly patients; mood-elevating music, dance, and
comedic relief of watching movies or TV programs were all encouraged in withdrawn
patients. Mood-elevating activities such as these helped improve overall quality of life,
functioning, and depression (Clabby & Howarth, 2007). Wood, Verney, and Atkinson
(2004) used music as a vehicle to bring discharged patients together and foster feelings of
community. Group music therapy, as well as workshops, visits, and concerts were used in
an out-patient or community setting to prevent isolation and depression as a result of
discharge. Group contact and engagement boosted confidence, fostered friendships, and
improved feelings of well-being (Wood et al., 2004).
Music therapy has been successful with individuals with Alzheimer‟s disease as
well. Bringing music back into the life of a person with Alzheimer‟s disease can be an
extremely beneficial and joyful process. Alzheimer‟s patients may unintentionally
deprive themselves of the music that once filled their lives; they may have forgotten how
to turn on the radio or the lyrics to their favorite songs. Simple ways to introduce music
for persons with Alzheimer‟s disease include singing songs and encouraging sing-alongs,
uncovering favorite types of music and providing CDs, tapes, or records and radio
stations, playing musical instruments, watching musicals together on video, or even
listening to popular music from his/her past. Music can stimulate memory and even
enhance verbal and visual skills; musical rhythm stimulates timing processes in the brain,
which may in turn improve timing of motor actions such as walking (Alzheimer‟s
activities guide, 2005).
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Intergenerational Programming
Intergenerational arts programs explore commonalities and differences, foster
respect and tolerance, and empower participants. Perlstein (1999) researched community
arts groups, such as Elders Share the Arts (ESTA), which create an environment within
which participants can discuss, share, see, question, think, and truly appreciate one
another. Intergenerational programming teaches participants to transform their life stories
into artistic expressions of many forms. Creative expression honors personal stories,
traditions, and cultures through theater, dance, music, writing and visual arts. These
programs can be used in senior centers, schools, nursing homes, hospitals or other
community center settings. Perlstein‟s (1999) research took place once weekly for thirty
weeks, creating programs which culminated in a community celebration called the “living
history festivals” (p. 72).
Bonhote et al. (1999) used intergenerational arts programming to encourage
therapeutic creative expression. The integrated model used combined biological,
psychological, and social and supportive approaches in open group arts settings. The
study showed that such programming decreased feelings of powerlessness and facilitated
insight into coping strategies for adapting to life changes and associated losses (Bonhote
et al., 1999). The programs helped to combat stereotypes of aging as well. Larson (2006)
researched intergenerational arts programming, as well. Older participants found
enhanced life satisfaction, decreased isolation, increased fulfillment and sense of
meaning, and new skills and insights, while younger participants found increased self-
esteem, improved behavior, and a sense of historical and personal continuity.
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Dunkle and Mikelthun (1982) studied adopt-a-grandparent programs. The
research showed that hostile attitudes between age groups, or ageism, could be socially
destructive and lead to feelings of rejection on the part of the older population by the
younger age groups (Dunkle & Mikelthun, 1982). Adopt-a-grandparent programs were
used to overcome these feelings and alienation and isolation on both poles of the
spectrum, encouraging shared experiences and bonding. Kennett (2000) used themes of
personal growth and creativity to explore a range of social and creative opportunities for
older adults at an intergenerational day program. Participants created a large mural of
underwater scenes, a collection of creative writings, and a number of individual pieces
for exhibition. Kennett (2000) identified main themes of enjoyment, enthusiasm,
excitement, pride, achievement, satisfaction, sense of purpose, mutual support and
permanence, and interpreted these themes as positive expressions of self-esteem,
autonomy, and social interaction and hope.
Reminiscence and Life Review
Reminiscence is another important experience for older people; reviewing one‟s
life in old age is both therapeutic and culturally important, it can reveal coping and
adaptive strategies helpful in successful aging (Kirshenblatt-Bimblett et al., 2006; Weiss
& Subak-Sharpe, 1988). Reminiscence can be an engaging activity for people of all ages,
but is specifically therapeutic for older adults. Reminiscence, Zablotny (2006) argued, is
an essential part of healthy aging. Case and Dalley (1992) suggested that art therapy work
with elders often centers on the past and significant life events. Telling stories and
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repeating parts that hold significance is part of the creative process of passing on one‟s
legacy (Zablotny, 2006).
Reminiscence is part of a normal life review process brought about by realization
of mortality (Quigley, 1981). Remembering processes can be focused or guided, and are
often therapeutic (Quigley, 1981). Thinking or talking about the past can be especially
comforting for individuals with Alzheimer‟s disease; celebrating special occasions can be
a good way for people to share special moments, and can trigger memories of past
experiences as well as create new memories. Some examples include putting photos in an
album, talking about childhood, watching old movies or television shows, or facilitating
“once upon a time” story-telling (Alzheimer‟s activities guide, 2005; Hubalek, 1997;
Quigley, 1981).
The life review process allows individuals to integrate thoughts and feelings into a
visual representation of self. In other words, life review work with lifebooks allows
memories to be put to paper in collages of pictures, clippings, and sayings or poems. The
life review process is especially important for individuals near the end stage of life, noted
Magniant (2004), because introspection may allow these individuals to resolve repressed
issues and leave a legacy for family and friends (p. 54-55). The life review process helps
to resolve and reorganize troubling issues, while the lifebook technique works in concert
to structure thoughts and feelings in a meaningful way.
The creative art-making process may evoke many emotions and memories, thus
the process may provide many benefits to the elder participant. It can provide a visual
link between an individual and their past experiences, facilitating life review, or focus on
exploration and emotional growth. An older adult may find new means for overcoming
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physical impairment and be able to relate to their changing environment in new and
exciting ways. (Stephenson, 2006).
Kirshenblatt-Bimblett et al. (2006) studied the use of folklore and folk art by older
persons for entertainment and social engagement. Folklore is built from the memories of
older people, passing on traditions that would have otherwise been forgotten
(Kirshenblatt-Bimblett et al., 2006). Older people are the custodians of heritage and
culture; they are also experts on what the later segment of the life cycle is all about. By
focusing on the active present of elders, Krishenblatt-Bimblett et al. (2006) were able to
discover the varying creative cultural responses to aging. Shared cultural or social
experiences, such as weddings, baptisms, or funerals, bind communities and individual
life cycle‟s together (Baker, 2004; Jungels, 1985; Kirshenblatt-Bimblett et al., 2006). It is
through these shared communal experiences that individuals rehearse their roles and
scripts.
