Assignments
HEREFORHELP1
HSAChapter10.docxChapter 10
Recreation and Activities
What You Will Learn
• Meaningful activities involve more than just games and outings. Apart from some common overarching goals, activity programming differs from the roles of social work and rehabilitation therapies.
• Federal regulations do not specify the qualifications for activity personnel, but those certified by the National Certification Council for Activity Professionals automatically satisfy federal requirements. Some states may specify qualifications, but variations exist.
• Activity professionals must have skills in assessment, documentation, communication, engagement, planning, and coordinating. They must be innovative and resourceful. A pleasant disposition is also essential.
• Similar to other members of the multidisciplinary team, activity professionals have responsibilities for care planning and documentation of patients’ activity goals and progress.
• Activity programming should take into consideration the age of participants, nature and extent of their disabilities, space availability and timing, supplies and equipment, staffing, and use of community resources.
• Activities must be designed to build strength, stimulate the mind, promote social interaction, express one’s individuality, build self-esteem, and provide spiritual fulfillment.
• Activities need to be spaced out during the day. Some evening and weekend activities should also be scheduled. Participation may be active or passive.
• Intervention approaches can be designed for sensory and cognitive stimulation. These interventions include sensory stimulation, reality orientation, reminiscence, validation therapy, and multisensory stimulation.
• Continuous activity programming, stimuli based on a resident’s current preferences, and an individualized approach have been shown to benefit patients with advanced dementia. Small-group activities are appropriate for those with less severe dementia.
• Activities must be matched with individual needs and interests, and the resident’s risk awareness profile must be taken into account. A balance between quality and quantity of programs should be achieved.
• Programs should be planned with certain outcomes in mind. Achievement of expected outcomes should be the focus of program evaluation.
• Various approaches are necessary to recruit and retain volunteers.
Introduction
Activity programming is not simply a matter of putting together some recreational programs to comply with regulatory requirements. Meaningful activities call for a great deal of skill and resourcefulness. Activity programs must strike a balance between quantity and quality. Perhaps the biggest challenge for activity directors is to make sure that the programs meet the needs of individual residents regardless of their physical, mental, social, or emotional status. Activities must be viewed as part of a person’s overall holistic healing.
Goals and Purpose of Activity Programs
In this chapter, the term activity means active or passive involvement of patients in any activities—outside the activities of daily living (ADLs)—that provide meaning and personal enrichment. Meaningful activities must achieve several goals: (1) promote a sense of well-being, (2) build self-esteem, (3) give pleasure, (4) create a sense of personal fulfillment, (5) provide a sense of accomplishment, (6) promote physical and mental fitness, and (7) accomplish social and spiritual fulfillment.
Meaningful activities involve more than just games and outings. “Activities should do more than produce an occasional bright spot of entertainment in an otherwise dull existence; activities must help people learn new information, skills, or behaviors or improve their feelings of self-worth” (Carroll et al., 1978).
The purposes and roles of activities must be distinguished from the purposes and roles of social work and rehabilitation therapies, although the goals pursued by each of these disciplines generally overlap. For instance, maximizing independent functioning, promoting self-esteem, meeting psychosocial needs, and enhancing quality of life are the overarching goals pursued by all three disciplines. Yet, there are two main differences: (1) each is a specialized discipline that addresses patient care issues that other disciplines do not address, and (2) the approach used for achieving the common goals just mentioned is different in each discipline. Therapeutic recreation is the primary approach used in activities; social services focus mainly on coping and social adaptation; and rehabilitation therapies employ a clinical approach to specific functional deficits, mainly by using established therapeutic modalities. By their nature, social services and rehabilitation are intervention oriented. They deal with problems and issues that are clearly defined. In activities, intervention may be used but only to a limited degree. Among the three disciplines, recreational activities also allow the greatest degree of latitude for residents to pursue their own interests.
For the most part, activities are program oriented rather than intervention oriented. Program orientation means that programs are structured with the needs of various residents taken into consideration, but residents’ participation is voluntary. Compared with intervention-oriented therapies, participation in activities allows the resident a much greater degree of voluntary choice, personal control, autonomy, and self-confidence. Intervention orientation respects autonomy and choice to a degree, but participation is nonvoluntary unless the patient signs a release refusing treatment.
Activities must offer a wide variety of programs that enable individuals to pursue their personal interests and to develop new interests, with the objective of finding meaning and purpose in life despite chronic illness, frailty, and functional impairment. Social adaptation and maintenance rehabilitation are often the by-products of activities, although they may not be specifically pursued. For example, group activities provide opportunities for socializing and exercise programs have rehabilitative value.
Activities allow residents freedom of expression, which, from a holistic viewpoint, adds a necessary dimension to nursing home services that no other discipline in the facility can furnish. Achieving self-fulfillment by engaging in meaningful diversions adds necessary balance and a sense of control to the lives of residents in an otherwise restricted environment. Because personal interests can vary substantially across the resident population in a nursing facility, activity programming presents special challenges in creativity and resourcefulness.
