Green Care Farms: An Innovative Type of Adult Day Service to Stimulate Social Participation of People With Dementia

A scoping review on the psychosocial interventions used in day care service for people living with dementia

BACKGROUND

Adult Day care centres provide an important aspect of care provision through all phases of the dementia illness from diagnosis to the end of life (Dabelko HI 2008) supporting the well-being of both older people living with dementia and their care partners. Services within adult day care settings are designed to provide biopsychosocial health benefits to participants as well as care partner respite.

OBJECTIVE

To examine research studies, literature reviews and grey literature and identify and map the literature on psychosocial interventions used in day care services for older people living with dementia and chart their use, evaluation and outcomes. The research review question is "what are the psychosocial interventions used in day care service for older people living with dementia?" Psychosocial interventions are important non-pharmacological interventions which support people's wellbeing.

METHODS

Inclusion/Exclusion criteria were identified and guided the search strategy. Participants were people aged 60 years and over living with dementia attending day care services. The use of psychosocial interventions for this cohort was the focus of the review. Databases were searched (Cochrane Reviews, CINAHL, Embase, Medline EBSCO, Medline Ovid, Medline PubMed, PsycINFO, Scopus, Open Grey, Lenus and WHO Global Index Medicus databases) using keywords/terms with Boolean operators from 2011 to 2023. Rayyan was used to extract and manage the data.

RESULTS

The findings present a narrative and charting of the data from the 45 papers that met the review criteria, and this data is mapped onto the five objectives. Within this review, interventions were grouped into five broad types: nature (n = 6 papers), memory/cognitive (n = 11 papers), social (n = 17 papers), animal (n = 4 papers), or physical/sensory (n = 7 papers) based interventions.

CONCLUSIONS

This review has illustrated the wide variety in the types, range and facilitation of psychosocial interventions within adult day care services. This review highlights the potential benefits of these interventions. However, findings must be considered in the context that many were provided as brief intervention studies with little evidence of continuation after the study and further research is required given the complex and diverse range of interventions. Results will be of interest to practitioners planning to implement or evaluate psychosocial interventions used in day care services for older people living with dementia.

Feasibility of an adaptive riding pilot study and acceptability to dementia care partners: "Your spirits are lifted"

OBJECTIVES

We sought to assess the feasibility and acceptability of an adaptive riding program with dyads (persons living with dementia, family care partners) and a gardening comparison condition.

DESIGN

This is a two-arm (adaptive riding and adaptive gardening), mixed methods, convergent, feasibility study that occurred February 2019-June 2019.

INTERVENTIONS

Upon enrollment, dyads (n=9) self-selected into either community-based adaptive riding (n=5) or adaptive gardening (n=4), two complementary interventions in Northern Colorado. Interventions occurred for hour-long, weekly sessions for eight weeks.

OUTCOME MEASURES

Feasibility was measured with recruitment (actual/planned, response rate, participants enrolled/month) retention, adherence to study procedures (attendance, retention, fidelity), and data collection processes (planned versus collected); and analyzed with descriptive statistics. Acceptability of adaptive riding was measured with pre/post care partner interviews and analyzed using thematic analysis. Afterwards, findings were converged.

RESULTS

We recruited n=10/24 dyads (6 dyads per month), with the highest response rates for referrals and in-person events, n=9 dyads enrolled. We adhered to study procedures with attendance (6/8 gardening, 8/8 riding), retention (100%), fidelity (100%) and data collected (98%). Care partners (n=5) found the adaptive riding intervention acceptable with two themes Overall hopes: "Joy in the present moment" and "Experience as a Whole: "Your spirits are lifted," affirming quantitative attendance and retention data.

CONCLUSION

Findings underscore the feasibility and acceptability of including care partners of persons living with dementia in complementary interventions involving horsemanship activities. Feasibility data can guide study designs and implementation processes for other nature-based complementary interventions for this population.

Being sheltered from a demanding everyday life: experiences of the next of kin to people with dementia attending farm-based daycare

PURPOSE

Farm-based daycare (FDC) is a type of daycare service for people with dementia. The aim of the present study was to explore the next of kin's experiences with FDC and how the service may affect their daily life.

METHODS

The study has a qualitative, descriptive design. Eight semi-structured interviews with next of kin were conducted. The data were analysed in accordance with content analysis.

