PioneeringChangeActivitiesEducation Module

toPromote Excellent Alternatives in Kansas Nursing Homes

ABOUT THIS MODULE This educational module is intended for use by nursing homes who wish to promote more social, non-traditional models of long-term care. The intent of this module is to assist organizations in implementing progressive, innovative approaches to care that should make a significant difference in the quality of care and the quality of life for those living and working in long-term care environments. These materials may be reproduced for educational/training activities. There is no requirement to obtain special permission for such use. If used for these purposes, the following statement should appear on all pages of such reproductions: Reproduced from PEAK Module: (title of individual module or booklet), Center on Aging, Kansas State University, Manhattan, KS. This permission statement is limited to the reproduction of materials for educational/training use. Reproduction or distribution of more than 30 copies in one year may be done only with prior written permission. Reproduction on computer disk, CD, or by any other electronic means requires prior written permission. No copies of this material, in full or in part, may be made available for sale. For more information on this publication or to request permission to use/reproduce portions of this material, please contact: Center on Aging Kansas State University 103 Leasure Hall Manhattan, KS 66506-3501 785-532-5945 gerontology@ksu.edu Information provided on specific nursing homes was obtained through interviews with staff members and the print version of this information was approved by same prior to publishing. Information was accurate at the time of publication. There are no guarantees that the nursing home or program will be exactly as described at any time later than the date of publication of this document. Mention of particular services, methods of operation or products does not constitute an endorsement, but are to be used for informational purposes only. Opinions expressed by individuals in this document do not necessarily represent the opinion of the KSU Center on Aging, the Kansas Department on Aging, or the Kansas Department of Social & Rehabilitation Services. The development of PEAK materials was supported by the Kansas Department on Aging and the Kansas Department of Social and Rehabilitation Services through a Title XIX contract and matching funds provided by Kansas State University, Kansas Association of Homes and Services for the Aging, Kansas Health Care Association, and volunteers from the Long-Term Care profession. Kansas State University is committed to nondiscrimination on the basis of race, sex, national origin, disability, religion, age, sexual orientation, or other nonmerit reasons, in admissions, educational programs or activities and employment (including employment of disabled veterans and veterans of the Vietnam Era), as required by applicable laws and regulations. Responsibility for coordination of compliance efforts and receipt of inquiries concerning Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and the Americans With Disabilities Act of 1990, has been delegated to Clyde Howard, Director of Affirmative Action, Kansas State University, 214 Anderson Hall, Manhattan, KS 66506-0124, (Phone) 785-532-6220; (TTY) 785-532-4807. Revised December 1, 2003

1

Table of ContentsActivities

Course Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Pretest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Meaningful Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Transforming Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Daily Pleasures Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Getting to Know You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Learning Circle Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Think Outside the Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Connect the Dots Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Same Old, Same Old . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Calendar Analysis Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Mastering Something New . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12I’d Rather Be Fishing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Why Are Activities So Important?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Activity Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Adult Development Stage Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Motivations for Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Types of Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Physical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Social . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Intellectual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Spiritual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Creative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Ideas by Type Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

The Role of the Activity Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Regulations and Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Keeping Their Favorites Going . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

SOC Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Encouraging New Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Setting Up Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

2

Evaluation Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Don’t Get Stung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

Other Ideas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Animal Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Considering Pets Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Friendly Visitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42Animal Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43Green and Growing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45Horticulture Therapy in Nursing Homes by Candice Shoemaker . . . . . . . . . . . . . . .46Horticulture Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50Put ‘Em Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51Going High Tech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57Post-test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Pretest and Post-test Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62Clip Art Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

Appendix A: Daily Pleasures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66Appendix B: Getting To Know You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69Appendix C: Connect the Dots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70Appendix D: Pet Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

3

Course Objectives:

1. To instill an understanding of the importance of meaningful activity on qualityof life.

2. To reinforce the importance of relationships and explain their necessity inmeaningful activity.

3. To demonstrate the effects of individualized activity on residents and staffroles.

4. To develop an understanding of how the home’s culture impacts residentindividuality and choice.

5. To highlight the importance of individualizing care plans and having all staffutilizing the plans for an activity program.

4

PretestThe pre- and post-tests included with this module are optional. The questions provide information aboutthe materials to be covered and can be used for learning self-evaluation. At some future date, these testsmay be used as a part of a continuing education requirement.

1. In a culture change home, which of the following types of individuals could be involved inmeaningful activity with an elder?

A. Activity personB. CNAC. Family D. Maintenance personE. NurseF. All of the above

2. Meaningful activity is dictated by theA. Activity calendar.B. Resident council.C. Resident’s preferences.D. Staff’s preferences.

3. Spirituality activities must include a religious element.A. TrueB. False

4. Which of the following is a culture change strategy for learning the preferences of elders?A. Learning CirclesB. Asking family and friends of the elder before giving the elder an opportunity to shareC. Caregivers learning about an elder during ADLsD. A and CE. All of the above

5. Which of the following illustrates the compensation component of the Selective Optimizationwith Compensation (SOC) theory?

A. Sewing needles with a larger eye holeB. Making an afghan using only the stitches that the person can still doC. Growing only one type of vegetables in a container garden because it is your favorite

to eatD. Using utensils with larger handles so a cake can be easily stirred E. All of the aboveF. A and D

5

6. The benefits of being engaged in meaningful activity include all of the following exceptA. Maintained autonomyB. Improved quality of lifeC. Worsened health outcomesD. Increased socialization

7. Which of the following quality-of-life domains can be directly influenced by individualizedactivity programs?

A. RelationshipsB. Spiritual well-beingC. AutonomyD. All of the above

8. A comprehensive activity assessment is necessary to provide individualized activity.A. TrueB. False

9. Which of the following has not been identified by Bill Thomas of the Eden Alternative as ascourge of nursing home living?

A. LonelinessB. HopelessnessC. BoredomD. Helplessness

10. Which of the following is not a component necessary for activity regulatory compliance?A. Resident activity preferences are assessed.B. Resident preferences are used in planning activities.C. Modifications are made to the care plan as needed.D. Activity staff members are the only people who can lead activity that is documented.E. All activities must last at least 25 minutes.F. D and E

Answers can be found on page 61.

6

Meaningful Activity

Happiness is a state of activity.-Aristotle

Introduction

Activities are among the most importantcomponents of resident care, but in themedical model of nursing homes theymay be treated as merely a way to keeppeople busy between clinical careinteractions. Staff can be so wrapped upin providing the best clinical care thatthey fail to provide the best care for thewhole person. In the past, with the focusbeing primarily on clinical care, thechoice for activities was deciding toattend Bingo or not to attend Bingo. Now activity choices include trips to LasVegas, airplane rides, and honeymoons!

