What do nursing home residents do? Exploring residents’ engagement in activities

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Content 1
Running Head: Exploring Residents’ Engagement in Activities

What Do Nursing Home Residents Do? Exploring Residents’ Engagement in Activities

By
Carin Wong

Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
Doctor of Philosophy (OCCUPATIONAL SCIENCE)
May 2019
Exploring Residents’ Engagement in Activities 2

Table of Contents
Abstract ........................................................................................................................................... 4
Chapter 1: Introduction ................................................................................................................... 6
Overview ..................................................................................................................................... 6
Significance ................................................................................................................................. 7
Overview of Chapters.................................................................................................................. 8
Chapter 2: Background ................................................................................................................. 10
Literature Review ...................................................................................................................... 10
Nursing Home Quality of Life Policy ....................................................................................... 10
Nursing Home Quality .............................................................................................................. 11
Activity Engagement and Health .............................................................................................. 15
Nursing Home Activity-based Interventions............................................................................. 17
Activity engagement for residents with dementia ................................................................. 18
Activity engagement for the broader resident community—those without dementia ........... 19
Theoretical Approach ................................................................................................................ 21
Occupation and health ........................................................................................................... 21
Social Ecological Model ........................................................................................................ 23
Methods: Overview ................................................................................................................... 26
Chapter 3: Manuscript #1.............................................................................................................. 28
Abstract ..................................................................................................................................... 28
Methods ..................................................................................................................................... 30
Results ....................................................................................................................................... 36
Discussion ................................................................................................................................. 46
Conclusion ................................................................................................................................. 48

Exploring Residents’ Engagement in Activities 3

Chapter 4: Manuscript #2.............................................................................................................. 50
Abstract ..................................................................................................................................... 50
Design and Methods .................................................................................................................. 52
Results ....................................................................................................................................... 55
Discussion ................................................................................................................................. 65
Conclusion ................................................................................................................................. 67
Chapter 5: Manuscript #3.............................................................................................................. 68
Abstract ..................................................................................................................................... 68
Methods ..................................................................................................................................... 70
Results ....................................................................................................................................... 75
Discussion ................................................................................................................................. 83
Conclusion ................................................................................................................................. 86
Chapter 6: Conclusion................................................................................................................... 87
Summary of Key Findings ........................................................................................................ 87
Theory Approaches Guiding Results ........................................................................................ 88
Social Ecological Model ........................................................................................................ 89
Implications and Future Research ............................................................................................. 90
Appendix A. Resident Interview Guide ...................................................................................... 108
Appendix B. Staff Interview Guide ............................................................................................ 109

Exploring Residents’ Engagement in Activities 4

Abstract
Long-term nursing home residents often lack activity engagement. For a population that
is already frail, inactivity may result in further physical and cognitive decline. In an effort to
mitigate functional decline and optimize quality of life, nursing homes are federally mandated to
provide activities to residents. Despite the requirement for facilities to provide activity programs,
little is known about the structure, development, and delivery of these sessions. Thus, this
dissertation aimed to understand the current practice of engaging nursing home residents in
activities.
The first manuscript, intended to evaluate the scope and depth of activity sessions within
a nursing home context. By extracting data from facility activity calendars, we examined the
diversity of programming and the relationship with organizational-level characteristics.
Descriptive statistics were used to quantify the frequency of each type of activity provided.
Linear and logistic regression was also conducted to analyze an association between the
organizational characteristics and the types of activities identified on the calendar. There was no
statically significant relationship found between facility characteristics and activity types.
However, the descriptive statistics identified a broad range of activities delivered.
The second manuscript sought an in-depth understanding of how three purposely sampled
facilities executed activity programs. This qualitative study comprised of semi-structured
interviews with key nursing home stakeholders (i.e., administrators, activity providers, and
residents) and facility observations. Four major themes were identified: (a) the organizational
process that guide program development, (b) strategies for fostering engagement for newly
admitted residents, (c) facilitating engagement during activity sessions, and (d) optimizing
engagement outside of structured activity sessions.
Exploring Residents’ Engagement in Activities 5

The aim of the third manuscript was to compare and contrast approaches for delivering
activities in three purposively selected nursing homes to understand current practices to engaging
residents in activities. Qualitative data from interviews and observations were obtained,
compared, and contrasted across the three facilities. Types of activities were also quantified and
evaluated for differences across the nursing homes. The facilities varied in the delivery of
structured and unstructured activity programs, yet across facilities there were commonalities in
types of activities offered.
The cumulative findings of these three studies highlight the depth, breadth, and frequency
of current activities provided as well as the divergent strategies used to execute facility
programs. This scope of work addressed a gap in literature by providing an understanding of
current practice which can help inform nursing home staff with strategies for delivering activity
programming. Furthermore these findings can also be used to inform future policy efforts.
Enhancing resident’s quality of life through activity engagement has been integrated into policy
and practice however there is a need to deliver patient-centered programming.

Exploring Residents’ Engagement in Activities 6

Chapter 1: Introduction
Overview
Optimizing patient outcomes by improving the quality of nursing home care is a priority
in healthcare policy. As the population ages and the concern regarding rising costs and poor
health care quality are growing, there is an incentive to improve patient outcomes (Harris-
Kojetin et al., 2016). Enhancing the quality of nursing home care has been a high priority for
consumers, providers, and policy makers, which is reflected in a variety of national policy
initiatives over the last several decades (Castle & Ferguson, 2010; Werner & Konetzka, 2010).
For example, the passage of the 1987 Omnibus Budget Reconciliation Act (OBRA), which
included the Nursing Home Reform Act, mandated that all nursing homes focus on improving
the residents’ quality of life, which included providing activities that “…meet the interests and
the physical, mental, and psychosocial well-being of each resident,” (Omnibus Budget
Reconciliation Act, 1987). However, despite efforts to improve quality of care and residents’
quality of life, many nursing home residents are found to be inactive, bored, and depressed,
leading to a lower quality of life (Pruchno & Rose, 2002; Wood, Womack, & Hooper, 2009).
Conversely, residents who are engaged in activities have a higher quality of life, better physical
function, less depression, and greater overall well-being (Bo, Fontana, Mantelli, & Molaschi,
2006; Chen et al., 2008).
However, there is a paucity of research examining contemporary nursing home activity
programming. In this clinical context, research has primarily focused on residents with dementia.
There is a strong evidence-base evaluating successful activity-based interventions for residents
with dementia (Beck et al., 2002; Cohen-Mansfield, Dakheel-Ali, Jensen, Marx, & Thein, 2012;
Connell, Sanford, & Lewis, 2007). Yet, the nursing home residents without dementia are absent
Exploring Residents’ Engagement in Activities 7

from the activity-based intervention research. Moreover, in order to develop appropriate activity-
based interventions for all residents, this broader population needs to be included, and the current
state of activity engagement should be understood. Thus, the overall research objective of this
dissertation is to focus on understanding contemporary practices for activity engagement. The
specific aims of the dissertation study are:
• Aim 1: Characterize and evaluate the breadth, depth, and frequency of activity
programming and its relationship to organizational factors.
• Aim 2: Explore stakeholder perspectives on current activity engagement practices.
• Aim 3: Compare and contrast approaches for delivering activities in nursing homes to
understand current practices to engaging nursing home residents in activities.

Significance
While research on the effectiveness of activity-based interventions in nursing homes has
emerged, the majority of studies have focused on residents with dementia. Furthermore, in this
specific resident population, literature has also examined practices for developing and delivering
activity programming. However, little research has been conducted regarding activity practices
for the broader nursing home community—residents who do not have dementia. As a group that
makes up half of the nursing home population, it is important to understand their needs as well
and how these individuals are engaged in activities. This dissertation addressed the gap in
knowledge by examining the types of activities that are provided in nursing homes, how
activities are delivered, and the strategies and barriers to engaging residents.
Exploring Residents’ Engagement in Activities 8

In addition, this research took a unique approach in using mixed methods to explore
current practice in activity engagement. Previous research utilized either quantitative methods to
evaluate an activity-based intervention or used a qualitative approach to obtain perspectives from
residents with dementia and their family members (Tak, Kedia, Tongumpun, & Hong, 2015).
Furthermore, this line of inquiry compared traditional nursing home care to a Green House
nursing home, which uses a model of care focused on providing high quality care with the goal
of optimizing resident quality of life in a home-like environment (Cohen et al., 2016). Previous
research that evaluated Green House nursing homes to traditional nursing homes often compared
the two at a macro level, evaluating differences on staff satisfaction and patient outcomes. This
dissertation focused on comparing and contrasting activity engagement and the approaches to
program delivery. The findings of this study informed the knowledge gap of how activities are
provided for nursing homes residents when not designed specifically for residents with dementia.

Overview of Chapters
This dissertation is structured into six chapters. The subsequent chapters provide a review
of the literature, a chapter for each of the three respective studies, and a conclusion chapter.
Chapter three to five are structured as stand-alone manuscripts formatted for submission to an
academic journal. The first manuscript (chapter 3) presents results from obtaining activity
calendars and identifying relationships between activities and facility characteristics. This
manuscript will be submitted to the Activities, Aging, and Adaptation Journal. The second
manuscript (chapter 4) presents the results from qualitative interviews with key stakeholders on
their perspectives on activity engagement, which will be submitted to the Gerontologist. Finally,
the third manuscript (chapter 5) compares and contrasts three different approaches to providing
Exploring Residents’ Engagement in Activities 9

activities. The manuscript will be submitted to the Journal of Aging Studies. Chapter 6 provides
a summary of the findings from the dissertation and implications for future research, practice,
and policy.

Exploring Residents’ Engagement in Activities 10

Chapter 2: Background
Literature Review
The demand for long-term services and supports is expected to rise as the size of the
population above 65 increases from 40.2 million people in 2010 to 88.5 million in 2050 (Harris-
Kojetin, Sengupta, Park-Lee, & Valverde, 2013). Long-term services and supports (LTSS) are a
broad range of health, personal care, and supportive services for older adults who are limited in
their capacity to care for themselves (Harris-Kojetin et al., 2013; Harris-Kojetin et al., 2016).
The goal of LTSS is to support older adults in the least restrictive environment while maintaining
their physical functioning and quality of life (Harris-Kojetin et al., 2016). Nursing homes are one
location in which LTSS can be provided. Toward this end, with the aging of the US population,
the utilization of nursing homes is expected to increase from 15 million people in 2000 to 27
million in 2050 (Harris-Kojetin et al., 2016). The resident population of a nursing home is often
diverse in demographics as well as physical and cognitive abilities (Harris-Kojetin et al., 2013).
For example, residents with a diagnosis of dementia, physical disabilities, other cognitive
impairments, or a combination of multiple diagnoses (Harris-Kojetin et al., 2013; Harris-Kojetin
et al., 2016). With such a diverse nursing home population, each individual’s care needs are
different.

Nursing Home Quality of Life Policy
Enhancing nursing home care quality and resident quality of life has been a high priority
for consumers, providers, and policy makers, which is reflected in a variety of national policy
initiatives over the last several decades (Castle & Ferguson, 2010; Werner & Konetzka, 2010).
For example, in response to widespread reports of abuse and neglect in nursing homes during the
Exploring Residents’ Engagement in Activities 11

1980s, the Institute of Medicine (now known as the National Academy of Medicine) conducted a
formal investigation into poor nursing home care (Institute of Medicine, 1986). The resulting
recommendation was to reform nursing home regulation by amending facility requirements due
to the concern over the quality of care and resident quality of life.
In order to improve quality, federal government regulations (i.e., Omnibus Budget
Reconciliation Act of 1987) were developed to target this major issue. Through this legislation,
recommendations included revisions in the nursing home performance criteria and standards,
modifications to the survey process, enforcement of policies and procedures, and implementation
of processes to standardize data on residents. Additionally, the legislation mandated that all
nursing home residents have a comprehensive assessment completed, which included evaluating
functional and cognitive levels. The legislation also called for outcome oriented quality
indicators to be developed, such as those that evaluated resident behavior, functional status,
cognitive status, and overall health condition. This led to the development of the Minimum Data
Set (MDS), a uniform residential assessment instrument mandated in all nursing homes receiving
Medicare payment to be completed for each resident (Rahman & Applebaum, 2009). In addition
to clearly delineating regulatory standards, the Nursing Home Reform Act aimed to establish
quality standards in order to improve overall nursing home care quality. As a result, this
legislation laid the foundation for improving overall nursing home quality of care.

Nursing Home Quality
Since the 1986 IOM report that led to the passage of the Nursing Home Reform Act, the
monitoring and evaluating of nursing home quality has been a high priority area. Within nursing
homes, efforts to improve patient outcomes and quality of care are reflected in the
Exploring Residents’ Engagement in Activities 12

implementation of mandated reporting of quality measures. Toward this end, in 2002 the Centers
for Medicare and Medicaid Services (CMS) implemented the Nursing Home Compare Website
(https://www.medicare.gov/nursinghomecompare/). The objective of this website is to provide
consumers with quality-related information on all Medicare certified nursing home facilities and
hold providers accountable for the care they provide (Arling, Lewis, Kane, Mueller, & Flood,
2007). The quality measures included on the website for each facility can be compared to
neighboring facilities as well as national or state averages in performance. The quality measures
collect information on a variety of domains, including residents' health, physical functioning,
mental status, and general well-being, which is obtained from the MDS. Table 1 lists the quality
measures that are utilized in Nursing Home Compare for long-term residents.

Exploring Residents’ Engagement in Activities 13

In addition to the individual quality measures drawn from the MDS, Nursing Home
Compare pulls data from annual health inspections and staffing data to create a composite score,
referred to as the 5-star quality rating system. This rating system comes from reviewing health
inspection results, staffing data, and quality measures. The health inspection ratings are derived
from the three most recent health inspections. The annual health inspections represent an
assessment of quality from the state and federal government. The staffing data is based on
registered nurse hours per resident per day and the total staffing hours per resident per day. For
each of these two components, a one to five rating is assigned based on percentile cut points. The
rating for each component is then evaluated together to identify an overall one to five rating for
the staffing domain. Finally, the quality measure rating is an aggregate of sixteen different
quality measures based on clinical data from the MDS (Table 1). For each individual measure,
20 to 50 points are assigned based on the facility’s results relative to the national distribution of
quality measures. The points are then summed together and given a rating of one to five based on
cut-points. The rating of each domain is then combined to provide a composite rating of one to
five, which reflects the overall quality of the nursing home. Utilizing the 5-star rating system, it
provides patients, families, and providers the ability to compare across different nursing home
facilities based on quality by accessing the Nursing Home Compare website.
More recently, the “Triple Aim” has served as the conceptual framework for national
healthcare policy efforts intended to improve care quality. Specifically, the Triple Aim is a care
philosophy, which is focused around enhancing the delivery of evidence-based care and
optimizing the patient’s experience, thereby improving outcomes and reducing health care costs
(Berwick, Nolan, & Whittington, 2008). The core principles of the Triple Aim provide a
foundation for optimizing healthcare by putting patients and families at the center of their care
Exploring Residents’ Engagement in Activities 14

experience, redesigning services, managing population health, controlling healthcare costs, and
enhance coordination of care (Berwick et al., 2008). The Affordable Care Act (ACA) is one
example of a national policy that was designed based on these core principles (Magnan et al.,
2012). Within the U.S. healthcare system, the Triple Aim guided reform efforts, which emphasize
the delivery of evidence-based patient-centered care by linking provider payment to performance
on quality measure in an effort to improve patient outcomes. Similarly, these concepts can be
used in nursing homes to improve quality through optimizing patient outcomes.
In order to continue to improve nursing home quality, in 2016, CMS implemented
modified and new regulations for nursing homes through the Reform of Requirements for Long-
Term Care Facilities Participation (Centers for Medicare & Medicaid Services, 2016). One goal
of these new mandates was to improve the resident’s quality of life through prioritizing patient-
centered care. There are new requirements that promote resident’s right to be involved in the
development of their comprehensive care plan, which includes incorporating their preferences in
all aspects of care and services provided, such as activity programs. This new requirement is
implemented through the MDS assessment where providers document residents’ activity
preferences.
The delivery of activity programs have been targeted through the national policies as
well. As a result of the 1987 Omnibus Budget Reconciliation Act, nursing homes are required to
provide activity sessions for residents, yet there is no regulation on the type of activities that are
provided. In addition, recent federal regulations have revised nursing home requirements of
participation under Medicare with the goal of improving care quality. Specifically, the
regulations require activity programs in nursing homes to be included in the comprehensive care
plan of each resident detailing residents’ preferences to activities (Centers for Medicare &
Exploring Residents’ Engagement in Activities 15

Medicaid Services, 2016). However, many nursing home residents are found to be inactive and
do not engage in activities (Kolanowski, Buettner, Litaker, & Yu, 2006; Pruchno & Rose, 2002).

