Daily life in a nursing home

Daily life in a nursing home

Has it changed in 25 years?

Gillian Harper Ice*

Department of Social Medicine, College of Osteopathic Medicine, Ohio University,

309 Grosvenor Hall, Athens, OH 45701, USA

Accepted 4 March 2002

Abstract

In 1974, Gottesman and Bourestom reported that nursing home residents spent 56% of their day

doing nothing. Since then, activity programming has significantly expanded. This study reexamined

how nursing home residents spend their day. Twenty-seven residents of a nursing home facility were

observed for 13 h each. At 5-min intervals, location, position, mood, and activity were recorded.

Residents spent 65% of their time doing little or nothing, and 12% of their time in social activities.

They spent the majority of their time in their rooms, sitting and alone. Although this facility has a high

standard of care and a creative activities department, residents still spent a great portion of their days

inactive, immobile, and alone. These results indicate that improvements in programming are still

needed. More engaging long-term care facilities may promote and support social interaction and

meaningful activity throughout the day.

D 2002 Elsevier Science Inc. All rights reserved.

Keywords: Activities; Quality of life; Social interaction; Learned helplessness

1. Introduction

As life expectancy increases and social structure changes in the US, a greater number of

elders are in need of long-term care services (Brock, Guralnik, & Brody, 1990; Mulrow,

0890-4065/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved.

PII: S0890 -4065 (02 )00069 -5

* Tel.: +1-740-593-2128; fax: +1-740-593-1730.

E-mail address: [email protected] (G. Harper Ice).

Journal of Aging Studies

16 (2002) 345–359

Gerety, Cornell, Lawrence, & Kanten, 1994). Although the majority of frail elders still

receive care at home, 5% of older Americans currently lives in institutional settings (Dwyer,

Barton, & Vogel, 1994). Some predict that approximately 43% of adults over 60 years of age

will spend some portion of their lives in a nursing home (Montgomery & Koloski, 1994). As

the baby boom generation ages, there will be an even greater need for long-term care. Thus,

the concept of quality of life in institutional settings has become critical in public, clinical,

and academic circles (Johnson & Grant, 1985; Kane, 2001; Voelkl, Fries, & Galecki, 1995).

Although there is little consensus on what constitutes a good quality of life, most agree that,

minimally, emotional well being, autonomy, and a sense of purpose are important compo-

nents (Clark, 1995; Kane, 2001; Lawton, 1997).

Most elders enter institutional settings due to failing health. Thus, nursing home residents

are frail, with numerous chronic, comorbid conditions and multiple functional deficits

(Mulrow et al., 1994). They often depend on assistance with both instrumental activities of

daily living and activities of daily living (Mulrow et al., 1994). In addition, approximately

60% of nursing home residents suffers from cognitive, behavioral, and emotional impair-

ments (National Center for Health Statistics, 1991; Rovner, Kafonek, Filip, Lucas, & Folstein,

1986). As a result of their physical and psychological condition, residents of nursing homes

must rely on staff and visiting family members to provide not only for their physical needs

but also their social and psychological needs. Unfortunately, multiple demands of staff and

family members may be at odds with resident needs. Residents often have to wait for care,

live by institutional schedules, and are idle most of the day (Gottesman & Bourestom, 1974;

Kane, 2001). This general inactivity, idleness, and loneliness may lead to low self-esteem and

depression and, consequently, a low quality of life (Voelkl & Mathieu, 1993).

In the 1960s, Goffman (1961) and Sommer & Osmond (1960) described the isolation

experienced in institutional settings. Goffman (1961) described these settings as total

institutions, self-encompassing environments isolated from the outside world. Many have

likened Goffman’s work on total institutions to current-day nursing homes (Foldes, 1990;

Thomas, 1994). In the 1970s, Gottesman and Bourestom (1974) described daily activity

patterns of 40 nursing homes. They found that residents spent 56% of their time doing

nothing. Thus, nursing home residents were vulnerable to loneliness, boredom, and negative

self-esteem. At the time, these authors recommended that residents be afforded the

opportunity to lead more normal lives (Gottesman & Bourestom, 1974).

