INCREASING ENGAGEMENT IN A HOME FOR THE ELDERLY BY PROVIDING AN INDOOR GARDENING ACTIVITY

LIZ POWELL, DAVID FELCE. JUDITH JENKINS and BARRY LUNT

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

Summary-This project investigated the effect of a new recreational activity on the generali) low level of engagement of residents in two lounges of a Local Authority home for the elderly physically frail. Indoor gardening sessions open to all residents were held on one afternoon each week in the dining room of the home. In the setting-up phase a researcher ran the gardening sessions. developed a set of written instructions on how to organize the activity and used these. plus performance feedback. to train a volunteer to run the sessions. The experimental phase evaluated the residents’ level of engagement during the weekly gardening sessions and on another afternoon each week when there were no planned recreational activities. The results show that indoor gardening was very successful in producing sustained activity by the residents attending and that engagement of the residents was significantly higher on gardening than on non-garden- ing days.

A common source of concern to visitors to homes for the elderly is that residents

spend large amounts of time sitting passively, apparently involved in no activity (Meacher. 1972; Robb, 1968; McClannahan and Risley, 1975a). Such inactivity is associ- ated with reduced life satisfaction and morale as reported by the elderly residents them- selves (Havens, 1968), and may lead to additional physiological problems which could curtail their range of activities even further (e.g. Comstock et al., 1969). Some writers (e.g. Jeffers and Nichols, 1961; Routh, 1969) maintain that involvement in activity can help elderly people to retain their skills and halt the degenerative process.

A major task of the managers and care staff of homes for the elderly is thus to set up and run ho’mes so that residents have the opportunity to engage in a wide range of activities and thereby maintain their health, skills and interest in life. Currently a number of obstacles to attaining this objective seem to exist in the organizational structure and design of many residential homes. For example, in most homes staff’ are employed to carry out domestic, catering and household maintenance tasks which are inevitably required daily for any group of people living together. When these tasks are done exclusively by paid staff, residents are effectively denied the opportunity to participate in activities which previously constituted a major part of their daily occupa- tion. It may be the case that the residents are not able to do all these tasks unaided. but it does not follow that they should therefore live in a situation where the opportuni- ties to participate in any of them are few. Also, on admission to residential care. each elderly person inevitably parts with a wide range of personal possessions and a degree of regular contact with friends and neighbours. thus probably further reducing the various activities to which they have been accustomed. The home does, of course, pro- vide some alternative opportunities, both materially in the (usually standard) furnishings necessary for daily living, and socially by contacts with other residents and staff. How- ever. mere availability of materials and other people are unlikely to be sufficient to ensure active participation by most residents (McClannahan and Risley, 1975a). The staff, then. must organize the daily running of a home in ways which are seen to stimulate residents to use the materials and equipment and to interact meaningfully with each other.

This focus on organization is important for any group-living situation. It becomes highlighted in settings where the residents. through disabilities or other reasons. arc

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128 Lli! POWt.LL cr ul

less able to arrange satisfactory living conditions for themselves. Hart and Risley (unpub- lished) note that environmental arrangements can have extremely handicapping effects on people who are already disabled. The elderly in residential care are a case in point. There are now increasing numbers of very old people in the population. Current econo- mic restraints and the consequent fall in the number of new residential places provided have resulted in the typical resident of homes for the elderly being older and much more frail than in the past. Arrangement of residential care to maximize their partici- pation thus becomes of crucial concern.

There are many possible strategies for solving this problem. Alternative forms of accommodation are under consideration (Department of Health and Social Security, 1976; Department of Environment, 1976), which could allow elderly residents to retain more of their persona1 possessions, social contacts and former style of life (Goldsmith. 1974; Bosanquet, 1976). Research findings on the effect of architectural design of homes on patterns of residents’ activities (Lipman and Slater, 1976; Hitch and Simpson, 1972) are available, as well as on the effects of radical reorganizations of domestic routines in existing homes (Marston and Gupta, 1977).