Activity Department
Staffing
Each state specifies the staffing levels and required qualifications for activity personnel, but clear-cut guidelines are generally lacking. Because of the unique nature of activities, a facility needs a separate activities department headed by an activity director or activity coordinator. The director/coordinator reports to the administrator. In small facilities, one full-time person may be assigned the responsibilities of both social work and activities. However, to the extent possible, the administrator should try to have separate personnel for these two services; otherwise, the effectiveness of both services is likely to be compromised. In facilities with more than 50 beds, a full-time activity director is generally needed. Additional personnel are necessary in facilities of more than 100 beds. Part-time activity assistants may be used to fill in as needed.
Qualifications
The Omnibus Budget Reconciliation Act of 1987 (OBRA-87) mandates that activity programs be directed by qualified professionals. Federal regulations do not specify the qualifications, but activity professionals certified by the National Certification Council for Activity Professionals (NCCAP) automatically satisfy federal requirements.
Directors may also meet OBRA-87 requirements by satisfying the licensure or registration requirements specified by their state. Directors who do not meet the qualifications specified by the state are required to have regular consultation from an outside qualified activities consultant. The consultant’s role is to train the activity staff, evaluate existing programs, make recommendations for program enhancement, assist in implementing new programs, and ensure that all requirements mandated by federal and state regulations are met (Tedrick & Green, 1995).
Skills and Competencies
Administrators should carefully evaluate the skills and competencies discussed here when activity professionals are recruited. Many of the general skills that activities specialists need for effective performance are very similar to those necessary for social workers. For instance, the skills of engagement, assessment, communication, and documentation are necessary for activity directors. They must also have knowledge of aging and the elderly. Indeed, these skills can actually improve the performance of any professional who needs to interact with nursing home patients as a care provider.
Activity professionals also need to have special skills of engagement and communication with the residents and family members. For example, during assessment, vital information must be obtained from both the residents and their family members, the latter being the key providers of information for residents who are cognitively impaired. Motivating the elderly to participate in activities is one of the special challenges for activity professionals. Because motivation varies from person to person, getting to know each individual resident’s needs, interests, and abilities is essential (Hastings, 1981).
Friendliness, cheerfulness, and a pleasant disposition are special personality traits administrators should try to cultivate in activity personnel. Activity professionals must be innovative in designing appropriate programs to meet individual needs, resourceful in engaging family members and volunteers to enhance the activity programming, skilled in planning and coordinating a wide variety of programs, and able to evaluate the effectiveness of the different programs.
Activity staff members participate in the multidisciplinary team. The Minimum Data Set (MDS) contains a section for assessing activity preferences. Assessment yields valuable information on the needs and desires of each resident and forms the basis for planning and developing appropriate programs. Similar to other members of the multidisciplinary team, activity professionals have responsibilities for care planning and documentation of patients’ activity goals and progress.
Program Development
The various factors discussed in this section should be evaluated carefully to generate ideas that can add variety, novelty, appeal, and meaning to resident activities.
Basic Considerations
Programming requires developing and carrying out a meaningful plan. Programming means structured methods of delivering needed services. Planning an effective program requires that the activity professional consider (1) the kind of service to deliver, (2) the manner in which it will be delivered, and (3) its anticipated effect on the residents involved (Lanza, 1997).
Six basic considerations are valuable in developing a well-rounded activity program (Greenblatt, 1988; Lanza, 1997):
1. Age of participants. Nursing facilities generally have substantial age differences among residents, and individual interests often vary according to a person’s age group.
2. Nature and extent of disabilities. Disabilities must be assessed because active participation requires a certain level of functioning. Certain activities are suitable for passive participation by those who may be unable to have active involvement. Abilities and skills required for participation may be limited by disorders in any of these three behavioral arenas (Greenblatt, 1988):
• Sensory motor skills are affected by poor ambulation, strength, range of motion, vision, or hearing.
• Cognitive functioning is affected by disorders such as inability to recognize, store, or retrieve information; make judgments; or maintain attention span.
• Affective functioning is impaired by depression, anxiety, anger, agitation, fear, or frustration.
In addition to functional limitations, any medical contraindications must be carefully considered. For example, patients with serious cardiovascular conditions, asthma, or respiratory problems may require medical clearance for participation in certain types of activities. Use of certain medications produce side effects such as dizziness, drowsiness, and sensitivity to sunlight that require necessary precautions, such as assisting residents on certain medications to move slowly or using sunscreen for outdoor activities. Regardless of the type of limitation, therapeutic activities should use patients’ unaffected capabilities; otherwise, functional loss in the remaining areas can occur. This additional functional loss, called secondary disability , can be reversed or prevented. For example, an elderly person with the primary condition of hearing loss may tend to isolate himself, which can lead to deterioration of other types of functional capabilities (Greenblatt, 1988).