Since this early work, others have shown how institutional life can lead to learned

helplessness and instrumental passivity (see Voelkl, 1986 for a good review). The concept of

learned helplessness refers to the phenomenon of residents learning passive behavior through

repeated situations in institutional settings over which they have no control (Abramson,

Garber, & Seligman, 1980). The instrumental passivity hypothesis proposes that residents’

passive behavior results from encouragement of dependency and discouragement of inde-

pendence by staff (Baltes, Wahl, & Schmid-Furstoss, 1990). Since activity level in general

contributes to life satisfaction, maintenance of cognitive function, physical health, and

functional performance (Baltes et al., 1990), residents may become increasingly apathetic

and experience a spiraling loss of control as their tenure in a facility increases. Research has

also shown that residents, who can maintain or learn a sense of control through activities or

G. Harper Ice / Journal of Aging Studies 16 (2002) 345–359346

therapeutic recreation, have improved physical ability, mental alertness, and life satisfaction

with interventions (Voelkl, 1986).

To combat problems associated with loss of self-esteem and self-control in long-term care

facilities, activities and therapeutic recreation have developed over the last 25 years,

prompted by the National Therapeutic Recreation Society and the National Association of

Activity Professionals as well as some legislation. A major goal of therapeutic recreation is to

maximize functional capabilities of clients and to help in the rehabilitation of the ‘‘total

person’’ by alleviating humanistic problems related to psychological and physical disability

(Greenblatt, 1988). Numerous activities are offered to nursing home residents including

music activities, pet activities, cooking, horticulture, bingo, current events, religious activ-

ities, and art. These activities are sometimes called therapies to denote their restorative

function. In addition, targeted interventions can be prescribed as recreation therapy.

Numerous studies demonstrate the positive effects of such activities or therapies including

improved self-esteem, quality of life, and mental health (Bassen & Baltazar, 1997;

Berenbaum, 1994; Christie, 1992; Hendy, 1984; Kartman, 1980; McCulloch, 1984; Rosling

& Kitchen, 1992; Savishinsky, 1985; Wolfe, 1983). Although these programs likely benefit

residents by alleviating the tedium of nursing home life and possibly by promoting a sense of

self-esteem and purpose, they are often offered only on an intermittent basis and do not

appeal to everyone.

The Nursing Home Reform Act section of The Omnibus Budget Reconciliation Act of

1987 (OBRA’87) addressed the quality of life of nursing home residents (US Congress 1987)

and mandated activities to meet the physical and psychological needs of all residents. In

addition, activities became part of the standardized Resident Assessment Instrument or

Minimum Data Set, and the Healthcare Financing Administration mandated that activity

programs be directed by qualified professionals. This mandate led to the expansion of activity

programs and the inclusion of activities personnel in the assessment process in some facilities

(Perschbacher, 1993). This may have prompted greater targeting in activity programs as they

now must be directed to specific patients’ therapeutic goals.

Because activities are thought to be an important component of quality of life and are

believed to help residents overcome learned helplessness and instrumental passivity,

numerous research projects that examine determinants of activity participation have been

conducted (Lawton, 1985; Voelkl, 1986). This research has often focused on individual

characteristics that enhance or impede activities. For example, Resnick, Fries, and Verbrugge

(1997) found a relationship between sensory impairments (hearing, vision, communication)

and little time spent in activities and social engagements. Voelkl and Mathieu (1993) found

significant variation between depressed and nondepressed residents in frequency of attending

activity programs and organized activities. Voelkl et al. (1995) evaluated the effect of certain

variables (resource use, cognitive abilities, depression, activity preferences, sense of initiat-

ive/involvement, location preferences, gender, and a facility indicator) on participation in

activity programs and found them all to be important factors in predicting time spent in

activities. Voelkl and Nicholson (1992) interviewed residents about their perceptions of their

environments and the programs they were involved in and discovered that residents enjoyed

structured time but also enjoyed unstructured time. These residents, however, were oriented

G. Harper Ice / Journal of Aging Studies 16 (2002) 345–359 347

and able to entertain themselves during down time. This research informs the design of

appropriate activities for residents. It also shows that activity programs should be sensitive

to individual needs and that a wide variety of activities are needed to fit a varied group

of residents.

Previous research has only touched on a small portion of a resident’s life in an institution.

Planned activities are offered at specific times of the day and may not be available to all

residents given the time constraints of staff and the multiple needs of different residents. Little

recent research has focused on daily activity patterns of nursing home residents. We know

little about how residents actually spend their day or how often they interact with others. The

primary objective of this research was to revisit the issue of daily schedules. What do residents

do during the day? Do residents spend less time doing nothing than they did in the 1970s as

reported by Gottesman and Bourestom? These questions were addressed in a pilot study by

examining a small sample of residents in an ‘‘average’’ nursing home in Columbus, OH.