Even where such dramatic changes cannot be made, small-scale changes in arrange- ments made by staff can be introduced successively and their effects on the residents assessed. For example. a number of studies have already examined the provision of additional recreational activities. McClannahan and Risley (1975b), working with severe- ly disabled nursing home residents, placed a selection of materials on the trays of the residents’ geriatric chairs and successfully prompted their use. Jenkins et al. (1977) offered a choice of recreational materials to residents in two homes for the elderly with similar success. Quilitch (1974) increased patients’ activity in a day room of a geriatric ward by setting up a bingo session and awarding tokens. exchangeable for refreshments. to those who participated. Blackman et al. (1976) encouraged attendance in a communal area of a home for the aged by offering refreshments, and found that social interaction between the attenders also increased.

The aim of the present study was to increase the engagement of residents in a home for the physically frail elderly by organizing a weekly indoor gardening activity run by a volunteer. This particular activity was selected for several reasons. There were already a few weekly planned activities; gardening would increase the choice available to residents. The head of home and several residents identified gardening as an activity residents had previously enjoyed. It could also be made self-financing by selling some of the products. Using a volunteer to run the sessions followed recommendations to encourage volunteers as a means of easing staff shortages (Department of Health and

Social Security. 1976).

METHOD

Subjects and setting

The research took place in a modern, purpose-built Local Authority home of 55 places for elderly people categorized as physically frail. Residents who habitually sat in two particular lounges were chosen as subjects for this study as preliminary research had shown that they seemed to be the least successful in arranging engaging activities for themselves. The head of home stated that they were also the frailest residents in the home.

Between 26 and 28 residents were observed at different sessions. Owing to deaths, transfers and new admissions. 32 different people were involved as subjects during the study. Average age was 81 (range 57-100). Nine residents were partially sighted or blind, four used hearing aids. Only three moved around the home unaided. The rest used wheelchairs. Zimmer frames or walking sticks.

Gardening sessions were held on one afternoon each week in the dining room, which contained easily cleaned tables and chairs, and was rarely used apart from meals. Hold-

Indoor gardening activity for the elderly 129

ing sessions there avoided any intrusion on the privacy of residents who did not choose to participate.

The sessions were organized initially by a researcher who had taken part in an earlier study with some of the subjects but had no experience of running a weekly group activity. The volunteer who took over once the procedures were established was an active member of the home’s League of Friends, knew the residents well and had con- siderable expertise in gardening, but again, no previous experience of organizing a group activity.

Running the gardening sessions

Before the first session, the head of home individually invited residents to attend, and a notice publicizing the day, time and place for indoor gardening was posted on a board in the entrance hall. At the start of each weekly session the organizer went to the lounges to remind residents of the activity.

The organizer was responsible for obtaining and setting out materials, instructing and praising residents doing the activities, assisting only if necessary, and clearing up the dining room after each session so the domestic staff could lay the tables for tea.

Various activities were offered in each session according to the seasonal supply of materials. These included making pictorial calendars with dried flowers and grasses, flower arranging, writing and decorating labels, as well as tending houseplants, taking cuttings and planting seeds.

Experimental procedures and design

The study was divided into two phases. The setting-up phase involved developing the necessary procedures to organize successful gardening sessions and training the volunteer to take over. The experimental phase investigated the impact of providing gardening sessions in terms of the extent of engagement in activity by all the residents.

Setting-up phase

The researcher ran 10 gardening sessions to work out how to organize the various activities to attain .high resident engagement. A short set of instructions for running the sessions was written, and from this a checklist was abstracted of nine points that appeared to be critical in organising the activity. The volunteer read the instructions and checklist. agreed to follow these and took over the next five sessions. The researcher monitored her performance using the checklist, gave positive and corrective feedback and discussed ideas for future sessions. The criterion for successful sessions in the set- ting-up phase was 60 per cent or higher resident engagement (residents had been observed to engage at this level during another weekly activity run by a staff member). All 15 sessions achieved at least this level; average engagement for this phase was 84 per cent, ranging over sessions from 69 to 97 per cent. The volunteer followed the instructions closely. making only one error as measured on the checklist.