Bonhote et al. (1999) also used reminiscence therapy, which allowed group
members to connect through shared life experiences such as the Great Depression, World
Wars I and II, and various technological milestones. This exercise allowed the older
adults to transfer knowledge and values to the younger participants while renewing
feelings of citizenship and camaraderie. Participants were able to express their
reminiscence stories through “life stories” scrapbooks, poems, or transcribing complete
by the younger participants. The reminiscence expression process allowed each
individual to experience a meaningful connection to a vital aspect of each members‟ life
history.
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Holistic and Spiritual Therapies
Holism is the theory that people have an existence greater than the mere sum of
their parts, and the holistic healing movement draws from many bio-psycho-social and
spiritual dimensions with the thinking that each dimension influences the others within
the human system (Kirkland & McIlveen, 1999; Lucas & Lloyd, 2005; Lowry, 2002;
Peterson, 2006). Holistic or spiritual strategies may include aromatherapy, centering or
yoga, therapeutic touch, prayer, guided imagery, or Tai Chi. Holistic practitioners believe
that health is more than the absence of disease or infirmity; health is optimal and overall
wellness.
Aromatherapy, centering, and yoga practices are other examples of holistic
therapies. Aromatherapy uses aromatic plants and essential oils, which act
pharmacologically as oils enter the bloodstream either through the lungs or skin contact.
The oils have a physiological effect on the body, and may affect emotions through the
limbic system (Lowry, 2002). Centering is a process of becoming calm and present in the
moment, allowing for deep interpersonal connections leading to limbic system responses
(Lowry, 2002). Yoga, which originated as a Hindu spiritual practice, can be likewise
beneficial, encouraging inner-calm and deep connections (Lowry, 2002).
Therapeutic touch is an example of a holistic and sensory stimulating health
strategy. TT was developed in the early 1970s by a registered nurse and lay healer who
combined traditional and spiritual therapeutic strategies (Lowry, 2002). Prayer has
different meanings to different people; it may be a request for Divine intervention, a type
of meditation, or an otherwise healing act (Amick & Amick, 1991; Lowry, 2002; Lucas
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& Lloyd, 2005).Guided imagery may also be used to evoke the senses and overall
positive limbic system responses. Kirkland and McIlveen (1999) used both life review
discussion questions and sensory stimulation though touch, sound, and smell as spiritual
or holistic therapy. Lucas and Lloyd (2005) found religious involvement to have
salutogenic psychosocial „side-effects,‟ promoting overall health and well-being.
Chen, Hsu, Chen, and Tseng (2005) used Tai Chi to promote psychological well-
being of elders in long-term care. Tai Chi is a low-intensity exercise involving mind-body
communication through a series of fluid and graceful dance-like movements. Tai Chi is
easy to implement in long-term care because it can be practiced in any place at any time
without equipment. Tai Chi can be practiced by older adults whether or not they are able
to stand independently, as it is easily amendable to wheel-chair bound individuals.
Tai Chi has been shown to enhance cardiovascular and respiratory functions,
improve health-related fitness and can be effective in lowering blood pressure, enhancing
positive mood states, and improving muscle strength and endurance. Chen et al. (2005)
showed that participants‟ physical health status and social functioning had significantly
improved after one month of Tai Chi. The study found that participants appeared more
lively, vital, energetic and full of pep, and seemed to enjoy the graceful movements
(Chen et al., 2005).
Summary of Literature
The various therapies detailed above, including art, music, reminiscence and
holistic therapy, have been shown to meet the basic values of Activities departments. Art
25
therapy or music therapy can be used to increase personal growth and develop, as well as
providing outlets for emotional expression. Holistic or spiritual therapies such as Tai Chi
promote healthy personal habits and can encourage functional improvements in ADLs.
Group literary arts programs can increase socialization and foster interpersonal
relationships and adjustment to facility settings. In short, there is ample research to
support the application of various alternative therapies to existing long-term care
Activities departments.
Chapter 3
Brief History of Green Ridge Health Care Center
Green Ridge Health Care Center (GRHCC) at Carmelwood Village opened in
October 2005 on a five acre land parcel at 2000 Boulevard Avenue in Scranton,
Pennsylvania. GRHCC is a state-of-the art 64-bed fully-licensed skilled nursing center
offering short-term and long-term care. GRHCC offers skilled medical services and
comprehensive medical rehabilitative services; this includes infusion therapies, cardiac
recovery services, renal disease services, cancer services, digestive diseases services, as
well as physical and occupational therapy, restorative nursing, speech pathology and
audiology, social services and medication (GRHCC, 2009). GRHCC is privately owned
by Michael Kelly and Susan Keefer as Senior Health Solutions, Incorporated (Craven,
2009). The small, private ownership influences and shapes operations at GRHCC;
although Kelly and Keefer are not necessarily involved on a daily basis, their regular
26
presence in the building speaks volumes to their commitment to and involvement in
providing top-notch services (Craven, 2009).
GRHCC is committed to a holistic philosophy of care, committed to improving
overall health and maximizing self-sufficiency. The mission and vision of GRHCC can
be seen in the Employee Handbook introduction:
Our basic goal is to deliver quality care to all of our residents. By meeting this
objective, we can be assured of a growing list of satisfied residents and continued
success of our Community. It will soon become apparent that reaching this goal
requires a total team effort. Each one of us is entrusted with a responsibility to our
residents, ourselves, and our fellow workers to do the best job we can to assure
the success of all. (GRHCC, 2005)
In designing the single-story facility, careful consideration was given to
emphasize comfort, ease of living, and security all while promoting a home-like
appearance (Craven, 2009; GRHCC, 2009). The Administrator, Ellen Craven, N.H.A.,
has been involved with GRHCC since conception of the Boulevard Avenue site. The
majority of the management team at GRHCC has been on staff since conception of the
new site as well. Craven began her professional career in long-term care by serving as
Lackawanna County Ombudsman for six years, from 1981 to 1987. She transitioned to
the Assisted Living setting in 1989, and then to skilled nursing in 1991 after receiving her
nursing home administrator‟s licensure (Craven, 2009). Craven never asks anybody to do
something she would not do herself, and seeks input and feedback from all staff (Craven,
2009). Craven‟s management style is democratic and humanistic, fostering close
relationships with residents and staff through her open-door policy.
27
Introduction to the Activities Department
The Activities department at GRHCC consists of the Director Louanne Giles, and
two assistants. The author worked most closely with Giles and her assistant Geri Gardner.
Both Activities workers have decades of experience working in long-term care recreation.
Three days each week Gardner facilitates a small group session for lower-functioning
GRHCC residents which is discussed in further detail below. Both assistants are also
responsible for conducting one-on-one sessions three times weekly with seven residents
identified as requiring individualized activities.