RESULTS

We identified three main categories: (1) I am fine when you are fine, (2) Significant aspects of the service at the farm, and (3) FDC as a part of the dementia trajectory. The findings were summarized in one overarching, latent theme: "Being sheltered from a demanding everyday life".

CONCLUSIONS

The findings indicate that next of kin's experience of respite is closely connected to the well-being of their relatives at the FDC and the quality of the service. FDC provides significant support through a part of the trajectory of dementia. Despite experiencing respite and support, next of kin continue to struggle with ethical and moral decisions about the futures of their relatives with dementia.

Comparing the care environment at farm-based and regular day care for people with dementia in Norway-An observational study

People with dementia should be able to live in the community, and day care services are recommended as a means for people to live in their own homes for as long as possible. In this study we wanted to compare the quality of care at one type of small-scale day care situated at community farms to regular day care provided in connection with residential care facilities for elderly people. A total of 42 participants from 10 farm-based day care offers and 46 participants from seven regular day care offers were included. A qualitative observational design using the validated Maastricht Electronic Daily Life Observation tool was used. The data were collected between March and June 2018. Ecological momentary assessments of the activities taking place, level of engagement, physical effort, location, social interaction and mood were conducted while the participants attended their day care offer. The results showed that familiar daily activities were common at farm-based day care, and a linear mixed model analysis showed that farm-based day care attendees used more physical effort, spent more time outdoors, had more social interaction and experienced more positive mood compared to regular day care attendees. These findings contribute with valuable information about care provided at different types of day care services, and indicate that farm-based day care has more activities with the potential to meet the social and activity needs of people with dementia compared to regular day care. There are two main implication of this study. First, regular day care services should focus on including more familiar daily activities found to be important for attendees' sense of identity and feelings of contributing. Second, regular day care services should utilise the potential of available outdoor areas as time spent outdoors has been found to facilitate physical activity, relaxation, health and well-being.

The Homestead: Developing a Conceptual Framework through Co-Creation for Innovating Long-Term Dementia Care Environments

Alternative care environments for regular nursing homes are highly warranted to promote health and well-being of residents with dementia that are part of an age-friendly and dementia-friendly city and society. Insight is lacking on how to translate evidence-based knowledge from theory into a congruent conceptual model for innovation in current practice. This study reports on the co-creation of an alternative nursing home model in the Netherlands. A participatory research approach was used to co-create a conceptual framework with researchers, practitioners and older people following an iterative process. Results indicate that achieving positive outcomes for people with dementia, (in)formal caregivers, and the community is dependent on how well the physical, social and organizational environment are congruently designed. The theoretical underpinnings of the conceptual model have been translated into "the homestead," which is conceptualized around three main pillars: activation, freedom and relationships. The Homestead Care Model is an illustrative example of how residential care facilities can support the development of age-friendly communities that take into consideration the needs and requirements of older citizens. However, challenges remain to implement radical changes within residential care. More research is needed into the actual implementation of the Homestead Care Model.

The experience of attending a farm-based day care service from the perspective of people with dementia: A qualitative study

People with dementia have different needs, and it is important to have variation in the services that are offered for this population. Farm-based day care aims to meet this diversity in need, but research on such services is lacking. The present study provides knowledge about how people with dementia experience attending farm-based day care services in Norway. Ten semi-structured interviews were conducted for five different services, while the participants were at the farm. The interviews were analysed in accordance with the content analysis of Graneheim, U., & Lundman, B. (2004) [Nurse Education Today, 24(2), 105-112] and revealed three main categories that included (1) social relations, (2) being occupied at the farm, and (3) individually tailored service. The findings were summarised in the overall theme that attending day care at a farm makes me feel like a real participant. Our findings indicate that the farm-based day cares in the present study provide person-centred care. The farm setting facilitates services that are tailored to the individual, where the participants get to use their remaining resources and spend time outdoors. Further, farm-based day care was described as being suitable for people with or without farm experience and must be seen as an important supplement to regular day care for those who could benefit from a more active service.

Physical activity in people with dementia attending farm-based dementia day care - a comparative actigraphy study

BACKGROUND

Despite public focus on the importance of physical activity and findings showing the benefits of such activity, research has shown that people with dementia are less physically active and have more sedentary behaviour compared to others in similar age groups. In Norway, there is a focus on day care services as a means to allow people with dementia to experience social, physical and cultural activities. Farm based services have been highlighted as an innovative and customized day care service, but little research has been done on physical activity and such services. This study therefor aims to investigate the potential of farm-based day care services as services that can promote physical activity for people with dementia.