2. Materials and methods

This study was part of a larger project entitled, ‘‘Stress and Adaptation among Elders in

Life Care Settings.’’ Twenty-seven nursing home residents from one facility participated in

the portion of the study described. Participants in the study were interviewed (if possible)

about their health and social history, had a series of body measurements and one sample of

blood taken, and were observed while research staff collected physiological measurements

(ambulatory blood pressure and salivary cortisol). Medical charts were reviewed for

additional information. This article describes the observations recorded while each nursing

home participant was wearing the ambulatory blood pressure monitor.

The research nursing home was part of an urban, nonprofit, continuing care retirement

community with multiple levels of care including independent living, assisted living, skilled

nursing home, and behavioral care units. The facility belongs to a chain of Presbyterian

homes; however, they had residents of all religions. A new 72-bed nursing home unit was

recently added to the complex. It was both Medicare- and Medicaid-certified. The nursing

home was divided into three units, which contained a ‘‘hub’’ with a nurse’s station and small

lobby-like area and all supply rooms including housekeeping, a meeting room, laundry room,

linen supply, and shower/tub room. All rooms were either semiprivate or private. Each room

was equipped with a bathroom (with a toilet and sink) and a bedside sink. The facility also

contained several activities rooms, a chapel, beauty shop, and library. The facility is slightly

smaller than the national average, but the facility’s residents were similar to national averages

(Gabrel, 2000a, 2000b).

The average age of the facility residents was 85. Seventy-eight percent of residents were

women and 90% were white. Approximately half of the residents was Medicaid-supported.

This sample consisted of 4 men and 23 women with an average age of 87 years (range of 65–

100 years of age) who resided in the new nursing home unit. All residents were recruited

except for those who were comatose. This sample included all those who were willing and

either personally consented or for whom family consented. This protocol was approved by


The Ohio State University’s Institutional Review Board. Participants had an average of two

living children. Most of the participants (78%) were widowed. Medicaid supported 60% of

the participants. Most participants were European–American, two were African–American.

The residents had an average of seven medical diagnoses and were prescribed an average of

seven medications. All but two residents required extensive assistance with activities of daily

living and only one resident was able to ambulate independently. Over half (59%) of the

residents needed assistance with eating. Thus, these participants follow trends of ‘‘typical’’

nursing home residents in that they are primarily female, white, widowed, and functionally

impaired with multiple comorbid conditions (Dwyer et al., 1994; Miller, McFall, & Camp-

bell, 1994; Mulrow et al., 1994). The group as a whole was dependent on staff and family to

provide for both physical and psychosocial needs.

The participants were observed for approximately 13 h (8 a.m. bedtime) on 1 day. Data

recorded included location, position, mood, activity, number of people in the vicinity, and

ambient noise in the area (see Fig. 1). Codes were used to record position, location, and

mood. A description of activity was written for each observation. The observer interacted

with the residents only while setting up the equipment and collecting saliva, or if safety was

compromised. Otherwise, the observer attempted to stay out of the view of the participant as

much as possible. The method of data collection was timed focal individual sampling where

one individual was observed, and the data recorded at 5-min intervals. In addition to the timed

sampling, qualitative field notes were collected.

In order to analyze the data, each category recorded was divided into groups. The data

category of mood was separated into three general moods: neutral (lack of obvious emotion),

negative affect (agitation, crying, expressions of distress), and positive affect (smiling or

laughing). Position was divided into sitting, standing upright, and reclining. The number of

people in close proximity was lumped into the following groups: none (0), individual

attention (1–2), small groups (3–5), medium groups (6–10), large groups (10+). Locations

were defined as: personal room, dining room, activity rooms, ‘‘parking areas’’ (areas where

Fig. 1. Observer data sheet.


residents were often placed for long periods including the hall and the ‘‘hub,’’ an open area in

front of nurses stations), and other (chapel, outside, physical therapy room). These variables

were straightforward; however, separating activities into categories was more of a challenge.

Following Gottesman and Bourestom (1974) as a general model, activity was divided into

personal care, expressive and social activity, and passive activity. One additional category

was added, ‘‘movement,’’ which included walking and moving in a wheelchair independ-

ently. Personal care consisted of eating, transport, grooming, washing, toileting, and medical

care (i.e., all general care). Expressive and social activity included all conversations, games,

physical activity associated with games, programmed activities, church, reading, and visiting.

