Altering the boundaries of everyday life in a nursing home context

Abstract

Background: Despite global and local policy frameworks that explicitly aim to privilege participation and active engagement of older adults living in nursing homes, this group often has limited possibilities to engage in occupations and to have influence in their everyday lives.

Aim: To explore how older adults’ engagement and influence in an occupation can emerge in everyday life in a nursing home setting.

Material and methods: A participatory qualitative approach was applied. Older adults living in a nursing home participated in a Book Club that was created collaboratively between researchers, residents, and the nursing home community.

Findings: The analysis identified qualities of altering the boundaries of everyday life and addressing the uncertain conditions for influence and engagement as processes actualized by the residents when engaging in the Book Club. Further analysis identified how these processes involved ordinariness, familiarity, fellowship, and connectedness.

Conclusion and Significance: Engagement and influence in occupation in a nursing home is possible when enabling partnerships and resourcefulness among the residents. However, such enablement is not guaranteed and needs to be actively upheld by the nursing home community in order to build practices aligned with policy frameworks of participation.

Keywords:

• participatory methods
• hermeneutic analysis
• third space
• persons with dementia
• residential care facilities
• older adults

Introduction

Older adults’ engagement in occupations is an important issue in the development of quality standards and the person-centred approach [1–3] within nursing home (NH) and has been a clear focus in aging research [4–8], occupational therapy research [9–16], policy [17–19] and in clinical practices. It is well known that older adults’ engagement in occupations contributes positively to quality of life and meaning making [13,20–25]. Although an occupational perspective [26] is often an important part of NH settings, many programs fail to incorporate and accommodate the residents’ views and resources [2,11,14,24,27,28]. Occupations can take a more instrumental form, as a tool that serves delimited purposes, e.g. training the body or cognitive abilities instead of focusing on accommodating and adapting everyday life activities to create a meaningful everyday life [29]. Research shows that older adults living in NHs often spend their time passively [16,30,31] by sleeping, passing time, waiting for meals, having limited possibilities to engage in meaningful occupations [30,32,33]. Research also shows that older adults are often seen by NH staff as passive recipients [34] who have limited possibilities to influence available occupations. These constrained possibilities to influence occupations [4,10,24,34–36] could, for example be due a stereotyped view of older adults’ preferences and interests [28]. However, there is limited knowledge about how occupations could be embedded in everyday life and aligned with older adults’ interests, preferences, and values in the NH context.

When older adults are seen as resourceful, a shift can occur towards enactment of their capabilities [12,25,37] and fostering of engagement [11,25]. This understanding of doing together [38,39] and to connect with peers challenges an individualistic view of engagement by proposing doing and co-creating in an emergent dialog through occupations. An example of this is how simple household chores such as helping to fold clean laundry or setting the table can be experienced as meaningful [21,23,40,41] or connecting with peers [12,23,42–45] when performed in accordance with older adults’ capabilities, desires, and interests. However, there is still limited knowledge about how this dialog through doing is played out in real situations. Although NHs might strive in practice towards the ideal of a meaningful everyday life, these efforts can easily be overshadowed by institutional routines [4]. This tendency carries the risk of institutions affecting the experience of occupations [46,47] and thus being detrimental to peoples’ engagement in occupations and everyday life. Importantly, occupations valued by older adults living in NHs can differ significantly from the institutions’ routine activities.

This study proposes to focus on the qualities that occupations can bring into older adults’ living in a NH everyday life. The aim of the study is to explore how older adults’ engagement and influence in an occupation can emerge in a nursing home setting.

Material and methods

Project context

This project was conducted in a NH in an urban area of Sweden with a total capacity for about 200 residents divided into smaller units. Three occupational therapists were employed in this facility, and their main focus was on the prescription of assistive devices, adaptations in the residents’ flats, and organization of entertainment activities that took place once a month. A total of 20 nurses and three physiotherapists were also part of the professional team. Nurse assistants assisted the majority of the residents in daily life activities, such as toileting, dressing, getting in and out of bed, and during mealtime.

The unit involved in this project had a capacity for 54 residents and was divided into groups of nine residents each. The building had three floors, one of which was profiled for people diagnosed with a dementia disease. The two other floors were open for old adults diagnosed with a variety of chronic conditions. The residents’ flats were about 20 m², distributed in one room and a bathroom and were rented by the residents.

There was a weekly group activity scheduled in the unit in which this project was conducted. The residents gathered together for two hours in order to participate in singing and playing bingo or memory games. Besides this group activity, the setting was generally lacking in other activities the older adults could engage in. Other activities were less frequently carried out by the nurse assistants, such as gymnastics, reading the newspaper together or watching a TV show, but these were also lacking the active influence of the older adults living at the NH.

Project design: the creation of a third space

A participatory approach was applied in this study [48–50]. This participatory approach gears towards planning and conducting the research process with people whose life-world and meaningful actions are under study [50] as a way to bridge the gap between research and practices, the researcher and participants [51]. In order to create a space where older adults in the NH could enact influence over occupations, this study makes use of the concept of third space [52]. This concept, originally emerged in the post colonialist research, is defined as a a site for collaboration, contestation and negotiation [52]. The third space is a place, both symbolic and concrete, where new identities are tried out, and reformulated, as it aims to bring new contributions and fill gaps within the current context [53], opening an arena for possibilities and struggle. The third space in this study is defined as a co-created practice that was not part of the regular culture of the NH at the moment, and at the same time could meet some expressed needs and wishes of the participants living there. The third space granted access to situations where the participants’ views and values could have a place within the institutional culture. In this study, the third space took the form of a Book Club that served as a source to answer the research inquiry and at the same time as a feasible occupation that could be part of the everyday life practices at the NH. The concept of third space, became a theoretical resource that served to inquiry about how dialog through doing together may be played out- in real life- in an institutional setting.