METHODS

Actigraphy data from people with dementia attending farm-based day care services (n = 29) and people with dementia attending regular day care services (n = 107) was used to assess levels of physical activity in each group and to compare the two groups.

RESULTS

People attending farm-based day care had significantly higher levels of moderate activity, approximately 23 min each day, compared with persons attending ordinary day care (p = 0.048). Time spent in sedentary or light activity were similar for both groups. For the group attending farm-based day care services, days at the service, were significantly associated with less time spent in sedentary activity (p = 0.012) and more time spent in light (p < 0.001) and moderate activity (p = 0.032), and in taking more steps (p = 0.005) compared to days not at the service.

CONCLUSION

The findings indicate that participants in farm-based day care for people with dementia have higher levels of physical activity compared to ordinary day care and that farm-based day care increases levels of physical activity for its attendees. Farm based day care services has the potential to help their participants reach or maintain recommended levels of physical activity. Further research is needed to investigate what facilitates this increase in activity and how such knowledge could be used in all types of day care services.

Green spaces, dementia and a meaningful life in the community: A mixed studies review

Engagement in green spaces impacts positively on wellbeing and quality of life. However, little is known about the impacts of green space engagement specifically for people living with the experience of dementia in the community; people with a heightened need to maintain a quality life. In this mixed study review, we explore existing evidence for quality of life impacts of contact with green spaces by people living with dementia in the community. Findings show that gardens and horticultural programs, green care farms, parks, urban woodlands and neighbourhood outdoor environments can impact positively in several ways. Four key mechanisms are identified: Engaging in meaningful activities; Empowerment; Positive risk taking; and Reinforcing Identity. These findings provide conceptual links between psychosocial understandings of the relationships between nature and wellbeing with rights-based dementia discourses. We conclude that evidence specific for people living with dementia in the community setting is growing and there is potential for green spaces to enable an active and meaningful community-life, despite cognitive decline. This is worthy of consideration by policy makers, practitioners and carers. Future studies can broaden this field of research and include investigations into lesser-explored aspects of quality of life, such as spirituality, and methods that incorporate the voices of people living with dementia.

How Can Autonomy Be Maintained and Informal Care Improved for People With Dementia Living in Residential Care Facilities: A Systematic Literature Review

Background and Objectives

For people with dementia living in residential care facilities, maintaining autonomy and receiving informal care are important. The objective of this review is to understand how caregiving approaches and physical environment, including technologies contribute to the maintenance of autonomy and informal care provision for this population.

Research Design and Methods

A literature review of peer-reviewed articles published between January 1995 and July 2017 was performed. Realist logic of analysis was used, involving context, mechanism and outcome configurations.

Results

Forty-nine articles were included. The improvement of the relationship between residents and formal/informal caregivers is important. This increases the knowledge (sharing) about the resident and contributes to their autonomy. A social, flexible, and welcoming attitude of the formal caregiver improves the provision of informal care. Specially designed spaces, for instance, therapeutic gardens, create activities for residents that remind them of themselves and contribute to their autonomy. Use of technologies reduces caregiver’s time for primary tasks and therefore enables secondary tasks such as interaction with the residents.

Discussion and Implications

The results revealed how residential care facilities could maintain autonomy of their residents and improve informal care delivery using caregiving approaches and the physical environment including technologies. The results are supporting toward each other in maintaining autonomy and also helped in enhancing informal care provision. For residential care facilities that want to maintain the autonomy of their residents and improve informal care delivery, it is important to pay attention to all aspects of living in a residential care facility.

Care Farming for People with Dementia; What Can Healthcare Leaders Learn from This Innovative Care Concept?

There is growing recognition that traditional dementia care models fall short for people with dementia and their family caregivers. This has led to a call for new dementia care approaches. In response to this call, innovations in long-term dementia care are taking place both in the community and in residential care. One of these innovations is the care concept called “care farming.” Care farms are farms that combine agricultural activities with care and support services for a variety of client groups, including people with dementia. Although the concept is being implemented in an increasing number of countries, the Netherlands and Norway are still front-runners in providing and researching this innovative dementia care approach. Over the last couple of years, several research projects have been carried out in these countries addressing a wide range of issues related to dementia care provision at care farms and using a wide range of research methods. This paper synthesizes the knowledge that has been generated in these research projects. By sharing the knowledge obtained in the Netherlands and Norway, we hope to inspire leaders in healthcare undertaking similar efforts to innovate care for the increasing number of people with dementia. By providing starting-points for future research, we additionally hope to contribute to a research agenda to further advance the field.