Description of Existing Small Group and One-on-One Activities
The author observed and helped to facilitate activities at GRHCC over a seven
month period from September 2009 until April 2010. Activities at GRHCC include bi-
weekly Rosary and Bible Study sessions, weekly Communion, visits from the
Lackawanna County Bookmobile, various trivia and word games, bi-weekly “Bingo!”
sessions, as well as daily “Move with Music,” “Coffee & Donuts,” monthly diner-style
“Breakfast Club” breakfasts, and countless physical game activities. While there are
many activities at GRHCC, but this section will focus on small group and one-on-one
activities conducted by Gardner as observed by the author.
In general, “Small Group” is an activity conducted on Tuesdays, Wednesdays,
and Fridays at 10:00am by Gardner. This activity includes seven to nine lower-
functioning residents, identified as such due to their level of infirmity, extreme age, or
28
other conditions that otherwise prohibit them from actively participating in larger group
activities on a daily basis. At the most basis level, “Small Group” consists of energizing
activities with these residents on a semi- one-on-one basis, including tossing a large
beach ball back and forth. Residents that might otherwise not lift their head from their
chest all day are able to sustain direct eye contact with Gardner and tap the ball back with
surprising force and accuracy.
During the half-hour session, Gardner might also play music, and sing-along with
residents. Other times, the session might include daily news television programming with
highlight recapping by Gardner as a ball is tossed. Sometimes additional residents wander
into the activity room during “Small Group,” and quietly enjoy reading the newspaper or
magazines. Other times individuals might engage in a creative crafts activity with
Gardner‟s guidance. The author feels these sessions are especially meaningful for the
small group of residents due to the heartwarming smiles witnessed, as well as the
sustained direct eye contact during individualized activities.
During lulls in the activity schedule, Gardner finds time to conduct one-on-one
visits with residents that are unable or unwilling for any reason to leave their rooms.
Gardner conducts one-on-one visits three times each week with four to five individual
residents. Personalized activities include trivia and word games for a bed-bound resident
with a sharp mind. Another, a photography buff, enjoys Gardner helping him with
organizing albums and reminiscing about past events. Some residents enjoy the simple
pleasure of Gardner‟s company and therapeutic touch, such as hand-holding, while
watching television programming or listening to music. At any rate, personalized one-on-
one activities for a sub-set of residents are abundant at GRHCC.
29
Chapter 4
Theoretical Base
Older adults face losses and role changes as they age. Elders may face the loss of
a spouse or significant other, peers, as well as a loss of job or familial roles. Once the
breadwinner or provider, a retiree may become dependent on a pension or Social Security
income. Some older adults may see retirement as an opportunity to begin a new chapter –
to travel, begin a business, volunteer, to take up art-making (Kirshenblatt-Bimblett et al.,
2006; Berg, Dahl, & Nilsson, 2007), whereas others may become economically burdened,
dependent, and depressed.
The elderly may also become socially isolated from their family or peers; this
may occur as a result of compounding health or economic factors. Functional losses,
physical impairments, and separation from family or peers often precipitate social
isolation. Social isolation occurs when individuals are unable to participate fully or
meaningfully in social relationships. These individuals are unable to make necessary
interpersonal contacts due to physical or emotional reasons. When an individual is
socially isolated, their basic need for human contact and intimacy is unmet (Hodges,
Keeley, & Grier, 2001; Fisher & Specht, 1999). Individuals may have withdrawn from
their social network, or vice versa; regardless, isolation becomes reciprocal. The loss of
social integration is alienating, and exacerbates debilitations and limitations. Social
isolation leads to further feelings of loneliness, and social and cognitive impairments
which in turn further exacerbates the isolation (Hodges et al., 2001).
30
When an elder transitions from an independent to dependent living situation, the
emotional aspects of this move are stressful too. This life transition is inevitable for many
elderly; elders face „the unknown‟ in a new building, facility, and with new faces in
potentially sharing a room with a stranger. The elder has no control over these variables,
and Madori (2007) points out that this lack of control can lead to depression.
Programming for these emotional needs can be difficult as verbal communication is hard
to facilitate; an individual may be unable to verbalize exactly how he or she is feeling,
which adds to feelings of isolation and lack of control (Kates, 2008; Madori, 2007).
Cognitive changes, changes in functional health, along with declining economic and
social status all contribute to the onset of depression in older persons.
Elders often feel a sense of loneliness, isolation and fear and anxiety throughout
the aging process (Case & Dalley, 1992). As a person ages they face death, as well as
comorbidities and chronic disease, all of which fuels feelings of alienation and isolation.
Fisher and Specht (1999) argue that all institutionalized elderly suffer some level of
depression due to feelings of uselessness or invisibility. Many symptoms, such as social
isolation, contribute to depression for elders secondary to other quality of life and
physical health concerns (Clabby & Howarth, 2007; Landgarten, 1983).
Mindel and Wright Jr. (1982) showed that health status is the premier indicator of
subjective well-being; good health is associated with higher levels of satisfaction in later
life. Perception of well being is undeniably the most important factor in measuring
success in aging. Individuals with strong self efficacy are more likely to feel in control
and competent; coping with life challenges head-on allows these individuals to survive
stresses and grow throughout life, not merely at the end of life.
31
Theories of successful aging have come to the forefront of recent gerontological
study; successful aging and prolongevity are goals adults seek for themselves, their
spouses, and possibly their parents and children. Successful aging is a balance of mental,
physical, and social health, and more succinctly can be defined as maintenance of three
key lifelong behaviors: low risk of disease or related disability, high mental and physical
function, and active engagement (Rowe & Kahn 1998, p. 38). Successful aging is a
combination of measurements of physical and functional health, cognitive functioning,
and active societal involvement and thus successful older persons are at lower risk for
disease and disability, or impairments in the ability to complete daily tasks (Hooyman &
Asuman Kiyak, p. 115).
By this definition, maintaining healthy lifestyle factors, such as diet and exercise,
while remaining mentally and socially active is the key to success. This broad definition
includes most biopsychosocial factors, however omits additional factors such as
spirituality, economic situation, and self efficacy and coping which undoubtedly
influence a persons aging process. Individual feelings about aging and life achievement
and happiness cannot be ignored when evaluating successful aging.
Successful aging at any age is most importantly measured by the individual. A
physically healthy older adult who sees no value or achievement throughout their life is
not successfully aging, whereas a bed-ridden chronically ill person who looks back at
their life proudly and finds simple pleasures in day-to-day living is successful. Successful
aging, in many ways a measurement of a person‟s life happiness and satisfaction, is best
seen in the eyes of the beholder. Perception of well being is undeniably the most
important factor in measuring success in aging. Individuals with strong self efficacy are
32
more likely to feel in control and competent; coping with life challenges head-on allows
these individuals to survive stresses and grow throughout later life.
