Beyond performance: being in place as a component of occupational therapy

Being in Place: Toward a Situational Perspective on Care

An optimum focus in any care situation is creating and sustaining environments that facilitate an ongoing sense of "being in place" for all involved. Using this rationale, we propose a Situational Model of Care for exploring dynamic relationships among aging persons receiving care, the convoy of persons offering this care and support, and the place where this occurs, as evolving situations throughout the course of a disease. The model is grounded in extant literature and illustrated through a case study derived from in-home observations and interviews. Emphasizing an underlying goal of fostering a sense of being in place as a desirable outcome facilitates situationally nuanced directions in research and clinical care.

Qualities of the environment that support a sense of home and belonging in nursing homes for older people

The aim of this study was to contribute with knowledge about how a sense of home and belonging is enacted and can be supported in everyday life, with a particular focus on the relationships that connect everyday life and the environment in nursing home contexts. The concepts ‘a sense of home’ and ‘belonging’ were chosen with the ambition to grasp values grounded in experiences and everyday practices, with an openness for various aspects that can support an enjoyable life and comfort for nursing home residents. The study focused on communal areas, e.g. dining room, kitchen, corridors and gardens, that serve as arenas where nursing home residents’ everyday lives expand beyond the private room. Ethnographic methods were applied to identify and explore situations where a sense of home and belonging were enacted in nursing homes that had been acknowledged as good examples of nursing home environments. Through the analytic process, four qualities were identified: (a) a cornerstone for stability and everydayness, (b) the beating heart, (c) spatial dynamics, and (d) magnetic places. Following from the chosen methodology, the findings provide a situated understanding of how communal areas in nursing homes can invite a sense of home and belonging for the residents.

Place for being, doing, becoming and belonging: A meta-synthesis exploring the role of place in mental health recovery

BACKGROUND AND AIM

The role of place in mental health recovery was investigated by synthesizing qualitative research on this topic.

METHODS

Using a meta-ethnographic approach, twelve research papers were selected, their data extracted, coded and synthesized.

FINDINGS

Place for doing, being, becoming and belonging emerged as central mechanisms through which place impacts recovery. Several material, social, natural and temporal characteristics appear to enable or constrain the potential of places to support recovery.

CONCLUSIONS

The impact of place on recovery is multi-faceted. The multidimensional interactions between people, place and recovery can inform recovery-oriented practice. Further research is required to uncover the role of place in offering opportunities for active engagement, social connection and community participation.

An Occupational Perspective of Migrant Mental Health: Indian Women's Adjustment to Living in New Zealand

It is widely recognised that immigration may be more distressing than anticipated, disrupting occupations and threatening health and wellbeing. In New Zealand, increasing numbers of new immigrants are reported to be accessing mental health services. This article reports the findings of a small-scale qualitative study into the things that Indian women, who have recently immigrated to New Zealand, do in their everyday lives as they endeavour to settle into New Zealand society.

The article describes a pattern of engagement in occupations that unfolds as the women learn about their new environment, the resources available to them and how things are done in New Zealand. Oh God, where did I come? describes how being in an unfamiliar environment initially compels the women to do familiar activities that boost their confidence and support wellbeing. The second pattern, Being in the change, sees the women getting to know their environment and engaging in both new and familiar activities. A New Zealander with an Indian soul finds the women doing more activities that challenge their abilities and knowledge of New Zealand culture.

It is argued that occupational therapists, with their knowledge of the person-environment-occupation interplay, are well placed to support immigrant health by facilitating occupational adjustment.

Finding a Sense of Home across the Pacific in Old Age- Chinese American Senior's Report of Life Satisfaction in a Foreign Land

Finding a sense of home for international migrants is challenging. It is even more so for older adults who migrate to a foreign country later in life to follow their adult children. This study examines Chinese immigrant elders' report of their sense of home and life-satisfaction. Based on 21 intensive interviews and107 surveys with elderly immigrants of Chinese descent, this research finds that a comfortable living condition in a natural and built environment contribute to Chinese elders' narrative of a sense of home. The lack of English language, however, makes immigrant Chinese elders feel very unsettled. Being together with children and having good social benefits are major pull factors that contribute to immigrant elders' decision to settle down in a foreign country. Those who report a stronger sense of home tend to report a higher level of life satisfaction. In conclusion, the authors argue that immigrant elders are defining their sense of home with a greater sense of independence from their adult children. Favorable social policies toward older adults, such as Medicare, Medicaid, low income housing, and social services, are important factors that make older immigrants feel a sense of home in a foreign land, although the inability to communicate is a barrier to a complete sense of home for transnational migrants in old age.