Regular Doses of Nature: The Efficacy of Green Exercise Interventions for Mental Wellbeing

This study investigated the efficacy of medium-term Green Exercise (GE; being physically active within a natural environment) interventions for improving wellbeing, by pooling data collected at the start and end of participants' engagement with a range of GE interventions. Hypotheses were that (i) interventions would show good efficacy for improving wellbeing in the overall sample; (ii) compared to participants reporting 'average to high' wellbeing at the start of their project, participants with 'low' starting wellbeing would report greater improvements post-intervention; and (iii) improvements would significantly differ between age groups. The pooled dataset was categorized in line with UK norms (n = 318) and analyzed using a standardized meta-analysis approach. Effect size was large: g = 0.812 (95% CI [0.599, 1.025]), and differences in wellbeing changes associated with project duration, age or sex were not statistically significant. Compared to those reporting 'average-high' starting wellbeing, participants reporting 'low' starting wellbeing exhibited greater improvements (BCa 95% CI [-31.8, -26.5]), with 60.8% moving into the 'average-high' wellbeing category. GE can play an important role in facilitating wellbeing and can provide alternative pathways for health and social care practice. Public health commissioners should consider integrating such interventions for patients experiencing low wellbeing or associated comorbidities.

The impact of care farms on quality of life, depression and anxiety among different population groups: A systematic review

Care farming (also called social farming) is the therapeutic use of agricultural and farming practices. Service users and communities supported through care farming include people with learning disabilities, mental and physical health problems, substance misuse, adult offenders, disaffected youth, socially isolated older people and the long term unemployed. Care farming is growing in popularity, especially around Europe. This review aimed to understand the impact of care farming on quality of life, depression and anxiety, on a range of service user groups. It also aimed to explore and explain the way in which care farming might work for different groups. By reviewing interview studies we found that people valued, among other things, being in contact with each other, and feeling a sense of achievement, fulfilment and belonging. Some groups seemed to appreciate different things indicating that different groups may benefit in different ways but, it is unclear if this is due to a difference in the types of activities or the way in which people take different things from the same activity. We found no evidence that care farms improved people's quality of life and some evidence that they might improve depression and anxiety. Larger studies involving single service user groups and fully validated outcome measures are needed to prove more conclusive evidence about the benefits of care farming.

Re-thinking the nature of day programs for people with dementia: Implications for research

Day programs are commonly identified in dementia strategies as a solution for keeping people with dementia home for as long as possible. Limited research evidence is available to support these policy approaches, and much of what exists demonstrates equivocal results. While key day program researchers have called for improvements in methodological and theoretical efforts, we argue that basic assumptions concerning what a day program is, and how the effects of day programs should be studied, also require reconsideration. Problematization is a systematic review strategy used to identify and critique assumptions guiding research practices and knowledge development in a field of study. The approach entails a broad overview of a field of research alongside a close reading of key texts to identify prevailing assumptions about the object of study and how it can be known. The intent is to discern how these assumptions are influencing research practices and thus knowledge development. A review of historical texts and research literature reviews was used (1) to identify trends in day program research between 1990 and 2018 and (2) to support identification of influential and typical studies for closer analysis (n = 36). The outcome of our analysis of the research literature suggests three sets of assumptions that guide much of the day program research literature: dementia is mainly treated as a problem of the individual; day programs are treated as stand-alone units of substitute care; and the space of day programs is seen as a simple background to care. We argue that the assumptions regarding care and space have narrowed the field of research and contributed to the production of equivocal findings. We suggest alternative framings of notions of care and space, informed by a Science and Technology Studies' approach to care practices, to generate knowledge about day programs that can usefully inform policy and practice.