Viva Las VegasA resident wanted to go to Las Vegas forher 103rd birthday. Staff at AnthonyCommunity Care Center in Anthony,Kansas worked with the resident and herfamily to set up the trip. The home usedsome proceeds from the annual carnival

and other fundraisers to send her.The staff members that traveled

with her received a littlehelp from fundraisersand donations, but alsocontributed funds for the

trip. When she got off theplane she shouted, “Viva, Las Vegas!”

What a wonderful way to celebrate 103years of living!

Flyin’ the Friendly SkiesA resident from Lyons Good Samaritanin Lyons, Kansas said he wanted to go onan airplane ride. The staff discussed itand then advertised the resident’s wish.A volunteer pilot from the communitycame forward, and soon he was flyinghigh! When Lyon’s Good Samaritan residents want something the facilitycannot provide they advertise theresident’s desire to the community. Volunteers step up and fulfill residents’wishes.

A Golden HoneymoonA resident at The Cedars in McPherson,Kansas was preparing to celebrate her50th wedding anniversary. Since she andher husband had never had an officialhoneymoon, the staffdecided to give them oneas an anniversary gift. She could not ambulateand had to be transferredwith a lift, so going on a tripwould be very difficult. Thestaff made arrangements forthe couple to stay in an assistedliving apartment. They enjoyed awonderful dinner by candle light. After the dinner, staff members helpedher into a double bed, so she and herhusband could spend the night together.

7

While these are special activities thatcannot be facilitated every day, theindividuality, autonomy, and creativitycan be replicated, in various ways,throughout the day for each resident. Individuality and spontaneity are needsthat have typically been maintained byfamily members and friends. Activitiesare a great way for caregivers to beginfulfilling these needs and improveresidents’ quality of life.

A study by Kane (2001) identified elevendomains associated with quality of life. The domains include: safety, security andorder, physical comfort, enjoyment,meaningful activity, relationships,functional competence, dignity, privacy,individuality, autonomy and choice, andspiritual well-being. Many of thedomains identified can be directlyenhanced by activity. Throughout thismodule many of the domains will bediscussed in relation to activityprograms. Kane (2004) suggested astronger correlation between the numberof people on the activity staff andresident quality of life than between thenumber of nursing staff and residentquality of life. This indicates thatactivities have a huge potential to changeand enhance the lives of residents.

This module, as past modules, is anopportunity for administration andleadership to share concepts with staffmembers through case studies, examples,activities, discussion questions andprojects that can be implemented andevaluated.

Transforming Activities

To begin the transformation of activities,it is necessary to define meaningfulactivity. Meaningful activity is when“residents engage in a discretionarybehavior, either active activity or passiveobservation that they find interesting,stimulating, worthwhile. Converselythey are not bored” (Kane, 2004). Eachresident should have the opportunity tobe involved in activities ofinterest to him or her.This involvementcould be in the formof participation orenjoyment throughwatching others. Staff may thinkthat residentsalready havesuchopportunities. The differencebetween the choice to participate in anactivity versus a meaningful activitycomes from an understanding of eachresident and what gives him or herpleasure or fulfillment. Without a trueknowledge of each person, therelationships necessary to providemeaningful activity cannot be developed. This knowledge has to include aresident’s preferences, hobbies, interests,past occupations, goals, dreams, andother personal history.

There are many ways to learn aboutresidents. An idea from Action Pact is

8

called Daily Pleasures (personalcommunication with LaVrene Norton onFebruary 25, 2006). This interview toolhelps staff learn what residents enjoyhaving or doing on a daily basis. Nortonsuggests, “The key is taking the residentback to when they were living at home.” This enables residents to mention

pleasures from home includingthose they consider

impossible in a nursinghome. Some of the

pleasures discoveredthrough the interviewwill be small, like“Having a cup of

coffee in my pajamasevery morning,” while

others will be more complexand require more planning. After theinterview is conducted, a group of staffmembers and residents brainstorm abouthow these pleasures can be attained. Acopy of the directions and interviewquestionnaire and be found in AppendixA at the end of this module.

Daily Pleasures Activity

Take a moment to list the daily pleasuresof the people in the staff learning group.It might be necessary to share some ideasto get the group started. Ideas mightinclude a certain kind of perfume or atype of food. List the responses given. Once you have a list, ask if each itemwould be possible in the nursing home. If something listed is not currentlypossible, brainstorm ideas about how thispleasure could be facilitated in the home.

Getting to Know You

Most nursing homes use activityassessments that ask questions abouthobbies, interests, how the elders like tospend their time, and their preferredschedule. Assessments such as thesehelp develop an understanding of theelders’ preferred lifestyle. Thisinformation helps assure the day goesaccording to the resident’s plan and notone set by staff. In Appendix B of thismodule there is a sample “Getting toKnow You Questionnaire” that is verycomprehensive. It contains in, additionto the basics, questions like “Is theresomething you would like to learn?” and“What is something you never got to dothat you wanted to?” Questions such asthese will offer further insight aboutresidents.

No matter how staff goes about gettingthe information about what residentsenjoy, the important thing is to do it! Most elders are not going to ask forthings or make theirinterests knownunless staff offer theopportunity. Staffneed tolisten andobservecarefully because theinformation may bepresented subtly. Family members or friends are a valuablesource of information about residents’past preferences and interests as asupplement or if elders cannot provide

9

this information themselves. Anotherway to gauge interest is to observe theresidents to see if they seem engagedwith an activity or if they are sleeping,focusing their attention elsewhere, orbeing disruptive. The body language of aresident during activities gives cluesabout the types of activities the residentenjoys. Observing the items in aresident’s room may provide insight aswell.

The information received from residents,family members, or observation shouldbe shared, so all staff members have anopportunity to get to know the resident. Staff will probably find they enjoy theconversations as much as the residents!This information should be used in careplanning to develop an activity programfor the individual resident.

Collecting information about a residentonce is not enough. People change, andthe residents’ desires will need to beconstantly updated to reflect theirchanges in preferences and ability. Asrelationships develop, elders may openup and share more. The care plans needto reflect changes as well as newinformation to allow the activity plan tocontinue to be life enhancing.

Learning circles are a wonderful way togather information and provideopportunities for a group to continuelearning about one another. The learningcircle can be a powerful tool in the homefor learning about each other, makingdecisions for the home, and building a

team. To facilitate a learning circlesomeone will need to be the leader. Thisperson will state the question or problem. He or she will give his or her responseand then ask for a volunteer. Thepersons on each side of the volunteer willdetermine whichway theconversationmovesdependingon whowould liketo sharenext. Each person inthe circle has an opportunity to speakwithout being interrupted by anyone. Ifthe person does not want to share theymay say “pass”. After everyone in thecircle has had a chance to contribute,those who passed are given a secondopportunity. After everyone who wantsto has given input, the group opens upfor discussion. This tool gives everyonethe opportunity to share and putseveryone on the same level, soparticipants feel comfortable. Thelearning circle is a very simple conceptbut is invaluable in knowing residentsand creating home.