Passive activity included time when residents were waiting, sleeping, doing nothing,

fidgeting, and sitting in front of, or watching, a television.

Some activities were difficult to designate. For instance, watching television was chosen

by Gottesman and Bourestom (1974) to be a nonpassive activity, but they realized that this

did not always apply depending upon the context. In this study, watching television was

Table 1

Daily time budget

Mean % time

observed

Minimum % time

observed

Maximum % time

observed

Location

Room 43.4 5.1 83.8

Dining room 25.4 0 79.2

Parking areas 25.6 0 61.5

Activity rooms 4.2 0 26.3

Position

Sitting 69.1 20.4 99.4

Standing 1.6 0 9.1

Reclining 28.7 0 77.9

Mood

Neutral 91.7 55.5 100

Negative 7.3 0 43.8

Positive 1 0 5.7

Group size

Alone 37.2 0.6 67.8

Individual 20.6 6.9 40.8

Small group 12.5 0 34.2

Medium group 10 0.7 49.4

Large group 18.9 0 42.6

Activities

Passive 65.5 30.7 85.7

Personal care 18 0 43.6

Social/expressive 12 0 43.2


categorized as a passive activity because the residents involved in this study were often

parked in front of the television and did not appear to be watching or were actually sleeping.

The data collected in this study support this categorization. Televisions were on 19% of the

observation time, yet television watching as an activity was only recorded 3% of the time.

Although not all residents had assistance when eating, eating was placed in the personal

care category, as it did not fit easily into any other category. Personal care activities included

both care with assistance and self-care activities, although given the frailty of this group, most

personal care, with the exception of eating, was with assistance.

For each individual, the percentage of time spent in each mood, location, posture, activity,

and group size was calculated. This percentage was calculated by adding the number of

observations in a category divided by the total number of observations for that resident (over

the 13-h period). The percentages were averaged across the group. The minimum, maximum,

and mean are presented in Tables 1 and 2.

Table 2

Detailed activity budget

Activity Mean % time

observed

Minimum % time

observed

Maximum % time

observed

Passive activities (total) 65.5 30.7 85.7

Sleep 36.1 0.6 77.4

Nothing 16.2 1.5 51.7

Fidget 6.1 0 29.3

Waiting 3.1 0 23.5

Television 3.0 0 28.9

Look/listen 1 0 7.6

Read 0.3 0 5.6

Social/expressive (total) 12.0 0 43.2

Talk 6.6 0 32.4

Activities 3.1 0 17.1

Visit 1.1 0 15.8

Personal care (total) 17.9 0 43.6

Personal carea 6.1 0 26

Eat 9.8 0 19.1

Transfer 0.6 0 2.9

Transport 1.4 0 4.3

PT 0.2 0 1.4

Toilet 0.8 0 4.3

Medications 0.6 0 1.4

Movement (total)

Walk 0.9 0 6.5

Move in wheelchair 2.0 0 4.3a Including a.m. and p.m. care and grooming activities.


3. Results

A total of 3794 observations were recorded with an average of 146 per individual. The

percentage of time that residents spent in each location, activity, mood, and position is

presented by category. Table 1 presents the mean, minimum, and maximum of time spent in

each location, posture, mood, activity, and group size.

3.1. Location

The residents spent most of their time in their rooms (43%), an average of 25.4% of their

time in the dining room, and an average of 25.6% of their time in ‘‘parking areas.’’ The

residents spent only a small percentage of their time in activity rooms (4.2%).

3.2. Position

During this study, residents were relatively immobile. The residents sat for the majority of

the day (69%). They stood upright only 1.6% of the time and reclined in bed for about a third

of the day.

3.3. Mood

The residents showed little sign of outward emotion. They were coded as neutral 91.7% of

the time. The residents had expressions of negative affect only 7.3% of the time. The

residents almost never displayed expressions of positive affect.

3.4. Group size

The residents spent the greatest portion of the day by themselves (37%), an average of

20.6% of the time with individual attention (1–2 people), in small groups (3–5 people) an

average of 12.5% of the time, in medium-sized groups (6–10 people) an average of 10% of

the time, and an average of 18.9% of the time in large groups (10+ people).