Activity Engagement and Health
Engagement in activity has been associated with overall health and can be impacted by
age-related changes. With increased age, individuals can experience normative changes, such as
functional loss and increased susceptibility to disease (Moody, 2006). Further, individuals are at
a higher risk for physical decline, which can lead to decreased functional ability. When
normative aging changes occur in concert with comorbid conditions, age related changes are
exacerbated, often resulting in poor outcomes.
Despite normative changes, for older adults’ residing in the community, engagement in
activity has been associated with overall positive well-being, good health, and meaning to one’s
life (Tatzer, van Nes, & Jonsson, 2012; Wilcock, 2005). Through activity engagement,
community-dwelling older adults have improved physical function, mental health, and social
interaction. For example, engagement in activities has been shown to reduce/delay functional
decline and physical impairment (de Leon, Glass, & Berkman, 2003). Research has also
illustrated that older adults who are more socially engaged, are more likely than those who are
not socially engaged, to have less physical disability, fewer mobility limitations, and greater
independence in activities of daily living (de Leon, Glass, & Berkman, 2003; Rosso, Taylor,
Tabb, & Michael, 2013). Additionally, social activities, such as attending groups outside of the
home, having regular contact with a friend/spouse/family, or participating in social networks,
have slowed physical decline in older adults (Stav, Hallenen, Lane, & Arbesman, 2012). Social
isolation is a health risk that is associated with mortality, physical and cognitive impairments,
Exploring Residents’ Engagement in Activities 16

decreased quality of life, and lower overall well-being (Grenade & Boldy, 2008; Hawthorne,
2006; Steptoe, Shankar, Demakakos, & Wardle, 2013). Through activity engagement, cognitive
health has also showed improvement. For example, individuals who have high social
engagement have often been associated with higher cognitive functioning (Krueger et al., 2009).
However, despite the benefits of being engaged in meaningful activities, many older adults are
found to be inactive, such as decreased participation in social activity, paid work, physical
activity, and leisure, which can lead to loneliness, depression, physical impairments, and other
comorbidities (Bennett, 2005; Cavalli, Bickel, & Lalive d'Epinay, 2007; Gruenewald,
Karlamangla, Greendale, Singer, & Seeman, 2007).
Consistent with the community-living older adult population, inactivity among nursing
home residents is pervasive, despite the positive health benefits of engagement. Residents are
often found to be inactive and do not participate in the structured activity sessions that are
provided by facility staff (den Ouden et al., 2015; Palese et al., 2016; Pruchno & Rose, 2002).
This lack of engagement can contribute to a loss of physical function, social isolation,
depression, behavioral symptoms, and a lower quality of life (Kolanowski & Buettner, 2008;
Kolanowski et al., 2006). Conversely, residents who are engaged have a higher quality of life,
better physical function (i.e., balance, strength, endurance, mobility), less depression, and greater
overall well-being (Bo et al., 2006; Chen et al., 2008; Heo, Stebbins, Kim, & Lee, 2012).
Among long-stay residents, nationally prioritized patient outcomes include reducing falls,
pain, pressure ulcers, and depressive symptoms. Falls among nursing home residents are
common and often result in injury, which can lead to morbidity and mortality (Leland, Gozalo,
Teno, & Mor, 2012). Toward this end, functional limitations are common fall risk factors
(Tromp et al., 2001). Engaging in physical exercise targeting balance and strength training have
Exploring Residents’ Engagement in Activities 17

been found to improve functional ability and reduce risk for falls (Rapp et al., 2008). Similarly,
pain is often a concern among nursing home residents because if left untreated, residents can
become limited in their functional ability and have an overall lower quality of life (Zanocchi et
al., 2008). Engagement in a physical exercise program, such as stretching, muscle strengthening,
and dancing, have been found to relieve pain in older adults and improve functional mobility
(Tse, Wan, & Ho, 2011).
In addition, nursing home residents are at a higher risk of pressure ulcers, which can
cause pain and other medical complications (Park-Lee & Caffrey, 2009). As a result, reducing
the occurrence of pressure ulcers is a prioritized outcome among this population. Since impaired
mobility is a common risk factor for pressure ulcers, engagement in physical activities, such as
exercise, can reduce the risk (Reddy, Gill, & Rochon, 2006). Nursing home residents are also at
a higher risk of having depressive symptoms, which can lead to lower quality of life, loss of
interest in normal activities, poor appetite, and other health problems (Jongenelis et al., 2004).
Engagement in physical activities (Buettner & Fitzsimmons, 2002) and social activities
(Achterberg et al., 2003) are associated with lower depression symptoms in this population.

Nursing Home Activity-based Interventions
Activity-based efficacy studies as highlighted in the above section have been able to
improve older adults’ physical, cognitive, and social well-being. Within nursing homes, this line
of inquiry has often targeted residents with dementia. However, nursing home residents without
dementia make up half of the nursing home population (Harris-Kojetin et al., 2016).
Furthermore, activities designed for residents with dementia may not be generalizable to other
Exploring Residents’ Engagement in Activities 18

populations. Nonetheless, the activity-based interventions for residents with dementia have
shown benefits in improving their targeted outcomes as presented in the following section.

Activity engagement for residents with dementia. There is strong evidence evaluating
effective activity-based interventions for residents with dementia and reducing occurrences of
negative behavioral symptoms, such as aggression, wandering, and agitation, reducing boredom,
and improving functional ability. One type of activity-based intervention that is effective in
reducing aggressive and agitated behaviors is through delivering individually tailored activities.
Individualized activities that take into account resident’s preferences and physical and cognitive
abilities are able to reduce negative behavioral symptoms when compared pretest to posttest
(Buettner, Fitzsimmons, & Atav, 2006).
Similarly, other activity-based interventions have been evaluated for effectiveness on
improving the quality of life for residents’ with dementia through decreasing negative behavioral
symptoms. Music therapy is a common intervention that is used for individuals with dementia.
By engaging residents in a music program, Svansdottir and Snaedal (2006) were able to decrease
behavioral symptoms. Music therapy was provided in a group setting for individuals with
dementia for six weeks. Negative behavioral symptom occurrences were measured three times
during the intervention period and one time four weeks after the music therapy intervention had
concluded. Results indicate that there were decreases in negative behavioral symptoms,
specifically aggression and anxiety, at all measurement points of the study except at four weeks
after the intervention had concluded. Other studies designed for this resident population have
also assessed context and environment, exercise, and daily-routine based interventions to reduce
behavioral symptoms (Wong & Leland, 2016).
Exploring Residents’ Engagement in Activities 19

In addition to the efficacy studies, qualitative studies have been conducted to understand
meaningful activity for individuals with dementia residing in nursing homes (Harmer & Orrell,
2008). Among this specific patient population, one qualitative study done by Harmer and Orrell
(2008) engaged a variety of stakeholders to understand activity preferences. The authors
completed focus groups with residents with dementia, family members, and staff members to
elicit the activities that the residents valued and why activities were considered meaningful. The
participants agreed there often was a lack of meaningful activity provided in nursing homes and
they preferred activities that were based on their values and beliefs and related to their past roles,
routines, and interests.

Activity engagement for the broader resident community—those without dementia.
Despite the positive outcomes of activity-based interventions for nursing home residents with
dementia, there is limited research examining activities for nursing home residents without
dementia. Additionally, there are limited studies that have evaluated activity preferences of this
nursing home resident population. However, despite the limited evidence for activity-based
interventions, efficacy studies have been completed to identify the positive benefits to overall
physical and mental health when engaging in activities.
Within a diverse nursing home population made up of individuals with varying physical
and cognitive capacities and limitations, there have been some activity-based interventions that
have been designed for other specific populations, such as individuals with dyspnea, sleep
problems, and depression. In order to target these other populations, physical exercise activities
were often implemented to evaluate the efficacy of these interventions. For example, Bo and
colleagues utilized an aerobic physical activity program to reduce dyspnea in long-term nursing
Exploring Residents’ Engagement in Activities 20

home residents (Bo et al., 2006). In the study, 22 participants with dyspnea residing in a long-
term facility were provided with the intervention for four weeks. At the end of the study period,
residents who received the intervention had significantly increased their walking distance and
decreased their dyspnea.
Other examples of physical exercise programs targeting specific populations was for
individuals with depression and sleep problems. One was a biking program for nursing home
residents with depression (Fitzsimmons, 2001). This intervention evaluated the effect of a biking
program on a resident’s depression in a long-term facility. A total of 39 residents were randomly
assigned to participate in the program for two weeks with 19 residents receiving the biking
intervention and 20 residents in the control group. Results indicate that residents who
participated in the biking program had significantly lower levels of depression than those
residents who were in the control group. In order to target sleep problems, Richards and
colleagues (2011) implemented an intervention that provided a social activity and a
strengthening and walking activity. The combination of both the social activity and physical
activity was found to be most effective in improving nocturnal sleep among residents (Richards
et al., 2011).
The most common type of activity-based intervention not designed for specific resident
populations were physical exercises. A majority of these interventions were aimed at improving
functional ability through physical activities, such as tai chi, strength resistance training, aerobic
exercise, and ballroom dancing. For nursing home residents without dementia, tai chi has been
able to significantly improve all aspects of physical health, such as flexibility, strength, and
blood pressure (Chen et al., 2008). Similarly, Chin and colleagues (2006) utilized a program for
Exploring Residents’ Engagement in Activities 21

resistance training, which was able to improve physical fitness and performance among nursing
home residents without dementia.
Various effective activity-based interventions have been highlighted to benefit overall
health. However, little is known on the long-term effects of these interventions and how these
activities can be implemented into current activity programming. More specifically, there is a
gap in knowledge of what is currently provided in nursing homes and how residents are engaged
in activities. Thus, before these effective activity-based interventions can be integrated into
nursing homes, we need to know whether these activities are currently provided and residents
perspectives on the delivering activities.

Theoretical Approach
The overarching research question is informed by the following concepts. Activity
engagement and its relationship to health is informed through occupational science. This area
supports the benefits that engaging in activities has on nursing home residents. Further, this
section also presents the Social Ecological Model as a framework to understand the different
components that can impact activity engagement in nursing homes.

Occupation and health. Within occupational science and occupational therapy research,
literature has aimed to establish a relationship between occupational engagement and health
(Stav et al., 2012; Wilcock, 2005). Among older adults, occupational science research has
focused on the impact that occupational engagement has on health, well-being, and quality of life
(Stav et al., 2012). Further, this research differs from the activity-based interventions described
Exploring Residents’ Engagement in Activities 22

in previous sections with the focus on understanding the experience with changes in engagement
as one ages.
For example, one qualitative study conducted by Tatzer and colleagues (2012) evaluated
the role of occupation during the course of aging in four older Viennese women. The findings
from this study indicated that engaging in occupations for these women were important in
continuing their identity as a way to maintain their quality of life.
One study also examined older adults’ engagement in occupations and its relationship to
their current roles and overall health (Knight et al., 2007). A mixed methods study consisting of
qualitative interviews and a completion of a time use diary was done with 71 older adults who
resided in the community. Results indicated that the participants felt their occupations
contributed to their health both directly and indirectly.
Occupation has also been evaluated in the context of life transitions for older adults.
Jonsson completed a (2011) a qualitative longitudinal study of Swedish men and women over the
course of work to retirement. In relation to occupational engagement, the results of the study
identified different purposes that occupations had. For example, some occupations were
considered to “kill time,” while others were done with purpose and commitment and considered
engaging occupations. In addition, engaging occupations were considered those that were highly
meaningful, important, and occurred regularly. These types of occupations contributed
significantly to an individual’s well-being (Jonsson, 2008).
From these findings, it informed the importance that occupational engagement has on
older adults. Research is limited in the area of nursing home residents’ occupational engagement
and the types of occupation that individuals are engaged in. Even though this dissertation does
not identify a relationship between occupation and health for nursing home residents, it describes
Exploring Residents’ Engagement in Activities 23

the current practice for delivering activities, which can first contribute to understanding what is
available and then informing future research to identify what activities can contribute to overall
health, well-being, and quality of life.

Social Ecological Model. The social ecological model provides a framework to examine
the factors that influence an individual’s behavior from a system perspective, which includes the
microsystem, mesosystem, exosystem, and macrosystem (Bronfenbrenner, 1977). McLeroy and
colleagues modified Brofenbrenner’s ecological model to examine behavior related to health
(McLeroy, Bibeau, Steckler, & Glanz, 1988). Their model includes the intrapersonal,
interpersonal, institutional, community, and public policy levels. The intrapersonal factors aim to
capture the individual’s characteristics, including one’s own knowledge and psychological
characteristics. The interpersonal factors describe the relationships between individuals and how
these relationships influence one’s health behavior. Institutional factors include the formal and
informal rules and regulations that are established within an organization that influence the
behavior. The community factors capture the impact that relationships among organizations and
geographic locations can have on health behavior. Finally, public policy characteristics are laws
and policies established at the local, state, and national level.
By viewing nursing home activity engagement through the social ecological model, it can
illustrate how different levels of the model can impact engagement. For example, at the
intrapersonal level, many individual factors can affect residents’ ability to engage in activity
sessions, such as physical impairment and depression. At the interpersonal level of the model,
the quality, frequency, and scope of social support that nursing home residents have can affect
their engagement in meaningful activities. Specifically, the facility staff and the support they
Exploring Residents’ Engagement in Activities 24

provide for residents can impact engagement. Staff members who build a relationship with
residents and have discussions with residents and family members about desired activities can
assist in facilitating activities that residents want to participate in. Collaboration between nursing
home staff and residents is reflective of patient-centered care and the focus of engaging patients
in shared decision-making (Hibbard & Greene, 2013).
Within nursing home facilities, there are organizational characteristics that influence
activity engagement. For example, in order to have a diverse activity program, facility resources,
such as staffing, space, and finances, are needed. Despite providing activity sessions in the
facility, nursing home residents are often found to be bored, inactive, and depressed because
these programs are not meaningful for the residents (Pruchno & Rose, 2002; Wood, Womack, &
Hooper, 2009). Lack of resources is commonly found as a barrier for residents to engage in
activities (Sehrawat, 2015). In addition, staffing within facilities can be a barrier to providing
activities (Schnelle et al., 2004). Facilities that have a limited number of staff members may not
be able to engage residents in activities.
At the national level, there are public policies that can influence activity engagement. The
passage of the 1987 OBRA Act highlighted the importance of nursing home care quality and the
importance of improving residents’ quality of life through meaningful activities.(Omnibus
Budget Reconciliation Act, 1987) Following this mandate, it is important for nursing homes to
provide appropriate activities for residents. Additionally, engaging resident in meaningful
activities can assist in achieving the goals of the Triple Aim in healthcare reform.(Berwick et al.,
2008) The Triple Aim promotes patient-centered care as an approach to improve overall
healthcare delivery and patient outcomes. Engaging nursing home residents in meaningful
activities and understanding their preferences is reflective of patient-centered care, which can
Exploring Residents’ Engagement in Activities 25

lead to improved health outcomes. Thus, multiple factors can potentially impact meaningful
activity engagement in nursing homes.
Exploring Residents’ Engagement in Activities 26

Methods: Overview
Using a concurrent mixed methods design, (Creswell & Plano Clark, 2011) this study
examined current practices for activity engagement. The overarching research question for this
dissertation is: “What are current practices for engaging nursing home residents in activities?”
Subsequent questions that explored in the dissertation include:
• Are nursing home organizational factors associated with activity sessions?
• What are nursing home residents’ preferences to engaging in activities?
• What are barriers and facilitators for engaging nursing home residents in activity
sessions?
There were three specific aims of the study.
• Aim 1: Characterize and evaluate the breadth, depth, and frequency of activity
programming and its relationship to organizational factors.
• Aim 2: Explore stakeholder perspectives on current activity engagement practices.
• Aim 3: Compare and contrast approaches for delivering activities in nursing
homes to understand current practices to engaging nursing home residents in
activities.
In order to complete the first aim of the study, activity calendars were collected from
purposively sampled nursing homes. The activity calendars were then quantified by frequency
and type of activities delivered to evaluate if there were any relationships between activity
calendars and organizational characteristics. The second and third aims were completed through
conducting interviews and observations in three purposively sampled nursing homes to identify
stakeholder perspectives (i.e., residents, activity providers, and administrators) on delivering
Exploring Residents’ Engagement in Activities 27

activities. The different practices from the three nursing homes were than evaluated together to
identify similarities and differences.
Health, well-being, and quality of life of older adults can be impacted by activity
engagement. However, with the lack of engagement in nursing homes, it highlights a gap in
knowledge. Thus, this dissertation aimed to establish the current practice in delivering activities
in nursing homes in order to identify areas that can be improved.
Exploring Residents’ Engagement in Activities 28

Chapter 3: Manuscript #1
Understanding Current Nursing Home Activity Programs from Activity Calendars
Target Journal: Activities, Aging, and Adaptation Journal
Abstract
In order to improve nursing home resident engagement, it is important to first understand
the current state of facility activity programs. Thus, a purposive sample of nursing homes
(n=100) provided a 30-day activity calendar. Organizational characteristics of the facilities were
also obtained. Activities were identified and grouped into 38 mutually exclusive categories. Data
was analyzed to quantify the frequency of each activity and evaluate the association between the
organizational characteristics and the types of activities that were offered to the residents. Results
indicated that organizational characteristics did not have a statistically significant relationship
with the activities that were provided. However, these findings provide perspective on the
current state of nursing home activity programming, including the type and diversity of activities
provided, which can inform future program development efforts.