Life span development is inherent to biological theories of aging, but also to
psychosocial theories as well; transitions from one stage of life to another (adolescence to
early adulthood and onto middle-age for example) highlight behaviors to be expected or
exhibited in later life as further transitioning occurs. How a person adapts when moving
away from home in early adulthood indicates how a person can be expected to adapt to
moving away from home and into a nursing home or retirement center in older age.
Personal agency is another important concept to consider in the aging process;
individual choices and behaviors shape a person‟s entire life and growth process,
physically, mentally, and socially. Persons who are accept their life choices are achieve
greater success in aging (Rowe & Kahn 1998).
Psychological models of successful aging include the Selective Optimization with
Compensation (SOC) model, which focuses on how people react to losses throughout
their lives (Ouwehand, de Ridder, & Bensing 2007). Proactive coping, aimed at
preventing threats to life goals, is a valuable life-long strategy; proactive coping is
likewise crucial for successful aging (Ouwehand et al. 2007). Life satisfaction and
happiness, at any age, is achieved through accomplishment of important life goals.
Successful attainment of goals in later stages in life is dependent on successful
achievement of goals in earlier stages of the life span (Bengtson Gans, Putney, &
Silverstein, 2009).
Aging does not begin at some arbitrary point in life, but is a gradual and lifelong
process, thus successful aging in later life cannot be measured without some
33
understanding of events occurring earlier in the lifetime (Bengtson, Gans, Putney, &
Silverstein, 2009). By successfully coping with stresses and major life changes, such as
retirement or loss of spouse in the older adult, an individual does not become disengaged
from their life goals and can continue to be satisfied and happy. Individuals who can
compensate and overcome the many bumps in the road of life are able to successfully age
from adolescence to adulthood and well into older adulthood. Persons with good coping
skills are healthier than persons with limited or no coping skills (Ouwehand et al., 2007).
Coping and resilience are skills which must be learned and practiced throughout life, thus
individuals who successfully coped throughout life will successfully cope in later life,
and vice versa.
Fernández-Ballesteros, Kruse, Zamarrón, and Caprara (2007) studied issues of
quality of life, successful aging, wisdom and positive affect. Until the late 20th century,
gerontology focused on the negative or pathological conditions associated with aging,
such as decline, impairment, and functional and system deterioration (Fernández-
Ballesteros et al., 2007). Fernández-Ballesteros et al. (2007) point out that a key
assumption of aging involves not only decline, but positive changes and development.
Quality of life is broadly defined to include meaning and satisfaction, all of which
are crucial to successful aging. Quality of life and life satisfaction are best be measured
by self perception, hence why many older adults rate their health positively whether or
not they may suffer several chronic or acute conditions (Hooyman & Asuman Kiyak,
2008; Ouwehand et al., 2007). Activities of daily living (ADLs), or the ability of older
adults to function independently (Hooyman & Asuman Kiyak, 2008), are an important
measure of successful biological aging, but give little information about self-perceived
34
quality of life. Individuals can be satisfied with their aging process and still be severely
limited in their ADLs.
Harwood (2007) examined social identity theory in the elderly. Group
membership, or identity attributed to age group as “older people” versus “younger
people,” is important as individuals age (Harwood, 2007). Group identity contributes to
sense of self, and active engagement with one‟s social group contributes to positive or
successful aging (Harwood, 2007). Mental and social wellbeing outweigh physical
condition in the older adult, and vice versa. Older adults often compare themselves to
their peers and have a sense of accomplishment at having merely survived to old age;
self-perception is the main determinant of whether or not an older adult can be deemed
successful.
Older adults are, by sheer biological age, prone to suffering more chronic and
acute conditions than their middle-aged counterparts. Frail older adults, those
experiencing severe limitations in ADLs (Hooyman & Asuman Kiyak, 2008), as well can
still experience meaningful later years and perceive their health situation positively.
Lucas and Lloyd (2005) found that elders described their health in terms of social
relationships and function. Women were more likely to define their personal health in
terms of relationships to other people, whereas in general respondents indicated overall
health as being able to do things they needed to in everyday life (Lucas & Lloyd, 2005).
Scrutton (1992) found that as aging people experience losses in their circle of
friends and family, their job, or their independence it may become increasingly difficult
to remain socially active and avoid isolation. Isolated and socially inactive elders are
likely to be unhappy, bored and unfulfilled (Scrutton, 1992). Mental and physical skills
35
decline rapidly without active social stimulation, leading to apathy, lethargy, and other
functional declines. Activity personnel in long-term care have the opportunity to facilitate
social interaction through daily programming; by engaging individuals otherwise prone to
withdrawal, activities can help delay mental and physical decline attributed to withdrawal
and social isolation.
Wells-Federman and Mandle (2002) also examined social support systems of
elders. The researchers found that close networks of family, friends and professionals in
long-term care can reduce stress, protect against or delay the development of dementia,
and reduce incidence of heart disease or related health problems (Wells-Federman &
Mandle, 2002). Stress is the negative physical, psychological, social or spiritual effect of
life pressures and events. Although individuals respond to stress differently, often they
revert to or increase less healthy behaviors such as sendentary lifestyle, or violent
outbursts or behavior (Alvarado, Zunzunegui, Béland, & Bamvita, 2008; Wells-
Federman & Mandle, 2002).
Recognizing these behaviors can help healthcare workers intervene, especially in
a long-term care setting where activities can be used to promote coping mechanisms. It is
important for long-term care professionals and staff to be empathetic, to take resident‟s
perspectives into consideration and communicate understanding back to that person;
empathy can be facilitated by active listening, which can clarify issues and help sooth
escalating emotional exchanges (Wells-Federman & Mandle, 2002). The ultimate goal of
any stress management program or activity is to improve quality of life through effective
coping (Briller, Proffitt, Perez, Calkins, & Marsden, 2001; Wells-Federman & Mandle,
2002). Coping is a way of finding balance between acceptance and action, between
36
letting go and taking control (Brody, 1985; Wells-Federman & Mandle, 2002); for elders
in long-term care coping may be harder for residents already prone to feeling isolated,
useless, or out of control.
Shore (1997) used Erickson‟s hierarchy of needs model to emphasize the use of
art therapy in successful aging. Erickson‟s hierarchy of needs model highlights the need
for refection on life in older age. Elders should feel senses of fulfillment and success in
later life; older adults unable to successfully age and feel fulfilled will instead feel regret,
bitterness, and despair. Shore argued that art therapy work, even with the most severely
impaired individuals, uses the creative process to uncover their capacity for wisdom.