3. Space availability and timing. Availability of space is an important consideration for group programs. Certain individual pursuits such as knitting, crocheting, reading, drawing, painting, or listening to music can be carried out in the patient’s own room. For group activities, an activity room is often provided in medium-size and large facilities. This room is generally equipped for crafts, cooking, and baking and can accommodate small- to medium-size groups. Large facilities may also have a chapel for religious services. Other activities generally require some ingenuity in adapting existing common spaces. For example, dining rooms, day rooms, lounges, lobby areas, open spaces near nursing stations, and alcoves can, with some improvisation, all be used for different activities. Use of common areas for activities requires proper planning and coordination to minimize interference with other services. For instance, activities should not interfere with the use of dining areas for meals. Only a limited number of programs should be conducted at a given time so that space is also available for individual leisure or private visiting. When weather conditions permit it, outdoor spaces such as patios, gazebos, and balconies should be used for certain types of activities. Outdoor gardening, tending to flowers and shrubs, and bird-feeding are therapeutic for many residents.
Activity schedules should take into account possible conflict with meal times and nursing care routines. Structured activities should be scheduled to take place when patients are likely to be inactive and bored. At the same time, residents should be given the choice to engage in individual pursuits. Activities should also be planned for evenings, weekends, and holidays. The length of each program will depend on the physical and mental endurance of participants.
4. Supplies and equipment. Reusable supplies and equipment are acquired over time. Simple, inexpensive equipment is generally quite sufficient for most activities. Additional needs can be met by seeking donations or purchasing things in good condition at garage sales. Any remaining needs should be met by allocating adequate financial resources in the annual budget. In most facilities, a multipurpose, folding mobile cart is an important piece of equipment for bringing games, crafts, magazines, books, and other items to residents in their rooms, particularly those who are room bound. The same cart can be used for serving refreshments and distributing items, such as prizes won, at parties and other social gatherings (Hastings, 1981). Some equipment commonly used for activity programs includes folding tables and chairs; adjustable over-the-bed tables for use with wheelchairs; movie projectors, slide projectors, and portable screens; compact disk and cassette players; DVD equipment; computers; movable organs or pianos; cameras; radios; woodworking tools; garden tools; ceramic kilns; cooking utensils; microwave ovens; ice cream makers; popcorn makers; barbecue grills; Christmas ornaments and other festival or seasonal decorations; and a variety of games, puzzles, and large-print books.
5. Staffing. The number of associates, and their qualifications, training, experience, and personality traits, are key factors in developing and implementing high-quality programs. Building strong volunteer support is often necessary to supplement staffing in the activity department, because additional hands are often needed for programs such as parties, shows, and outings. Involvement of families can also be successfully pursued, because many of the residents’ family members are retired but in good health, and family and friends often would like to stay involved in the lives of their loved ones.
6. Community resources. Maintaining a link with the outside community is vital to enhancing the residents’ quality of life. Local religious establishments; civic organizations, such as Rotary and Kiwanis clubs; schools; Boy and Girl Scouts; nonprofit social service agencies; businesses; libraries; shopping malls; and many other types of organizations and establishments can support a facility’s activity programs by offering their resources. Using community resources does not always mean bringing the resources into the facility. Community resources are also used when residents are taken for outings. For example, a trip to the mall may require making advance arrangements to accommodate a relatively large group of residents at the ice-cream parlor, or a group visit to a department store would require some coordinating so that residents could be taken at an appropriate time to look at preselected merchandise display areas.
Meeting a Variety of Needs
Federal guidelines require that activity programming be multifaceted. Programs must incorporate each individual resident’s needs. Programs should also provide “stimulation or solace; promote physical, cognitive and/or emotional health; enhance to the extent practicable each resident’s self-respect by providing, for example, activities that allow for self-expression, personal responsibility and choice” (Lanza, 1997). The theories of biophilia and thriving and creation of enriched environments provide the guiding principles for developing programs that incorporate a variety of needs.
Multifaceted programming must cover the main human needs in a holistic context, and every need category is associated with goal achievement:
|
Need |
Goal Achievement |
|
Physical |
Build strength |
|
Cognitive and educational |
Stimulate the mind |
|
Social |
Promote interaction |
|
Affective |
Express one’s individuality |
|
Integration or awareness |
Build self-esteem |
|
Spiritual |
Provide spiritual fulfillment |
Activities that provide movement and general physical stimulation of the body, such as dance therapy, exercise programs, and outdoor walks, specifically address physical needs. Exercises and sports programs often require simulation. For example, a balloon volleyball, in which residents toss the balloon among themselves while seated in a circle, can simulate the real game.
Cognitive and educational needs can be met through word games, games such as Trivial Pursuit, discussion of current events, and book reviews. Nursing facilities must also provide residents with computers, Internet access, and other self-directed pastimes.
Social needs call for activities that provide opportunities for active and passive interaction and companionship with others. Examples of such programs include parties, functions, room visits, sing-alongs, and birthday parties and other celebrations.