Learning Circle Activity

Using the instructions above form alearning circle. Make sure everyone inthe group understands the rules. Youmight want to begin the learning circlewith a question to help participantsbecome better acquainted. For example,“If you could invite one person to a

10

dinner party who would it be and why?”The depth of this question depends onthe level of comfort within the group. Now have the group answer thefollowing question about the activityprogram. “What do you think theoutcome will be when activities areindividualized?” You may wish to addmore questions depending upon thegroup’s discussion.

Think Outside the Box

One of the goals of this moduleconsistent with all culture changeprinciples is out of the box thinking.Persons providing meaningful activitieswithin a nursing home environment,whether they be paid activityprofessionals, front-line staff, volunteersor others, have to think outside of thebox! In homes with consistent staffingwhere relationships between caregiversand residents are strong, staff can beginto recognize the individualneeds and desiresrelated to day-to-day livingwithin theresidentcommunity.In thisenvironmenttraditionalactivities likeBingo andreminiscing become less significant, anda quiet moment for Bible study andprayer or preparation of a midnight snackbecome more so. In a culture change

environment unscripted moments, likereading a family letter or styling theresident’s hair, are recognized asactivities and are therefore worthy ofbeing recorded.

Connect the Dots Activity

This activity isdesigned toencourage staff tothink outside the box.Give each person acopy of the connectthe dots worksheetlocated in Appendix

C of this module. Ask them to connectall of the dots by drawing four straightlines. Tell them they cannot lift theirpencil off of the paper or retrace any ofthe lines, but the lines may cross. Havethem turn their paper over when theyhave finished. Allow 3-5 minutes fordrawing.

Once the time is over ask if anyone hasthe solution. If not, show the solutionlocated in Appendix C. Spend a fewminutes discussing the activity.

Write down a few of the responses to thefollowing questions, so they can berevisited if the concept needs to berefreshed in staff’s minds.Why did most of us not think of goingoutside of the lines?____________________________________________________________________________________________________________________________________

11

___________________________________________________________________________________________________

Why did we think we had to stay withinthe lines?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Discuss the importance of looking forsolutions from outside the box. Note thatwhen providing activity from anindividual perspective there may betimes the request does not fit within thebox of the current environment. Bythinking outside the box, we can findways to bring residents what they want. What are examples of times when out ofthe box thinking has improved the life ofa resident in our home?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Same Old, Same Old

“Older adults who can acquire newleisure pursuits, strengthen involvementin existing ones, and adapt activities andequipment to sustain their involvementsmay enjoy longer periods ofindependence and happier lives.”

Mahon and Searle, 1994, p. 41

Many staff members have said that the“residents want the same few activitiesrepeated throughout the week and are

unwilling to try newthings.” Whilesome residentsmay enjoy someof the standard

nursing home activities,like Bingo and sing along,

others may only be participating becausethe activity is widely available and astaple in the home’s culture. Mahon andSearle (1994) suggest there is adiscrepancy between activities olderadults like to engagein and what they aredoing. A culture ofactivity conformityin a nursing home maycause residents to feelrestricted by the home’sculture when they pursue leisureactivities.

Calendar Analysis Activity

As elders enter or leave the home andinterests change, the activity calendarshould be changing also. Take a look at

12

your current activity calendar. Compareit with the oldest calendar you still haveon file. Discuss the similarities anddifferences in the calendar.

What activityoccurs mostfrequently on eachcalendar? _________________________________________________________________________________________________________

Does the calendar reflect the desires ofthe elders of the home?___________________________________________________________________________________________________

Discuss strategies for making a calendarof activities that reflects the residents’desires in the home.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Mastering Something New

Residents who only want to participate inthe standard types of activities or wish tobe disengaged should be encouraged to

try new things. When residents say theyare not interested in participating in anactivity it may have more to do with theirself-efficacy than it does not liking theactivity. Rowe & Kahn (1998) suggestthat building self-efficacy for an activityrequires gradual engagement in theexperience. In this process a residentbegins at a comfortable level ofinvolvement where he or she will be ableto achieve success. After this level hasbeen mastered the level of difficulty orinvolvement is slowly increased. Duringthis increase the resident receives praiseand encouragement. After the residenthas mastered this new level, the cycle isrepeated. In this way the increase inparticipation is so gradual and successfulthat the resident no longer feelsoverwhelmed or fears failing.

13

Case Study: Puzzling Out A Solution(This is a true story, but the resident’sname has been changed to protect hisidentity.)

Randy, a resident at Medicalodge PostAcute Care Center in Kansas City,Kansas, never spoke to anyone. He onlywanted to stay in his room and sleep. Knowing that Randy spent all his timealone, one of the activity staff membersworried about his well being. Shedecided she was going to figure out whatRandy really enjoyed. She began tryingdifferent activities with him during her“House Calls.”

After a great deal of trial and error, shetook in a puzzle. Randywatched her andseemed interestedin what she wasdoing. She begangetting Randyto help byhaving only afew piecesthat needed to beput in. He wouldtry to find the rightspots for those pieces. When he put a piece in she praised him. Each time she left more pieces out until,eventually, he was putting the puzzlestogether from start to finish.

Now, Randy enjoys multiple activitiesand visits with staff. Since staff membersdeveloped a relationship with Randy andoffered him encouragement andopportunities to succeed, he has come

out of his shell and is able to enjoy hisleisure time.

Is there someone at your home who isisolating him/herself? Someone whodoes not seem engaged with the currentactivities offered? ___________________________________________________________________________________________________

As a group, list possible interventionideas for the resident identified above. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Discuss who could best facilitate theinteraction. This could be someone whoalready has a relationship with theresident, a person with similar interests,or someone who is very passionate aboutimproving the quality of life for thisparticular resident. It does not have to bean activity staff member; it could beanyone at your nursing home.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14

I’d Rather Be Fishing

Activities are of little value if they arenot meeting the needs of the residents. Even the most exciting and creativeactivity loses its luster if the residentshave no interest in participating. Oneresident might want to play golf whileanother may just want to spend the day atthe local fishing hole or even watchingold movies. Remember, what oneresident finds enjoyable another mightfind miserable. Care must be taken toensure that residents are not forced toparticipate in or disturbed by activitiesthey do not enjoy.