3.5. Activities

The residents spent approximately two-thirds of their day performing passive activities.

The residents were observed in personal care activities 18% of the time and in expressive or

social activity an average of 12% of the time. Table 2 has a more detailed list of activities. Of

the passive activities, sleeping was the most common activity, which was recorded for 36.1%

of the observations. Television watching was only recorded for 3% of the observations, even

though television sound was recorded during 19% of the observations. This supports the

notion that television ‘‘watching’’ is not a social/expressive activity. The greatest number of

social/expressive activities consisted of talking, which was recorded in 6.6% of observations.

On average, 3.1% of observations included planned activities. The type of planned activities


varied according to time of day. Most of the activity programs were geared towards alert and

relatively oriented residents. Morning activities tended to consist of smaller groups than

afternoon activities.

Based on the above data and field notes, a ‘‘typical’’ day can be described as follows. An

average day for these residents began with a.m. care (includes assistance out of bed, bathing,

oral care, and dressing), usually between 5 and 7:30 a.m. (before the observation period).

Breakfast was served between 8 and 9 a.m. At all meals, there were three seatings for

residents, two for residents who needed to be fed, and one for those who fed themselves.

Although residents normally only ate for 10–20 min, mealtime lasted an hour or more.

Residents waited for their food in the dining room and then waited to be taken back to their

rooms when finished. Statistics also reveal this: residents spent only 9% of their day eating

but 25% of their day in the dining room. When taken back to their rooms, residents were

often toileted and put in bed, placed in front of the television, or brought to an activity area.

Although not examined quantitatively, we observed that staff members had preferences on the

order of resident transport out of the dining room. At a decided disadvantage were those who

were heavy or ‘‘difficult’’ (aggressive or easily agitated); these residents spent more time

waiting. The gap between breakfast and lunch was often idle time spent in residents’ rooms

with the television on. In their rooms, residents either slept, watched television, read, or did

nothing. Some residents attended activities such as trivia, current events, baking, bible study,

or church. Most morning activities were geared towards residents who were alert and

somewhat oriented; however, some activities were offered to less alert and oriented residents,

such as music or one-on-one time. Activities typically involved 6–12 and 1–5 residents,

respectively. Even with these activities offered in the morning, most residents spent much of

the morning sleeping or doing nothing.

The afternoon was similar to the morning. Around noon, the residents went from their

rooms or activities to the dining room where they waited to eat, ate, and then waited to be

taken back to their room to be toileted and, in some cases, put back to bed. Some residents

were parked in the ‘‘hub’’ or hallways with other residents rather than their room. After lunch,

they did little until 3 p.m.

At this time, many residents were brought together for an activity program. It took about

half an hour to get set up and then activities began. These were usually large-scale activities

where residents formed a circle in the hub or activity room. These activities typically involved

15–30 residents. Programs consisted of group volleyball, paddleball, musical instrument

play, and sing along. Some activities were offered in smaller groups including arts and crafts,

reading, and nail painting. Again many of these activities were geared toward alert and

relatively active residents. Few activities were offered for less active residents at this time,

although some residents who were not alert enough to be engaged in the large group activities

still attended.

If residents had visitors, they typically visited during the afternoon, although some visited

during lunch and others at suppertime. Very few of the residents in this study had visitors on

the day of observation, accounting for only 1% of the total observations. This does not

necessarily reflect the true frequency of time spent with visitors since observation occurred on

a single day, primarily during the workweek.


From around 4:30–5:30 or 6 p.m., residents waited in the hub for transport to the dining

room for dinner. Once transported to the dining room, residents again waited to eat, ate, and

then waited again to be taken to their rooms. Because p.m. care (includes oral care, bathing,

dressing, and assistance for bed) was given to residents after dinner, some residents waited

a considerable amount of time to be taken out of the dining room. Once in their rooms,

residents were changed or toileted, given p.m. care, and put into bed. In many residents’

rooms, the television was often left on until the evening shift finished their last rounds at

10:15 p.m. Most residents either had no remote control or were without the capacity to

use a remote to turn the television on/off or to change the channel. We rarely observed

staff asking residents if they would like the television on or off. In fact, many times

the television was turned on for staff enjoyment. In other cases, staff may have believed

that a resident would want the television on if they could request it. Bedtime ranged from

7 to 9 p.m. No activities were offered to the residents while they were waiting to be put

to bed.