Affective needs require activities that enable residents to express their feelings, emotions, and creativity. Art therapy, music therapy, touch therapy, pet therapy, bird-feeding, and other types of programs that provide sensory stimulation and foster reminiscence are some examples. Affect-related activities also include movies, puppet shows, fashion parades, magic shows, live bands, chamber music, plays and skits, and cooking demonstrations. Some residents may be interested in journal-writing to reminisce their past.
Integration or awareness needs call for programs that include roles in which the resident is needed by others, such as mail delivery, folding linens in the laundry, participation in resident council, acting as surrogate grandparents to children from the local day care center, and telling stories to children.
Spiritual needs are answered, in the lives of many elderly residents, by religious and spiritual pursuits considered important in their lives for achieving personal satisfaction, well-being, and self-realization and as a means of coping with stressful situations. Private devotions, quiet meditation, reading, and congregational religious programs brought in by local churches and synagogues are examples of activities in which many elders like to engage to find personal fulfillment and peace.
Scheduling
High-quality activity programming calls for a variety of scheduling patterns. As a rule of thumb, scheduling should attempt to mirror the residents’ usual patterns of rest and recreation before they were institutionalized. In this regard, Greenblatt (1988) proposes that holidays, to the extent possible, should be celebrated on the days they actually occur. Crafts and hobbies ought to be pursued in late morning before lunch; the elderly often take naps or just like to rest after lunch. Parties normally take place in late afternoon or early evening. Residents like to have leisure time after dinner, which is generally over by 6:30 p.m. As a rule of thumb, some morning activities should be offered starting at around 10:00 a.m.; then afternoon activities, starting at around 2:30 p.m.; and evening activities, starting at around 7:00 p.m. Within these guidelines, residents’ own preferences for activity times should be accommodated (Lanza, 1997).
On weekends, family visits are common; hence, fewer activities may be needed. On the other hand, it is also an irony that activity programming is frequently curtailed during periods when the residents have the most leisure time available. Hence, scheduling of activities poses some challenges, but striving for balance is the key.
Active and Passive Stimulation
Residents can get active and passive stimulation during individual activities as well as group activities. Some residents are intimidated by small group settings, in which more active participation is generally required, whereas others may not like being in large groups. Small groups often form spontaneously as friendships between people develop. The activity staff can help such groups find something meaningful to do together. Structured group activities, as opposed to informal group activities, are particularly beneficial for depressed residents (Meeks et al., 2007).
Passivity is characterized by a decline in human emotions, withdrawal from interactions with others and surroundings, and a decrease in motor activity (Colling, 1999). Passivity can lead to isolation and cognitive and functional decline (Kolanowski & Buettner, 2008). Residents who cannot actively participate can simply be passive “bystanders” and receive stimulation from listening and watching other active participants.
Intergenerational Appeal
Children’s interactions with the elderly are enriching and have universal appeal. Eyes brighten up, smiles begin to form, and muffled laughter is often heard when the elderly are exposed to little children. Children also get a special sense of fulfillment when they can sit in an older person’s lap, tell a tale, show the elder their favorite toy, or ask the elder some question. Every nursing home should explore ways to facilitate intergenerational contact. By working with local schools, child day care centers, and parents, many facilities across the country have developed formal programs that allow children to make regular visits to nursing homes and to participate in activities with the elders.
Intervention Approaches
In contrast to most other types of activity programming, therapeutic services for cognitive disorders generally require an intervention approach. Using such an approach means that voluntary choice and personal control do not play as much of a role as they do in most program-oriented approaches, because in many instances residents who need therapeutic services are unable to express their wishes. However, the patients’ past practices and habits are taken into account to develop appropriate interventions. This section categorizes activities that are specifically designed for sensory and cognitive stimulation. A variety of programs are appropriate for individual as well as group interaction, including:
• Sensory stimulation
• Reality orientation
• Reminiscence
• Validation therapy
• Multisensory stimulation
Sensory Stimulation
Sensory stimulation incorporates therapies that stimulate the senses in patients with dementia or in those in comatose or vegetative states. It can benefit residents who have cognitive, visual, or hearing impairments, or those who are bedridden and are likely to undergo sensory deprivation over time. Sensory deprivation speeds up degenerative changes in mind and body and accelerates the loss of functional cells in the central nervous system. This loss can lead to secondary physical and psychological abnormalities (Oster, 1976). A patient’s perception and alertness can be improved by eliciting responses to stimuli in the five sensory areas: vision, hearing, smell, taste, and touch. Use of objects with bright colors, lighted objects, music therapy, aroma therapy, and pet therapy are means of providing sensory stimulation.