The Concepts of Habit and Routine: A Preliminary Theoretical Synthesis

Although a number of diverse research areas underscore the importance of habit and routine, there has been little theoretical coherence to this work considered as a whole. Varying definitions of habit and routine, as well as the extremely broad range of phenomena to which they apply, have hampered the ability to develop any overarching synthesis. In connection with a recent conference sponsored by the American Occupational Therapy Foundation, this article offers a preliminary theoretical synthesis of habit and routine with respect to definitional issues, relation to quality of life, and potential benefits to consumers with disabilities.

Habituation and Being in Place

Over the duration of our lives, we each develop a rhythm and a routine in our use of space and in our relationships with the places of our lives that provide a sense of being in place. We gradually come to wear our environment like a glove, as, with increasing familiarity, it almost literally becomes a part of our persona. As we grow older or become increasingly frail, we adapt to reduced physical capabilities and changes in our environment in a manner that allows us to continue functioning effectively. This article explores the implications for occupational therapy of habitual use of the environment by older people and the sense of being in place that characteristically results. It is argued that sensitivity to the development and the maintenance of being in place provides a template for effective intervention when physical capabilities are compromised. Using the framework provided by complexity theory, and empirical observations from an ethnographic study of growing old in an Appalachian community, the article considers homeostatic adjustments that older people make in the use and the meaning of the spaces and the places of their lives as they accommodate to changing circumstances. By exploring the role and the uses of habituation (learning through repetition) in this process of gradual, often almost imperceptible, environmental adjustment, occupational therapists will be able to enrich their potential for developing strategies for intervention that effectively use a knowledge of habit in treatment.

A Correlational Study of a Test of Playfulness and a Test of Environmental Supportiveness for Play

This study examined the reliability and validity of the Test of Environmental Supportiveness (TOES), as well as correlated data from the Test of Play fulness (ToP) and the TOES. Correlation coefficients for a sample of children with disabilities were compared with coefficients from a sample of typically developing children. Data from 160 children and their environments were used. Following a 15-minute observation of free play, raters, using the ToP, assessed children for playfulness and using the TOES, assessed the environments in which they played for supportiveness. Rater reliability and person response validity met acceptable goodness of fit criteria for the Rasch Measurement model. Scale validity fell below the desired fit because of the failure of one item (space is physically safe) to fit the measurement model. A positive, significant correlation was found between playfulness and environmental supportiveness. The magnitude of the relationship was greater for the typically developing children than it was for the children with disabilities.

Daily Life and Forms of “Communitas” in a Personal Care Home for Elders

This study examined daily life in a personal care home using anthropological theories of liminality and communitas associated with rites of passage. Purposes of this article are to (1) describe daily life in terms of its setting, activities, and social system (elements of normative communitas) and (2) examine cultural beliefs and values that may foster ideological and existential communitas. Ethnographic methods included participant observations and semistructured interviews. Ongoing data analysis and interpretation were conducted by a five-member research team. Factors that foster social cohesion include a small-scale residential environment, a familiar round of activity routines, a social system with flexible roles of residents and staff, and a culture in which mutual support of persons with varying capabilities is valued. Some of these qualities, for which residents and staff used the metaphors of home and family, might be purposely cultivated in other residential settings for elders.

Adaptation by Elders to New Living Arrangements Following Hospitalization: A Qualitative, Retrospective Analysis

Relocation experience emerged as a major finding from two previous studies that tracked elders in the community after discharge from a transitional unit. This study involved follow-up of 5 elders from the two previous studies who relocated to a variety of new living arrangements. Purposes were (a) to identify how decisions were made to change living arrangements, (b) to describe the process of adaptation to relocation as it evolved over time including challenges and strategies used to address them, and (c) to identify indicators of effective adaptation. A phenomenological approach based on interviews, observations, and comparative analysis was used to capture the insiders' views of these elders. An account of each individual adaptive process was developed. Comparison across cases led to two major themes—sense of place and sense of self—which are proposed as indicators of effective adaptation. Implications of findings for service provision, public policy, and future research are examined.