Experimental phase

This phase, covering 12 weeks, compared engagement levels of the residents under gardening and non-gardening conditions. Data were collected during the weekly garden- ing time on all residents, whether they were attending gardening in the dining room or sitting in either of the two lounges. Data were also collected on the residents in the lounges on another regular afternoon each week when no special activity was arranged. (No residents were in the dining room at this time.) Thus a series of natural reversals of gardening and non-gardening conditions was obtained.

On sessions 4, 1 1, 15 and 19 (all gardening sessions) an alternative activity was pro- vided away from the home by the local Red Cross Club. Gardening was still provided and observed on these days, but data were not collected in the lounges.

130 LIZ POWELL Cl ul.

A follow-up observation was made of a gardening session four months after the end of this-phase.

Respor7.s~~ rlqfi77itio77. The dependent variable was the level of residents’ engagement in activity. A resident was defined as engaged if he or she was interacting with another person. or using recreational materials. or materials connected with daily living activities.

or getting around using equipment designed to aid mobility. R~ortfin~~ ~uK~~L~u~.c. Observations of resident engagement were made at 3-min inter-

vals by an observer placed as unobtrusively as possible in each room. For each observa- tion the observer looked in a predetermined order at each resident at a rate of about one per second. decided whether he or she was engaged. keeping a running count of the total number of residents engaged. The observer recorded this total and then counted and recorded the number of residents present for that observation. The numbers engaged and the numbers present were totalled for all observations and then converted to a percentage engagement score for the whole session.

R~~~i~lbiljf~. Reliability observations were taken during three sessions in the setting-up phase and during four sessions in the experimental phase. On these occasions another observer collected data simultaneously. but independently, of the main observers. The reliability observer covered both lounges and the dining room. observing for portions of the session in each place. The main observer in each pface cued the reliability observer when to start each observation but otherwise they did not interact.

Inter-observer agreement on numbers of residents recorded as engaged was obtained by calculating. for each pair of observations. the difference in the numbers recorded engaged by the two observers, dividing this by the number recorded present, multiplying by 100 and subtracting the result from 100 per cent. In the case of a disagreement in the number recorded present. the smaller number was taken as the denominator. These agreement scores were summed and averaged over the whole session to give the inter-observer agreement for that session. inter-observer agreement on numbers recorded as engaged averaged 94 per cent (range 85-100 per cent). There were no differ- ences in levels of agreement between different pairs of observers. There was complete agreement on every observation on the number of residents recorded present.

Rrspt77.w &$77itio77. The independent variable was the volunteer’s performance in run- ning gardening according to the written instructions. This was measured using the check- list of nine key performances abstracted from the instructions. These included points concerning practical organization and interactions with the residents. Figure t shows a copy of the checklist.

Rrcorditly procrdurr

As the organizer carried out the items in running the session, the observer completed the checklist. in between the regular observations of resident engagement. by circling Yes or No (or occasionally writing Not Applicable). Observations on the volunteer’s rate of interactions with the residents were made at five predetermined I-min periods spread throughout the session.

Reliability observations of the volunteer’s performance were made once in the set- ting-up phase and once in the experimental phase. The main observer cued the reliability observer to start the periodic checks on whether the organizer interacted with residents. The other items on the checklist were filled in independently by each observer as they occurred during the session.

Indoor gardening activity for the elderly 131

RUNNING AN INDOOR GARDENING SESSION-MONITORING CHECKLIST

1. Did the organiser cover the tables and lay out materials? Yes/ No

2. When residents arrived did the organiser show them materials and offer them an activity? Yes/No

3. Did the organiser tell all the residents what to do? Yes/No

4. Were all the residents occupied before the organ&r left the room room to collect more people? Yes/No

5. During each of 5 one-minute periods did the organiser

Tick under number

contact at least one resident? (1) (2) (3) (4) (5)

6. Did the organ&r tell residents that the activity would soon be finishing? Yes/No

7. Did the organiser pack materials for different activities separately? Yes/No

8. Did the organiser arrange for the plants to be tended until the next session? Yes/No

9. Were the tables and floor left clean? Yes/No

Fig. 1. Checklist for observation and monitoring of volunteer’s performance.