Reality Orientation
Reality orientation is a form of therapy for demented, confused, or disoriented individuals and consists of reiteration of the person’s identity, orientation to time and place, and reinforcement of consistency in daily routine. Repeated attempts are made to draw the person into conversation, using simple questions, pictures, or whatever may spark their interest. Simple, straightforward, factual information on a regular basis can help residents with substantial cognitive disabilities or those experiencing delirium remain oriented and communicative. Facts such as the resident’s name, the name of the facility where the patient is residing, the day, the date, and the season are presented to the resident one at a time, and the resident is encouraged to verbalize the information. Use of calendars, clocks, pictures, and information boards are used as aids (Buettner & Martin, 1995; Lanza, 1997).
Reminiscence
Reminiscence refers to remembering and in some way reliving past experiences. Engaging in certain activities can help bring back “the good old days” and pleasant events that a person experienced in the past. Such activities for residents include singing or listening to old-time favorite songs, seeing clips of old TV shows, watching old movies, going through photo albums, or discussing memorabilia from a certain era.
Validation Therapy
In validation therapy , a person’s belief that he or she is actually living in the past is accepted and validated by the staff members working with the patient. Many elderly, especially before death, want to return to the past to wrap up loose ends. Demented patients often “live in the past.” The theory behind this therapeutic approach is that validation or acceptance of the values and beliefs of a person, even if they have no basis in reality, helps the individual come to grips with the past. The therapy involves listening with empathy. In the absence of such therapy, the person is likely to withdraw. Hence, if a 70-year-old man says that he is a senior in high school and has to go to school so he can run the 100-yard dash, it is accepted as real.
Multisensory Stimulation
Multisensory stimulation (MSS), also known as multisensory behavior therapy (MSBT), is commonly known as Snoezelen in European countries, and it is becoming increasingly popular in the United States. Snoezelen is now a registered trademark of ROMPA Ltd, England, a developer and marketer of sensory products. The objective of MSS is to stimulate all of the primary senses—touch, hearing, sight, smell, and taste—through a combined effect of textured objects, soft music, colored lighting, aromas, and favorite foods. Sensory experiences are manipulated, intensified, or reduced in relation to the needs and desires of the individual (Botts et al., 2008). MSS procedures have not been standardized, but according to Baker and colleagues (2001), three main characteristics differentiate MSS from other therapies:
• Visual, auditory, tactile, olfactory, and gustatory stimulation is offered to patients, often in a specially designed room—sometimes called a Snoezelen room or multisensory environment (MSE).
• Associates work one on one with patients, adopting a nondirective, enabling approach in which they follow the patients’ lead. Patients are encouraged to engage with sensory stimuli of their choice.
• Stimuli used are nonsequential and unpatterned, experienced moment by moment without relying on short-term memory to link them to previous events. They present few specific attentional or intellectual demands on patients with dementia.
MSS therapy has been used with autistic children, people who have developmental disabilities, and older people with dementia. In controlled clinical studies, MSS has been shown to promote positive emotions and relaxation, but it does not appear to reduce aggressive and adaptive behaviors (Chan et al., 2005). MSS also does not appear to have positive effects on mood and cognition in dementia patients (Baker et al., 2003). There is some evidence, however, that MSS may reduce apathy and agitation and improve activities in patients who have moderate to severe dementia (Chung & Lee, 2002; Staal et al., 2007).
Activities for Dementia Patients
Behavioral problems of dementia are often more distressing than mere cognitive and functional decline. Behavioral problems are also a main reason for institutionalization (Phillips & Diwan, 2003). Hence, both agitated and aggressive behaviors are common in nursing home dementia patients. Wandering, soliloquizing, repetitious yelling, and other types of agitation, crying, or staring are some of the commonly observed negative behaviors in patients with dementia. Generally, these residents possess a lot of nervous energy that must be channeled into more constructive outlets. Otherwise, the resulting noisy and chaotic environment can provoke a sense of bewilderment and anxiety, which, in turn, reinforces disruptive patterns of behavior, such as combativeness and other aggressive manifestations. Studies show that residents in dementia care units are unoccupied most of the time; appropriate activites not only engage them but also reduce negative behaviors (Cohen-Mansfield et al., 2007). Continuous activity programming has been shown to reduce negative behaviors, and also decrease the need for psychotropic medications and improve nutritional intake (Volicer et al., 2006). In continuous activity programming , a dementia patient is always in the presence of a staff person who engages the patient in meaningful activities. This can be structured activity like exercise or unstructured activity like casual conversation (Volicer et al., 2006).
Passive behaviors are also among the most common behavioral symptoms of dementia patients. It should be recognized that as cognitive and physical abilities change, individuals with dementia may not be able to engage in activities they once found enjoyable. Some activities may lead to extreme frustration because of a mismatch with the individual’s current skill level (Kolanowski & Buettner, 2008). People in mid- to late-stage dementia may not be able to tolerate the stimulation of group activity. Taking an individualized approach to each person and formulating activities based on a resident’s current preferences—rather than past preferences—are potent in engaging the resident; hence the importance of finding out a person’s current interests (Cohen-Mansfield et al., 2010). Even brief individualized activities led by certified nursing assistants bring pleasure and engagement in persons with dementia (Van Haitsma et al., 2013).