Managing Changes in Everyday Occupations: The Experience of Persons with Alzheimer's Disease

The aim of this study was to uncover how people with dementia respond to the problems and changes they experience in everyday occupations. Seven participants with dementia were included. Data were collected by means of repeated interviews and observations that focused on the person's experiences of competence and management in everyday occupations. The analysis was carried out from within a phenomenological perspective and resulted in a structure describing management strategies. It was concluded that the participants used a wide variety of strategies. Some strategies were directed toward managing the altered conditions caused by the disease while others served the purpose of responding to the occupational problems of everyday life. The latter strategies were of three types based mainly on environment, habituation, and cognition. Overall, the implicit and explicit cognitive awareness underpinning many strategies seems to call for great caution when assuming that people with dementia soon lose their awareness of disability.

Elders' and Family Caregivers' Experience of Place at an Assisted Living Center

This study was designed to explore elders' and their family caregivers' collective experience of place within an assisted living center. Using an ethnographic approach, data were collected through participant observation, interviews, and focus groups. This study found key features of the assisted living center that most influenced residents' and family caregivers' phenomenological experience of place. These features included the characteristics, experiences, and meanings that participants attributed to the assisted living center's structure, physical nature, sociocultural nature, and temporal-occupational nature. In this place, occupational forms stood out as important, naturally occurring features of place that, over time, helped characterize the place's temporal-occupational nature. Occupational performance pointed to people's experience of that place.

Initial validation of the dimensions of home measure

BACKGROUND

Research has established a need to consider further aspects of the home environment in home modification provision and evaluation. The Dimensions of Home Measure (DOHM) was developed as a self-report outcome measurement tool for home modification practice to meet this need. Its development was informed by a literature review and qualitative exploration which identified six dimensions of the home environment: the physical, social, personal, temporal, occupational and societal dimensions which contribute to one's experience of home. This paper reports the initial evaluation of the validity of the DOHM.

METHOD

The DOHM was completed by 163 community dwelling older adults and people with disabilities. The Rasch measurement model was used to evaluate three aspects of construct validity: rating scale structure, unidimensionality and targeting.

RESULTS

The five-point DOHM rating scale function was evaluated using Linacre's (2002) guidelines. The middle rating category did not function well, and this resulted in collapsing the rating scale from five to four points. The unidimensionality of the DOHM's subscales was supported by Rasch-based principal component analysis and item fit analysis. However, hierarchical results of item difficulties revealed significant gaps in each of the DOHM's subscales, indicating that more items will be needed to capture the full range of participant's experiences of home.

CONCLUSION

The DOHM was developed to provide a relevant evaluation tool for home modification practice which comprehensively measures the home environment. This study identified preliminary validity of this tool, with revision and further psychometric validation required.

"What Do You Think We Should Do?": Relationship and Reflexivity in Participant Observation

This article uses three concepts as a framework by which to examine how the interrelational elements of ethnographic approaches to qualitative inquiry reflect dimensions of therapeutic engagement. Participant observation, reflexivity, and context are all widely and routinely included within research methods; however, they are less frequently attended to directly in their experiential capacity through the lens of the researcher, clinician turned investigator. A unique study design will be profiled to reflect the complicated juxtaposition between methods, questions, sample population, time, space, and identity. Studying occupational therapy students traveling abroad for a short-term immersion experience, this narrative study called on a necessary and attentive awareness of locality as the researcher traveled with the group. Conducting ethnographic research where the researcher's therapeutic skills aided and constrained relationships resulted in rich, guarded, and relevant insights that parallel the therapeutic use of self in occupational therapy practice.

Whose Occupational Balance is it Anyway? The Challenge of Neoliberal Capitalism and Work–Life Imbalance

Introduction:

Occupational therapists/scientists maintain that achieving occupational balance through participation in ‘doing’ and ‘being’ occupations enhances personal and social wellbeing. However, the influence of paid work on occupational balance is not well researched. The purpose of this study was to explore the influence of workplace cultures on the lived experience of occupational balance for occupational therapists.

Method:

Two representative workplaces were accessed: one health and one social services setting, both in Wales. Twenty-nine occupational therapists took part, 18 from healthcare and 11 from social services. The study was qualitative in design, using in-depth interviews and interpretative phenomenological analysis.