An agreement was counted if both observers circled the same word or both marked an item as Not Applicable. Disagreements were counted if observers circled different words, if one observer did not check off an item or marked it Not Applicable. One item (No. 5) was checked by a number of tallies; if the total number of tallies was different for the two observers this was scored as a disagreement. On the first reliability session the observers agreed on seven of the nine items, on the second session they agreed on eight of the nine.

RESULTS OF THE EXPERIMENTAL PHASE

Figure 2 shows the engagement of residents attending gardening sessions and of resi- dents sitting in the lounges on gardening days and non-gardening days.

Engagement by residents at gardening sessions was extremely high, averaging 90 per cent (range 78-98 per cent). This was a slight improvement on the level attained during the setting-up phase. In the lounges, engagement was much lower and did not signifi- cantly differ across conditions; on gardening days it averaged 30 per cent (14-39 per

cent), and on non-gardening days it averaged 31 per cent (2243 per cent). That is. residents who attended gardening engaged much more extensively in the dining room on days when gardening was organized than when sitting in the lounges on other days. On the other hand, residents who did nor attend gardening behaved no differently while sitting in the lounges on days when gardeners were there with them than on days when gardeners were in the dining room.

132 LIZ POWELL cr ul

; 70 -

E I - B

60

&so- % ; 01 p 40 -

30 - __a-------4.

20- &- /c

10 -

1 2 3 4 5 6 7 6 9 10 11 12 13 14 15 16 17 18 19 20 21 Post Check

SESSIONS

Fig. 2. Engagement levels of residents either attendmg gardening or sitting in the lounges. on gardening days and non-gardening days.

Attendance at gardening averaged 6.1 residents per session. ranging from three to nine people. The lowest four attendance figures were on days when the Red Cross Club was also taking place. This attendance level represents about 23 per cent of all the residents sitting in the two lounges at any one time. Over the whole study. I2 different residents. i.e. about 38 per cent of the total residents involved. came to garden- ing sessions.

The post-check. taken four months after the end of the experimental phase. indicated that gardening sessions were still being run by the volunteer. Engagement was 79 per cent at this session, with seven residents attending.

123 4567

n

8 9 10 11 12 13 14 15 16 17 18 19 20 21

SESSIONS

u Non-gardentng days Porportlon Of total engagement contrhted b” gardening

•J Gardmmg days No data collected m lounges on days 4,1,,15,19

Fig. 3. Total engagement of all residents on gardening days and non-gardening days

lndoor gardening activity for the elderly 133

Figure 3 shows the total engagement on gardening and non-gardening days, i.e. the combined engagement of residents sitting in both lounges and in the dining room. Total engagement on gardening days averaged 43 per cent (range 34-51 per cent). A one-tailed t-test shows this to be significantly higher than the non-gardening days’ total engagement average of 31 per cent (p < 0.005). Only on three of the 11 non-gardening days did total engagement equal or exceed levels reached on gardening days.

Figure 3 also shows the contribution of the gardening activity to the total engagement, by the heavily shaded portion of the bar for each gardening day. The extremely high engagement of the gardeners contributed an average of 47 per cent of the total engage- ment on gardening days (ranging from 33 to 70 per cent contribution to the total level).

Throughout the experimental phase the volunteer’s performance was monitored on the checklist. Over the 10 gardening sessions in this phase, she consistently followed the procedures in the instructions; out of a total of 90 checklist items (9 items x 10 sessions) she made only three errors. On the post-check, with no monitoring or feedback for the past four months, she made one error.

DISCUSSION

Clearly, the weekly gardening sessions were successful events and maintained well for a long period of time for the residents who chose to attend. The very high engage- ment levels reached in gardening sessions contrast strongly with the levels observed in the lounges on gardening and non-gardening days. The reversal design indicates that the gardeners, who constituted part of the lounges’ population on non-gardening days, are well able to engage at much higher levels than seen in the lounges, when they are given the opportunity to do so. In relation to the engagement of the whole group of residents, the reversal design also suggests that gardening was the variable producing the somewhat higher total engagement levels found in gardening days. Total engagement levels observed on gardening and non-gardening days fluctuate and partially overlap, thus obscuring the effect of the reversals. However, as Fig. 2 shows, the residents sitting in the lounges did not engage either systematically more on gardening days (which would have suggested that some factor other than gardening was causing the increased levels in total engagement) or systematically less (which would have suggested that gardening sessions were attracting the usually high engagers and engaging them even more vigorously). The residents remaining in the lounges on gardening days continued to engage at a relatively low level, while the gardeners engaged at a very high level. Therefore, as shown by Fig. 3. a substantial proportion of the total engagement on those days was actually contributed by the gardening activity.