Creative activity fosters a sense of purpose, competence, and growth in problem-solving
skills which is transferable to daily life. Fisher and Specht (1999) also highlighted the
benefits of creative arts activities for elderly patients. The researchers showed that
adaptability, flexibility, and coping were all inherent in the creative process, and
therefore participating individuals cultivate adaptive competence, problem-solving skills,
and purposeful or meaningful involvements.
Yaretzky et al. (1996) argued that small group art therapy is most amenable to use
with the elderly. Not only do participants benefit from the creative process, the
researchers argued, but social health is nurtured through mutual support and inspiration
within the group dynamic. Hodges et al. (2001) used one-on-one art experiences between
elderly patients and their caregivers to create a shared experience from which both could
address feelings of isolation, despair, fear, and hope. The researchers found that
participants not only benefited from the cathartic art therapy processes, but found
renewed strength in their caregiving relationship. Art therapy may have benefits without
37
requiring actual art-making processes, too. Wikstrom (2000) exposed a small group of
elderly participants to masterworks of art, and found that through stimulated dialogue
participants‟ perceptions of their life situation shifted positively.
Besides art therapy, both reminiscence and music therapy can be valuable for
nursing home residents. Bonhote et al. (1999) introduced reminiscence therapy in small
groups as a way to bridge barriers to social interaction and promote connectedness.
Reminiscence can promote the transmission of knowledge and values and renew feelings
of citizenship among nursing home residents. Aldridge (1999) examines the basis of
music therapy for use with older persons; For older persons, listening to music can trigger
recollections of past dancing and other movements, and with these movements come
emotions.
Successful aging is more than just a healthy body and mind; successful aging is a
process that is on-going. Aging is a lifelong process, so it goes without saying that
successful aging is as well. Individuals who age successfully throughout life – are able to
overcome illness, disability, stress, cope with loss and hardship – will continue to
successfully age into later years.
Chapter 5
Methodology
The author created and conducted an opinion survey of nurse aides at Green
Ridge Health Care Center (GRHCC). The “Nurse Aide Activities Opinion Survey” was
38
conducted over two days and two shifts, including the morning 7:00am to 3:00pm and
evening 3:00pm to 11:00pm shifts. The author chose to survey nurse aides at GRHCC
because of the close relationships between residents and aides, and because of the
representatively large size of the aide staff in comparison to other departments. Nurse
aides at GRHCC were informed of the opinion survey being conducted for academic
purposes, and twelve voluntarily participated. Participants anonymously answered eleven
“Agree, Neutral, Disagree” questions, selecting the sentiment most closely corresponding
with their individual feelings. Lastly, two open-ended questions allowed participants to
note any suggestions or recommendations regarding activities at GRHCC. The full survey
is provided in Appendix A.
Discussion of Nurse Aide Survey Results
The results of the “Nurse Aide Activities Opinion Survey” were promising. The
author found that an overwhelming 92% of respondents felt well informed of the
activities available for residents at GRHCC. 100% of participants responded as actively
encouraging residents to participate in activities. Also, 83% of participants noted interest
in participating in activities if able or encouraged to do so. The complete results can be
seen below in Table 1.
Perhaps the key results related to the statements “I am satisfied with the activities
available to residents,” and “The activities available for lower-functioning residents at
GRHCC are adequate.” Both of these statements were closely split between “Agree” and
“Neutral.” The author focused on the 33% of respondents who remained neutral on these
39
statements; this result indicates ambivalence over the adequacy of general activities and
activities specifically designed for lower-functioning residents. At the very least, these
results highlight areas for improvement.
At the same time, 83% of respondents indicated awareness of alternative therapies
such as Art, Music, and Reminiscence therapy. This is positive information for GRHCC;
because many staff members are aware of these therapies, the addition of them into the
Activities department is less likely to be met with resistance due to misinformation or
confusion. Also, the majority of participants responded as being interested in
participating in various activities. Not only is a general positive attitude regarding
activities helpful when implementing changes, but the results indicate the potential for
staff support in labor-intensive endeavors.
Table 1
Nurse Aide Opinion Survey Results Questions 1-11
Question: % of respondents
“Agree” with
statement
% of respondents
“Disagree” with
statement
% of respondents
neither “Agree”
nor “Disagree”
“I am well informed of the
activities available to
residents at GRHCC.”
92% - 8%
“I feel that residents at
GRHCC are encouraged to
participate in activities.”
83% 8% 8%
“I actively encourage
residents to participate in
activities.”
100% - -
“I am satisfied with the
activities available to the
residents.”
42% 25% 33%
40
“I feel that my aide duties
often prohibit me from
encouraging residents to
participate in activities.”
25% 17% 58%
“I do not feel that encouraging
residents to participate in
activities is one of my duties.”
17% - 83%
“I do not feel that
participating in activities with
residents is one of my duties.”
17% 75% 8%
“I would be interested in
participating in activities with
residents if able and/or
encouraged to do so.”
83% 8% 8%
“The activities available for
lower-functioning residents at
GRHCC are adequate.”
42% 25% 33%
“I feel more could be done for
lower-functioning residents at
GRHCC.”
58% 8% 33%
“I am aware of various
“Alternative therapies” such
as Art Therapy, Music
Therapy, and Reminiscence
Therapy and the various
applications for lower-
functioning nursing home
residents.”
83% 17% -
The bottom portion of the survey listed two open-ended questions: “Do you have
any suggestions for the Activities department, or specifically for lower-functioning
residents?” and “In your opinion, what more can be done for our lower-functioning
residents?” Some of the results are provided in Table 2. In general, respondents suggested
more one-on-one activities and sensory-stimulation activities, as well as noting the
potential for more individualized activities for all residents.
41
Table 2
Nurse Aide Opinion Survey Results Questions 12-13
Question: Responses of note:
“Do you have any
suggestions for the Activities
department, or specifically
for lower-functioning
residents?”
“…something to keep them more occupied…”
“…puzzles, folding clothes, crafts, music, dance…”
“…more one-on-one…”
“…more physical to maintain functions…”
“…visual activities, more card games…”
“…less dependence on movies and TV shows…”
“…bring them to all activities at least to get them out of
(the residents‟) rooms…”
“…sensory activities such as Snoezelen stimulation…”
“…more individualized activities in general…”
“…small, everyday task-type activities…”
“In your opinion, what more
can be done for our lower-
functioning residents?”