Case Study: Living to the Music Mary never responded to anything goingon around her. She just sat lookingblankly out the window of her room. Staff members always brought Mary outto the living room for group activities,but she was never engaged. She just satthere, in her own world, waiting for timeto pass. No one had ever heard Maryspeak.

One day Mary was still in the livingroom when another resident’sgranddaughter began to play an oldhymn on the piano. Out of nowhereMary came to life and began to singalong. She knew all of the words andnever missed a beat. She even moved herbody with the rhythm of the music.

The activity director (AD) decided thatMary would be a wonderful candidatefor music therapy. She pulled out all ofthe educational materials she had on thesubject. One piece suggested playingmusic frequently around the resident tokeep him or her engaged. The ADbrought a radio into Mary’s room andturned iton. Marysmiled assheswayed tothe music.

15

There was one problem...Mary’s suitemate Ida had never liked music. Shealways thought of it as noise. Having the

radio playing in theroom was sodistracting that shecould not evenconcentrate on herscrapbooking. Idawas glad to see Marycoming out of hershell but hated thather quiet retreat hadturned noisy.

List a few options the AD has for makingsure both residents are able to enjoy theirleisure time and their private space.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

When the individual needs of two ormore residents are conflicting, how couldyou negotiate a positive outcome for all?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16

Why Are Activities SoImportant?

Older adults engaged in meaningfulactivities are more likely to haveincreased socialization, higher self-esteem and improved health outcomes(Clark-McGarth, 2004). The Kaneresearch shown at the beginning of thismodule points to the power of activitiesin improving quality of life.

Activity Theory

The activity theory of aging is based onthe idea that activity is the essence of lifeno matter a person’s age. The theoryalso suggests any activity or role aperson is forced or chooses to give upshould be replaced with a new activity orrole. This is where relationships comeinto play. Staff need to know residentsin order to know what they have given upor lost. Without this knowledge staffcannot help the residents discover newactivities or modify their current orformer activities. When people stayactive they are “more likely to have apositive self image, social integration,and satisfaction with life” (Hilliar andBarrow, 1999).

Case Study: Finding New MeaningPrior to his accident Sam was a fireman. He spent his time away from work caringfor his two children and playing softballin a league with a group of friends. Samwas very involved in church and thelocal community.

He never missed an opportunity toconnect withothers. Sam wasin charge of thecity recreationcommittee andcoached soccerand softball. Sam spokefrequently with

local school children about fire safety. He was an avid fisherman and liked tocheer on his alma mater as president ofthe alumni chapter. Sam always had alarge garden and took great pleasure insharing the fruits of his labor with hisfriends and neighbors.

Now Sam spends his days in awheelchair and has to have assistancewith all of his ADLs. Sam is paralyzedfrom the neck down. Each day hebecomes more angry and is withdrawingfrom his family and friends.

Discuss theroles thatSam hasbeenforced togive up (ex.fireman). ______________________________________________________________________________________________________________________________________________________________________________________________________

17

What roles does Sam still have that havehad to be modified (ex. father)?_____________________________________________________________________________________________________________________________________________________________________

Using what you know about Sam,modify his former roles or think of somenew roles and activities for him. Listthem here. _____________________________________________________________________________________________________________________________________________________________________

Adult Development Stage Theory

Activities are designed to be therapeuticin outcome. They can also serve as avehicle for continuing development. Many of the activities discussed later inthis module are integral parts of theadult development stages identified byErik Erickson (1963). In his humandevelopment stage theory, he referencedtwo stages that take place in adulthood. The first is generativity v. stagnation. Inthis stage, adults are looking foropportunities to care for others and givesomething back to their society. If thisstage is not properly satisfied, the adultwill feel like he or she has notaccomplished anything and will not beable to successfully move on to the nextstage.

In the final developmental stage, ego

integrity v. despair, the elders will bereflecting on their lives and trying to

accept what was. If theyare not able to reacha point of fulfillmentwith their lives, theyexperience regret

and discontentment. This will causemany to becomefearful of theirown deathbecause they are

not ready. By ensuring that theindividual’s activity program is meetinghis or her needs the staff can help themto progress through the final stages ofdevelopment.

Motivations for Activity Motivations for older adults to beactively engaged include: offsettingmonotony and boredom, developingsocial interaction and a sense ofbelonging, engaging inphysical activity for healthbenefits, achieving personalenjoyment and satisfaction,and expressing creativityand talents (Clark-McGarth, 2004). Thesemotivations may not beeffective if the opportunitiesto satisfy them are notavailable. The role of anactivity professional becomesmuch more complicated whentrying to determine appropriateopportunities for each resident.

18

Individualizing activity programs is notonly necessary to ensure residents areengaged in activities they enjoy, but it isalso useful in establishing andmaintaining resident autonomy. Leisureexperiences where elders exercise choiceand discretion, over time, build thefeelings of personal control intopersonality (Coleman and Iso-Ahola,1993). “Activities that induce higherlevels of perceived freedom and intrinsicmotivation are more likely to help peoplemaintain a sense of internal control”(Coleman and Iso-Ahola, 1993 p. 13).

Types of Activities

There are numerous activities to considerfor elders. The following pages are adescription of the main activity types,some research on their effects, and a fewideas from other nursing homes abouthow to implement them. While eachtype is important, it is necessary to havea variety, so elders have a well-roundedactivity experience. Wang, Karp,Winblad, and Fratiglioni (2002) suggestliving a stimulating life that includeseducational, creative, and interactiveopportunities may provide protective

benefits against the development ofdementia. For some residents, one typemay be more important than another.Many activities will contain elements ofseveral different types of activities. Thismakes it possible to provide manyoptions for each type.

Physical

It is possible that many people withmobility issues living in nursing homesare there because of the cultural andsocial expectations about what it meansto age. One of the most powerful ofthese expectations is that as persons agethey will lose physical abilities needed tobe functional. In truth, while declinesare normal and inevitable, loss to thepoint of disability is not.

In the early 1990's a study was conductedin a nursing home with nine residentsover the age of 90 (Fiataronne, et al.,1990). For eight weeks the participantsexercised leg muscles with heavyweights. At the end ofthe study, leg strengthhad increased by anaverage of 173%. Perhaps moresignificantly, functionalability improved to thepoint that two menstopped using walkingaides and anotherfound himself able toget up and go to thebathroom unaided.

19

Photo Courtesy of Asbury Park.

The results of this study prove not only that lost leg strength can be recoveredbut that some of it should not have beenlost in the first place. It validated anearlier researcher’s claim that loss ofstrength was not due to overuse but todisuse (Bortz, 1982).