Exploring Residents’ Engagement in Activities 29

By year 2050, 27 million people are expected to be residing in long-term nursing homes
(Harris-Kojetin et al., 2016). With an increase in utilization, the quality of nursing home care as
well as quality of life for residents is a concern. One way to improve residents’ quality of life is
through activity engagement. However, residents in nursing homes often report low activity
engagement levels, which can contribute to symptoms of depression, feelings of isolation and
loneliness, boredom, functional decline, and overall decreased quality of life (de Leon et al.,
2003; den Ouden et al., 2015; Rosso et al., 2013; Stav et al., 2012). Conversely, older adults who
are engaged in activities exhibit improved physical and cognitive function as compared to
individuals who are not participating (Fitzsimmons, 2001). Thus, national mandates targeted
activity engagement in order to improve overall quality of care and quality of life for nursing
home residents.
The Omnibus Budget Reconciliation Act of 1987 was among the first national policy
efforts that included activity engagement by requiring nursing homes to provide activities that
meet the needs and preferences of residents (Omnibus Budget Reconciliation Act, 1987). This
federal regulation mandated activity programs to foster meaningful engagement, stimulate
physical and cognitive abilities, and facilitate the maintenance of overall social, emotional, and
physical function. Activity programs are also required to be delivered on a daily basis and meet
the needs and interests of each resident. Often, activity sessions are listed on a monthly calendar,
detailing the type, location, and time of the planned activity. The calendars are provided to
residents or posted in a visible place within the facility (Buettner & Fitzsimmons, 2003).
Despite the mandate for daily activity programming, there is limited research on the
current state of nursing home activity programs. Instead, current research on activities has
focused on the effect of short-term activity interventions on the physical, social, or cognitive
Exploring Residents’ Engagement in Activities 30

factors of residents, particularly among residents with dementia (Bielak, 2010; Bo et al., 2006;
Chen et al., 2008; Dickens, Richards, Greaves, & Campbell, 2011). To this author’s knowledge,
there are a limited number of studies that aimed to understand what activities were provided for
their residents with dementia within this clinical context (Buettner & Fitzsimmons, 2003; Tak et
al., 2015). However, in long-term nursing homes, about 50% of residents do not have dementia
and thus the activities provided are usually not directed towards just one population of residents
(Harris-Kojetin et al., 2013). Consequently, there is a mismatch between research and the current
practice in implementing activities. There is a gap in research examining activities for residents
without dementia. Therefore, the purpose of this study is to identify the current practice for
providing activity programs in nursing homes and to understand the frequency and types of
activities that are provided.

Methods
Study Population and Data Collection
To understand the current practice of providing activities in nursing homes, activity
calendars were obtained from a sample of facilities. To ascertain eligibility, a list of all nursing
homes in Los Angeles County California was obtained from Long-term Care: Facts on Care in
the US (LTCFocus; http://ltcfocus.org/), which is a publicly available database that provides data
on nursing home care in the US. The database is comprised of data including health and
functional status of nursing home residents, characteristics of care facilities, and state policies
relevant to long term care services and financing. The data is obtained from the Minimum Data
Set (MDS), Online Survey Certification and Reporting (OSCAR), State Medicaid data, county
level resources databases, and residential history files.
Exploring Residents’ Engagement in Activities 31

From LTCFocus, we obtained a list of 1,177 nursing home facilities within the state of
California and extracted the names of all 327 facilities located within Los Angeles County.
These facilities were then evaluated based on our inclusion and exclusion criteria. We included
facilities that had long-term residents and excluded those that were an assisted living, only had
Alzheimer’s or dementia residents, or only had short-stay residents. Based on the inclusion and
exclusion criteria, we identified 228 nursing homes in Los Angeles County.
From the list of 228 eligible facilities, our goal was to purposively sample activity
calendars from 100 facilities based on five variables: geographic location (i.e., poverty rate
obtained from Census data), number of beds in the facility, chain status, ownership status (i.e.,
for-profit or non-profit), and number of nurse staffing hours. Therefore, from the alphabetized
list of 228 facilities, 20 facilities at a time were categorized according to the five facilities
variables. Specifically, the first 20 facilities were identified based on geographic location with
ten facilities from areas with low poverty rates and ten facilities from areas with high poverty
rates. The subsequent 20 different facilities were stratified by number of beds in the facility (i.e.,
facilities with less than 75 beds and more than 75 beds). After facilities were stratified by
number of beds, 20 other facilities were identified based on chain status (i.e., ten facilities that
were part of a chain and ten facilities that were not) and 20 for ownership status (i.e., ten
facilities that were for-profit and ten non-profit). Finally, the last set of 20 facilities was
identified based on number of staffing hours (i.e., ten facilities with staffing hours below 3 hours
of direct care per resident and ten facilities above 3 hours of direct care per resident).
Once the initial group of 100 facilities was identified, each nursing home was approached
via in-person, telephone, or email to request an activity calendar. One activity calendar of any
month within the years 2017 to 2018 was collected from each facility. When a facility was
Exploring Residents’ Engagement in Activities 32

unable or refused to provide an activity calendar, the facility was replaced with another nursing
home that they were stratified for. For example, if a facility was identified as a for-profit facility,
another for-profit facility was added to the sample. Of the 228 facilities, 132 nursing homes were
approached to obtain an activity calendar. Thirty-two facilities were unable to provide an activity
calendar. For the final sample, 100 activity calendars were collected.
In order to understand if the activities provided varied from facility to facility,
organizational characteristics were also obtained through LTCFocus. These characteristics
included total number of beds, ownership status, chain status, percent of residents with Medicare
and Medicaid, staffing hours, and Medicare’s star quality rating. The total number of beds
available in each facility reflects the size of each facility. Ownership status for each facility was
defined as for-profit or non-profit facilities. The chain status of each facility was also identified
as being a facility within a chain or not within a chain. Medicare and Medicaid are the most
common health insurance coverages that residents utilize, and thus we obtained from LTCFocus
the percentage of residents whose primary support was Medicare or Medicaid in the facility.
Finally reported staffing hours were obtained and defined as the number of direct care staffing
hours per resident day for each facility.
Medicare star ratings were also obtained for each of the nursing homes from Centers for
Medicare and Medicaid Services (CMS) Nursing Home Compare Website. The objective of this
website is to provide consumers with quality-related information on all Medicare certified
nursing home facilities and hold providers accountable for the care they deliver
((https://data.medicare.gov/data/nursing-homecompare). The star rating system is a summary
score given to each facility by CMS based on health inspection results, staffing data, and quality
measures. Quality measures are based on a variety of domains for both long-term and short-term
Exploring Residents’ Engagement in Activities 33

residents, including residents' health, physical functioning, mental status, and general well-being.
This star rating is on a 5-point scale with five stars as excellent, four stars as above average, three
stars as average, two stars as below average, and one star as poor (Owen, 2014). The 5-star rating
for each facility was treated as a continuous variable. In addition, poverty rate was obtained for
each geographic location from Census data and was defined as the percent of people in poverty
in that region.

Data Analysis
The activity calendars were reviewed to identify the specific types of activities provided,
the frequency of activities, and the number of different activities that were delivered over a
month long period. Similar activities were grouped together to construct mutually exclusive
categories. For example, painting, drawing, and coloring activities were collapsed to create the
arts and crafts group. More specifically, a total of 4,090 activities were integrated to create 38
activity categories, which are defined in Table 1 (e.g., beauty and nail salon, bingo, gardening,
video games and computers, etc.). Activities that fell into multiple categories were classified by
their primary purpose. For example, watching a movie at a movie theater was classified as an
outing as the primary focus is taking a trip out into the community. Similarly, the activity of
exercise with music was categorized as exercise since that is the highlight of the activity.
Descriptive statistics were also conducted to summarize the frequency of the types of
activities provided and the organizational characteristics of the facilities. The mean and standard
deviations were determined for each of the activity types that were identified in a one-month
period. In addition to the frequency of the 38 activity types, activities that required extra
resources (i.e., pet therapy, gardening, resident’s choice, technology, outings, and outdoor
activities) were further analyzed for association with organizational characteristics. A separate
Exploring Residents’ Engagement in Activities 34

variable was created for each of the activity type variables to indicate if the activity was provided
in each facility or not. For example, gardening was identified as being provided or not (yes/no)
for each facility.
In addition, a sub-analysis was conducted to examine the association between the
delivery of the higher resource activities and organizational characteristics (i.e., staffing hours,
total number of beds, percent of Medicare residents, percent of Medicaid residents, poverty rate,
and 5-star rating). The higher resource activities were defined as those that would require extra
supplies or staff. Since activity calendars only provided a name of an activity without a
description, the authors made the decision on which activities would most likely need extra
resources. As a result, we specifically evaluated pet therapy, gardening, resident’s choice,
technology, outings, and outdoor activities. For each of the six activities, two sub-analyses were
completed. The first analysis evaluated the association between organizational characteristics
and whether or not the activity was offered—a dichotomous outcome variable for each of the six
types of activities. This analytic approach used a logistic regression and included all facilities in
the sample (n=100). The second analysis examined the relationship between organizational
factors and the frequency in which an activity was provided over the 30-day period, a continuous
outcome variable was used for each of the six outcome measures. This second analysis was
limited only to those facilities that offered the activity of interest (e.g., pet therapy).

Table 1. Definition of activity categories
Type of activity Definition
Arts and Crafts a variety of activities that involve making things with one’s own hands
Beauty and Nail
Salon
activities that involve nail care, skin health, hair care, foot care, and facial
aesthetics
Bingo activities that relate to the game of Bingo
Exploring Residents’ Engagement in Activities 35

Cards activities that involved using playing cards as the primary device of a game
Coffee Break activities that involved a time for drinking coffee or tea
Cooking
activities that involved residents cooking or observing a cooking
demonstration
Current Events
activities that involved providing residents current news through any means
(e.g., TV, newspaper, etc.)
Dancing activities that involved any aspect of dance
Group Discussions
activities that involved residents providing their comments, thoughts, or
perspectives on a topic in a group
Education activities that involved any educational aspect (e.g., lectures or seminars)
Exercise a wide variety of activities that focused on physical activity
Games
(unspecified)
activities that were labeled "games," but did not specify what type of game
was being provided
Gardening any gardening related activity
Humor activities that involved telling or listening to jokes or funny stories
Meditation
activities that involved meditation, breathing exercises, or relaxation
techniques
Movies activities that involved watching a movie in the facility
Music
activities that involved listening to music, watching a musical performance,
or playing a musical instrument
Outdoor Activity activities that were held outdoors
Outings trips and outings that were organized by the facility for all residents
Pet Therapy
activities that involved bringing a pet into the facility to interact with the
residents
Reading and
Writing
activities that involved reading of any kind or writing
Religious activities that involved religion or spirituality
Resident's Choice activities that were chosen by the residents
Resident Council
Meetings
meetings that residents have with each other and the facility staff members
Room Visits activity personnel providing any activities to the residents in their rooms
Sensory activities that involve engaging the different senses or sensory stimulation
Socials
activities that involve social engagement or celebrations for special
occasions (e.g., birthday parties, Christmas parties, etc.) that bring residents
together
Stories
activities that involve residents telling stories or reflecting their life
experiences
Trivia and Brain
Games
activities that involved trivia or brain training games
Exploring Residents’ Engagement in Activities 36

Table Games and
Puzzles
activities that involved board games or puzzles
Technology activities that involved playing video games or using technology
Travelogue
activities that involved watching a program about places visited by a
traveler
TV activities that involved watching TV in the facility
Volunteer
activities that involved residents being volunteers (e.g., preparing food for
veterans)
Other
any activities listed on the activity calendar that were unclear on what the
activity entailed

Results
The facilities (n=100) that contributed activity calendars represented 15 of the total 88
cities in Los Angeles County. A majority of the facilities were for-profit (87%) and not part of a
chain (63%) with an average number of 96.3 (±43.8) beds (Table 2). The facilities had the
following distribution for the Medicare star ratings: 1-star (5%), 2-star (26%), 3-star (27%), 4-
star (21%), and 5-star (19%).

Table 2. Facility Characteristics
Organizational characteristics
Variables
(N=100)
Number of beds, mean (sd) 96.3 (43.8)
Chain status

Yes, % 37
No, % 63
Profit status

Yes, % 87
No, % 13
Medicaid, % 56.7
Medicare, % 15.8
Nurse Staffing hours, mean (sd) 4.2 (1.1)
Medicare 5-star rating 3.2 (1.2)
Poverty Rate, % 15.9 (4.5)

Exploring Residents’ Engagement in Activities 37

Types of Activities
On average, a facility provided 191.7 (±42.7) total activity sessions each month and 20.1
(±3.2) different unique types of activities each month. In addition, Table 3 summarizes the 38
types of activities that were identified and the average number of times each specific type of
activity is provided in facilities in a one-month period (e.g., average number of times music is
provided within each facility).