“…cooking activities…”
“…the four walls of (the residents‟) rooms can get
boring…”
“…music, crafts, cooking, quilting, crocheting…”
“…more individualized activities…”
“…more encouragement to get out of (the residents‟)
rooms…”
“…specialized activities just for (the lower-functioning
residents)…”
“…evening activities for Sun-downers, and more “hands-
on” activities…”
“…activities specifically designed for individual/personal
needs…”
“…sensory stimulation activities…”
“…more one-on-one attention…”
There were some limitations with the survey. There exists the potential for
skewed results, not only in the small sample size, but also in the differentiation in
morning- versus evening-shift opinions. The small sample size may be partially explained
by the small nature of GRHCC, as the respondents represented 92% or twelve of thirteen
nurse aides on shift during the surveying days. Also, the open-ended questions at the
bottom of the survey were limited. While these responses were informative and helpful,
42
they cannot be universalized. Only nine of twelve respondents wrote in any responses to
the open-ended questions. In all, the results of the survey provide a useful snapshot of
nurse aide opinions at GRHCC that is useful for the Activities department and
administrative team.
Chapter 6
Brief History of Culture Change in Skilled Nursing
Nursing homes are slowly attempting to shift towards personal communities as
opposed to simply numbered wards, wings, or units – this is culture change. These
communities should have a neighborhood feel, and be staffed by regular, familiar
caregivers. These wings, floors, or units might now be referred to as neighborhoods or
households – many times they are named by the residents who reside in them or at
Resident Council meetings (Zigmond, 2009). Culture change terminology can refer to
creation of smaller, homelike housing that features private living spaces encompassing a
central core area such as a kitchen or living space (NCSL, 2006). This type of culture
change might range from renovation or new site creation to simply breaking down long
corridors or floors into smaller “neighborhood” units with shared amenities; at one
extreme, nursing stations might be removed completely, at the other end they may be
broken down into smaller more frequent stations staffed by a tight-knit group of regular
caregivers. Another type of culture change emphasizes environmental changes such as
43
the introduction of pets, plants and children into the community environment to provide a
true feeling of home (NCSL, 2006).
Culture change is, in many ways, the “new face” of long term care. There are two
basic goals of culture change: improving the lives of residents by granting them
autonomy in decision-making, and likewise allocating more decision-making authority to
staff members rather than management (Rahman & Schnelle, 2008; Zigmond, 2009). An
emphasis is placed on relationship building, both among residents, staff, and between
them. By focusing on what makes residents and staff feel happy and fulfilled, both
residents‟ and staff members‟ opinions are valued from the ground level (Doty, Koren, &
Sturla, 2008; Ragsdale & McDougall Jr., 2008).
Culture change applies common sense approaches to living with and caring for
elders to create a home-like atmosphere in long term care facilities. Most importantly,
this “person-centered” or “resident-directed” model gives residents autonomy in their
day-to-day decisions (Collins, 2008; Zigmond, 2009). Culture change means shifting
from a medical, top-down approach of patient care to a person-centered resident directed
model.
The culture change model may also be referred to as the culture of care, a culture
within which staff and residents connect and form meaningful relationships (Ronch,
2004). Culture change demands decentralized and collaborative decision-making and
care; relationships are fostered between staff and residents, between staff and family, and
between the facility and the local community, too (Zigmond, 2009).
Culture change communities are not preferably referred to as facilities, and are
meant to feel like “home, sweet home.” There should be private spaces for family and
44
friends to visit, and overall facilitate continuation of life with as much independence and
responsibility as possible for residents. Ultimately these communities should not feel
“home-like,” because for many in long term care they are home (Action Pact, 2009).
Each day should be informal, like a regular day in any other home where elders are self-
directed in their waking and sleeping, meal times, and other daily activities. Some culture
change communities have gone as far as giving “neighborhoods” their own homey
kitchens, dining rooms and living rooms where staff and residents cook and eat together
(Action Pact, 2009; Collins, 2008; Doty et al., 2008).
Kane (2001) highlighted ten aspects by which to measure resident quality of life
in long term care: enjoyment, meaningful activity, relationships, sense of safety and
security, functional competence, dignity, autonomy, privacy, holistic well-being, and
individuality. Four of these aspects are central to culture change. First, residents should
and need to perceive that their daily lives are full of interesting and meaningful events
and activities, not merely mandated tasks day-in and day-out. Second, relationships are
stressed because relationships – whether they are of love, friendship or even rivalry –
make life worth living (Kane, 2001). Thirdly, dignity must be respected regardless of
whether or not a person can perceive indignity. Lastly, autonomy, or making decisions
and choices and thereby directing one‟s own life is ultimately key to culture change.
Culture change as a movement is largely seen as beginning in 1997 when a
meeting of the Pioneer Network in Long Term Care, formerly the Nursing Home
Pioneers, coined the term “culture change” in their resultant report (Zigmond, 2009;
Kane, 2001; Rahman & Schnelle, 2008; Ragsdale & McDougall Jr., 2008). The Pioneer
Network encourages resident autonomy in choice about decision-making related to
45
residents‟ needs; the Network also advocates fostering the relationship between staff and
residents and encourages integrating plants and animals into the community (Ragsdale &
McDougall Jr., 2008). Pioneer Network members are dedicated to exemplifying the
following values: responding to mind-body-spirit needs, putting individuals before tasks,
residents and staff as unique individuals, as staff are treated so are residents to be treated,
and accepting risk taking as a part of normal daily adult life (Kane, 2001).
In 2005, the Centers for Medicare and Medicaid Services (CMS) endorsed culture
change when it directed state Quality Improvement Organizations (QIOs). QIOs are to
work with nursing homes to improve organizational culture; following this “official
blessing” and the 50 government-contracted support agencies, the movement gained
momentum (Rahman & Schnelle, 2008). CMS also demands that nursing homes: provide
24-hour access to visitors, signaling a shift from official visiting hours; encourage and
assist residents to complete their own activities of daily living (ADLs) if possible,
including dressing in their own clothes as opposed to hospital-type gowns; promote
dignity and resident independence, for example avoiding standing over residents during
meals (Baker, 2007; Zigmond, 2009).
Marsden et al. (2001) noted the positive effects of encouraging home-like wall
displays or hangings in facility settings. Decorations in personal settings might include
personal art, blankets or rugs with sentimental meaning, or personal pictures. Marsden et
al. (2001) recommended creating personal shadow boxes outside individual rooms; this
helped declining residents locate their personal rooms more easily, and also extended
home-like feelings and warmth throughout the buildings.
46
Ronch (2004) argued that culture change can be deemed successful when nursing
homes follow a philosophical model that fosters relationship building committed to
shared creation of ideas, issues, values and goals. When members of the nursing home
community are valued as individuals rather than for their instrumental use, place or role,
the humanistic goals of culture change will be reached.