Dementia care-giving and employment: a mixed-studies review on a presumed conflict

Many persons with dementia live at home and are cared for by their relatives. If the relatives are still employed, this can lead to higher burden and losses in their work-life. The interplay between informal care-giving and working is complex. Different studies have explored this issue, but the results have not been yet synthesised. In this mixed-studies review, we elucidate the underlying complexity. Our objective is to identify the factors related to care-giving that influence employment, and to describe their impact on dementia care-givers’ employment. We performed a literature search of primary studies using four databases and one meta-database, and retrieved English- and German-language articles. We used the Mixed Methods Appraisal Tool to assess their methodological quality. Evidence identified was synthesised by a parallel-results convergent synthesis design. We included 55 qualitative, quantitative and mixed-method studies published up to January 2018. The emerging model identified factors linked to the care recipient with dementia, the informal care-giver and the care-giving context. The impacts of these factors on care-givers’ employment are mostly negative (e.g. stopped/reduced work, decreased job performance). Nevertheless, the results provide encouraging insights as working can counterbalance care-giving strain, and managing both roles can enhance care-givers’ wellbeing. Practical efforts should focus on enabling informal care-givers to better manage the balance between care-giving and work responsibilities.

Social Farming: An Inclusive Environment Conducive to Participant Personal Growth

Social farming can ameliorate the everyday life of people engaged in farming activities, including perceived changes in mood or behavior. It can also be therapeutic, as it can address a range of public health and service provision issues. This paper presents the findings of an Italian project that explored the impact of social farming on the well-being of the participants and their ability to perform certain tasks linked to agricultural activities. In addition, this paper tries to evaluate how the organization of the network system around the participants helps them to improve their relational capabilities. Participant observations were made in class rooms and farms where the participants carried out their agricultural activities. Such observations focused on the way in which participants and other subjects (i.e., tutors and training staff) inside the network system interacted. A number of in-depth interviews were carried out with tutors and trainers in order to understand if the participants would play a relevant role in social farming activities and what that role would be.

Creating a dementia-friendly environment through the use of outdoor natural landscape design intervention in long-term care facilities: A narrative review

There is an increasing volume of literature on the positive effects of outdoor natural landscapes on health and well-being. However, to date, there is a paucity of research on the effect of outdoor natural landscapes designed for people with dementia living in long-term care (LTC) facilities, in particular, those which have incorporated the characteristics of a dementia-friendly environment (DFE). This narrative literature review synthesizes current knowledge on the effect of outdoor natural landscape design, which is aligned with the characteristics of a DFE, to improve agitation, apathy and engagement of people with dementia living in LTC facilities. The reviewed studies predominantly support the positive effects of outdoor natural landscapes on agitation, apathy and engagement of people with dementia. However, there are concerns about the methodological approaches, principles incorporated in the applied outdoor natural landscapes' designs, and the environmental assessment. Further rigorous research is required to understand the impact of the outdoor natural landscapes, with the application of DFE characteristics in the design, on agitation, apathy and engagement of people with dementia living in LTC facilities.

The use of nature - based activities for the well-being of older people: An integrative literature review

BACKGROUND

During the last decades scientific literature has focused on the positive relationships between Nature - Based Activities (NBA) and health. The aging of the population and the increasing costs of health services make it important to investigate the benefits for older people.

OBJECTIVE

The purpose of this study was to systematically review the existing literature regarding Nature - Based Activities addressed to older people.

METHODS

A systematic search of the literature was made in PubMed, Web of Science and Scopus from 2005 till December 2018.

RESULTS

We identified 42 articles that satisfied the inclusion criteria. The results highlighted the multidisciplinary use of nature in many settings as well as a variety of different research designs, both quantitative and qualitative. The majority of experimental assessments were carried out in the setting of nursing homes and residential facilities. A variety of treatments, e.g. horticultural therapy, gardening, green visiting, green exercise and of settings, e.g. residential facilities or adult day services, participants' homes, outdoor settings, and green care farms were examined.

CONCLUSIONS

The examined studies offered numerous examples of the healing power of nature for the health and well-being of older people. Occupational therapists could gain substantial insight from earlier experiences of NBA for application in their practices.

A pilot programme evaluation of social farming horticultural and occupational activities for older people in Italy

The aim of this study was to evaluate a 1-year social farming programme conducted between 2014 and 2015, including horticultural and occupational activities on six agricultural farms for older people in good general health. Social farming is a practice that uses agricultural resources to provide health, social or educational services to vulnerable groups of people. Activity participation, social relationships, physical activity, and the quality of life of the participants were assessed using a pretest, posttest design. A total of 112 subjects were interviewed at baseline, though only 73 participants were retained through the end of the follow-up, resulting in a dropout rate of 34%. Data analysis revealed significant improvements in both social relationships and overall occupational engagement at the end of the programme, with significant increases in the frequency of contact with friends or relatives as well as the number of activities performed by the participants. This work adds to the literature on the effects of social farming and indicates that farming may provide opportunities for older people to engage in activities that stimulate social behaviours.