Table 3. Activity Calendar Summary (n=100)
Types of Activities
Activities per month,
mean (SD)
Total Number of Activities
a
191.7 (42.7)
Unique Types of Activities
b
20.1 (3.2)
Arts and Crafts 6.0 (6.0)
Beauty and Nail Salon
4.3 (5.5)
Bingo
12.5 (7.3)
Cards
2.3 (3.6)
Coffee Break
18.1 (15.7)
Cooking 1.4 (1.5)
Current Events 14.7 (15.7)
Dancing 1.4 (3.0)
Group Discussions 0.4 (1.2)
Education 1.3 (3.2)
Exercise 25.1 (13.7)
Games (unspecified) 4.0 (5.8)
Gardening 0.5 (1.1)
Jokes 0.1 (0.4)
Meditation 0.8 (4.8)
Movies 8.8 (4.8)
Music 12.8 (10.6)
Outdoor Activity 1.3 (5.0)
Outings 1.4 (2.4)
Pet Therapy 0.5 (1.6)
Reading and Writing 1.2 (3.3)
Religious 12.4 (9.4)
Resident's Choice 1.2 (3.4)
Resident Council Meetings 1.1 (0.9)
Room Visits 6.2 (11.9)
Exploring Residents’ Engagement in Activities 38

Sensory 3.0 (5.6)
Socials 12.6 (9.8)
Stories 1.5 (4.4)
Trivia and Brain Games 8.4 (7.3)
Table Games and Puzzles 7.8 (7.5)
Technology 0.6 (2.2)
Travelogue 0.4 (1.1)
TV 6.2 (9.7)
Volunteer 0.1 (0.4)
Other 7.9 (14.4)
a
The total number of activities with repeated activities
included
b
The different unique type of activities that do not
include repeated activities

The most frequently offered type of activity was exercises, which included stretching,
strengthening, and sports activities. The exercise activities were provided, on average, 25.1
sessions (±13.7) a month. Similarly, other frequently scheduled activities included current events
that were provided a mean of 14.7 times (±15.7) in a 30-day period. This activity was often
scheduled in concurrence with coffee hour (mean=18.1, ±15.7). Providing music (mean=12.8,
±10.6), movies (mean=8.8, ±4.8), and TV (mean=6.2, ±9.7) were also common activities found
in all calendars.
From our sub-analysis, we evaluated pet therapy, gardening, resident’s choice,
technology, outings, and outdoor activities to the organizational characteristics. Table 4
highlights the descriptive statistics of the organizational characteristics for each of the six
activities included in the sub-analysis. Pet therapy was one of the least common activities, with
only 17 facilities offering the opportunity for pets to be brought into the facility to interact with
the residents. Among the facilities that provided pet therapy, there was an average of 4.68
(±1.68) nurse staffing hours. Additionally, 16 of the 17 facilities that had pet therapy were for-
Exploring Residents’ Engagement in Activities 39

profit facilities and had an average of 106.65 (±47.60) beds. On average, facilities that provided
pet therapy also had a Medicare five-star rating of 3.06 (±1.09).

Tables 5-11 presents the logistic and linear regressions to examine the relationship
between the six activities and the organizational characteristics. For facilities that provided pet
therapy, there was no statistically significant relationship between organizational characteristics
of facilities that delivered pet therapy and those that did not (Table 5). Similarly, among the
facilities that had pet therapy, the frequency of delivering this activity had not statistically
significant relationship with organizational characteristics.

Table 4. Descriptive Statistics for Sub-Analysis Outcomes

Pet
Therapy
n=17
Gardening
n=25
Resident's
Choice
n=21
Technology
n=10
Outings
n=68
Outdoor
Activity
n=17
Variables
Number of beds,
mean (sd)
106.65
(47.60)
98.96
(44.42)
96.24
(31.81)
80.60
(33.51)
97.93
(48.99)
91.76
(31.94)
Medicaid, %, mean
(sd)
56.07
(27.80)
52.00
(25.98)
59.99
(23.89)
40.45
(34.34)
56.42
(25.76)
59.60
(25.96)
Medicare, %, mean
(sd)
21.02
(15.94)
19.31
(14.14)
16.26
(10.29)
16.55
(17.22)
14.39
(11.10)
12.57
(11.12)
Nurse Staffing
hours, mean (sd)
4.68
(1.65)
4.34
(1.15)
4.00 (0.76) 4.13 (0.78)
4.20
(0.87)
4.81 (1.81)
Poverty Rate, %,
mean (sd)
15.59
(4.48)
15.00
(4.86)
14.34
(5.01)
18.66 (3.09)
16.17
(4.57)
16.79
(4.88)
5-star Rating, mean
(sd)
3.06
(1.09)
3.00
(1.18)
3.14 (1.11) 3.50 (1.35)
3.30
(1.19)
3.13 (1.30)
Exploring Residents’ Engagement in Activities 40

Table 5. Regression Analyses for Pet Therapy and Facility Characteristics

Model # 1
a

n=100
Model #2
b

n=17
Variable Odds Ratio
95%
Confidence
Interval
Coefficients
95%
Confidence
Interval
Number of Nurse Staffing
Hours
1.70 1.03, 2.81 0.86 -0.42, 2.12
Total Number of Beds 1.01 0.99, 1.02 0.00 -0.05, 0.05
Medicare, % 1.06 1.01, 1.12 0.12 -0.23, 0.47
Medicaid, % 1.02 0.99, 1.05 0.03 -0.11. 0.18
Poverty Rate, % 0.97 0.88, 1.13 0.02 -0.42, 0.45
5-star rating 0.78 0.45, 1.35 -1.25 -4.77, 2.26
a
Pet therapy is a dichotomous variable as yes/no to identify if it is provided or not
b
Pet therapy is a continuous variable as a frequency

Gardening activities, either outdoors or indoors, were only available in 25 of the
facilities. Among facilities that had gardening activities had an average of 4.34 (±1.15) nurse
staffing hours and an average of 98.96 (±44.42) total number of beds. In addition, facilities that
had gardening activities, they had an average of a 3.00 (±1.18) star Medicare rating. Table 6
highlights further analyses that were conducted to identify a relationship between gardening
activities and organizational characteristics. When examining the relationship between facilities
that provided gardening, there were no statistically significant results when compared to other
organizational characteristics. Additionally, among facilities that delivered gardening activities,
there was no statistically significant relationship between the frequency and organizational
characteristics.
Exploring Residents’ Engagement in Activities 41

Table 6. Regression Analyses for Gardening and Facility Characteristics

Model # 1
a

n=100
Model #2
b

n=25
Variable Odds Ratio
95%
Confidence
Interval
Coefficients
95%
Confidence
Interval
Number of Nurse Staffing
Hours
1.17 0.77, 1.79 0.02 -0.57, 0.62
Total Number of Beds 1.00 0.99, 1.01 -0.01 -0.03, 0.00
Medicare, % 1.02 0.98, 1.06 0.01 -0.05, 0.06
Medicaid, % 0.10 0.98, 1.02 -0.00 -0.03, 0.03
Poverty Rate, % 0.95 0.85, 1.05 -0.01 -0.22, 0.10
5-star rating 0.64 0.40, 1.04 -0.43 -1.26, 0.40
a
Gardening is a dichotomous variable as yes/no to identify if it is provided or not
b
Gardening is a continuous variable as a frequency

Activities that allowed resident’s to choose the activity they wanted occurred in 21
facilities. On the activity calendar, this type of activity was reflected as “resident’s choice.” A
majority of the facilities that had resident’s choice as an option were often for-profit facilities
(n=20). In addition, the average 5-star Medicare rating for facilities that had a resident’s choice
activity was 3.14 (±1.11). Table 7 presents the logistic and linear regression for identifying the
relationship between resident’s choice activity and facility characteristics. There was statistically
significant relationship between facilities that provided resident’s choice and the organizational
characteristics. In addition, among facilities that had resident’s choice activities, there was no
statistically significant relationship between the frequency and the facility characteristics.

Exploring Residents’ Engagement in Activities 42

Table 7. Regression Analyses for Resident’s Choice and Facility Characteristics

Model # 1
a

n=100
Model #2
b

n=21
Variable Odds Ratio
95%
Confidence
Interval
Coefficient
95%
Confidence
Interval
Number of Nurse Staffing
Hours
0.79 0.45, 1.40 -1.48 -5.02, 2.06
Total Number of Beds 0.10 0.99, 1.01 -0.02 -0.09, 0.06
Medicare, % 1.01 0.97, 1.06 0.22 -0.04, 0.48
Medicaid, % 1.01 0.99, 1.03 -0.03 -0.16, 0.09
Poverty Rate, % 0.90 0.80, 1.00 0.36 -0.16, 0.88
5-star rating 0.88 0.56, 1.40 -0.23 -3.05, 2.60
a
Resident’s choice is a dichotomous variable as yes/no to identify if it is provided or not
b
Resident’s choice is a continuous variable as a frequency

Other activities that were provided less frequently included technology held in ten
facilities, meditation in ten facilities, and outdoor activities in 17 facilities. Facilities that
delivered technology activities had an average of 80.60 (±33.51) beds and a 5-star Medicare
rating of 3.50 (±1.35). In addition, of the ten facilities that had technology, six were for-profit
facilities. Table 8 presents the regression analyses between technology activities and the facility
characteristics. There was no statistically significant relationship identified between
organizational characteristics and facilities that had discussion group activities. Among facilities
that did provide technology activities, there were no statistically significant results for the
frequency of this activity and the organizational characteristics.

Exploring Residents’ Engagement in Activities 43

Table 8. Regression Analyses for Technology and Facility Characteristics

Model # 1
a

n=100
Model #2
b

n=10
Variable Odds Ratio
95%
Confidence
Interval
Coefficient
95%
Confidence
Interval
Number of Nurse Staffing
Hours
0.53 0.22, 1.28 -0.50 11.40, 10.40
Total Number of Beds 1.01 0.99, 1.02 0.01 -0.05, 0.05
Medicare, % 1.01 0.95, 1.07 0.02 -0.42, 0.52
Medicaid, % 0.99 0.96, 1.02 0.02 -0.28, 0.31
Poverty Rate, % 0.87 0.75, 1.02 -0.37 -1.60, 0.85
5-star rating 1.56 0.77, 3.14 -1.60 -7.19, 3.98
a
Technology is a dichotomous variable as yes/no to identify if it is provided or not
b
Technology is a continuous variable as a frequency

Outing activities were delivered in facilities that had an average of 97.93 (±48.99) beds in
the facility and an average of 3.30 (±1.19) Medicare star rating. A majority of the facilities that
delivered meditation were for-profit (n=58). Table 9 illustrates the logistic and linear regression
analyses conducted for outings and facility characteristics. When comparing facilities that
provided outings to organizational characteristics, no statistically significant relationship was
found. Similarly, there was no statistically significant relationship between the frequency of
outing activities and organizational characteristics for facilities that delivered meditation.

Exploring Residents’ Engagement in Activities 44

Table 9. Regression Analyses for Outings and Facility Characteristics

Model # 1
a

n=100
Model #2
b

n=68
Variable Odds Ratio
95%
Confidence
Interval
Coefficient
95%
Confidence
Interval
Number of Nurse Staffing
Hours
1.21 0.71, 2.06 -2.63 -11.19, 5.93
Total Number of Beds 1.01 0.10, 1.02 0.16 0.09, 0.26
Medicare, % 0.10 0.93, 1.06 0.08 -0.23, 0.85
Medicaid, % 1.01 0.98, 1.04 0.31 -0.23, 0.85
Poverty Rate, % 0.95 0.81, 1.10 -0.64 -2.90, 1.62
5-star rating 1.08 0.58, 2.02 0.67 -8.30, 9.65
a
Outings is a dichotomous variable as yes/no to identify if it is provided or not
b
Outings is a continuous variable as a frequency

Outdoor activities were also provided in facilities that had an average 5-star Medicare
rating of 3.13 (±1.30) and 91.76 (31.94) number of beds. Of the 17 facilities that delivered
outdoor activities, 15 facilities were for-profit. Table 10 presents the regression analyses to
examine the relationship between outdoor activities and organizational characteristics. There was
no statistically significant relationship between facilities that delivered outdoor activities and
their facility characteristics. Additionally, among facilities that provided outdoor activities, there
was no statistically significant relationship between the frequency of the activity and the
organizational characteristics.
Exploring Residents’ Engagement in Activities 45

Finally, any facility providing a higher resource activity (i.e., pet therapy, gardening,
resident’s choice, technology, outings, and outdoor activities) was evaluated with facility
characteristics to identify a relationship (Table 11). There was no statistically significant
relationship identified for facilities that had these higher resource activities and the facility
characteristics. Similarly, the frequency of the higher resource activity was not statistically
significantly related to organizational characteristics.

Table 10. Regression Analyses for Outdoor Activities and Facility Characteristics

Model # 1
a

n=100
Model #2
b

n=17
Variable Odds Ratio
95%
Confidence
Interval
Coefficient
95%
Confidence
Interval
Number of Nurse Staffing
Hours
1.97 0.98, 3.56 2.22 -1.11, 5.56
Total Number of Beds 0.10 0.98, 1.01 -0.01 -0.37, 0.29
Medicare, % 0.97 0.92, 1.03 -0.30 -0.86, 0.27
Medicaid, % 1.00 0.98, 1.03 0.14 -0.15, 0.43
Poverty Rate, % 1.06 0.92, 1.21 0.43 -0.90, 1.75
5-star rating 0.84 0.49, 1.44 0.75 -6.78, 8.28
a
Outdoor activities is a dichotomous variable as yes/no to identify if it is provided or not
b
Outdoor activities is a continuous variable as a frequency
Exploring Residents’ Engagement in Activities 46

Table 11. Regression Analyses for High Resource Activities and Facility Characteristics

Model # 1
n=100
Model #2
n=63
Variable Odds Ratio
95%
Confidence
Interval
Coefficient
95%
Confidence
Interval
Number of Nurse Staffing
Hours
1.21 0.71, 2.06 0.04 -0.12, 0.209
Total Number of Beds 1.01 0.10, 1.02 0.00 -0.00, 0.00
Medicare, % 0.10 0.93, 1.06 -0.01 -0.03, 0.00
Medicaid, % 1.01 0.98, 1.04 -0.00 -0.01, 0.01
Poverty Rate, % 0.95 0.81, 1.10 -0.02 -0.07, 0.02
5-star rating 1.08 0.58, 2.02 0.01 -0.17, 0.19
a
High resource activities is a dichotomous variable as yes/no to identify if it is provided or
not
b
High resource activities is a continuous variable as a frequency

Discussion
Current literature has highlighted the positive impact that activities have on physical
function, cognition, and social interactions for older adults in the community (de Leon et al.,
2003; Rosso et al., 2013; Stav et al., 2012). Therefore in order to enhance the health, well-being,
and quality of life of its residents, nursing homes must facilitate activity engagement. In
response, this study addressed a critical gap in the evidence by characterizing contemporary
nursing home activity programs.
The results of our study indicate that there might not be an association between the types
of activities provided and the organizational characteristics of the facility. However, the
descriptive findings do show that there are a diverse range of activities provided in nursing home
Exploring Residents’ Engagement in Activities 47

facilities. The more common activities (i.e., exercise, coffee hours, current events, etc.) were
provided in almost all of the facilities whereas the less frequently provided activities (i.e.,
gardening, pet therapy, outdoor activities, etc.) were mainly in larger for-profit facilities with at
least a 3-star quality rating. This finding contradicts existing literature that has often found non-
profit nursing home facilities to provide better overall quality of care as compared to for-profit
facilities (Comondore et al., 2009). However, our findings might be explained by for-profit
facilities having more financial resources as compared with non-profit facilities (Bos, Boselie, &
Trappenburg, 2017). Thus, for-profit facilities might have access to the necessary resources to
support these less common activities, such as gardening, outings, and pet therapy, which require
additional supplies.
The less frequently occurring activities were provided in facilities with at least a 3-star
rating. This is consistent with current literature in how many of these activities are able to
improve physical and social well-being of older adults, which can impact the quality of nursing
homes. For example, gardening and outdoor activities have been able to improve life satisfaction
and social interactions with other resident in nursing homes (Chapman, Hazen, & Noell-
Waggoner, 2007; Tse, 2010). Similarly, pet therapy activities can also improve social and
emotional well-being for older adults in nursing homes (Sollami, Gianferrari, Alfieri, Artioli, &
Taffurelli, 2017). Thus, it suggests that one method to improve the Medicare star rating for
facilities is to focus on activities that can improve resident’s physical ability and social
interactions.
Few facilities also provided the “residents’ choice” activities where residents were
explicitly stated to allow a choice in what they wanted to participate in. Overall healthcare
reform has focused on providing patient-centered care and allowing patients to direct their care
Exploring Residents’ Engagement in Activities 48

and make informed decisions about their healthcare (Bangerter, Heid, Abbott, & Van Haitsma,
2016). Studies have found providing patient-centered care for residents exhibited greater life
satisfaction and promoted quality of life and quality of care (Bangerter et al., 2016; Poey et al.,
2017). Therefore, by applying patient-centered care concepts to activities may also allow
residents to drive their own activity preferences and enhance their experience. Future research
should focus on evaluating the benefits and sustainability of a resident-driven activity program.