Culture change cannot take place without an environment that is filled with
warmth, compassion, and unwavering dedication of employees and staff. Employees
need to feel that their work is a calling and not simply a job; staff needs to provide care
from their hearts, developing strong and meaningful relationships with the residents they
work with. The most important step a nursing home can take towards culture change is
asking the residents what they want. By defining a culture, finding a niche, and sticking
to it, long term care centers could become fully realized examples of culture change.
Models of Culture Change
This section will discuss several culture change models, including the Eden
Alternative, Wellspring, Green House, and Meadowlark Hills, and identify feasible
recommendations for Green Ridge Health Care Center (GRHCC). The author will
contend in Chapter 7 below that supplemental activities would make significant steps
towards positive culture change at GRHCC as well.
While the Eden Alternative is arguably the best example of the culture change
model (Ragsdale & McDougall Jr., 2008; Kane, 2001; Rahman & Schnelle, 2008), with
the key concept being bringing lost control back to the residents in a truly homelike
47
setting, it may not be appropriate for every organization. The Eden Alternative was
founded in 1991 by Dr. William Thomas, a physician and certified geriatrician, with the
goal of remaking the experience of aging around the world (Eden Alternative, 2009).
The Eden Alternative has trained over 17,000 “Eden Associates” worldwide and has over
300 registered Eden homes (Eden Alt., 2009). The Eden Alternative (2009) lists the bulk
of its work as being in “de-institutionalizing the culture and environment” of nursing
homes and long term care facilities. The Eden Alternative strives to create “a life worth
living” for residents under Eden care (Eden Alt., 2009).
This model encourages moving away from top-down hierarchical management to
meaningful decision-making by elders and their caregivers. The mission of the Eden
Alternative is to “improve the well-being of elders and those who care for them by
transforming the communities in which they live and work;” the vision is to “eliminate
loneliness, helplessness, and boredom (Eden Alt., 2009). Eden nursing homes integrate
plants, animals, and children into daily life, which thereby increases quality of life
(Ragsdale & McDougall Jr., 2008). The Eden Alternative teaches simply that where
elders live must be a habitable environment for human beings and not merely a sterile
medical institution (Eden Alt., 2009). Eden Associates, individuals trained in Eden
culture, are dedicated to fulfilling the vision of Eden, thereby eliminating loneliness,
helplessness, and boredom that make life intolerable for many long term care residents
(Eden Alt., 2009; Kane, 2001).
The Wellspring program is another example of a culture change model. The
Wellspring model, initiated in 1994, focused on clinical quality improvement and
environmental culture change within nursing homes and long term care settings (Rahman
48
& Schnelle, 2008). Wellspring began as a proactive response to managed care
environments in eastern Wisconsin. Now an Alliance of Wellspring participants spans
through the Mid-Atlantic and Carolina region of the United States (Lifespan Network,
2009). Wellspring focuses on quality education and coaching for frontline staff and
caregivers, as well as shifting care decisions to the level closest to the resident (Lifespan
Network, 2009). Wellspring encourages workforce empowerment, thereby increasing
resident and employee satisfaction, reducing staff turnover, and improving quality of life
(Lifespan Network, 2009; Rahman & Schnelle, 2008). Wellspring encourages proactive
changes in care, care planning, environment and daily life and activities in nursing
homes.
The Green House model is an offspring of the Eden Alternative. A Green House
is a warm, inviting small-scale home while also a licensed skilled nursing facility. In a
Green House, certified nurse aides (CNAs) are referred to as Shahbaz, and outside
community volunteers or caregivers are called sages. A full support team is present
within the premises of a Green House community and is available as needed (Ragsdale &
McDougall Jr., 2008).
Meadowlark Hills is another example of a culture change community, shifting
from a traditional model to a household model. The skilled nursing home broke down
“traditional barriers” by adding a front door, a living area, and assigning separate staff
groups to each “household;” staff then had permanent resident assignments and could
foster meaningful caregiving relationships (Ragsdale & McDougall Jr., 2008).
Meadowlark Hills found that staff turnover fell from roughly 80% to 30% after
implementing culture changes (Zigmond, 2009).
49
At GRHCC, several positive improvements could be made in the Activities
department to positively contribute to culture change. Aspects of the above culture
change models could be incorporated into large group activities. The Resident Council
could play an active role in facilitating a discussion about the atmosphere of the several
“wings,” recommending changes or naming of hallways as neighborhoods. Even by
dedicating a small area on a hallway wall as a “mural,” the Activities department could
plan staff, resident, and family involvement to create individualized, personalized,
welcoming art in the facility. Activities like these might be messy, they will likely be
time consuming and labor intensive, but they would be beneficial and the author contends
that they would be well received by residents and staff.
GRHCC has the advantage of being newly built in that the layout is conducive to
a small, neighborhood feel. At the same time, much more could have been done upon
designing the building to be proactive in the way of culture change; each hallway, or
“unit” is home to around 16 residents and has a small living space. These spaces could
be, and might need to be, easily adapted to include a small kitchen area. The building,
since very small, maintains a cohesive aesthetic feel; however this means that each
hallway or “neighborhood” is not distinct in decoration of visual aesthetic. The nurses‟
station, too, is the central hub of the building.
Staff turnover at GRHCC is self-reportedly “average,” given the nature of the
work. It is a staff of roughly 80 employees, so they are a tightly knit group. There are
staff incentives or give-backs, including Thanksgiving turkeys for all staff members. The
management is, however, looking to improve staff longevity and decrease turnover in the
future so maintain greater stability for residents. This benefits the facility‟s culture in that
50
the management feels like family and works very well together, with every department
director having worked together at least since the site‟s opening. Craven maintains a strict
open-door policy, encouraging informal meetings with staff and residents. She is always
willing to address problems or concerns as they arise, and is very participatory in daily
activities. Her hands-on style may be viewed as micromanagerial, but given the small
size of the facility it works well.
Overall, the small size of GRHCC is a huge benefit towards culture change.
Although more could have been done proactively upon designing and building the site,
the current physical environment is homey and welcoming. Staff work closely with the
same residents daily, and everybody truly knows everybody else. GRHCC could easily
progress towards more of a culture change model through small aesthetic layout changes,
or by including permanent pets or living plants.
Chapter 7
Intended Use of the Professional Contribution
The Professional Contribution is intended to be used as a blueprint for change in
the Activities department at Green Ridge Health Care Center (GRHCC). Although the
existing small group and one-on-one activities are well-received, the author feels that
more can be done. The Activities Director should take advantage of resources in the
Scranton, Pennsylvania, area, namely Marywood University.