Small-group programming may be more appropriate for patients with mild to moderate dementia. Under a grant from the New York State Department of Health, one facility discovered that a small-group program may best address the needs of dementia patients. This model proposes a staff-to-resident ratio of 1:8, particularly when patients with mid-stage dementia are involved (Hutson & Hewner, 2001). Further research suggests that small-scale dementia care in group living environments results in greater involvement in preferred activities (Smit et al., 2012). The small-group program requires cross-trained staff teams consisting of social workers, activity assistants, and certified nursing assistants. One associate works with a small group of 6 to 10 residents at a time, and practitioners of the three disciplines rotate among the small groups. Group composition is roughly homogeneous; for example, wanderers are in one group and patients displaying disruptive behaviors are in another group (Hutson & Hewner, 2001).
Various intervention approaches discussed earlier in this chapter are appropriate for dementia patients. For example, reality orientation can be modified to provide cognitive stimulation as long as it is implemented in a sensitive, respectful, and person-centered manner (Woods et al., 2012). Cognitive function and behavior can be improved with reminiscence therapy (Nawate et al., 2008). Some dementia patients can also be involved in constructive activities, such as folding towels and other simple “household” chores. Cognitive activities, such as matching painted rocks with colors painted inside an egg carton, can also be employed. Other activities meet the residents’ affective needs. For example, soothing music often elevates mood and counters social withdrawal and depression (Humphrey, 2000). Music has been consistently demonstrated to have a positive effect when it is individualized. For example, with individuals for whom English is not the first language, music played in the language of origin is more effective than music played in English (Runci et al., 1999). Technology-based therapies, in the form of CDs, DVDs, and technology-assisted sensory stimulation machines that emit water sounds, are also available. Use of bright lights in the care environment may reduce agitation for persons with disturbed sleep-wake cycles (Lyketos et al., 1999).
Program Planning and Implementation
The number and types of activity programs are limited only by the resources that a facility is able to provide and by the knowledge, creativity, and resourcefulness of its activity staff. However, the activity director should work within these constraints and plan programs that provide the greatest variety of activities in accordance with the interests of most residents, yet no one’s needs should be left out. In essence, the special challenge for activity professionals is to create maximum recreational opportunities for each resident and appropriate interventions for those who lack the ability to choose. Implementation requires three stages:
• Identifying suitable programs by evaluating the numerous factors discussed in the section, “Program Development”
• Planning programs by selecting and scheduling specific activities
• Conducting each activity in accordance with the plan
Identifying Suitable Programs
Identification of appropriate programs begins with resident assessment. The next step after resident assessment requires compiling information on individual interests and needs and putting them into a composite profile. An interest checklist (Lanza, 1997) can be developed to facilitate this task. Such a checklist can be easily created using a standard spreadsheet program such as Excel, in which a horizontal row can be assigned to each resident and the vertical columns can be marked with various interests such as art, baking, dancing, fishing, reading, etc. Columns can also be used for the degree of social integration preferred. The computer spreadsheet enables the activity director to produce useful summaries of the data. The summaries can be effective in planning the range of programs without leaving out any resident. This information can be easily updated on a regular basis as the facility’s population changes over time. Lanza (1997) recommends developing a risk awareness profile, which can also be maintained on a computer spreadsheet. A risk awareness profile incorporates a resident’s limitations as well as cautionary information about things such as allergies or other health conditions or treatments that may require associates to observe certain precautions, as in case of drug side effects.
Planning Programs
The step just described is likely to identify a large number of programs suitable for the facility’s residents. However, specific programs should be selected on the basis of various considerations such as space, equipment, staffing, and availability of community resources. Activities that would meet the common needs of most residents become the core activity programs. Additional activities should be planned to accommodate the special needs and interests of the remaining residents. A policies and procedures manual for activities should include a variety of choices to suit various resident needs and interests. Much like a recipe book, the procedures section of the manual should list the “ingredients” for various activities, such as the name and description of each activity, the resources the activity requires, the amount of time to be allocated, the functions of the associates involved in carrying it out, and the type of resident for whom the activity is appropriate.
Activity calendars provide the most effective means for planning. A master calendar is prepared to earmark the main activities for an entire year. This calendar helps the activity staff plan and prepare for major events, special celebrations, and seasonal festivities well in advance. The master calendar is also used to identify programs of wide appeal that would be offered on a regular basis and programs for which some lead-time is necessary.
A tentative weekly calendar of activities, showing the time and place for each activity, should be circulated among department heads, key nursing staff, and the administrator a couple of weeks in advance. This review helps address any potential conflicts and allows for sufficient time to finalize the weekly calendar. The final weekly calendar should be sent to all key departments and personnel a few days in advance, but it should not be posted until Monday morning; otherwise, it is likely to be mistaken for the current week’s calendar by residents and families.