Improvements in strength are notthe only valued outcomes fromphysical activity for olderpeople. Many studies have been

conducted that show reduction inthe following (Haber, 2003):*Heart disease*Diabetes *High blood pressure*Colon cancer*Depression*Anxiety*Excess weight*Falling*Bone thinning*Muscle wasting*Joint pain*Incontinence

Greater results will be seen with greaterinput, but any physical activity will havebenefits. Few nursing homes haveimplemented weight training programs. Those who have, have seen tremendousresults.

Asbury Park in Newton, Kansas utilizesNautilus equipment in the Freedomthrough Functionality program. Residents work with trainedrehabilitation and therapy staff on avariety of machines. Residents have

seen improvement in strength,coordination, and stability which leads tomore independence. Since the beginningof the program in 2001, the number ofparticipants has doubled. There aremany success stories from the program. One of the most powerful is a gentlemanwho came into Asbury Park wheelchair-bound and took part in the Freedomthrough Functionality program, alongwith other multi-disciplinaryinterventions. He went back homewalking without assistance. One residenthas a friendly competition with her sonto see who is lifting more weight. Otherresidents have maxed out on themachines. Staff members and residents atAsbury Park are thrilled with theprogram’s results.

Another way to help maintain theresidents’ functional ability is to hiremore aides who have restorative trainingor pay for the training of existing aides.

20

Photo courtesy of Village Manor.

Building physical activity into aresident’s daily life is a goal of therestorative program.

Additional information about physicalactivity will be included in a latermodule.

! Residents at Village Manor inAbilene, Kansas can be foundplaying noodle ball on a regularbasis. For this game, residents aregiven a swimming pool noodle cut inhalf. A balloon is tossed into thecircle, and residents swing thenoodles to hit the balloon around inthe circle. Multiple balloons can beplayed at once, but residents saythat’s when it gets wild. Residentsalso caution that balloons pop andsome people scream! Many said theyhave so much fun they forget theyare exercising.

! Life Care Center of Seneca, Kansashas a chair aerobics class twice aweek. Residents can be seen kickingup their feet and breaking a sweatalongside members of the localcommunity. The combination ofphysical activity and interaction withthe community makes chair aerobicsa fun event for all. This class is ledby a local volunteer who is anexercise physiologist. Word ofmouth has grown the group to about35 participants at each class. Someresidents at Life Care Center like theexercise; others join in just to visitand watch.

Social

It has been said thatrelationships makelife worth living. In order to fosterrelationships,outlets forsocialization mustbe provided. Social support inan elders’environments is beneficial to theiroverall health because social interactioncan be used to process negative eventsexperienced (Tremethick, 1997). Eldersmay be experiencing many losses andhaving outlets to connect with others cancompensate for these losses. Givingelders an environment rich insocialization not only fosters newrelationships but also nurtures existingones.

21

Just because an elder is in the nursinghome surrounded by other residents andstaff does not mean that he or she is notfeeling isolated and lonely. In order toovercome the sense of loneliness, Weiss(1974) suggests that relationshipsare needed to provideattachment, socialintegration, opportunity fornurturance and reassuranceof worth. Social activitydoes not have to be partiesor large group gatherings. Simply setting up time and quiet placesfor individuals to visit or make a phonecall to an old friend provides needed andbeneficial social contacts.

! Meadowlark Hills in Manhattan,Kansas hosts wine and cheeseparties every Friday. These mixersgive residents the opportunity tosample fine wine and cheese as wellas catch up with friends. To keepthe event fresh they change the menuby adding Mexican food andmargaritas, beer and hot dogs, Italianfood and red wine, or fresh fruit anddaiquiris. No matter what the menu,they enjoy an afternoon of food, fun,and friends. This activity sets up awonderful environment for residents

to socialize. Family andfriends are invited to join in

the fun. Meadowlark alsobelieves they have some

residents who keep theirweight up due to this

event.

! At Medicalodge in Wichita, Kansasseveral ladies are members of the RedHat Society. The ladies meet on aregular basis to enjoy the friendship

and fun that goesalong with thegroup. The group

has many socialactivities including

teas, dinners out, andhosting events at the facility.

The group has even enjoyed atrip to the dog tracks. Several othernursing homes also have Red HatSocieties, and all report that residentsbenefit from the comradery that existswithin the groups.

! The men at Medicalodge in Wichita,Kansas are not left out. They have agroup that meets weekly to watchsports on TV. They watch any typethey can find and pig out on “sports”foods. No matter whose team wins orloses everyone enjoys the malebonding. The evenings get wildwhen Wichita State University isplaying!

Intellectual

It has been said that you cannot teach anold dog new tricks; so, why botherproviding intellectual stimulation toresidents? The truth is elders are stillvery capable of learningand want to exercisetheir brains. As thebrain ages, declinesare seen in how

22

quickly an individual can processinformation, and there is a reduction inexplicit memory. This type of memoryinvolves the “intention to remember, andthe subsequent ability to recall a specificname, number, or location on demand”(Rowe & Kahn, 1998, p. 131). This doesnot mean that the older brain cannotlearn. It instead means that in order toteach elders new things, the way theteaching is done needs to be modified.According to Successful Aging (Rowe &Kahn 1998), older adults need a differenttype of environment for learning. Theyneed to work at their own pace, have achance to practice new skills, and nothave to keep up with younger people toallow them to avoid embarrassment. While intellectual stimulation for somemay involve learning somethingcompletely new, for others it may beabout keeping the knowledge theyalready have. It has been said that aperson must use it or lose it. This seemsto be true when it comes to the humanbrain.

! The FFA is going strong atSchowalter Villa in Hesston, Kansas. Since many residents are “FormerFarmers of America” a group wasformed to keep members in the loopwith farming. They meet regularly toenjoy a van tour to observe theharvest, evaluate the crops, visitfarming operations or learn fromspeakers like the director of theKansas State University ResearchFarm located near Schowalter Villa. Local farmers come visit and share

information about theirfarming operations and

educate themembers aboutnewtechnology andproducts.There have

been manyadvances infarming, but

any oldfarmer will tellyou, “Once afarmer, always

a farmer!”

! Meadowlark Hills in Manhattan,Kansas is home to a Kansas StateUniversity class in adultdevelopment. Residents enrolled inthe course work side by side studentsto learn the theories of aging, dispelmyths and stereotypes, andengage in livelydiscussions! Itgives studentstheopportunityto learnfrom thosewho haveexperiencewith laterlife and givesthe elder anopportunity to share their wisdom.