4. Discussion

Residents at this facility spend a great deal of their time with little or nothing to do. The

results of this study indicate that residents spend the majority of their time in passive

activities, such as doing nothing, sleeping, and waiting. The results also indicate that they

spend close to equal time in personal care and social/expressive activities. These results are

consistent with research by Gottesman and Bourestom, (1974) who found that residents spent

56% of their time doing little or nothing in passive activities, 23% of their time in personal

care, and 20% of their time socializing. While there are no recent studies that are directly

comparable to this one, other studies suggest that this is not a unique finding. In a study of

facilities in Wales, nursing home residents spent approximately 70% of their time engaged in

passive activities (Nolan, Grant, & Nolan, 1995). Boredom, loneliness, and helplessness are

still reported as common problems for nursing home residents (Slama & Bergman-Evans,

2000; Thomas, 1996). Despite the emphasis on activities programming over the last 25 years,

daily life in a nursing home may not have changed a great deal. While we have improved the

quality of programmed activities and targeted activities according to therapeutic goals, we

have largely ignored what residents do with the rest of their day.

It may be that this level of inactivity is no different from healthy elders. Few studies have

examined daily activity patterns of community-dwelling elders. However, as part of this

project, we collected data on independent-living residents. They spent approximately 40% of

their time in passive activities and 28% of their time in social/expressive activities (Harper,

1998). In a recent study of healthy community-dwelling elders, we found that 38% of

participant’s time was spent in social/expressive activities, while 17% was engaged in passive

activities (unpublished data). Baltes et al. (1990) found that elderly Germans spent

approximately 30% of their time engaging in leisure pursuits. Therefore, nursing home

residents are spending less time engaged in social activities than is typical for elders who can

pursue activities independently.


Does this mean we should add more programmed activities? Not necessarily. Not all

residents like group activities and not all those who attend planned activities are engaged in

them. For obvious budget and time constraints, activity programs cannot be offered

continuously. While numerous studies have demonstrated that individual planned activities

improve affect and self-esteem, no research has demonstrated that more is better. Further-

more, if residents must rely on planned activities for their only source of social engagement,

we may further encourage instrumental passivity and learned helplessness. Perhaps what is

called for is a more fluid approach to engaging residents than simply providing planned

activities programs. Can we find ways to make the environments more engaging? How can

we promote social engagement and leisure pursuits in residents with significant impairments?

We may have to start thinking outside the box for solutions.

Several innovative approaches have been used to increase social interaction and self-

esteem in nursing homes. Allen-Burge, Burgio, and Bourgeois (1987) described an inter-

vention to enhance social engagement with the use of memory books. These books, which

were carried by the residents during the day, were filled with information of the residents’

past using photographs, letters, drawings, etc. In their intervention, Allen-Burge et al. trained

staff to stop on occasion and review the memory book with a resident. This intervention

increased social interaction and also reduced agitation. Another approach is to have

volunteers visit individuals on a regular basis. In congregate care facilities, a large number

of residents with minimal impairments represent a pool of volunteers that might be tapped for

social activities. The Live Oak Project tries to promote a sense of community by encouraging

residents to contribute in various ways (Barkan, 1981). For example, at one facility, residents

formed a peer counseling group to help with welcoming and orienting new residents. Other

residents were encouraged to visit with their peers struggling with depression.

Not only are institutions lacking a sense of internal community but they are largely

detached from the external community. By fostering interaction between the larger com-

munity and nursing homes, we may be able to increase social interaction and engagement for

residents. For example, junior high, high school, and college students are often looking for

volunteer programs. Some colleges have ‘‘adopt-a-grandparent’’ programs, which match

students to isolated elders in the community. Similar programs might be used for long-term

care residents. School programs can benefit both nursing homes and the surrounding

communities. At one continuing care retirement community in Boulder, CO, a kindergarten

class moved into the facility’s library (McQueen, 1998). The children, residents, and staff of

the facility all reportedly benefited from this merger (McQueen, 1998).

Another way to foster social interaction is with the regular use of pets within a facility. Pet

programs have been effective, but they are offered on an intermittent basis. Although these

programs have a great deal of support, systematic research on efficacy is lacking (Jorgenson,

1997). Some have advocated the use of resident pets as opposed to visiting pets (Thomas,

1994). Certainly, more research is needed to compare the effects of live-in pets versus short-

term pet programs on the daily life of nursing home residents.