Many facilities display a large, wall-size activity calendar in a prominent place. The activity calendar is also useful in marketing the facility to prospective clients during the facility tour. During the pre-admission inquiry process, a stop at the posted activity calendar and some comments by the tour-giver on the variety and substance of the activities must be part of the facility tour.
No clear guidelines exist regarding the number of programs that should be offered. The key is to find the right balance between quantity and quality. Instead of planning a cramped schedule, the greatest benefit to residents may come from having fewer, high-quality activities that truly meet residents’ needs (Carroll et al., 1978). At the other extreme, a schedule with very few activities is also undesirable because it would lack variety and would leave residents with large blocks of time with not much to do.
In planning time for activities, Carroll and colleagues (1978) suggested that each full-time associate should spend approximately 25 hours per week actually conducting activities and devote the remainder to planning, documentation, and attending meetings. Twenty-five hours of programming per full-time associate allows for 12 or 13 separate group activities per week. Synergies can be added by using volunteers to complement staffing, which is often short handed. Realistic amounts of time should be allowed to set up the activity location, prepare materials and equipment, transport nonambulatory residents to and from the activity location, and return the area to its original setup.
Nursing staff members generally help with transporting or assisting the residents to the activity area. Cooperation from nurses is also needed for dressing residents appropriately, helping residents use the toilet before activities, and dispensing medications and treatments in a way that will not interfere with a resident’s ability to participate in activity programs. Hence, nursing schedules are often an important consideration in activity planning. The dietary staff may be involved when refreshments are a part of the activity. Housekeeping and maintenance staff members are needed for special setups that require moving and arranging furniture and cleaning up after activities (Carroll et al., 1978).
Conducting Activities
The actual implementation of an activity is greatly facilitated by how well a program is planned. Execution of most routine programs simply requires bringing together the planned resources. But for larger programs such as parties, functions, and outings, efforts and resources must be coordinated, and follow up is necessary to make sure that everything proceeds smoothly. Each program should be carried out in accordance with the plan, while allowing for any unforeseen circumstances that may occur. Whenever possible, if a planned program must be canceled, an appropriate substitute activity should be provided in accordance with a contingency plan. Hence, some backup programs that can be carried out on short notice are necessary.
Program Evaluation
Program evaluation is the process of systematically appraising a program to determine whether expected results are being achieved. Evaluating activity programs is a prerequisite for improving their quality. An outside activity consultant may be employed to either do the program evaluation or to train the activity staff on how to do the evaluation. When the evaluation validates the effectiveness of programs that associates have helped create, their morale is improved. Program evaluation, however, should not be used to criticize or penalize activity personnel.
Program goals and expected patient outcomes must be established at the planning stage. Evaluation then determines whether the goals and outcomes have been achieved. When desired outcomes are not achieved, the activity director must try to discover the reasons for the lack of success.
The process of program evaluation involves continuous and systematic collection of relevant data. Because resource inputs such as staff time for activities are generally fixed, data collection pertains mainly to the outcomes. To collect outcome data, two main records should be kept. First, an accurate attendance record should be maintained for each activity. A computer spreadsheet can greatly facilitate this type of recordkeeping. The data should reflect each resident’s participation by the specific program he or she attends and by how many times the resident attended each program. These attendance data would yield two critical pieces of information: which programs are the most popular and the level of participation for each resident.
The second type of record involves qualitative information on the goals and progress of the program in relation to the goals planned for each resident in the care plan. This information is directly related to the assessment, care planning, and progress of the resident and can greatly facilitate documentation in each patient’s medical record. When these two types of records are analyzed for each patient, it will be clear how well the activity programming is addressing each patient’s individual needs and what changes may be necessary when certain needs are not met.
Volunteer Support
The activity director is generally responsible for developing and coordinating the facility’s volunteer program. With proper training and supervision, volunteers from the local community can provide valuable assistance in a number of nontechnical areas because staff resources are often limited. Because most volunteers have regular and frequent contact with the facility, they also establish an important link between the facility and the local community.
Volunteer roles are not just confined to helping with activity programs. Depending on personal interests, volunteers may pass meal trays or pour water during lunch or dinner, sweep up the dining room after dinner, maintain wheelchairs in working order, and do other such tasks. Volunteers may also assist with shopping and other chores for patients, or provide transportation for outings.
Some key factors in recruiting and retaining volunteers are listed here:
• Recruitment efforts must be ongoing. Numerous community organizations can be tapped into.
• People most likely to volunteer are retirees, homemakers without small children to take care of, and young adults in school. As mentioned earlier, some family members are also potential recruits for volunteering.
• Making personal contacts is more effective than advertising. Methods such as contacting potential volunteers directly, visiting local schools and discussing after-school opportunities, using current volunteers to recruit others, offering incentives, or sponsoring a volunteer recruitment day in collaboration with other service agencies are some methods that work. The facility’s own employees can also refer friends and relatives.