23

Spiritual

When reading about spirituality, one maythink immediately of religion. Whilereligion is a component of spiritualitythere is more to it. Spirituality is definedas “personal views and behaviors thatexpress a sense of relatedness to atranscendent dimension or to somethinggreater than the self” (Reed 1992, p.339). Many individuals express theirspirituality through organized orindividualized religious activities. Astudy by Touhy (2001) found thatspirituality in institutionalized elderly was the only factor that predicted hope. In order for residents to live with a highlevel of wellness and wholeness, it isnecessary to provide support for thespiritual dimension of each person(Leetun, 1996). Spiritual needs ofindividuals may include the need to giveand receive love, have a meaning orpurpose for life, hope for tomorrow andpersonal reflection. “There may be nogreater goal of caring for elders thanhelping the person see a life well livedand meaningful to themselves and others,thus providing hope that life’s journeywas not in vain” (Touhy, 2001, p. 14).

People will nurture their spirit in avariety of ways. For some a visit with a

friend or a quiet momentto watch the birds will

providerejuvenationwhileothers maywant toreminisce

or become involved in a cause. It hasbeen suggested that intergenerationalactivities, pet therapy, and horticulturetherapy (which we will explore later inthis module) may be options fornurturing the human spirit because theygive residents something to care for anda sense of being needed (Touhy, 2001).No matter how residents choose tonurture their spirit, they must be giventhe autonomy to do so in the manner theydeem most valuable.

Most nursing homes offer religiousactivities andshouldcontinue toprovidetheseservices. Touhy (2001)found thatattending thenursing homechurch serviceswas important to many. Participants didnote they had trouble seeing the servicematerials. Since many residents havevision or hearing impairments, religiousservices should offer large print readingand music materials, and speakers needto be loud enough for all to enjoy.

For many years, reminiscence has beenwidely used as an activity in nursinghomes. Residents typically sit in a circle,and a topic is given to begin thediscussion. While this activity does havemerit, some residents may not feelcomfortable sharing their experiences

24

Photos courtesy of Stephanie Gfeller

with others or may wish to focus onsomething entirely different than thegroup. For many elders, this is the timein their lives when they may need towork through unfinished business withself, family, and/or friends. Providingopportunities for one on one interaction,

quiet personaltime, orspontaneoussharing may bemore beneficialthan setting upspecific timesfor groupreminiscence.

Many activitydirectors arenow working

to incorporatethis reflection into

all activity instead of having it standalone.

! Residents at Medicalodge Post AcuteCare Center in Kansas City, Kansasenjoy activities that nurture the mind,body and soul. They have access tomassage therapists daily and canenjoy a weekly Tai-Chi experience. Tai-Chi is an ancient Chinesediscipline currently used for thetherapeutic benefits of reducingstress, promoting balance andflexibility as well as helping to easearthritis pain. Every Monday,residents gather for Al’s Tai-Chi classto integrate their mind, body andspirit. Residents are led throughslow, rhythmic motions with a focus

on breathing to connect them with theirenergy within. In addition to a workoutthe class offers reflection, intellectualstimulation and some good laughs. Somein the group are even learning to speak alittle Chinese. When an elder in the classwas asked what she enjoys most aboutTai-Chi, she enthusiastically replied,“Everything!”

25

“Creativity is important throughoutone’s whole life. If you’re creative,you’re able to approach problems thatarise with greater success and, as aresult, will be happier.”

-61 year old study participant(Fisher and Specht, 1999)

Creative

Fisher and Specht (1999) conducted astudy of 36 elders who were

involved with artwork. The study comparedthe responses of the

participants withpublished literature on

creativity’s impact onsuccessful aging. The study

found the elders did feel therewas a strong connection

between being creativeand aging successfully

just as previous researchnoted. The study participants explainedthe link through interview responses. Their responses noted the ability to cope,keeping active or staying involved, andpersonal growth as the main reasons forthe correlation between successful agingand creativity. By giving residents theopportunity to continue nourishing theircreativity, successful aging is fostered.

Creativity is often discussed as “big C”and “little c”. The “big C” is the type ofcreativity that has an effect on a greatnumber of people like a society or

culture. An example of this would be thecreation of television. This

changed the waythe entireworldreceivesinformation. The othercategory,“little c,” isthe type ofcreativity

that affectsindividuals on a smaller scale (Cohen,2001). This effect could be experiencedby an individual or a small group. Olderadults are typically working in “little c.” Many people do not think that they arecreative because they see creativity asproducing major works of art or solvingproblems on a global scale. They shouldbe made aware that if it has an impact onthem personally or anyone else it iscreative.

When creative activities are mentionedthe first thing that comes to mind is craftprojects. Most of the crafts are probablykits that the residents put together. While craft projects can be a creativeactivity, Barrett (1993, p. 134) cautions,“Crafts in this sense are merely exercisesin technique and production rather thanart experiences which result in workexpressive of the individual.”

Nursing homes need to provideopportunities that truly allow residents totap into their creativity. There are manyother creative outlets to explore such as

26

music, dancing, photography, writing,drama, textiles, painting, cooking,gardening, and drawing. Checking with the localarts council or group is awonderful way to findout what creativeactivities and talents areavailable in thecommunity. Many artistsare willing to teach classes or leaddiscussion groups.

While some residents will enjoy activeparticipation in these activities, it isimportant to remember that creativity canalso be tapped through the enjoyment ofthe work of others. Also, the types ofcreative endeavors listed above focus onthe artistic side of creativity,but there are forms ofcreativity that are notartistic in nature likeproblem solving, self-exploration, andbrainstorming. Withcreativity there does nothave to be a productexcept the experience itself.

! At Montgomery Place in Chicago,each month residents read andproduce a different play. A residentchooses the play, sets up casting calls,casts roles and is in charge ofrehearsals. When the play is readythe activity staff advertises the show.Residents, family and friends come tosee the performance. One show led topuppet making and an idea to do

puppet shows for children (Hoban,2003). While some residents might enjoybeing in the spotlight as actors, othersmay prefer to help with show preparationor just enjoy an afternoon of theater.

! At Larksfield Place in Wichita,Kansas everyone looks forward to theFall Fashion show. Working with alocal boutique, residents choose anoutfit from the latest fashions. Theresidents then strut their stuff on therunway during a fashion show forother residents and family members. Many use this as an opportunity tosee what is new and add pieces totheir wardrobe.

! In conjunction with KAHSA’s Art ofthe Ages program many nursinghomes in the state have begunoffering art classes for residents. These include: a clay pot makingclass at Fort Scott PresbyterianVillage in Fort Scott, Kansas, an oilpainting class at Village Manor inAbilene, Kansas, and a weeklywatercolor painting class at NewtonManor in Newton, Kansas (KAHSAFocus, 2006).

Community

Many elders have been very involved inthe community prior to entering a nursing home. Just because individualsare in a nursing home does not mean thatthey lose their desire to be involved. Erickson’s (1963) stage of generativityinvolves giving back to the community.