Findings:

The study identified a potent link between neoliberal capitalism and occupational imbalance for occupational therapists as a consequence of the pressures of paid work on the rest of life, the social hegemony of paid work, and a sense of individual responsibility for both performance in paid work and success or failure in personal occupational balance.

Conclusion:

Occupational therapists can live unbalanced lives as a consequence of the pressures of the neoliberal workplace on ‘doing’ and ‘being’ activities outside of paid work. Individuals can experience a sense of personal responsibility about success or failure in work–life balance that can affect their achievement of wellbeing through occupational balance.

Occupational engagement among community dwelling older people: A time-geographic perspective†

How older people spend their time in different occupations could contribute to our understanding of everyday life in healthy ageing. This study adopted a time-geographic method and occupational perspective to explore the occupational engagement of community dwelling older people. The term occupational engagement encompasses what people do, where and with whom they spend their time and the perceived level of competence and meaningfulness of their time use. Nineteen volunteers born between 1932 and 1933, living alone in an urban area in northern Sweden and receiving no home care services, completed open time-geographic diaries for 5 days in May 2010. The diary data were analyzed using Daily Life software program. The study revealed the complexity and the diversity of the older people's occupational engagement and that most of their time was spent alone in their home. The older people reported they were very good at doing almost half of the occupations in which they engaged and that their occupations were primarily either very meaningful or meaningful. While some methodological limitations were identified, time-geographic studies of community dwelling older people living independently are considered to have potential to contribute to community and social planning for older people as they can provide interesting insights to older persons' time use and occupational needs.

Toward a physical environmental continuum for occupational intervention in a rehabilitation hospital

ABSTRACT A study was conducted to explore occupational therapists' perceptions of rehabilitation environments and the influence of these perceptions on practice and occupational interventions. Traditionally, inpatient occupational therapists have a choice of intervention environments, ranging from a gym-like to a more home-like setting. Choosing to provide interventions in these different environments can have an impact on occupational performance. In this qualitative exploration, 21 occupational therapists participated in focus groups designed to explore their perceptions of practice environments. Analysis of the transcribed data revealed that therapists felt rehabilitation environments should offer choices and be flexible, that environments influenced intervention strategies, and that the practice environment had an impact on professional identity. On the basis of this data, a conceptual matrix of the intersection of environmental setting and occupation-based interventions is presented to highlight the importance of these two aspects of therapy. Future research in this understudied area is needed to transform this matrix into a clinically useful model.

Moving Beyond 'Aging In Place' to Understand Migration and Aging: Place Making and the Centrality Of Occupation

'Aging in place' has become a key conceptual framework for understanding and addressing place within the aging process. However, aging in place has been critiqued for not sufficiently providing tools to understand relations or transactions between aging and place, and for not matching the diversity of contemporary society in which people are moving between and across nations more than ever before. In this article, the authors draw from concepts of place and migration that are becoming increasingly visible in occupational science. The concept of 'aging in place' is critically examined as an example of an ideal where the understanding of place is insufficiently dynamic in a context of migration. The authors suggest that the concept of place making can instead be a useful tool to understand how occupation can be drawn upon to negotiate relationships that connect people to different places around the world, how the negotiated relations are embedded within the occupations that fill daily lives, and how this process is contextualized and enacted in relation to resources and capabilities.

Understanding the dimensions of home that impact on home modification decision making

BACKGROUND/AIM

The home environment is a multidimensional and personally meaningful place, and the complexity of this environment often impacts on the home modification process and outcomes. Home modifications can appear as a straightforward solution to safety and occupational performance concerns; nevertheless, clients sometimes reject modifications or are unsatisfied with the completed works. To understand this phenomenon, this study aimed to determine what aspects of the home environment impact home modification decision making.

METHOD

In this qualitative descriptive study, 42 in-depth interviews using a semi-structured questionnaire were undertaken and analysed using a template analysis. The interviews explored the experience of the home modification process, including concerns and the decisions made about the modifications.

FINDINGS

Four dimensions of the home environment were commonly found to affect decision making namely, the personal, societal, physical and temporal dimensions of home as well as social and occupational dimensions.

CONCLUSIONS

An understanding of the dimensions of home that impact decision making provides occupational therapists with a greater appreciation of the experience of home and allows them to enhance the effectiveness and acceptance of home modifications.