• Volunteers’ availability, skills, and interests should be matched with the needs of the residents. The facility may state what its most critical needs are, but it should not pressure any volunteer into filling a certain role. The desired areas of service should be chosen by the volunteers.
• Volunteers must be carefully selected using a formal process that should include filling out an application, screening, interviewing, and reference checks. Orientation and training must follow.
• Maintain a log book for recording the time each volunteer spends in the facility.
• Praise and recognition are paramount. Apart from providing the opportunity for personal gratification that the volunteer derives from helping others, recognizing the volunteer’s work is the only way that the facility compensates volunteers for their efforts. The facility should plan an annual dinner and award ceremony exclusively for volunteers. Letting volunteers have meals at the facility at subsidized prices or for free, depending on the tasks they perform while they are in the facility, is also a good policy.
Terminology for Review
activity
continuous activity programming
multisensory stimulation
passivity
program evaluation
programming
reality orientation
reminiscence
secondary disability
sensory stimulation
Snoezelen
validation therapy
For Further Thought
As a nursing home administrator, how would you determine whether or not you have an effectively run activity program in your facility?
Case
iPods for Alzheimer’s
Contributed by Anne P. Stich, MMS, MPS, PA, Health Science College of Arts and Sciences, Bellevue University, Texas.
Nell, the activity director for a Continuing Care Retirement Community (CCRC) complex, has learned about the benefits of music therapy. She is convinced that the residents of the 30-bed Alzheimer’s unit, named Rosewood Court—a specialized unit in the complex’s skilled nursing facility—can really benefit from music therapy. However, she faces the dilemma of how to deliver the music that would appeal to the residents that range in ages from 52 to 91.
At the next interdisciplinary meeting of the Alzheimer’s unit, Nell made an appeal backed by current research on music therapy. During the ensuing discussion, most of the participants quickly dismissed the idea of providing a variety of piped-in music for the entire unit because it would create negative distractions for both residents and staff. The discussion focused mainly on the individual desires and interests of the patients. Most members of the team would like Nell to explore the feasibility of putting individualized music on iPods for each resident. Because the technology is rapidly changing, many people have upgraded their older iPods; Nell may be able to find used iPods for each resident.
Assuming that used iPods could be procured, selecting, obtaining, and downloading numerous musical genres that would appeal to individual tastes would remain a daunting challenge. Nell was given the responsibility to find the answers. She quickly arranged a brainstorming session with her six activity assistants who had responsibilities for the various units of the CCRC. Nell summarized the ideas generated by her activity team:
• Purchase of iPods will be very expensive. They should find ways to obtain donated iPods.
• They should identify how many residents would be able to use individualized music.
• They should ask family members about the residents’ individual tastes in music.
• The staff will not have the time to search for music, procure it, and download it to iPods. The facility should find ways to obtain music. Family members and volunteers could be solicited to assist with finding sources for obtaining at least some of the music.
• The CCRC has a formal Adopt a Grandparent program in which the second and third graders from the local Lawndale Elementary School participate. Ms. Johnson, the principal, should be contacted for leads to try and enroll students from the Lawndale Middle School to help download music and teach the staff on how to access music from the iPods.
Associates in the Activity Department assisted Nell in developing a brief survey for families:
A. Did your relative enjoy music prior to his/her admission to Rosewood Court? What kind of music? Please check all that apply:
B. Are there specific songs or music that your relative associates with good times in the past?
C. Do you have any of this music on vinyl records, tapes, CDs, or other media?
D. Would you be able to lend your media so we can download the music to iPods?
With Ms. Johnson’s help, the 24 students of the seventh-grade social studies class at Lawndale Middle School made it a cultural project. With the enthusiastic support of Mr. Reibold, the social studies teacher, the students helped with finding music on the Web and downloading it. The CCRC paid the nominal cost for the downloads. A local recording studio donated the time to convert some of the music from other media to a downloadable format for the iPods.
Nell and Mr. Reibold arranged a field trip for the students to meet the facility’s residents. Each student presented the individualized iPod to each of the residents in the presence of family members, staff, volunteers, and a few guests from the local community. The students also gave a demonstration on how to use the iPods. Some of the residents tried their “new” iPods. Muffled laughter was heard and smiles were seen forming. Nell and her activity staff were delighted. The celebration ended with cake and punch.
Questions
1. Suggest some ways how Nell could obtain used iPods for the residents.
2. Is there any other alternative to the use of iPods?
3. How does Nell’s use of music measure up to the six basic considerations for program development?
4. Nell is using which of the intervention approaches described in this chapter?
5. Despite the initial enthusiasm expressed at the completion of the project, what future problems do you foresee with the use of iPods?
FOR FURTHER LEARNING
The National Association of Activity Professionals is the only national group that represents activity professionals in geriatric settings exclusively.
The National Certification Council for Activity Professionals is one of the certifying bodies recognized by federal law and is the only national organization that exclusively certifies activity professionals who work with the elderly.
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