Thomas has described a successful integration of many of these approaches. At the Chase

Memorial Nursing Home in upstate New York, the ‘‘Eden Alternative’’ was developed. The

nursing home was seen as a human ecosystem. An integral part of this ecosystem is a variety


of birds (at least one in every resident’s room who wanted one) and facility cats and dogs. In

addition, numerous plants were distributed around the facility, including residents’ rooms, as

well as an extensive outside flower and vegetable garden. A child day care program is on the

premises and there are school and summer programs to maintain a constant presence of

children in the facility. Thus, residents have numerous interactions with and responsibilities

for animals, plants, and children. In addition, they have more interaction with staff because

staff enter residents’ rooms frequently to tend to plants and birds. Residents of Chase

Memorial have greater social interaction than a nearby control nursing home, they seem to

have greater self-esteem and sense of control, and they use fewer medications, especially

psychotropics (Thomas, 1994). Many nursing homes around the country have adopted the

Eden Alternative approach, while others have been inspired by the use of pets. Unfortu-

nately, the adoption is often merely superficial and some have noted that these facilities do

little more than add some birds (Kane, personal communication). More systematic research

is needed on the Eden approach to determine how this influences the daily activity patterns

of residents.

An additional concern about the daily life of nursing home residents is that residents with

cognitive impairments spend a large portion of their day in their rooms with little or no

supervision. A previous study at the study facility found that most accidents occurred in

residents’ rooms when they were left on their own (Harper, 1996). Although residents with a

high risk of falls wear fall alarms, these often warn staff when it is too late. No accidents were

witnessed during this study; however, observers intervened, for obvious ethical reasons, when

residents attempted to climb out of chairs or beds. Some effort was made at this facility to

keep ‘‘at-risk’’ residents in more centralized areas such as the ‘‘hub’’ or hallway. This was

seen as a safety precaution because residents would be more visible to staff. However, given

the busy schedule of staff, residents were largely overlooked and residents were typically

parked in these areas for hours either staring into space or sleeping.

Another concern is the lack of physical activity and general immobility. Because

residents spend such a large portion of their day sitting or laying down, they are at great

risk for muscle atrophy and skin breakdown. Mobility exercises should be incorporated into

the daily lives of all nursing home residents, not only for those receiving physical therapy.

One of the goals of OBRA ’87 is maintenance of optional functioning. Immobility counters

this goal.

Although this study was based on a small sample, the results suggest that improvements in

programming are still needed. The facility in which the study was conducted has a high

standard of care and a creative activities department, yet residents are still spending the

majority of their time in their rooms by themselves doing nothing. If these results are

replicated, it would suggest that planned activities alone do not engage resident populations in

their daily life. Therefore, we may need to focus on a new approach to nursing home life to

make it more engaging and provide opportunities for residents to engage in meaningful

activity on their own (Kane, 2001). In addition, we need to further consider the environment

and reconsider assumptions of what enhances pleasantness and engagement for residents.

Further research is needed to determine how much activity is needed to promote self-esteem,

a sense of control, and a meaningful life.


5. Conclusion

While we have increased our understanding of the role of activities in nursing homes,

promoted more activities through active lobbying of professional organizations, and

mandated activities through legislation, nursing home residents spend a large portion of

their day alone and inactive. While previous research on residents’ activity preferences and

risk factors for poor attendance is crucial in guiding activities programs, this study suggests

that we have not addressed the issue of how residents spend their time when not in structured

programs. This was particularly true for residents who are not alert and oriented. More

extensive research is needed to examine individual differences as well as different types of

facilities and nursing home settings. This study also suggests that improvements are still

needed in nursing home settings, since the end result (time spent in meaningful activities and

engagement in social interaction) does not appear to have changed and because the

ramifications of idleness still exist. We need to find ways to make life in long-term care

facilities more engaging to promote and support social interaction and meaningful activity

throughout the day.

Acknowledgements

I would like to thank Steve VanDyke who assisted in data collection and data analysis and

participated in an earlier version of this article. In addition, I would like to thank August

Ferenec for her assistance in data collection efforts. Thanks to the residents and staff of the

research facility without whom I could not have conducted this research. Lastly, thanks to

Bob and Rosalie Kane, Shanni Britt, Jackie Wolf, and Norman Gevitz, and anonymous

reviewers for their helpful comments on this manuscript.

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Daily life in a nursing home