Well-being and occupational rights: an imperative for critical occupational therapy

BACKGROUND

One of occupational therapy's core assumptions is that engagement in occupations influences well-being. Because occupational engagement is integral to human well-being, and because well-being is integral to human rights, this paper contends that the ability and opportunity to engage in occupations is an issue that concerns rights.

AIMS

To outline well-being and its centrality to human rights; to explore the relationships between well-being and occupation and between well-being and occupational rights; and to highlight the consequent imperative to engage in critical occupational therapy.

KEY ISSUES

The World Federation of Occupational Therapists asserts that all people have the right to participate in a range of occupations that enable them to flourish, fulfil their potential, and experience satisfaction congruent with their culture and beliefs; and further asserts the human right to equitable access to participation in occupation.

CONCLUSIONS

If occupational therapists are to take seriously their espoused commitment to enabling equitable access to participation in occupation, the inequitable conditions of people's lives will need to be addressed. Critical occupational therapy is a committed form of practice which acknowledges that well-being cannot be achieved solely by enhancing individuals' abilities, and that consequently endeavours also to address the conditions of people's lives.

Older men's participation in community-based men's sheds programmes

The purpose of this qualitative study was to investigate the lived experience of older men taking part in community-based shed programmes. Five men, aged 65 and over, who attended two different community sheds participated in semi-structured in-depth interviews in 2007. Data were analysed thematically with six main themes emerging as follows: 'company of fellas'; 'everybody's got a story to tell'; 'still got some kick'; 'passing on your experiences'; 'get on your goat' and; 'nobody's boss'. Participation in community-based men's sheds positively influences the health and well-being of older Australian men through provision of a 'men's space' in which meaningful activities occur. Provision of community-based men's shed programmes as among a range of activity options in the community may contribute positively to the physical, mental, social and occupational health of older men.

The Conceptualisation of Residential Home Environments: Implications for Occupational Therapy

This paper examines the views of staff about the environments of two residential homes: one representative of a homely environment and the other more reminiscent of a hotel. A qualitative study using in-depth semi-structured interviews was conducted with a purposive sample of 21 staff. Emerging themes in the data from the first facility related to kinship, recognition of history, individuality and meaningful relationships in the homely environment. This contrasted with a more conscious awareness of the tone of the second facility, the need for correct behaviours and a bureaucratic organisation in the hotel-like home.

The findings showed that the meanings attached to a residential home and its press for occupational behaviours are shaped by cultural, social and historical experiences. Such meanings are strongly influenced by management, with staff and residents adjusting to expectations as indicated by the social and physical environment. There is very little in the literature that reflects how one should conceptualise a residential home, yet it is the very nature of this perception that is crucial to the development of an atmosphere that indicates expectations for actions – for both staff and residents.

Place Integration through Daily Activities 1 Year after Stroke

Actions link meaning to particular places over time. This study examined how familiar places, in turn, inspired or influenced actions in the rehabilitation process for individuals who had experienced stroke. The aim of this study was to describe the meanings of actions in different places during 1 year of rehabilitation after stroke. The interview data were longitudinal and collected on four occasions during the first year after stroke (e.g., at 1, 3, 6, and 12 months). Seven categories emerged from the data analysis using a constant comparative method: (1) workplace in mind, (2) experiences at home enabling reflection, (3) rehabilitation setting creates uncertainty, (4) retrieving inspiration from familiar places, (5) matching the complexity of tasks across places, (6) understanding the reality by confrontation, and (7) on the way to place integration. From these themes, a core or overarching theme emerged: the desire for place integration inspires engagement in rehabilitation. The central finding in this study revealed a strong relationship between the desire to be reintegrated into familiar places, such as work and home, and motivation to engage in rehabilitation. Further, this desire for place integration was a constant driving force over the year that motivated the participants to find activities on their own that matched the task demands at their workplaces.