27

Creating opportunities for residents tomaintain connections and obligations tocommunity groups ensures that they havea positive well-being. According toRowe & Kahn (1998), the frequency ofattending organization meetings is one ofthe two strongest predictors of well-being. The other is the frequency ofvisits by friends.

! The Cedars in McPhearson, Kansashosted a fall festivalfor the communityto enjoy. Communitymembers showedup, many incostume, ready fortrick-or-treating,bobbing for apples,hayrack rides, pumpkin carving, andfood. The event focused on having funwhile teaching parents and children alittle more about safety. The policedepartment presented Stranger Danger. The Red Cross was on hand to giveparents literature on childsafety. The McPhersonSaddle Club joined in thefun by givinghorseback rides andteaching thechildren animalsafety. According tostaff at The Cedars theevent was such a successthat they are planning to doit again.

! At Schowalter Villa in Hesston,

Kansas the Wellness Center is a vital partof the community. Everyone benefitsfrom the center including residents, staff,community members and HesstonCommunity College students. TheWellness Center focuses on communityhealth and works with otherorganizations in the community toprovide wellness programs, exerciseclasses, physical therapy, massages, artclasses and special events. Thoseutilizing the center enjoy its amenitiesincluding a swimming pool, exerciserooms, jacuzzi, pool tables, indoor andoutdoor walking paths, library and more.The Wellness Center serves to link thoseliving at Schowalter Villa with the rest ofthe community.

28

Ideas by Type Activity:Now that you are familiar with the different activity types take a moment to think of oneresident. Using the space below and thinking of that elder, brainstorm activity ideas foreach type. The activities could be done individually or in a group. While many of youractivities will overlap into multiple categories, please think of a different activity for eachcategory.

Physical Activity: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Social Activity:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Intellectual Activity:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Spiritual Activity:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Creative Activity:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

29

Activity: Noodle BallType: PhysicalNumber of participants: 5 plus (can make multiple circles if necessary)Supplies: 1 noodle per person, balloonsSet up: Participants need to be in a circle.Time necessary: About 30 minutesParticipants: AnyoneOutcomes: Physical exercise, hand eye coordination, conversation, funDirections: Form a circle of chairs for participants. Have those in wheelchairscome and join the circle. Hand out a noodle to each person. Toss a balloon intothe air. Participants will swing their noodle and hit the balloon. The facilitatorwill have to be ready to run and grab balloons that are hit out of the circle. Add ons: 1. Include music in the background and have participants hit the balloon to thebeat of the music. 2. Have more than one balloon going at a time.3. Have participants hit the balloon to a specific person.

Community Activity:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

One way to use this information is to develop a set of file cards, like the one below, thatcould be filed under each of the categories. The cards could list the activity, theequipment or materials required for the activity, whether it should be performed as agroup or individual activity, the amount of time necessary, the procedure, and theexpected outcomes. With such a system, volunteers and other staff could provideactivities for residents and make the activity professional’s role more of a resourceperson. This would also free time for the activity staff to focus on relationship buildingand individual activities.

30

The Role of the ActivityDirector

While it is still necessary (and important)to have a certified activity professional,various individuals including activitystaff will be facilitating activities in aculture change home, so the role of theactivity director will change. Theactivity staff will play a vital role toensure that residents’ history andpreferences are known and utilized incare planning. The activity person willalso become a teacher for other staffmembers. The individualized care planswill be much more useful than cookiecutter plans. They will also need tomonitor the resident activity plans tomake sure that the appropriateadaptations are made for residents’ needsand abilities.

Activity staff will still be engaged withthe elders in activity, but with the newformat they will have more hands to helpout. Many people are employed bynursing homes to care for the physicalneeds of the elders. Fewer are therespecifically to provide for the social,emotional, and spiritual needs. Onceactivity programs are individualized andthe activity director becomes a resourceperson, the number of staff able toprovide for all of the needs of residentsincreases dramatically. Everyone willreap the benefits.

Activities in a culture change nursinghome will take many forms; they couldpossibly even include household chores

like dusting and laundry. It is necessaryfor the activities taking place to bedocumented.

Individuals other than activityprofessionals who will be involved inactivities need to be trained to locate andread individual activity plans, implementactivities, assess residents and activities,fulfill activity requirements and provideinformation that is needed fordocumentation. One way for activityprofessionals to gather informationabout activities facilitated byother staff or volunteersmight be to put a notepadin the residents’ rooms. Each time a caregiver orvolunteer engages a residentin an activity they could jotdown a quick note to let the activity staffknow all of the necessary informationlike a description of the activity, it’sduration and the resident’s level ofparticipation. The notebook could evencontain a blank copy of the activity log. Activity staff could then use thenotebook to transfer information to theirlogs. Another option would be to includea detailed activity log sheet in the chart,so staff members could chart activityalong with the other information.

Regulations and Activity

How is this new style of activitiesaffected by regulations? The type ofactivity program described in thismodule goes hand-in-hand withregulatory requirements. Regulations

31

state the “facility must provide for anongoing program of activities designedto meet, in accordance with thecomprehensive assessment, the interestand the physical, mental, andpsychosocial well-being of eachresident”( CMS, 2006, p. 2). The key tomeeting activity regulations is having theprogram center around the preferencesand choices of each resident.

Regulation requires that the activityprograms of residents be individualizedbased on resident interests and needsidentified in a comprehensive assessment(CMS, 2006). Regulations also requirethat the preferences of theresident, necessaryadaptations, the goalsand the time tablesfor activity aredocumented inthe resident careplan. Bowman (2005) notesthat goals are typically based on thenumber of activities a person shouldattend because it is easily measurable.“The time has come, however, for us tomake more meaningful goals and focuson a person’s highest practicable level ofwell-being” (Bowman, 2005, p.16).

Regulations specify that providingactivities is the role of the entire facilitynot just the activity department. Thismeans that activities can be led by otherstaff members, family members, andvolunteers as well as activity staff. Byproviding activity led by other persons,the facility, as a whole, is following

guidelines and working towardimprovement in resident quality of life.For the entire staff to take part inactivities, the entire staff must know theresidents well. The only way to providemeaningful, individualized activity thatproduces desired outcomes is to know aperson’s expectations and what ismeaningful to him/her.

What about documentation? With avariety of staff members leadingactivities it is necessary to offer training,so all staff members know the home’ssystem for documenting activities. Sinceregulations do not require a certain typeof documentation, staff can create asystem that works best for the home oreach resident. A few things to consider when training staff members include thefollowing:

! Routine ADL activities cannot becounted as an activity

unlessexpanded intosomethinggreater (CMS,

2006). For example,the act of combing a

resident’s hair on itsown is not an activity, but

by combing and doing a beauty shop-type style of the hair it is an activitythat is documentable.