51
The Marywood University Insalaco College of Creative Arts and Management
Graduate program in Art Therapy, for example, is a wonderful, albeit underutilized,
resource. Art therapy graduate students are required to complete a professional internship
at an approved site under the direct supervision of a licensed Art Therapist. Although
GRHCC does not have a licensed Art Therapist on staff, they might easily find first year
graduate students, or undergraduate students in the new undergraduate program, to
volunteer. Marywood prides itself on commitment to the community through
volunteerism. Eager students looking to get some experience in real work environments
might jump at the chance to help facilitate programs at GRHCC. Some programs at
Marywood even require volunteerism. Small group and one-on-one personalized
activities are labor-intensive, in that they require a lot of employees or a lot of a single
employee‟s time. By extending an open door to Marywood University students, the
Activities department at GRHCC could remedy manpower issues.
One issue with this suggestion is that initial site training or familiarization at
GRHCC would require an upfront commitment of the Activities director. Volunteers
need to be briefed on rules, regulations, standards of procedure, and health and safety
issues before being “set loose” in the facility. By optimizing a solid volunteer base and
training schedule, the Activities director could capitalize on Marywood volunteers as a
free labor source. Many residents at GRHCC would benefit from personalized or
individualized attention or activities, especially at times when group activities are not
available. In the evening there are few large activities to take part in, and the Activities
staff is largely not around during these times either.
52
The Nurse Aide Activities Opinion Survey, the results of which are discussed in
Chapter 5 above, indicated that staff felt more could be done for lower-functioning
residents at GRHCC. These residents by and large are unable to participate in large
activities and demand more individualized attention. An active volunteer base in the
Activities department could meet the needs of these residents.
Description of the Administrative Impact of the Professional Contribution
This section will discuss the administrative impact of the Professional
Contribution. The author feels that key findings of this Professional Contribution relate to
the plethora of alternative therapies shown through research to be successful skilled
nursing settings, and the overall positive attitude of workers at GRHCC. The survey
indicated that nurse aides felt they actively encouraged residents to participate in
activities and would be interested in participating with them if able or encouraged to do
so. This suggests to the author that employees at GRHCC truly have their hearts in the
right place with the residents. The aides recognize that residents benefit from activities.
The majority of suggestions received from the survey surrounded the idea that more
personalized or individualized activities would be beneficial.
In undertaking any change, as indicated in the above section related to culture
change, the first step is to have a dedicated management and staff. Without commitment
of the employees, culture change of any kind would be exceedingly difficult. At GRHCC,
however, the staff and employees are already in the right thinking. The aides recognize
53
already recognize a need. The next step now is for the administration to facilitate meeting
this need.
Although this is a challenging step, many positive changes can be made in the
Activities department through expanding activities and utilizing additional volunteers, as
discussed above. Positive steps towards culture change, such as embracing a true niche
environment or additional home-like amenities, can be combined into activities too.
Personalized shadow boxes adoring walls can be an activity, but will add warmth to the
facility. Creative arts activities might produce wall-hangings or decorations for the
hallways. Small group activities could branch out into underutilized living spaces
throughout the facility.
In short, the next steps for the administration at GRHCC are the follow-through
steps. This Professional Contribution provides all the tools and research to support
implementing positive changes in the Activities department. These changes in Activities
will help the progression of culture change and will likely find solid support by the nurse
aide staff.
Conclusions
Many skilled nursing home settings chose activities based on mass appeal and
relative low expense and ease. This Professional Contribution has shown that there are
several alternative therapies from which activity department directors can draw
inspiration. Therapeutic recreation first began to expand in the late 1950s, distinguishing
itself as a discipline from “hospital recreation” in acute care settings (O‟Marrow, 1976).
54
Therapeutic recreational activities may range from “traditional” arts and crafts, to dance,
drama, hobbies, literary activities, music, nature and outdoor activities, as well as social
and community service activities. Programming including music and dance, poetry, and
Tai Chi has been show to elevate overall mood and relieve depressive symptoms without
pharmacological intervention, for example.
Activities departments need to take advantage of the many programming
opportunities available to adapt with the changing culture of skilled nursing homes.
Simple acts, such as repainting or naming “wings,” have been shown to empower
residents and cultivate a warm, home-like atmosphere. Facilitating activities is a labor-
intensive task, even in a smaller 64-bed setting as Green Ridge Health Care Center
(GRHCC); for this reason, activities directors need to optimize surrounding resources
such as dependable university and high school students as volunteers. Although the start-
up of an active volunteer program at a skilled nursing setting might be daunting, the end
results for both residents and staff would be beneficial.
GRHCC is currently in a unique position. The staff, as illustrated through the
Nurse Aide Activities Opinion Survey above, is generally supportive of activities and is
educated or familiar with many of the “alternative therapies” presented in this
Professional Contribution. The Activities department staff has proven to be dedicated and
caring as well. With this support, as well as dedicated owners Kelly and Keefer, the
author feels that GRHCC could successfully undertake active steps towards culture
change, starting first in the Activities department.
55
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Appendix A
Nurse Aide Activities Opinion Survey
Green Ridge Health Care Center
Please circle the sentiment which most closely corresponds to your personal opinion.
1. Agree – Neutral – Disagree – I am well informed of the activities available to the
residents at Green Ridge Health Care Center.
2. Agree – Neutral – Disagree – I feel that residents at Green Ridge Health Care Center
are encouraged to participate in activities.
3. Agree – Neutral – Disagree – I actively encourage residents to participate in activities.
4. Agree – Neutral – Disagree – I am satisfied with the activities available to the
residents.
5. Agree – Neutral – Disagree – I feel that my aide duties often prohibit me from
encouraging residents to participate in activities.
6. Agree – Neutral – Disagree – I do not feel that encouraging residents to participate in
activities is one of my duties.
7. Agree – Neutral – Disagree – I do not feel that participating in activities with residents
is one of my duties.
8. Agree – Neutral – Disagree – I would be interested in participating in activities with
residents if able and/or encouraged to do so.
9. Agree – Neutral – Disagree – The activities available for lower-functioning residents at
Green Ridge Health Care Center are adequate. (“Small Group” residents)
10. Agree – Neutral – Disagree – I feel more could be done for lower-functioning
residents at Green Ridge Health Care Center.
11. Agree – Neutral – Disagree – I am aware of various “Alternative therapies” such as
Art Therapy, Music Therapy, and Reminiscence Therapy and the various applications for
lower-functioning nursing home residents.
12. Do you have any suggestions for the Activities department, or specifically for
lower-functioning residents?
13. In your opinion, what more can be done for our lower-functioning residents?