Limitations
A descriptive study was conducted that focused on nursing homes within Los Angeles
County, which may limit generalizability to other geographic regions. In addition, this may not
be representative of current nursing home activity programs given the sample size. Activity
calendars were also obtained for any month within 2017-2018 and variation in the types of
activities provided could be different month to month. Future research may want a more
homogenous set of calendars in the same calendar month to fully understand the current practice
of activity sessions and provide more comparability. Finally, the sample sizes for our sub-
analyses were relatively small. Thus future research will need to evaluate with larger sample
sizes to identify if there are relationships between the activities delivered and organizational
characteristics.
Conclusion
This study provides a foundational knowledge to better understand activity programs and
the type of activities that are delivered in nursing homes. Capturing the current state of activity
programs is important information that is necessary to guide the development of future activity
program initiatives. In addition, future research will need to further explore how these activities
Exploring Residents’ Engagement in Activities 49

are implemented to engage residents and which types of activities are most beneficial to
optimizing residents’ health, well-being, and quality of life.

Exploring Residents’ Engagement in Activities 50

Chapter 4: Manuscript #2
Nursing Home Residents’ and Staff Members’ Perspectives on Current Activity
Engagement Practice
Target Journal: The Gerontologist
Abstract
Purpose of the Study: To explore current nursing home activity program practices from the
perspectives of residents and staff members.
Design and Methods: Three purposively sampled nursing home facilities were recruited to
participate in a qualitative study. Data included audio-recorded and transcribed one-on-one semi-
structured interviews, observations (i.e., 4-5 hours/day for 14 days in each facility), and field
notes. Interviews sought the perspective of key stakeholders: residents (n=14), administrators
(n=3), and activity providers (n=9). Using a grounded theory approach, interview transcripts and
field notes were analyzed to identify codes and themes.
Results: A total of 201 hours of observation and 11.13 hours of interviews resulted in four
themes, which characterized contemporary nursing home activity program practices, including:
(a) the organizational process that guide program development, (b) strategies for fostering
engagement for newly admitted residents, (c) facilitating engagement during activity sessions,
and (d) optimizing engagement outside of structured activity sessions.
Discussion: The findings illustrated the development of activity sessions and the various
methods utilized to engage residents in activities, which can provide a foundation for improving
activity engagement in nursing homes.

Exploring Residents’ Engagement in Activities 51

The quality of care of nursing homes is often a priority for consumers, policymakers, and
researchers (Castle & Ferguson, 2010; Werner & Konetzka, 2010). A resident’s quality of life
can be greatly impacted by the quality of care of the facility. However, nursing home residents
are often found to have poor quality of life (den Ouden et al., 2015; Milke, Beck, Danes, &
Leask, 2009). One way to improve quality of life is through activity engagement, yet, nursing
home residents often lack engagement opportunities (Bo et al., 2006; Green & Cooper, 2000).
Specifically, residents are found to be spending most of their time inactive and expressing
depressive symptoms, boredom, and loneliness (den Ouden et al., 2015).
Activity engagement, which in this manuscript is defined as participation in activities, is
associated with improved physical health when engaged in different activities such as tai chi,
walking, and dancing (Bo et al., 2006; Chen et al., 2008; Guzman-Garcia, Hughes, James, &
Rochester, 2013; Wooton, 2010). Similarly, residents engaged in gardening, music, and other
social activities have a higher self-reported quality of life than residents who did not participate
in these activities (Kydd, 2001; Tse, 2010; Zimmerman et al., 2003). Despite these benefits,
residents are often not participating in any activities, which can put these residents at higher risk
for physical and cognitive decline (de Leon et al., 2003; den Ouden et al., 2015; Stav et al.,
2012).
Therefore, to optimize health and well-being, the Centers for Medicare and Medicaid
mandate that nursing homes must provide an ongoing activity program. Specifically, these
initiatives are required to take into account resident’s needs, preferences, and physical as well as
cognitive abilities (Omnibus Budget Reconciliation Act, 1987). Despite the positive health
benefits and national mandate, little is known about how activity programs are delivered to
residents. Qualitative studies have shown perspectives of nursing home residents with dementia
Exploring Residents’ Engagement in Activities 52

to understand their involvement in activities (Green & Cooper, 2000; Tak et al., 2015). However,
the perspective of residents without dementia is absent from the literature as are the
organizational strategies used to deliver activity programs. Thus, the purpose of this study was to
understand the current practices for activity engagement in nursing homes for residents without
dementia from the perspective of residents, activity providers, and administrators.

Design and Methods
In order to understand current practices for activity engagement, three different nursing
home facilities were purposively sampled to participate in a qualitative study. Data collection
included one-on-one interviews, facility observations, and field notes. Three facilities were
chosen to represent variation in types of nursing homes, which may in turn provide perspectives
on diverse approaches to delivering activity programs. The facilities were eligible to be included
in the study if they were a nursing home with long-term residents. Facilities were selected to
capture differences in geographic location, financial resources (i.e., staffing hours), and practice
culture (Schnelle et al., 2004). Staffing hours were obtained from Long-term Care: Facts on Care
in the US (LTCFocus; http://ltcfocus.org/), which is a publicly available database that provides
data on nursing home care in the US. The staffing hours represent the number of direct care
staffing hours per resident day for each facility. An initial list of facilities that met the eligibility
criteria was obtained from LTCFocus. Facility administrators were then contacted via email for
interest and participation in the study.
The final sample consisted of one facility located in a high poverty area based on Census
data and with low staffing hours. Conversely, the second facility was located in an area with low
poverty rates and high staffing hours. The third facility identified was a Green House nursing
Exploring Residents’ Engagement in Activities 53

home. A Green House nursing home is focused on a model of providing high quality care with
the goal of optimizing resident quality of life in a home-like environment (Cohen et al., 2016).
The institutional review board (IRB) at the University of Southern California approved the study.

Participants
Once the three facilities were identified, long-term residents, activity providers, and the
administrator was approached to participate in a one-on-one semi-structured interview, and
willing individuals were then consented according to the approved human subjects protocol. To
be eligible for the study, residents had to be at least 65 years or older, have lived in the facility
for at least 100 days, speak English, and willing to be interviewed. Given our focus on
understanding activity engagement among residents without dementia, residents who had a
diagnosis of Alzheimer’s or dementia were excluded. In addition, residents who attended activity
sessions and did not attend activity sessions were purposively sampled through observations.
Once a resident was identified, eligibility criteria were confirmed by the activity providers.
Eligible activity providers included the activity department directors and activity
assistants in the standard care facilities. Within the Green House nursing home, the shahbazim
are responsible for engaging residents in activities. It should also be noted that the Green House
model does not have structured activity programs as the standard care facilities do. The Green
House nursing home aim to have activities occur naturally for residents at their own choice. In
addition, the administrator or Green House nursing home equivalent (i.e., guide) was
interviewed.

Exploring Residents’ Engagement in Activities 54

Data Collection
The administrator and the activity providers were asked to participate in a semi-structured
interview by the researcher and consented. The time and location of the interview were intended
to meet the scheduling needs and comfort of the key informant, with efforts made to optimize
privacy and confidentiality. Similarly, residents were also invited to participate in interviews.
Residents were evaluated based on inclusion and exclusion criteria with assistance from the
activity director in the standard care facilities and the guide in the Green House nursing home.
Once eligibility was established, the researcher provided study information and requested
resident’s participation in the study. When a resident consented to participate, a time was
scheduled for the interview.
An interview guide was used to explore residents’ participation in activity programs
(Appendix A and Appendix B) Participants were also asked to complete a brief demographic
form that included age, gender, race/ethnicity, length of stay in the facility (for residents), and
years of experience in current position (for staff members).
To augment the interviews and capture the context and environment in which activity
programs were delivered, field observations were conducted in each of the three facilities. The
researcher sought to observe the facilities on a variety of days and times as well as during
structured activity programs and unstructured activities (e.g., family member engaging resident
in his/her room). Fourteen days of observations were done in each facility with each observation
session spanning four to five hours, for a total of 201 hours across the three nursing homes.
During the observations, field notes were taken to describe the activities provided and the
resident’s engagement towards the activity.

Exploring Residents’ Engagement in Activities 55

Data Analysis
Each interview was audio-recorded and transcribed verbatim. All transcripts were de-
identified. The transcripts were then analyzed using a grounded theory approach (Oktay, 2012;
Strauss & Corbin, 1998). A process of open coding was first done where each transcript was
reviewed and codes were applied broadly. During this process, codes were also compared and
grouped into larger categories (Charmaz & Belgrave, 2007; Moghaddam, 2006). The next step
was the axial coding phase. This phase is a deeper analysis of the codes that were initially
developed from open coding (Moghaddam, 2006). Specific themes were further explored during
this phase where subthemes can arise. Finally, the last stage was selective coding where core
themes were identified and analysis around these core themes was done (Moghaddam, 2006). In
addition, field notes were used to triangulate the data that came from the transcripts (Padgett,
2012). Atlas.ti, a qualitative data analysis software, was also used for data organization and
analysis.

Results
A total of 26 interviews were conducted in the three nursing homes with residents (n=14),
administrators (n=3), and activity providers (n=9). Table I presents the demographic
characteristics for the study participants. Residents were mostly female (78.6%) with a mean age
of 77.4 (±11.5) years and an average duration of 2.2 (±2.6) years in the facility. The majority of
staff members were also female (75.9%) with an average age of 45.1 (±12.9) years and a mean of
4.9 (±4.3) years of experience working in their current position.

Exploring Residents’ Engagement in Activities 56

Table I. Participant Characteristics
Variable
Participants (n=26)
Residents, n 14
Age in years, mean, (SD) 77.4 (11.5)
Female, % 78.6
Race/Ethnicity, %

African American/Black 7.1
Asian 7.1
Hispanic/Latino 14.3
White/Caucasian 71.4
Length of stay in years, mean, (SD) 2.2 (2.6)
Staff members, n 12
Administrator, n 3
Activity providers, n 9
Age in years, mean, (SD) 45.1 (12.9)
Female, % 76.9
Race/Ethnicity, %

African American/Black 7.7
Asian 7.7
Hispanic/Latino 38.5
White/Caucasian 38.5
Years of experience in current facility, mean, (SD) 4.9 (4.3)

Four themes emerged from our analysis (Table 2): (a) the organizational process that
guide program development, (b) strategies for fostering engagement for newly admitted
residents, (c) facilitating engagement during activity sessions, and (d) optimizing engagement
outside of structured activity sessions. Subthemes also arose from the data within each of the
four main themes as identified in Table II.

Exploring Residents’ Engagement in Activities 57

Table II. Themes and subthemes emerging from the findings
Themes Subthemes
Organizational process that guide program development
Residents’ feedback
Resources
Strategies for fostering engagement for newly admitted
residents
Building rapport with
residents
Residents’ preferences
Facilitating engagement during activity sessions
Barriers to engagement
Facilitators to engagement
Optimizing engagement outside of structured activity sessions
Barriers to engagement
Facilitators to engagement

Organizational Process That Guide Program Development
This theme focused on how activity sessions are chosen and designed. Two subthemes
also emerged that described resident’s feedback to activities and resources needed. The nursing
home staff members frequently described activity development as an ongoing process. Each
month, the activity providers have an activity calendar with an initial set of activities from the
previous month. Changes are made to the activity calendar based on activity providers’
observations and thoughts on which activities can engage residents. As one activity provider
described how her facility often “…comes out with new activities all the time. We also like to
surprise them with new activities. Come out with something different because they don’t like
having the same thing over and over and over again. We get tired. So I am always thinking and
inventing new things, different things.” By consistently adding a variety of activities, providers
aim to engage residents in activities.

Exploring Residents’ Engagement in Activities 58

Residents’ feedback. Activities often change based on feedback from the residents. Each
month, there is a resident council meeting where residents who are interested can come together
and meet with any member of the staff to discuss concerns or issues they have. One area that
residents can discuss is activities and provide their feedback to the activity providers on changes
they would like to see. For example, one activity provider noted how they decide what activities
to offer,
“We look it up or, you know, when we see the residents and they say ‘oh we’d like to
have nail polish’ or we’d like to have a spa day or something like that and so we just kept
the spa day on Thursdays. Another thing they were asking for, so during our resident
council meetings we ask them what outings they would like to see, are there any activities
that you miss, or used to do, which is part of the assessment. And if we’re like okay we
want to have more of a social or something, then we’ll add it.”

Resources. Activity development is also based on the resources that activity providers
have access to. At the beginning of each fiscal year, the activity providers meet with the
administrators to plan activities for the upcoming year and provide an estimated budget. Based
on this budget, the administrator allocates funds for the activity providers to develop their
activities. As one administrator described,
“So every year, we prepare a budget for the community and the life enrichment is a part
of that. So I hear first what our immediate needs are….So we basically get the input from
the life enrichment assistants and directors that do this and then we together as team
decide on the most efficient way for us to spend the dollars and maximize the quality of
life or meeting the needs of our residents.”
Exploring Residents’ Engagement in Activities 59

Strategies for Fostering Engagement for Newly Admitted Residents
The second theme was commonly brought up by the facility staff as a vital component in
facilitating activity engagement upon admission into the facility. When residents first move into
the nursing home, staff members felt it was important to inform residents of the activities
available and opportunities for engagement. Within this theme, two subthemes were identified as
strategies: building rapport with residents and understanding resident’s preferences.

Building rapport. Building rapport with residents begins when the resident is admitted
into the facility. The staff members described approaching the resident upon admission to the
facility to explain the availability of activities to them as part of the initial process to start
understanding the resident and make them feel welcome and comfortable. One activity provider
described the process that often occurred in her facility,
“When the resident arrives to the facility, the department head will visit the resident.
Introduce myself and I tell them, what is my name, what is my position in this place, and
that is the time that I bring my calendar too and I show the resident what is the kind of
activity that we have in the dining room and what is the time of the special events that we
celebrate. And we tell them about the room visit that we have. I explain to them that we
have movie time Fridays with the popcorn. So we essentially visit that resident as soon as
they arrive from the hospital with the calendar.”

Residents’ preferences. Similarly, during the initial visit, nursing home staff members
also approach the resident to understand their preferences. One resident described the activity
providers speaking to her when she came into the facility, “[Activity providers] came and
Exploring Residents’ Engagement in Activities 60

interviewed me and, you know, asked me about my interests.” However, another resident noted
that the staff members did not inquire about her interests and preferences when she first arrived
at the facility, “No, they [activity providers] did not ask [about activity preferences]. I would’ve
liked that [to be asked].”

Facilitating Engagement during Activity Sessions
Once a facility establishes an activity program, residents are able to attend the scheduled
activities. The participants reflected on how to optimize residents’ engagement in these activities.
Staff members described how they encouraged residents to participate in activities whereas
residents provided their thoughts on the activities provided. Specifically, two subthemes
emerged: the barriers to participating in activities and the facilitators to engaging residents
during activity sessions.