It could be argued that, while statistically significant, the total increase in engagement from 31 to 43 per cent is not of clear social importance, since many residents chose not to attend gardening and were unaffected by the intervention. Certainly, disengage- ment remained a problem for the non-attenders and for everyone on non-gardening days. (There was a small spin-off outside sessions for gardeners in terms of watering plants, making goods available for sale and in occasional conversation, but such extra- session activity was limited). However, over the seven months of the study, 12 different people (more than one-third of the whole subject group) did attend gardening either regularly or more sporadically, depending on, for example, the particular activities being offered at any one session.

Solving the problem of the non-attenders can be approached in a variety of ways. One strategy would be to alter recruiting procedures to improve attendance. McClanna- han and Risley (1974) found that public announcements shortly before a scheduled activity doubled attendance compared to no announcement. In the present study an- nouncements were made in both lounges at the start of gardening sessions and invi- tations certainly offered to some residents. It is not known whether more widespread invitations would have culled more gardeners.

134 LIZ POWYtLL et al.

Providing consequences contingent on attending is another possible strategy. Other research with the elderly (Quilitch, 1974: Blackman er al.. 1976; McClannahan and Risley, 1974) has shown a reinforcing effect of providing snacks or money for attending. In the case of gardening, the produce and the decorative and craft items which arise naturally out of the activity could be made available to the gardeners for their personal use rather than being used generally within the home. In this study. the gardening products were considered to be the property of the home. Money obtained from sales could also be used specifically to replenish gardening materials. While the activity was more or less self-supporting, it was not visibly so since sales proceeds went into the home’s amenities fund, which supplied money for many other things as well as gardening.

Another approach would be to provide a much wider range of activities (including

domestic, educational or work activities as well as recreation) on the assumption that no single activity will ever attract all residents on a regular basis. This approach. if it covered all days and times of day, would be much more radical and would first need extensive discussion about the objectives of a home and the careful consideration of the resulting tasks for staff. Marston and Gupta (1977) indicate that this is a difficult and time-consuming process, although the approach might presumably be adopted in a gradual fashion. In the meantime it seems important to effect any minor changes or additions to routine which can be shown to benefit some residents if not all of them.

Given current shortages of staff and strong pressure on staff to carry out ‘care’ duties as a top priority. the use of a volunteer to run the sessions on a permanent basis seems a helpful approach. While government policy endorses this, there is frequently frustration and dissatisfaction from both the volunteers and the voluntary organizations arising from uncertainty about the help most needed and of greatest benefit to elderly people (Aves, 1969; Scottish Hospital Centre. 1970). It seems important that volunteers’ skills. goodwill and fund of ideas should not be lost for want of guidance on how best to direct their efforts. Clear written instructions on organizing various specific activi- ties, together with feedback on a volunteer’s initial attempts to carry them out. seem to be important procedures in dealing with this problem. Future research into the design of instruction and monitoring procedures which produce successful volunteer perform- ance on various activities would seem to be well worth while.

A~k,~ow/rdyc,rt~crlrs-Our thanks are due to: Cohn Fisher. Assistant Director (Residential Care). Don Rowle! (Principal Adviser) and Eve Nicholson (Senior Adviser) of Hamtxhire Social Services. The residents and staff of Cornerways Home for the elderly physically frail for their co-operation and adLice throughout the research project. Mrs. J. B. Black for her enthusiasm in organizing the indoor gardening sessions. Research team colleagues who commented on drafts and helped to edit. type and print this paper.

Reprints may be obtained from Judith Jenkins. Health Care Evaluation Research Team. Dawn House. Sleeper’s Hill. Wmchester SO22 4NG. England.

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