Perceived Autonomy and Activity Choices Among Physically Disabled Older People in Nursing Home Settings: A Randomized Trial

Objectives: To evaluate the effect of individually tailored programs on perceived autonomy in institutionalized physically disabled older people and to describe participants’ activity wishes and content of the programs. Method: This blinded randomized trial with follow up included a total of nine nursing homes and 50 nursing home residents who were randomized into either a control group or an intervention group. Perceived autonomy was measured at baseline (T1), after 12 weeks (T2) of intervention and after 24 weeks (T3) Wishes for daily activities was identified at T1. Weekly reports of individual programs were drawn up. Results: Both groups perceived autonomy as average at baseline and increased their mean score at T2 to high or close to high. At T3, both groups scored average but exceeded the level of T1. Activity wishes and the content of the programs indicate incoherence. Discussion: Although the correspondence between the individual wishes for activities and the concrete content of the programs was not obvious, results indicate potential for enabling the perception of autonomy among physically disabled older nursing home residents. The clinical consequences may suggest a focus on existing traditions, methods, and tools in the nursing home practice.

Access technology and dementia care: Influences on residents’ everyday lives in a secure unit

There is a need to understand how technology can best be used to facilitate well-being in people with dementia. This study sought to describe how access control technology influenced the everyday lives of people with dementia living in a secure unit. The staff members and the unit's residents participated in the study. Data were collected through ethnographic observations and semi-structured interviews over 6 months, and were analyzed using the constant comparative method. The results show how access technology supported the residents' sense of security, territoriality, orientation, and adaptation to the environment. However, certain conditions were necessary for these influences to appear. Overall, the results indicate that access control technology may be used to support the well-being of people with dementia, and to increase their opportunities to feel in place in a secure unit. However, there is an urgent need in the future for further exploration of the conditions for use of technology in the field of dementia care, and the necessity of making careful evaluations of the use of technology in this field cannot be overemphasized.

The multiple meaning of home as experienced by very old Swedish people

The aim of this study was to explore aspects of the meaning of home as experienced by very old single-living people in Sweden. A grounded theory approach was used, and interviews were conducted with 40 men and women aged 80-89. The findings indicate that home has a central place in the lives of very old people because it is where they live and spend so much time. The significance of the home is based on the fact that it means so many different things to the participants. The theme comprises two key categories: home means security and home means freedom. Each of these has three sub-categories. In home means security, these are: living in a familiar neighborhood, everything functions, and having memories to live on. Home means freedom comprises a place for reflection, a social meeting-point, and leaving your own mark. Home is part of the environment and influences the meaning and selection of activities that very old people decide to engage in. When occupational therapists prescribe assistive devices or recommend changes in the home environment, they must be very well aware of and reflect on what home means to their clients and base their measures on that.

Autonomy among physically frail older people in nursing home settings: a study protocol for an intervention study

BACKGROUND

Experiencing autonomy is recognised to promote health and well-being for all age groups. Perceived lack of control has been found to be detrimental to physical and mental health. There is a lack of evidence-based knowledge elucidating how frail older people in nursing home settings themselves perceive autonomy in daily life. Further, there are no studies on the extent to which this perception can be influenced positively by participating in an individually tailored programme based on residents' own wishes for daily activities.

METHODS AND DESIGN

A total of 9 nursing homes and 55 participants aged 65 years or older were included in the study. All the participants were restricted in performing at least one P-ADL activity unassisted and had a Mini Mental State Examination-score above 16. Perceived autonomy was measured at baseline, after 12 weeks and after 24 weeks by The Autonomy Sub-dimension in the Measure of Actualisation of Potential test. Programmes were based on participants' individual assessment of their most important daily activities. Staff at all nursing homes who usually organize physical training, social or creative activities carried out individually tailored programmes using their usual methods and equipment. Participants in each nursing home were divided by lot into either a control group or an intervention group. The control groups received their usual care and treatment.

DISCUSSION

This study is designed to assess the status of perceived autonomy at baseline and to provide information about the effectiveness of individually tailored programmes according to perceptions of autonomy registered in institutionalised physically frail older people. This will add knowledge to assist response to present and future challenges in relation to health promotion initiatives for this group.

Do quality of life, participation and environment of older adults differ according to level of activity?

BACKGROUND

Activity limitation is one of the most frequent geriatric clinical syndromes that have significant individual and societal impacts. People living with activity limitations might have fewer opportunities to be satisfied with life or experience happiness, which can have a negative effect on their quality of life. Participation and environment are also important modifiable variables that influence community living and are targeted by health interventions. However, little is known about how quality of life, participation and environment differ according to activity level. This study examines if quality of life, participation (level and satisfaction) and perceived quality of the environment (facilitators or obstacles in the physical or social environment) of community-dwelling older adults differ according to level of activity.