Barriers to engagement. One of the most common barriers described by residents was
the limited opportunities to participate in activities. Even though there were multiple activities
provided in the facility in a given week, residents reported that there were other activities that
they would prefer to engage in, which were not provided in the activity program. Many residents
noted that they preferred having more activities around the music and arts available, especially
for residents who had interests in music and arts prior to coming into the facility. For example,
one resident expressed her interest in music, “I used to play the piano. I still remember how to
play…I would go to the music ones [activities] if they had it.”
In addition, of the activity sessions that were held, some did not meet the resident’s
interests or skill level. One resident noted that they “…were not interested in the current
Exploring Residents’ Engagement in Activities 61

activities.” The activities were not tailored for her interests. This was also reflected in the field
observations when the activity providers would invite residents into the activity rooms for the
program, but residents would refuse to go once they asked what type of session was being
provided that day. Similarly, some of the activities that were provided were not challenging for
the resident as one resident described her experience with activities, “I think the activities are
pretty lame. The activities are for toddlers…If they color, I’ll color even though I don’t like what
they’re coloring, but I think painting would be better than crayons. I think you need more skill to
hold a paintbrush than you do with crayons.” The lack of a challenge can discourage residents
from engaging in activities if they find it to be too simple for them.
The staff members also described individual characteristics of the residents as a potential
barrier to engagement. The individual characteristics include the resident’s health and functional
status as well as their individual personality. From the facility observations, there were residents
who preferred to be on their own and not participate in any of the activities delivered. Staff
members also described how residents who have cognitive decline are more difficult to engage
because it is a challenge to communicate with the residents to understand their needs and
preferences.

Facilitators to engagement. Staff members described strategies utilized to facilitate
engagement among residents. Staff members identified communicating with family members as
a strategy to better understand residents’ activity preferences and increase engagement,
especially for residents who have difficulty communicating their preferences. One staff member
described their constant communication with family members for residents who were unable to
communicate, “We are talking to the family members always. What they [the resident] engaging
Exploring Residents’ Engagement in Activities 62

in before, what they like, don’t like, all those things. We have discussed with them [the family].”
Activity providers also discussed including family members in activities as a strategy to
convince residents to participate in activities. An activity provider noted the strategy that she
utilized,
“I’ve noticed a few residents they [the resident] won’t go unless their wife or daughter or
sister or somebody is visiting them. So I would like walk into the room and say ‘hey you
want to do some exercise,’ and they’re [ the resident] like ‘no,’ and then the daughter
will be like ‘come on, mom, let’s go do exercises,’ and they’re like ‘okay.’ And then they
go and they find out they really love it and when the daughter, sister, or whatever leaves,
they still want to do it.”
This strategy was also witnessed in the observations where family members helped bring the
resident to the activity room and encouraged them to engage in the activity. A number of family
members also participated in the activity session as a way of promoting engagement.

Optimizing Engagement Outside of Structured Activity Sessions
The participants commonly described activity engagement occurring outside of scheduled
activity sessions. Within this theme, two subthemes emerged: barriers and facilitators to
engagement outside of the activity program. For residents who are unable to attend the activity
sessions, which can be a result of personal preference or health limitations, activity providers
engage residents in their rooms. The most common form of activity engagement was through
one-on-one resident-staff interactions. One of the activity providers described examples of
certain activities done in the residents’ rooms, “…from my perspective, the ones that use one-on-
ones the most are lower functioning, especially if they…something like music therapy that we do
Exploring Residents’ Engagement in Activities 63

a lot of like turning on the radios or…I’m trying to think of what else…or like pet therapy where
they bring the dog around to each individual…”

Facilitators to engagement. In addition to providing one-on-one activity sessions,
participants described the individualized attention as a facilitator to engagement for staff
members to connect with residents and understand their needs and preferences that are not
restricted to the activity programs. One resident described the importance of creating the
individualized interaction, “And they [activity providers] become real people with families. It’s
that thing they create and I don’t know how they create that connection with people. The doing
part is important but it’s also the doing with people that’s important.”
The organizational culture was also described as a facilitator on resident activity
engagement throughout the facility. When a nursing home prioritizes resident activity
engagement, it allows the staff members to feel confident to engage residents. This prioritization
occurs when management focuses on engagement as a key component of delivering care. One of
the administrators emphasized the importance of activities for the facility he was in,
“So, generally, life enrichment as a whole as part of the activity department is very
important for us. Without that we’re not really meeting all the needs of our residents. So
primarily the physical contributions that we make to the residents’ wellbeing is just a
relatively small part. The social aspect or the life enrichment or the activity, I will
consider equally if not more important than just assisting somebody with activities of
daily living.”
The same administrator was also observed attending activity sessions and encouraging both
residents and staff members (e.g., nursing, social work) to enter into the activity room and
Exploring Residents’ Engagement in Activities 64

participate in the activity session. Just by having staff members engaging residents for a few
minutes was able to provide a more upbeat and positive environment for residents.
In addition, by acknowledging the importance of activities, the activity providers feel
they have more support and access to resources that can help them engage residents. For
example, one activity provider described the training opportunities that were available to staff
members, “I appreciate that it’s an option that if there was something I wanted to go learn more
about, [Facility Name] as a whole, does have scholarship opportunities. Like if you wanted to go
back to school.” The extra support and resources allow staff members to feel empowered to
actively engage residents both during and outside of activity sessions.

Barriers to engagement. Staff members frequently referred to a resident’s physical
health as a common barrier to engaging in one-on-one sessions. Pain in particular was identified
as one of the most frequent limiting factor that inhibited residents from participating in activity
programs. One activity provider described pain as a major barrier to engage residents,
“Pain. We always, when the residents…they refuse [activities] all the time because they
are in pain. So then I have to communicate with the nurses and let them know that the
pain medication is needed in order for that resident, you know, to do activities. So I have
to be on top of that, making sure the resident received their pain medication.”
At an organizational level, time constraints were a commonly identified barrier by staff
members. Time constraints were described around the multiple responsibilities that a few activity
providers had that negatively impacted their ability to engage residents. For example, one
activity provider described her interaction with a resident and how her job responsibilities
impacts the time she can spend with a resident,
Exploring Residents’ Engagement in Activities 65

“But unfortunately she [the resident] wants me to sit there with her for an hour or so and
[talk], you know, you just wish you had that spare time to give her all of that quality of
time, but there is of course other things that take place, and you just can’t. And at times I
wish, you know, oh my god it would be so nice to be able to sit here, but that’s just…I
don’t think that’s realistic. It’s just hopeful. But that would be nice, yeah, to have a little
more time to actually get more involved and do what they would want to do.”

Discussion
The aim of the study was to fill the gap in literature and to explore how activity
engagement occurred in nursing homes. Thus, our findings identified how activities were
designed and the factors that impacted activity engagement from the perspectives of nursing
home staff members and residents. By understanding how residents are engaged in activities, it
can provide insight into how to improve engagement and consequently enhance residents’
quality of life.
Our findings indicate that staff members utilize different approaches to learn about and
respond to residents’ preferences and interests when developing activities. This could be a result
of federal mandates to meet the preferences of residents when providing activities (Omnibus
Budget Reconciliation Act, 1987). However, there were contradicting perspectives from
residents on the extent of whether their activity interests were taken into account. From our
findings, some residents reflected that activity providers asked about their interests while others
were not asked, which indicates the inconsistency in practice among activity staff. Research has
shown that individuals are more likely to engage in activities that they find more meaningful
(Stern, 2005; Tatzer et al., 2012; Wilcock, 2005). Thus in order to improve engagement it is
Exploring Residents’ Engagement in Activities 66

important to understand resident’s preferences, which can be done through effective
communication between staff members and residents.
In addition, barriers to activity engagement during activity sessions were also identified
by participants. It was frequently noted that some activities were not appropriate for resident’s
skill level. This reflects current literature that has found that individuals often engage in activities
that provide a challenge for them (Diamond, 2015; Park et al., 2014). Activities that do not
provide a challenge are often uninteresting for older adults. In order for residents to be engaged
in activities, the activity itself needs to present an appropriate amount of difficulty. It is
important for activity providers to assess the physical and cognitive limitations of the residents to
be able to properly develop activity programs. This can be difficult given the range of functional
statuses among nursing home residents. Thus, further training is needed of activity providers to
properly identify these limitations among nursing home residents and then develop appropriate
activities. Currently, only activity directors are federally mandated to be certified, however
activity assistants do not have the same requirements (Centers for Medicare & Medicaid
Services, 2011). Consequently, activity assistants may not go through the same training and
education that activity directors are required to. Thus, in order for all activity professionals to
understand how to provide appropriate activities for residents, federal requirements should
mandate all activity providers have training in delivering appropriate activities. This training
needs to educate staff members on how to tailor activities to residents’ health and functional
status.
The culture of a facility can be a driving force on what areas are prioritized by the staff
members. The findings from our study also characterized the importance of the facility’s culture
in terms of focusing significant efforts in developing an environment that encourages resident
Exploring Residents’ Engagement in Activities 67

activity engagement. If a facility has a culture of fostering activity engagement, staff members
will prioritize this during their daily routine, which can improve resident’s engagement. This is
reflective of the continuous push to bring culture change to nursing homes to improve overall
nursing home quality (Buettner, 2009; Zimmerman & Cohen, 2010).
In addition, with the prioritization of patient-centered care in healthcare, this can translate
into activity programming practice. By implementing quality initiatives in involving residents
and family members in activity development to design patient-centered programs, it can improve
engagement. Future research is needed to further understand the development and
implementation of patient-centered activity programs.

Limitations
This study was limited to facilities within one geographic region. In addition, only
residents, activity providers, and administrators were interviewed. There are many other key
stakeholders who interact with residents and can engage residents during their daily routines
(e.g., certified nursing assistants, family members), and can contribute to our understanding on
this issue. Thus, future research is needed to better understand the other disciplines and
perspectives of family members that have a role in engaging residents in activities.
Conclusion
This study illustrated how nursing home staff members engaged residents and how
activities were developed. The findings from the study also identified barriers and strategies to
engaging residents, which highlights areas that can be improved to optimize engagement. By
first understanding the current practice, it can contribute to future research and activity program
development on how to improve activity engagement.
Exploring Residents’ Engagement in Activities 68

Chapter 5: Manuscript #3
Three Different Approaches to Delivering Activities to Nursing Home Residents
Target Journal: Journal of Aging Studies
Abstract
Nursing home residents frequently spend their day inactive, despite mandates to provide
activities for residents that foster participation. This is particularly concerning given the
relationship between limited engagement and lower resident physical and cognitive function
than. Thus, the purpose of this study was to understand approaches to providing activities for
residents in different facilities. A mixed methods study was completed in three nursing homes,
which differed based on model of care and available resources. To understand how activities
were delivered, staff and resident interviews and facilities observations were conducted. To
quantify the range, frequency, and type of activity programs, calendars were also collected from
each facility. Results identified variation in the delivery of structured and unstructured activity
programs, yet across facilities there were some similarities in the types of activities offered (e.g.,
one-on-one activities). These findings can help inform future activity program development
intended to enhance engagement and optimize the overall health of residents.

Exploring Residents’ Engagement in Activities 69

Inactivity among nursing home residents is common, which can lead to decline in
physical function (den Ouden et al., 2015; Pruchno & Rose, 2002). Moreover, for nursing home
residents who are already frail, limited activity participation can lead to greater dependency and
lower quality of life (Palese et al., 2016; Stav et al., 2012). Thus, activity engagement is a vital
component to resident’s quality of life. Toward this end, nursing homes are mandated to provide
daily activity programming that takes into account an individual’s physical and cognitive
abilities as well as their social well-being in order to promote socialization and optimize
residents’ health and well-being (Omnibus Budget Reconciliation Act, 1987).
Despite this national mandate, residents may spend their day sleeping, involved in self-
care tasks (e.g., eating and hygiene-related tasks), or “doing nothing” (den Ouden et al., 2015).
Research has frequently focused on evaluating targeted interventions to illustrate the benefits of
activity engagement on physical function, cognitive ability, and social relationships (Chen et al.,
2008; Fitzsimmons, 2001; Stav et al., 2012). However, these interventions focused on
demonstrating effectiveness. The evidence has not yet progressed to evaluate implementation,
sustainability, or systematically explore the relationship between current practices and desired
outcomes. Furthermore, there is a dearth of evidence evaluating the current state of activity
programs in nursing homes, how routine activity sessions are sustained, or how programs differ
across organizations.
Studies that attempted to understand the state of current activity sessions in nursing
homes are largely focused around residents with dementia (Harmer & Orrell, 2008; Tak et al.,
2015). However, residents with dementia only represent half of the nursing home population
with residents having a range of physical and cognitive limitations (Harris-Kojetin et al., 2013).
Moreover, activities tailored specifically for residents with dementia may not be appropriate for
Exploring Residents’ Engagement in Activities 70

all residents given their varied abilities. Thus, there is a gap in research on how activities are
delivered to residents who do not have dementia. The aim of this paper is to understand different
approaches to delivering activities in nursing homes to characterize the current state of nursing
home activity sessions.

Methods
A mixed methods study was conducted to describe current practices for providing
activities to residents in nursing homes. Three different nursing homes were purposively sampled
based on organizational characteristics to represent the variation in facilities in order to capture
the various methods that activities are delivered. Specifically, we purposively sampled facilities
(n=3) providing “standard long-term care” and an “alternative model of care.” The “alternative
model of care” facility was a Green House nursing home. The Green House model is based on
the principles of residents living in a real home, providing residents a meaningful life, and
empowering the staff. The goal of the model is to change the culture of nursing homes and de-
institutionalize traditional nursing homes. The Green House nursing home is designed as a small
home-like facility with a focus on delivering person-centered care.
Among the facilities delivering “standard care,” two nursing homes were sampled to
reflect poverty in the geographic region and financial resources of the facility (e.g., staffing
hours). These two variables were identified since nursing home quality of care has been
associated with geographic location of the facility as well as staffing levels (Mor, Zinn,
Angelelli, Teno, & Miller, 2004). Facilities that have lower staffing levels are often located in
lower socio-economic locations. Staffing hours were obtained from Long-term Care: Facts on
Care in the US (LTCFocus; http://ltcfocus.org/), which is a publicly available database that
Exploring Residents’ Engagement in Activities 71

provides data on nursing home care in the US. The staffing hours represent the number of direct
care staffing hours per resident day for each facility.
Therefore, one facility was located in an area with high poverty rates based on Census
data and was a low resource facility, as indicated by low staffing hours (Schnelle et al., 2004).
The second facility was located in an area with low poverty rates and high staffing hours. The
third facility was sampled based on care model, where a Green House nursing home was
identified in order to compare to the standard model of nursing homes. Eligible facilities
included nursing homes with long-term residents. Facilities that were assisted livings, specialized
only in dementia care, or only cared for short-stay residents were excluded. An initial list of
nursing homes within Los Angeles County that met inclusion and exclusion criteria was obtained
through LTCFocus. Three facilities that met each of the criteria identified above were contacted
for participation in the study. A total of five facilities were contacted as two initial facilities
declined to participate. The institutional review board (IRB) at the University of Southern
California approved the study.

Participants
The purpose of the qualitative data collection was to identify key stakeholders’
perspectives on current practice of delivering activities. Semi-structured interviews were
conducted with long-term residents, activity providers, and administrators from each of the three
facilities. To be eligible for the study, residents had to be at least 65 years or older, have lived in
the facility for at least 100 days, speak English, and willing to be interviewed. In addition,
residents were then purposively recruited to capture the perspective of both those who attended
and did not attend activity sessions. Residents who had a diagnosis of Alzheimer’s or dementia
Exploring Residents’ Engagement in Activities 72

were excluded. Once a resident was identified, eligibility criteria were confirmed by the activity
providers. Eligible activity providers included the activity department directors and activity
assistants in the standard care facilities. Within the Green House nursing home, the shahbazim
are the ones who are responsible with engaging residents in activities. It should also be noted that
the Green House model does not have structured activity programs as the standard care facilities
do. In addition, the administrator or Green House nursing home equivalent (i.e., guide) was
interviewed.
Each of the key stakeholders were invited to participate in a semi-structured interview
with the researcher. Once the staff members consented, the time of the interview was determined
based on the staff’s availability and a location was chosen to optimize their privacy and
confidentiality. Residents, who were purposively identified to participate in the interviews, were
screened for eligibility criteria with assistance from the activity providers. Once residents agreed
to participate, a time was setup for the interview.