Using the natural environment to address the psychosocial impact of neurological disability: A systematic review

Engaging with the natural environment contributes to favourable psychosocial health outcomes. A systematic review of research published before June 2017 was conducted to establish how engaging with natural environments impact the psychosocial health of people with a neurological disability. Identified studies included populations with dementia (n=14), brain injury (n=2), and stroke (n=2). Evidence suggests that engaging with gardens, and gardening, can favourably impact the emotional and social health of people with dementia and, an explanatory theoretical model is proposed. Considerable research gaps exist and further research investigating the psychosocial impact of engaging with natural environments for people with different neurological conditions (for example spinal cord injury or stroke) is warranted.

Nature-based interventions in institutional and organisational settings: a scoping review

The objective of this review was to scope the literature on nature-based interventions that could be conducted in institutional settings where people reside full-time for care or rehabilitation purposes. Systematic searches were conducted across CINAHL, Medline, Criminal Justice Abstracts, PsycINFO, Scopus, Social Care Online and Cochrane CENTRAL. A total of 85 studies (reported in 86 articles) were included. Four intervention modalities were identified: Gardening/therapeutic horticulture; animal-assisted therapies; care farming and virtual reality-based simulations of natural environments. The interventions were conducted across a range of settings, including inpatient wards, care homes, prisons and women's shelters. Generally, favourable impacts were seen across intervention types, although the reported effects varied widely. There is a growing body of literature on nature-based interventions that could be applied to a variety of institutional settings. Within most intervention types, there is sufficient research data available to perform full systematic reviews. Recommendations for future systematic reviews are offered.

Exploring the Role of Farm Animals in Providing Care at Care Farms

We explore the role of farm animals in providing care to different types of participants at care farms (e.g., youngsters with behavioural problems, people with severe mental problems and people with dementia). Care farms provide alternative and promising settings where people can interact with animals compared to a therapeutic healthcare setting. We performed a literature review, conducted focus group meetings and carried out secondary data-analysis of qualitative studies involving care farmers and different types of participants. We found that farm animals are important to many participants and have a large number of potential benefits. They can (i) provide meaningful day occupation; (ii) generate valued relationships; (iii) help people master tasks; (iv) provide opportunities for reciprocity; (v) can distract people from them problems; (vi) provide relaxation; (vii) facilitate customized care; (viii) facilitate relationships with other people; (ix) stimulate healthy behavior; (x) contribute to a welcoming environment; (xi) make it possible to experience basic elements of life; and (xii) provide opportunities for reflection and feedback. This shows the multi-facetted importance of interacting with animals on care farms. In this study the types of activities with animals and their value to different types of participants varied. Farm animals are an important element of the care farm environment that can address the care needs of different types of participants.

Capturing Interactive Occupation and Social Engagement in a Residential Dementia and Mental Health Setting Using Quantitative and Narrative Data

Objectives: Despite an abundance of research acknowledging the value of interactive occupation and social engagement for older people, and the limits to these imposed by many residential settings, there is a lack of research which measures and analyzes these concepts. This research provides a method for measuring, analysing and monitoring interactive occupation and social engagement levels of residents in a secure residential setting for older people with mental health problems and dementia. It proposes suggestions for changes to improve the well-being of residents in residential settings. Method: In this case study design, the Assessment Tool for Occupational and Social Engagement (ATOSE) provided a ‘whole room’ time sampling technique to observe resident and staff interactive occupation and social engagement within the communal sitting room over a five-week period. Researchers made contemporaneous notes to supplement the ATOSE data and to contextualise the observations. Results: Residents in the sitting room were passive, sedentary, and unengaged for 82.73% of their time. Staff, who were busy and active 98.84% of their time in the sitting room, spent 43.39% of this time in activities which did not directly engage the residents. The physical, social and occupational environments did not support interactive occupation or social engagement. Conclusions: The ATOSE assessment tool, in combination with narrative data, provides a clear measurement and analysis of interactive occupation and social engagement in this and other residential settings. Suggestions for change include a focus on the physical, social, occupational, and sensory environments and the culture of care throughout the organization.