METHODS

A cross-sectional design was used with a convenience sample of 156 older adults (mean age = 73.7; 76.9% women), living at home and having good cognitive functions, recruited according to three levels of activity limitations (none, slight to moderate and moderate to severe). Quality of life was estimated with the Quality of Life Index, participation with the Assessment of Life Habits and environment with the Measure of the Quality of the Environment. Analysis of variance (ANOVA) or Welch F-ratio indicated if the main variables differed according to activity level.

RESULTS

Quality of life and satisfaction with participation were greater with a higher activity level (p < 0.001). However, these differences were clinically significant only between participants without activity limitations and those with moderate to severe activity limitations. When activity level was more limited, participation level was further restricted (p < 0.001) and the physical environment was perceived as having more obstacles (p < 0.001). No differences were observed for facilitators in the physical and social environment or for obstacles in the social environment.

CONCLUSION

This study suggests that older adults' participation level and obstacles in the physical environment differ according to level of activity. Quality of life and satisfaction with participation also differ but only when activity level is sufficiently disrupted. The study suggests the importance of looking beyond activity when helping older adults live in the community.

Assessing and Comparing Physical Environments for Nursing Home Residents: Using New Tools for Greater Research Specificity

PURPOSE

We developed and tested theoretically derived procedures to observe physical environments experienced by nursing home residents at three nested levels: their rooms, the nursing unit, and the overall facility. Illustrating with selected descriptive results, in this article we discuss the development of the approach.

DESIGN AND METHODS

On the basis of published literature, existing instruments, and expert opinion about environmental elements that might affect quality of life, we developed separate observational checklists for the room and bath environment, unit environment, and facility environment. We trained 40 interviewers without specialized design experience to high interrater reliability with the room-level assessment. We used the three checklists to assess 1,988 resident room and bath environments, 131 nursing units, and 40 facilities in five states. From the data elements, we developed quantitative indices to describe the facilities according to environmentally relevant constructs such as function-enhancing features, life-enriching features, resident environmental controls, and personalization.

RESULTS

We reliably gathered data on a large number of environmental items at three environmental levels. Environments varied within and across facilities, and we noted many environmental deficits potentially relevant to resident quality of life.

IMPLICATIONS

This research permits resident-specific data collection on physical environments and resident-level research using hierarchical analysis to examine the effects of specific environmental constellations. We describe practice and research implications for this approach.

Preferences and frequencies of visits to public facilities in old age—a pilot study in a Swedish town center

In societies with an increasing proportion of elderly active people it is valuable to gain knowledge about what elderly people actually do and want to do in relation to activity arenas in the public environment. The main aim of this study was to investigate elderly people's preferences and frequencies of visits to public facilities in a Swedish town center. A further aim was to gather information on elderly people's subjective perception of problematic and favorable environmental conditions in public environments. The study was conducted using a previously developed questionnaire, "My visit preferences to the public environment". The sample comprised 39 persons aged 75-84 years, living in a defined geographic area. The results of this study provide an overview of the public facilities elderly people rate as important to visit. There are public facilities preferred by most elderly people but with varying frequencies of visits. The study also generated information about elderly people's subjective perceptions of problematic and favorable environmental conditions in public environments, demonstrating that more problems were perceived along walking routes in the public outdoor environment than in the public facilities per se. The results are indicative for community planning supporting elderly people's activities in the public environment, but the questionnaire used should be further validated.

Content validity and clinical applicability of the Irena Daily Activity assessment measuring occupational performance in adults with developmental disability

The purpose of this study was to investigate the validity of the Irena Daily Activity (IDA) assessment which measures occupational performance in adults with developmental disabilities. The instrument's content validity was investigated by elucidating its general appropriateness, its clinical applicability and the feasibility of the measurement procedure. Data were collected from a multidisciplinary panel of clinical experts working in day activity centres. Each expert independently judged and reviewed the IDA instrument's content validity. The results show that the content validity index (CVI) values ranged from 0.8 to 1.0 for the instrument's general appropriateness and clinical applicability, and from 0.7 to 1.0 with respect to the significance of the IDA domains' clinical applicability. The applicability of the IDA items were judged as satisfactory (CVI > 80) with respect to their importance for planning treatment and intervention. The feasibility of the measurement procedure was estimated as satisfactory in relation to the items (CVI > 0.70) and satisfactory with respect to the time needed and material used, with CVI values ranging from 0.8 to 1.0. The results of this study support the use of the IDA as a feasible and time-efficient assessment that provides insights regarding the occupational performance of adults with developmental disabilities. A limitation of this study was that it could not illuminate all-important aspects of validity. In conclusion, the IDA has the potential to become a reliable and valid clinical assessment, but additional research on psychometric properties is still needed.