Data Collection
An interview guide was used by the researcher to facilitate the one-on-one interviews
with each of the stakeholders (Appendix A and Appendix B). Questions explored from each of
the different perspectives how residents were engaged in activities, the structure of delivering
activities, and barriers and facilitators to participating in activities. Participants were also asked
to complete a brief demographic form that included age, gender, race/ethnicity, length of stay in
the facility (for residents), and years of experience in current position (for staff members). In
addition, field observations were also conducted in each facility to better understand the culture
of the facility and the context of activities. Observations were completed on various days and
Exploring Residents’ Engagement in Activities 73

times and during formal activity sessions and unstructured activity occurrences (e.g., certified
nursing assistant engaging a resident in his/her room). Fourteen days of observations were done
in each facility with each observation session spanning four to five hours, for a total of 201 hours
across the three nursing homes. During the observations, field notes were taken to describe the
activity provided and the resident’s engagement to the activity.
The quantitative data collection comprised of the organization characteristics and activity
calendars from the three facilities. The organizational characteristics were obtained from
LTCFocus and included total number of beds, ownership status, chain status, residents with
Medicare and Medicaid, staffing hours, and Medicare’s star quality rating. As a proxy for facility
size, the number of beds captured the total number of beds available in each facility. Ownership
status for each facility was defined as for-profit or non-profit. The chain status of each facility
was also identified as being a facility within a chain or not within a chain. Medicare and
Medicaid are the most common health insurance coverages that residents utilize, and thus the
percentage of residents whose primary funder for the time in the facility was Medicare or
Medicaid in the facility was obtained. In addition, staffing hours were obtained and defined as
the number of direct care staffing hours per resident day for each facility.
Finally, Medicare star ratings were also obtained for each of the nursing homes from
Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare Website. The
objective of this website is to provide consumers with quality-related information on all
Medicare certified nursing home facilities and hold providers accountable for the care they
provide ((https://data.medicare.gov/data/nursing-homecompare). The star rating system is a
summary score given to each facility by CMS based on health inspection results, staffing data,
and quality measures. Quality measures are based on a variety of domains for both long-term and
Exploring Residents’ Engagement in Activities 74

short-term residents, including residents' health, physical functioning, mental status, and general
well-being. This star rating is on a 5-point scale with five stars as excellent, four stars as above
average, three stars as average, two stars as below average, and one star as poor (Owen, 2014). In
addition, poverty rate was obtained for each geographic location from Census data and was
defined as the percent of people in poverty in that region.
In addition, activity calendars were collected from the two standard care facilities. An
activity calendar is required for nursing homes to maintain in order to show residents a list of
activities that are provided on a day-to-day basis each month and is posted in an area that can be
seen by residents (Buettner & Fitzsimmons, 2003). Green House nursing homes do not provide
structured activity programs since the model is focused on de-institutionalization and it is
expected for residents to engage in activities organically throughout a day. Thus, types of
activities that occurred in the Green House nursing home were identified through the interviews
and observations.

Data Analysis
The qualitative data was analyzed using a grounded theory approach (Oktay, 2012;
Strauss & Corbin, 1998). The interviews were audio-recorded and then transcribed verbatim.
First, open coding was done where each transcript was reviewed and codes were applied broadly.
During this process, codes were also compared and grouped into larger categories (Charmaz &
Belgrave, 2007; Moghaddam, 2006). Subsequently, the axial coding phase, which was a deeper
analysis of the codes that were initially developed from open coding, was completed
(Moghaddam, 2006). Specific themes were further explored during this phase where subthemes
can arise. The last phase was selective coding where core themes were identified and analysis
Exploring Residents’ Engagement in Activities 75

around these core themes was done (Moghaddam, 2006). In addition, field notes were used to
triangulate the data that came from the transcripts. Atlas.ti, a qualitative data analysis software,
was also used.
The quantitative data analysis included evaluating the activity calendars and conducting
descriptive statistics to summarize the activities provided and the organizational characteristics
of the three facilities. The activity calendars were reviewed to identify the number of different
activities that were provided over a 30 day period. Similar activities were grouped together to
construct mutually exclusive categories. For example, basketball, stretching, and movement
activities were collapsed to create the exercise group. Activities that fell into multiple categories
were classified by their primary purpose. For example, watching a movie at a movie theater was
classified as an outing as the primary focus is taking a trip out into the community. Thirty-eight
mutually exclusive categories were identified (e.g., arts and crafts, outings, etc.)
The initial qualitative and quantitative analyses were conducted separately in each of the
three facilities. The results from the initial analyses were then compared across facilities
(Creswell & Plano Clark, 2011). The themes and subthemes that arose from the qualitative data
were compared and similar and different themes were identified. From the quantitative results,
the types of activities were also compared with each other across the three facilities.

Results
From our data analysis, we identified three different approaches to delivering activities.
In the following sections, we will present the different approaches that each of the three nursing
homes took to providing activities, summarize the quantitative findings for each facility, and
identify similarities and differences in delivering activities. Table 1 provides the descriptive
Exploring Residents’ Engagement in Activities 76

organizational characteristics of each facility and Table 2 highlights the demographics for the
participants in the interviews.

Table 1. Facility Characteristics
Organizational
characteristics
Low Resource
Facility
High Resource
Facility
Green House
Facility
Number of beds 81 54 24
Chain status Yes Yes No
Profit status For-Profit Non-Profit Non-Profit
Medicaid, % 26.32 Unavailable* Unavailable*
Medicare, % 64.47 57.89 Unavailable*
Nurse Staffing hours 3.73 5.30 5.17
Medicare Star Rating 3 5 5
Poverty Rate, % 20.50 15.30 17.90
*Unavailable = data was missing from LTCFocus

Table 2. Interview Participant Characteristics
Variable
Participants (n=26)
Residents, n 14
Age in years, mean, (SD) 77.4 (11.5)
Female, % 78.6
Race/Ethnicity, %

African American/Black 7.1
Asian 7.1
Hispanic/Latino 14.3
White/Caucasian 71.4
Length of stay in years, mean, (SD) 2.2 (2.6)
Staff members, n 12
Administrator, n 3
Activity providers, n 9
Age in years, mean, (SD) 45.1 (12.9)
Female, % 76.9
Race/Ethnicity, %

Exploring Residents’ Engagement in Activities 77

African American/Black 7.7
Asian 7.7
Hispanic/Latino 38.5
White/Caucasian 38.5
Years of experience in current facility, mean, (SD) 4.9 (4.3)

Differences across Facilities
The following section highlights the unique approaches that the three different nursing
homes utilize in developing and delivering activities. Each of the facilities had a different
method when providing their activity programs.

Low resource nursing home. The facility was considered a lower resource nursing
home because of geographic location (i.e., high poverty rates) and low resources (i.e., staffing
hours). It was a for-profit chain facility with 81 beds. The nursing home provided 20 different
types of activities in one month. The most frequent types of activities that were provided
included socials (e.g., ice cream socials), which occurred 27 times in a month and exercises,
which occurred 18 times. Religious (n=2) and cooking (n=4) activities that were less frequently
offered over a 30-day period.
A total of 3 staff members and 6 residents participated in one-on-one semi-structured
interviews. From the qualitative analysis, participants described the structure of the activity
sessions and how residents were engaged. In this nursing home, scheduled programs are
provided based on the activity calendar each month. Residents are informed of the opportunities
when they first arrive at the facility as the activity provider described the process,
“When the resident arrives at the facility, the department head [activity director] will
visit the resident. I introduce myself and I tell them my name, what is my position in this
Exploring Residents’ Engagement in Activities 78

facility, and that is the time that I bring my [activity] calendar too and I show the
resident what kinds of activity that we have in the activity room and what is the type of
the special events that we celebrate”
Residents are also approached during the beginning of their stay to make note of their
preferences to activities.
During the scheduled activity programs, residents are taken into the activity room by the
certified nursing assistants (CNA) to participate in the activities. From the field observations, the
activity room had on average 20 to 30 residents attending each scheduled session. However,
many residents also choose to remain in their rooms and not attend the activity sessions. One
resident described her reason for not attending the structured activities,
“I don’t feel comfortable sitting there [in the activity sessions]. Everybody is in
wheelchairs. Some don’t know where they are and they put them in the dining room so
they’re out of their rooms for a while. That would be the most dehumanizing thing for me.
I mean it’s wonderful to have that [activities]. Anyways, I just don’t participate. I think
it’s wonderful, just not for me”
For the residents who did not attend activity sessions, they had opportunities to engage in one-
on-one activities with the activity providers. During the day, one of the activity providers would
go on room visits for residents who chose to remain in their rooms and provide them with
materials (e.g., newspapers, books, etc.) to engage in activities. However, one resident noted the
limited supplies available to engage in activities on her own, “Believe me I would’ve been
watching movies. I have a lot of movies. I mean I wish I could’ve. I mean we don’t have
earphones or anything so it’s kind of difficult with two people [sharing a room] because we like
different things and the noise.”
Exploring Residents’ Engagement in Activities 79

High resource nursing home. The higher resource facility, which was defined as being
located in an area with low poverty rates and having high staffing hours, had 54 beds. It was a
non-profit facility and part of a chain. There were 21 different types of activities delivered each
month. The most frequent types of activities that were provided in a month included exercises
(n=26) and music (n=39) whereas the least frequently offered were cooking (n=2) and coffee
hour (n=4).
Four staff members and seven residents participated in the qualitative data collection. The
participants described the process of informing residents of activities and the structure of activity
sessions. Upon admission to the facility, a formal assessment is completed by the activity
providers as the activity director described, “We have this assessment, it’s just for us to know a
little bit more about the residents. And how they’re responding and how they’re reacting, that’s
when we know, okay this resident is higher functioning or this resident is lower functioning.”
Once the initial assessment is completed, the activity providers classify each resident based on
their function level as high or low. Activity sessions are then tailored for the residents’
functioning level. However, residents are able to attend any of the sessions regardless of
functional level if preferred. Since activity sessions are tailored, each schedule program have
fewer attendees as compared to the lower resource facility, which was identified through field
observations.
In addition to the scheduled activity sessions, the activity providers also provide residents
with activities one-on-one. One of the activity providers described how she would go around to
residents to offer them supplies so they can participate in an activity,
Exploring Residents’ Engagement in Activities 80

“Sometimes in the mornings I would just go around and if someone [a resident] is by the
nurse station and like if they’re just sitting there I would say ‘oh do you want a
newspaper?’ Or I call it my room visit folder, I just have crossword puzzles and word
searches and coloring. So I just walk in and go ‘hey can I interest you in anything.’ So if
they’re bored or something then it’s something they can do.”
A resident also described requesting supplies from the activity providers and have them bring it
to her in her room, “...she [activity assistant] asked me what my interests were and everything
and I told her that at home I liked to do adult coloring. And so she [activity assistant] is the one
who brought me those coloring books and coloring pencils.”

Green House nursing home. The Green House nursing home model is focused on
providing quality care in a home-like environment. Thus, in this non-profit facility every resident
had their own room with a total of 20 beds. This particular Green House nursing home was
located on a continuing care retirement community campus. Moreover, Green House nursing
homes, do not offer structured activities with a monthly calendar, which is different from the
“standard care” nursing home. In this context, it is expected for activity engagement to occur
naturally throughout a normal day as the resident interacts with the shahbazim. Toward this end,
activities could not be quantified.
Five staff members and two residents were interviewed in the Green House nursing
home. The participants described the different opportunities that residents have to engage in
activities. Most commonly, participants noted that since the shahbazim have the most interaction
with the residents, they are able to develop an individualized relationship with each resident to
understand their needs and preferences. One staff member noted, “…the deep knowing that
Exploring Residents’ Engagement in Activities 81

happens here enhances the quality of life for the residents…And so it [engagement] happens, I
think, often and throughout the day.”
The relationship that the shahbazim form with the residents allow the shahbazim to
engage residents and learn more about their preferences during routine activities of daily living
texts. For example, one staff member described how activities can occur, “…we [shahbazim]
kind of go with the flow of the home. But there is always some activity. It’s just not structured or
scheduled on the same time every day. It could be a movie, we [shahbazim and residents] could
watch a movie together, we could listen to music together, we could build a puzzle together and
so forth.” Activity engagement occurs organically to provide the feeling of the “home-like”
environment and allowing the residents to make choices.
However, since shahbazim are responsible for the residents’ care and maintenance of the
home, engaging residents in activities may not be their priority. It can also be a challenge to be
able to handle all of their responsibilities and provide activities for residents. As one resident
noted, “the shahbazim do it all. The challenge is that they can’t…just they can’t.”
In addition, residents also have the opportunity to engage in activities outside of the
nursing home. For example, one resident was interested in painting classes and the staff members
were able to help her to find a nearby community class for her. Since this particular facility was
on a continuing care retirement community campus, residents also had the opportunity to
participate in activities provided in the independent and assisted living buildings.

Similarities across Facilities
Table 3 illustrates the types of activities and frequency provided across the three facilities
that were identified from the activity calendars. Since the Green House nursing home does not
Exploring Residents’ Engagement in Activities 82

provide structured activities, there were no activity calendars available. Therefore, the
information about the types of programming was ascertained from the qualitative interviews and
observations. Activity types that were not acknowledged in the interviews or noted from
observations were marked as “not identified” because the assumption that the activity is not
provided cannot be made. Across the three facilities, similarities were identified on types of
activities delivered and current practices for providing activities.

Table 3. Frequency of Activity Types
Activity Types
Low Resource
Facility
High Resource
Facility Green House Facility
Arts 9 16 described from qualitative interview
Beauty Salon 4 4 not identified
Bingo 14 0 not identified
Card Games 0 5 not identified
Coffee Hour 12 4 not identified
Cooking 4 2 described from qualitative interview
Current Events 18 0 not identified
Educational Lectures 0 9 not identified
Exercise 16 26 identified from observations
Movies 4 4 identified from observations
Music 13 39 described from qualitative interview
Pet Therapy 0 9 identified from observations
Religious Activities 2 13 not identified
Resident Council
Meetings
1 6 not identified
Room Visits 0 8 described from qualitative interview
Socials 27 7 described from qualitative interview
Trivia Games 9 15 not identified
Technology 0 18 not identified

A total of 18 activity types were provided in at least one facility as listed in Table 3. Six
activity types were identified in all three facilities (i.e., arts, cooking, exercise, movies, music,
Exploring Residents’ Engagement in Activities 83

and socials). Room visits, which are one-on-one sessions with residents in their rooms, was also
provided in all three facilities however it was not listed in the activity calendars for the low
resource nursing home, but described by the staff members in the interviews. This was similar to
the Green House nursing home where participants explained engaging residents individually in
their rooms.
From the qualitative data, similar strategies were identified in all three facilities to
engaging residents. One such strategy was informing residents about activities upon admission
into the facility. Residents and staff members also described understanding residents’ preferences
to activities. This process was frequently done through assessments, informal conversations with
residents, or reaching out to family members for information.