! Activities do not have to last a certainlength of time in order to bedocumented. Guidance to surveyorson the activity regulations suggests

32

“activities be based on attentionspan”(CMS, 2006 p.7).

! Residents should be engaged in theactivity. Sleeping during anyactivity, even if it is typically enjoyedby the resident is not being engaged,and, therefore, at that point in timethe activity is not providingmeaningful activity to the resident.

What are surveyors looking for whenthey review the activity program? CMS (2006) offers the following todetermine compliance in the activitydepartment: ! Surveyors will look at the assessment

of a resident and the plan of care andobserve the activity taking place. Surveyors will be checking to see ifthe assessment of the resident isdetailed enough to provide a truepicture of the resident’s needs andpreferences. The plan of care shouldreflect the knowledge of the residentgathered on the assessment. The planshould state types of activities theresident enjoys, offer goals forparticipation in preferred activities,detail approaches (ex. How willresident get to activity?), documentparticipation, and be revised asnecessary.

! Surveyors will also interview aresident and possibly his/her familymembers to determine if the residentfeels like his/her needs are being met.Surveyors will also interview staff

members to see how well the residentand his/her preferences and needs areknown. The staff interview is used todetermine the level of involvementstaff has with activities.

A new Guidance toSurveyors has recentlybeen released. Thisdocument contains awealth of information onthe interpretation of activityregulations, information onhow to be compliant, andinterventions for residents thatneed adaptations or haveimpairments. This can be accessed as atext document from the Centers forMedicare and Medicaid website atwww.cms.hhs.gov, or CMS has ainternet streaming webcast titled NursingHome Journal Volume III: Surveying theActivities Requirements- Introduction ofNew Activities Guidelines available atwww.cms.internetstreaming.com. Case Study: Meeting NeedsIn his get-to-know interview James tellsstaff members he likes to spend timereading, fishing, and playing cards. James also enjoys woodworking. Hetells the staff members he has neverreally felt comfortable in groupactivities. While reading through hisplan of care, the surveyor notices theplan shows James will attend preferredsubject activities, like book club, woodshop and the fishing trip, but all aregroup activities. During the interviewphase of survey, she questions Jamesabout the type of activities in which he

33

participates. He tells her that while thegroup activities are related to things heenjoys, he is uncomfortable in the groupsand wishes he could have time to engagein the same type of activities either by himself or with just a few friends.

Is the facility in compliance withregulations?_____________________________________________________________________________________________________________________________________________________________________

Identify the areas where the home iscompliant._____________________________________________________________________________________________________________________________________________________________________

Now, identify the areas where the homein non-compliant. ____________________________________________________________________________________________________________________________________________________________

While the home has identified hispreferences for types of activity andincorporated them into the care plan, thepreferred group size has beenoverlooked; therefore, the home is notmeeting James’s activity needs.Residents can and should be given timeto pursue individual activities or havealone time for reflection if they so desire. Some activities, like cards, seem best

done in a group format, butopportunities for individual orvery small group gamescan be found. In theassessment of James,staff shouldhave askedwhat typeof card gamesJames likes toplay.

Keeping Their Favorites Going

As people age they may begin to losesome of their abilities. When certainabilities are lost it can make engaging inonce-loved activities very difficult. TheSelective Optimization withCompensation (SOC) model explains thecompensation necessary for elders tocontinue with an activity they enjoy(Baltes &Baltes, 1990). The selectioncomponent of the model suggests thatelders choose a few activities that are ofthe most importance to them. They mayreduce participation in other activities orgive them up completely. Compensationrequires the elder to look at how theyperform a task and identify adaptationsthat could be of assistance. The third andfinal part of the model is optimization. This is focusing on the strengths theystill possess. The nursing homeenvironment should be set up to facilitateactivity even when adaptations areneeded. Working through the SOC modelwould be an effective way to findactivities the residents consider mostmeaningful and explore the ways they

34

are still able to be successful at the task.

Case StudyMary had always loved to sew, knit andcrochet. She hadrecentlygiven themup and feltvery empty as she sat towatch TV in the evening. While brushingMary’s hair one evening Betty, hercaregiver, asked why she did not makeanything anymore. Mary replied that shewas no longer able do those things. Bettywanted to find a way to get Mary busyworking on her handy work again. Shebegan by asking Mary which was herfavorite. Mary replied that she hadalways had a fondness for crochetingbecause her grandmother taught her, andshe really liked making afghans to giveto friends and family.

As they were visiting about crocheting,Mary mentioned that she had trouble

getting her fingers to bend to dosome of the stitches. She also had troublefinding the edges ofthe strips to connectthem. Betty alsoenjoyed crochetingand asked whatstitches were hardto do. Mary toldher, and theybegan to discuss

the stitches that were not difficult. Marylisted several stitches she was still verygood at doing. Betty pointed out that

Mary could make an afghan using onlythe stitches she did well.

Since Mary had trouble seeing the edgesto connect the pieces Betty visited withMary about what colors she did see well. They decided that Mary should make theafghan using two verycontrasting colors. This wayshe would be able to find theedges of the strips andconnect them. Betty toldMary that she would get alarger crochet hook forher to begin using. Theyalso talked about thetypes of exercises Mary tocould do to improve her dexterity.

What was the selection component forMary’s activities?______________________________________________________________________________________________________________________________________________________________________________________________________

How did Betty help Mary optimize heractivity?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What compensations will Mary make tohelp her continue her activities?_________________________________

35

_____________________________________________________________________________________________________________________________________________________________________

Betty helped Mary think about heractivities and choose the craft sheenjoyed most as the selection component. By pointing out that the activity could becompleted using what Mary can still do,Betty helped Mary to optimize heractivity. By looking at solutions such asusing contrasting colors and doingdexterity exercisesto help Marycontinuecrocheting,Betty andMary used thecompensationcomponent ofthe SOC model.

SOC Activity

In this activity you will rewrite theactivity portion of a care plan usingSOC. Identify a resident who wouldbenefit from SOC. Working with theelder and his/her family, determinevarious activities the elder would like tocontinue. Now use the SOC method toidentify those activities of mostimportance, create adaptations andidentify the elder’s strengths. Place thisinformation in the elder’s care plan so allcaregivers have access.

Learning about the past and current

hobbies, jobs, and preferences of eldershas been discussed, now it is important tolook at creating new ones. Residents willneed encouragement, support, andtraining as they explore new hobbies. The level and type of support each elderneeds will depend on the day and theactivity.