Attitudes towards rehabilitation needs and support from assistive technology and the social environment among elderly people with disability

This study aimed to survey the attitudes of elderly people with disabilities who were living at home regarding their support from assistive technology and the social environment. These attitudes were compared with their identified needs by an occupational therapist and in relation to perception of social engagement, loneliness and overall contentment with life. From a sample of 102 participants who were interviewed using a standardized procedure, 53 persons were included in the study. The results indicated that attitudes among elderly people towards social and occupational engagement and change have a greater influence on their rehabilitation status than their disability as indicated by their health condition and limitations in activities of daily living and instrumental activities of daily living. The elderly people who accepted rehabilitation were more able, and were better equipped and better supported with assistive technology, than those who declined rehabilitation. Rehabilitation needs that the occupational therapists recognized were not always shared by the disabled elderly people, for several reasons; one reason of particular importance was the elderly person's attitude towards change and social engagement. However, the small sample size limits the generalization of the findings to the population of elderly people with disabilities. An ethnographic research design that allows for repeated interviews and observations of elderly people with disabilities for a prolonged period of time in their ordinary everyday lives may present an avenue for future research and lead to a deeper understanding of the issues.

Analysis of key decision-making incidents in the life of a nursing home resident

PURPOSE

This study examined change in the decision-making autonomy of a single nursing facility resident.

DESIGN AND METHODS

This case analysis was part of a larger 3-year ethnographic investigation of decision-making events in four nursing facilities. In this case analysis, the resident, her daughter, and three staff members closely associated with the resident's care were each interviewed five times over a 15-month period.

RESULTS

Analysis of interview transcripts revealed four themes in decision making. Temporal change was evident in a complex scenario regarding room changes. Spatial context reflected the need for predictability and adaptability in decisions using space. Interdependence of decisions and decision makers was most evident with medical treatment and health care decisions. Awareness, being informed, and knowing what was going on was the final theme.

IMPLICATIONS

Despite having the best interests of the resident in mind, the process of decision making in nursing facilities may contribute to a pattern of gradual withdrawal of decisional autonomy from residents regardless of their ability to make decisions.

Occupational therapy practice patterns with older Swedish persons at home

This paper explores and describes occupational therapy practice patterns during two periods for 89 elderly persons living at home. Occupational therapists working in one social welfare district in Stockholm, Sweden documented and reported every occupational therapy intervention provided. The results revealed that the elderly persons who received occupational therapy services during an extended period had an age span of 30 years, with a mean age over 80 years. They had several medical problems and were living in different types of settings. Occupational therapists provided a wide range of interventions, most frequently categorised as treatment, especially related to leisure activities. Irrespective of level of care, the median of interventions per person increased or was the same over time, and 72% of the elderly persons remained at the same level of care. Enabling occupation for elderly disabled person living in their home involves constantly adjusting to the current situation since the clients' capacities, goals and environment change over time. Therefore, occupational therapists need to have a client-centred approach working in home health community services.

Physical housing environment: development of a self-assessment instrument

The aims of this study were to construct and develop a self-administered assessment instrument, useful for studying clients' own perception of accessibility and usability in their housing environment, and to test the instrument for reliability. It was developed for use in combination with an objective, norm-based assessment of the physical housing environment, the Enabler instrument. The instrument developed in this study contains 31 questions about different aspects of the physical housing environment. Answers are given on a 7-point rating scale. Content validity was established by the use of an expert panel and pilot testing, followed by a test-retest study. Internal consistency of the instrument was good (Cronbach's alpha 0.96), and very good to moderate agreement between the two ratings was found on all items (mean weighted kappa, Kw 0.71) indicating good reliability. However, the removal of three items from the standardized part of the instrument is suggested. The instrument has a client-centred approach and is a valid and reliable tool, useful for occupational therapy practice and research.