Discussion
This study explored approaches to providing activities in three nursing homes with varied
organizational characteristics. Each of the facilities had a different approach in delivering
activities. The lower resource facility’s activity program was offered based on the activity
calendars where staff members took into consideration resident’s preferences, but the sessions
were provided for all residents. The higher resource facility stratified activity programs on the
residents’ physical and cognitive abilities to decide which sessions would best optimize
engagement. The Green House nursing home provided activities naturally with no scheduled
sessions, allowing for the residents to guide the occurrences of engagement.
The major difference between the “standard care” nursing home and the Green House
nursing home was the absence of structured activities and activity professionals. A unique
component of the Green House nursing home is to have the shahbazim provide all the care for
Exploring Residents’ Engagement in Activities 84

the residents and the house, which includes engaging residents in activities. The idea behind
having shahbaz as a universal worker was to allow for residents to have consistent care and to
empower staff to run the facility (Zimmerman & Cohen, 2010). However, our findings indicate
that the shahbazim may have too many responsibilities, which can hinder their ability to make
time to engage residents. This can contradict a key principle of the Green House model and thus
this implicates that continued development of this approach is needed to take into account the
responsibilities that shahbazim have and ensure aspects of residents’ care is not sacrificed.
For the higher resource facility, their activity programs were stratified based on the
functional levels of the residents. Since residents in nursing homes can have varied functional
and cognitive limitations, by tailoring activities to their appropriate abilities can allow them to
engage in the activity. This is reflective of literature that illustrates engagement in individualized,
tailored activities can improve quality of life of residents (Kolanowski et al., 2006). Future
activity development needs to take into account residents’ abilities in order to optimize
engagement.
There were also similarities in strategies that were used in the three facilities, such as
providing induvial sessions with residents and evaluating residents’ preferences when they enter
into the facility. Providing one-on-one engagement was common across all three facilities.
However, the approach to providing one-on-one engagement varied across the three facilities. In
the two “standard care” facilities, individual activity engagement occurred during room visits
and was provided for residents who did not want to attend the structured activity program. For
the Green House nursing home, the concept of individualized care is a core component of the
model and is applied to all aspects of care including engaging residents in activities (Cohen et al.,
Exploring Residents’ Engagement in Activities 85

2016). Residents in the Green House nursing home have shown to have higher rated quality of
life than residents in a standard care nursing home (Cohen et al., 2016; Koren, 2010).
In addition, all three facilities also describe ascertaining residents’ preferences when they
are admitted into the facility. By taking into account residents’ interests and needs for activities,
it adheres to the federal regulation that requires activities to be delivered (Omnibus Budget
Reconciliation Act, 1987). In addition, this strategy is also reflective of individualized care that
is a part of the Green House model (Cohen et al., 2016). Thus, this implicates that components of
the Green House model can be translated into the area of activity engagement through an
individualized care approach regardless of engagement in formal activity sessions.

Limitations
There were limitations to this study. Three facilities were purposively recruited to
represent different organizational characteristics; however, the facilities that were chosen may
not be representative of all nursing homes with the same characteristics. In addition, all facilities
were sampled from the same geographic region, which may limit generalizability to other areas
of the US. There are also many other key stakeholders that we did not interview who interact
with residents and can engage residents during their daily routines (e.g., certified nursing
assistants, family members), and can contribute to our understanding on this issue. Future
research is needed to better understand the other disciplines and perspectives of family members
that have a role in engaging residents in activities. Finally, for the Green House nursing home,
only two residents were interviewed because other residents were excluded based on our
eligibility criteria. Thus, this can limit the generalizability of the residents’ perspectives to other
Green House nursing homes.
Exploring Residents’ Engagement in Activities 86

Conclusion
Our findings highlight three approaches to delivering activities in three different nursing
homes. We identified both similarities and differences in providing activities for nursing homes
that had varied organizational characteristics. This can inform future research on evaluating
which approaches can be most effective in engaging residents. We also found there are other
methods to providing activities outside of the structured activity programs (e.g., room visits).
This suggests that there are various ways that residents can be engaged in activities. Thus, these
findings can help inform the development of future activity programs in nursing homes.

Exploring Residents’ Engagement in Activities 87

Chapter 6: Conclusion
Conclusion
The overarching aim of this dissertation was to understand the gap in research on the
current state of practice for engaging nursing home residents in activities. In the following
sections, the summary of key findings, the implications, and future steps will be presented.

Summary of Key Findings
The first manuscript of this dissertation (Chapter 3) aimed to identify activities that were
currently delivered in nursing homes through collecting activity calendars. Specifically, the
frequency of activities and the different types of activities were identified. In addition,
organizational characteristics were obtained and evaluated with the different types of activities.
Our findings did not find a statistically significant relationship between the types of activities
provided and the various facility characteristics. However, our descriptive statistics identified
various types of activities that were delivered and had variations among different facility
characteristics. The descriptive results identified that less common activities that required more
resources were counted more often in for-profit facilities or facilities with at least a 3-star rating.
In addition, our findings reflect the lack of resident choice activities, which we conclude is an
important area that can be improved based on the focus of providing patient-centered care in
healthcare services.
Qualitative interviews and observations in three nursing homes (i.e., a low resource
facility, a high resource facility, and a Green House facility) were presented in the second
manuscript. The aim of this study was to understand the current practice of activity engagement
from the perspective of residents, activity providers, and administrators. Our findings resulted in
Exploring Residents’ Engagement in Activities 88

four main themes: (a) the organizational process that guide program development, (b) strategies
for fostering engagement for newly admitted residents, (c) facilitating engagement during
activity sessions, and (d) optimizing engagement outside of structured activity sessions. We
highlighted that resident’s preferences should be taken into account when providing activities
and more training in delivering activities should be required for activity providers.
Three different approaches to providing activities to nursing home residents (i.e.,
delivering activities based on activity calendars, tailoring activities to meet residents’ physical
and cognitive abilities, and allowing activities to occur naturally by residents’ preferences) were
compared in the third manuscript. Two of the facilities were “standard care” and the third was
the Green House nursing home. Similarities were identified in types of activities provided,
specifically one-on-one activities. However, the methods in which the activity was delivered
varied between the “standard care” and the Green House nursing home. Our findings highlight
the individualized care approach from the Green House nursing home that could be translated to
other “standard care” facilities. However, we also identified a barrier to providing activities in
the Green House nursing home.

Theory Approaches Guiding Results
The social ecological model was initially used to inform the overarching research
question and overall methods for the dissertation. This concept also provided a different
approach to organizing the findings from this study.

Exploring Residents’ Engagement in Activities 89

Social Ecological Model
The social ecological model provides five different levels (i.e., intrapersonal,
interpersonal, organizational, community, and public policy) that can impact nursing home
activity engagement. The findings from our study identified factors that impact activity
engagement across four levels of the social ecological model: intrapersonal, interpersonal,
organizational, and public policy (Figure 1).

In the intrapersonal level, individual resident characteristics were identified to impact
engagement. For example, resident’s pain level could hinder their ability to participate in
activities. In addition, resident’s interests or lack of interests in certain activities can effect
engagement. Within the interpersonal level, building rapport between residents and staff
members was identified as important to facilitating engagement. Staff members described
Exploring Residents’ Engagement in Activities 90

informing residents upon admission about activity programs available and asking residents for
their preferences to activities. In the organizational level, factors that can influence activity
engagement are the resources and culture of the facility. The resources that are available can
impact the types of activities that are delivered. For example, one of the residents from our
qualitative findings noted the lack of resources that limited her opportunity to engage in activities
inside her room. In addition, the culture of the facility can encourage activity engagement. The
staff members in our study described their facility as prioritizing engagement and understanding
the importance of activities, which empowers staff members to have the support needed to
deliver activities. At the public policy level, the impact on activity engagement came from the
federal mandate to deliver and document activity programs that met residents’ preferences and
abilities. When developing and implementing activity programs, staff members described
adhering to the mandate through strategies described in the previous levels.
The social ecological model provides a framework to organize the different levels that
can be a barrier or facilitator to activity engagement. By understanding how activity engagement
is impacted, it can inform future research or activity program initiatives on the various levels that
can be targeted.

Implications and Future Research
Research
The findings from our study provide an initial understanding of the current state of
activity programs in nursing homes. Given the dearth in research on the area of activities in long-
term care nursing homes, further work is needed to improve engagement for residents. The
findings from our first manuscript identified specific types of activities that were delivered in
Exploring Residents’ Engagement in Activities 91

facilities and the organizational characteristics of the nursing homes that provided them. Despite
not finding a statistically significant association, the higher resource activities were delivered
more commonly in for-profit facilities with at least a 3-star Medicare rating. This implicates that
for-profit facilities may have more resources to provide these types of activities. Future research
is needed to evaluate whether these higher resource activities is effective in improving resident
outcomes, including overall health and quality with life.
The findings from our second manuscript described how activity programs were
developed and how staff members facilitated engagement. The lack of individually tailored
activities was a barrier to engaging in activities. Residents described how certain activities did
not interest them because they weren’t challenging, which suggests that activities need to be
individually tailored. Future research needs to further explore whether tailored activities for
nursing home residents improves overall engagement.
From the third manuscript, different approaches to delivering activities were identified in
three purposively sampled nursing homes with different organizational characteristics. The
participants described the use of one-on-one activities as a strategy to engage residents outside of
scheduled programs. This suggests that future research need to evaluate the effectiveness and
sustainability of providing one-on-one activities.

Practice and Policy
Within practice, the findings from this dissertation highlight areas that could be impacted.
From the second and third manuscript capturing residents’ preferences was a key strategy
utilized by staff members to optimize engagement. Staff members need to understand resident
preferences in activities and how it can be integrated into current activity structures. Similarly,
Exploring Residents’ Engagement in Activities 92

by taking residents’ preferences into account, it is an example of patient-centered care. The
Green House model is a way that patient-centered care is being delivered in nursing homes.
However, traditional nursing homes are still services that lack patient-centered care, specifically
in activities. Thus, it is an area that activity providers can improve in by providing resident-
driven activities. Both of these areas require training and education for staff members to have the
necessary tools to meet the needs of the residents and develop appropriate activities.
In addition, our qualitative findings implicated barriers to residents engaging in activity
programs. Specifically, some activities that were provided were not appropriate for residents and
were not tailored to their physical and cognitive abilities. This is an area that activity providers
may require additional education and training in. Since currently only activity directors are
required to attend certification classes, future policy may need to expand requirements to all
activity personnel so that all activity providers are equipped with the skills and knowledge to
deliver appropriate activities. Furthermore, from the Nursing Home Reform Act in 1987 to the
2016 changes to nursing home regulations, activity programs have been mandated and activity
preferences now documented within the comprehensive care plan for each resident. Future policy
initiatives are now needed to ensure the delivery of resident-centered activity sessions.

Occupational Science
This dissertation has several implications for the occupational science discipline. The first
manuscript identified different types of activities were provided to nursing home residents based
on the activity calendars. The aim was to understand what the current practice was for delivering
activities. This is an area where occupational scientists can further explore to understand the
extent of how residents experience these activities in order to improve their overall well-being.
Exploring Residents’ Engagement in Activities 93

For example, Jonsson’s categorization of occupations, which is focused on how an individual
experiences an occupation, can be used to understand how residents experience the activities
(Jonsson, 2008). Since our findings did not find a statistically significant relationship between
the types of activities provided and facility characteristics, it suggests an alternative way to
evaluating activities is needed. Identifying types of activities may not provide the scope of how
an activity impacts quality. Using an occupational science lens can help explore how residents
experience activities as well as the meaning and value of these activities, which may inform how
to improve overall health and quality of life for residents.
In addition, from our qualitative interviews, residents had described that certain activities
that were provided were “for toddlers,” and did not require much skill to participate in the
activity. This is reflective of the concept of flow, where an individual is engaged in a just-right
challenge and experiences intense focused concentration when completing the activity
(Csikszentmihalyi, 1990). Being in the state of flow when engaged in an activity can bring about
feelings of positive quality of life. Nursing home residents may lack access to the appropriate
activities as our findings indicate in the second manuscript. Occupational scientists and
occupational therapists can provide their expertise in training activity providers on developing
appropriate activities for a diverse nursing home population thereby fostering the just right
challenge. One of the barriers to engagement that activity providers described was pain. This is
an area where occupational therapists can train activity providers on how to modify activities so
that residents can still remain engaged.
Ultimately, the findings from our study are aimed to provide an initial understanding of
how activity programs are delivered in nursing homes. In order to improve engagement in
Exploring Residents’ Engagement in Activities 94

activities, future research can be conducted by occupational scientists and occupational therapists
to develop activity programs that address the physical and cognitive abilities of residents.
Exploring Residents’ Engagement in Activities 95

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Exploring Residents’ Engagement in Activities 108

Appendix A. Resident Interview Guide

1. Tell me about your experience in this facility?
a. Probe for daily routine
2. What is your experience with the activity sessions provided?
a. Probe for structure and organization
b. Probe for expectations
c. Probe for preferences
d. Probe for participation in facilities
3. What other opportunities for activity engagement are there?
a. Probe for activities outside of structured sessions
b. Probe for who engages them in these activities
4. Tell me about your activity engagement prior to coming to the facility?
a. Probe for how activity engagement has changed since
5. What are your preferences to activity engagement?
a. Probe for what changes they would like to see
b. Probe for importance of activity engagement
c. Probe for specific types of activities they want to engage in

Exploring Residents’ Engagement in Activities 109

Appendix B. Staff Interview Guide

1. How are activity sessions provided in the facility?
a. Probe for the structure and organization
b. How are activities designed
c. Probe for resources for activities
2. How are residents engaged in activities?
a. Probe for who engages residents
b. Probe for strategies and barriers to engagement
3. What other opportunities are there for activity engagement outside of activity sessions?
a. Probe for what other activities or resources are available to residents
4. Tell me about your thoughts on activity engagement in the facility.
a. Probe for what changes they would like to see
b. Probe for importance of activity engagement
c. Probe for specific types of activities they want to see

Asset Metadata

Creator Wong, Carin M. (author)

Core Title What do nursing home residents do? Exploring residents’ engagement in activities

Contributor Electronically uploaded by the author (provenance)

School School of Dentistry

Degree Doctor of Philosophy

Degree Program Occupational Science

Publication Date 03/01/2019

Defense Date 12/03/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag activity,engagement,Long Term Care,Nursing Home,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Advisor Leland, Natalie (committee chair), Henwood, Benjamin (committee member), Pyatak, Beth (committee member), Wilber, Kate (committee member)

Creator Email carinwon@usc.edu,carinwong3@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-128758

Unique identifier UC11675714

Identifier etd-WongCarinM-7124.pdf (filename),usctheses-c89-128758 (legacy record id)

Legacy Identifier etd-WongCarinM-7124.pdf

Dmrecord 128758

Document Type Dissertation

Format application/pdf (imt)

Rights Wong, Carin M.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Abstract (if available)

Abstract Long-term nursing home residents often lack activity engagement. For a population that is already frail, inactivity may result in further physical and cognitive decline. In an effort to mitigate functional decline and optimize quality of life, nursing homes are federally mandated to provide activities to residents. Despite the requirement for facilities to provide activity programs, little is known about the structure, development, and delivery of these sessions. Thus, this dissertation aimed to understand the current practice of engaging nursing home residents in activities. ❧ The first manuscript, intended to evaluate the scope and depth of activity sessions within a nursing home context. By extracting data from facility activity calendars, we examined the diversity of programming and the relationship with organizational-level characteristics. Descriptive statistics were used to quantify the frequency of each type of activity provided. Linear and logistic regression was also conducted to analyze an association between the organizational characteristics and the types of activities identified on the calendar. There was no statically significant relationship found between facility characteristics and activity types. However, the descriptive statistics identified a broad range of activities delivered. ❧ The second manuscript sought an in-depth understanding of how three purposely sampled facilities executed activity programs. This qualitative study comprised of semi-structured interviews with key nursing home stakeholders (i.e., administrators, activity providers, and residents) and facility observations. Four major themes were identified: (a) the organizational process that guide program development, (b) strategies for fostering engagement for newly admitted residents, (c) facilitating engagement during activity sessions, and (d) optimizing engagement outside of structured activity sessions. ❧ The aim of the third manuscript was to compare and contrast approaches for delivering activities in three purposively selected nursing homes to understand current practices to engaging residents in activities. Qualitative data from interviews and observations were obtained, compared, and contrasted across the three facilities. Types of activities were also quantified and evaluated for differences across the nursing homes. The facilities varied in the delivery of structured and unstructured activity programs, yet across facilities there were commonalities in types of activities offered. ❧ The cumulative findings of these three studies highlight the depth, breadth, and frequency of current activities provided as well as the divergent strategies used to execute facility programs. This scope of work addressed a gap in literature by providing an understanding of current practice which can help inform nursing home staff with strategies for delivering activity programming. Furthermore these findings can also be used to inform future policy efforts. Enhancing resident’s quality of life through activity engagement has been integrated into policy and practice however there is a need to deliver patient-centered programming.