In a previous study conducted in the same setting [24] occupational interests among older adults living at a NH and the facilitating conditions to enact those interests were explored. The main findings revealed that older adults wanted to feel connected with the world outside the NH, to put their capabilities in action, to have something to look forward to, to have a chance of meeting new people and to feel active in their own capacity. Through the previous study, we also found that older adults were interested in discussing literature. Therefore, the present study took the form of an adapted Book Club at the NH. It was adapted in the sense of being accommodated to the participants’ capacities and interests [29]. The first author, in collaboration with a nurse assistant, facilitated 27 sessions of the Book Club, and the fourth author also participated as a facilitator in the Book Club meetings on several occasions. The Book Club meetings lasted one and a half hour and took place once a week over a period of seven months.

The location of these meetings was considered a key element in the design of the project, and meetings at one of the participant’s flats was part of the dialogs and decisions made with the participants. The idea behind this was to have an authentic meeting where the participants could communicate easier with each other without interference from staff and other residents and thus have the chance to be themselves and to listen to each other in a comfortable atmosphere. At the end of each meeting, the group decided on the themes they wanted to discuss the next week, and the first author could bring several relevant illustrated books on the topic to the next Book Club meeting. At the meetings, some paragraphs of the books were read out loud, pictures were discussed, and an open dialog emerged. All of these activities, decisions, and negotiations were co-created with the participants, documented, and considered part of the data-gathering process [50]. These Book Club meetings became a key activity for the research inquiry by co-creating a new practice – a third space – with the participants where they could interact and have a say regarding the occupation [49]. The research project was approved by the Regional Ethical Committee in Stockholm.

Participants in the book club

The time spent in the NH by the first author in a previous study [24] served to build trust and engagement with the participants and to get an informed sense of their aspirations and interests related to occupations. Older adults who showed interest to participate in the Book Club were invited. An additional inclusion criteria was being able and comfortable with interacting in the Book Club’s meetings. The group of participants consisted of seven persons who participated regularly and five persons who participated less frequently. Three of them were men, and nine were women. The participants’ age ranged between 74 and 90 years, and their lengths of stay at the NH varied from two weeks to five years. The majority of the participants had multiple chronic conditions and diverse degrees of cognitive impairments, including being diagnosed with a dementia disease. The participants’ attendance in the Book Club meetings was dependent on multiple factors such as health status, energy, motivation, and logistics at the NH. The same nurse assistant participated throughout the entire project by facilitating the group dynamics, reading, and helping to set up the meetings. Prior to each meeting, the participants were visited by the first author and consulted about whether they felt they had the energy and motivation to participate that day. The participants came from three different floors of the unit of the NH, and they verbally agreed on each occasion to participate.

Data generation and analysis

The first author took the role of group facilitator with a reflective stance, as is traditional within the participatory traditions [53]. Data were generated through fieldwork that included Book Club participants and staff [54]. Focus was given to the Book Club meetings and the immediate moments before and after the meetings. As is characteristic for doing participant observations [55,56], the first author also posed questions to the participants during these moments to facilitate a better understanding of the unfolding situations. Situations of interest were those where the participants reacted, interacted, or encountered each other in new ways. Thick descriptions [57] of the observations were written as field notes after each meeting. Along with the project, the nurse assistant’s overall impressions of facilitating the Book Club were gathered through short conversations and an interview at the end of the project. The collaborative emphasis was put in the design, content and emergent character of the Book Club meetings. The first author actively placed her understanding of the emergent knowledge in dialog with the participants in order to assure the accuracy of this understanding [58,59].

The data were analyzed following Gustavsson’s hermeneutic interpretative approach [58]. This approach was chosen because it has a special focus on human action and its contextualization and can therefore contribute to a better understanding of occupations [60,61]. Gustavsson [58] recommends following an iterative approach in analyzing data between the whole, particular pieces of the generated data and theoretical resources during the interpretation. This interpretative framework explores the possible meanings that some accounts might have for the participants, and it emphasizes the contextualization of the process of interpretation.

Following Gustavsson’s approach, the data were interpreted in three main steps. The first step was to capture the most striking situations of each session related to the focus of the study. From each session, initial interpretations that could explain these situations were articulated. This initial analysis could be exemplified with an interpretation initially called ‘Vacillating while facing a new occupation’ to express the ambivalent attitude of the participants when the Book Club meetings were about to start or the hesitation towards initiating new commitments. Another interpretation found in the initial analysis was ‘Growing and being more together’ to express the actions taken by the participants of the group when encountering someone together or when positioning themselves in the discussions as a new form of response. The second step was to contextualize the data in a variety of everyday situations of the participants at the NH. Previously framed situations were put in dialog with analytical questions such as: Does this happen in other particular situations? Is this situation unique in its quality? Is this situation limited to the Book Club? This analytical step sought to discover more about the meaning embedded in the participants’ everyday life. Regular analytical meetings between the authors served to interpret particular situations in the particular context and to look for nuances and at the same time to sharpen the focus of what was novel and emerging in the Book Club. Based on this work, an iterative analysis of the material started to form more solid interpretations. For instance, the above-mentioned ‘Vacillating while facing a new occupation’ was interpreted as ‘Reconnecting timidly with former roles’, thus giving a more specific focus to the situated and local experiences of the participants at the NH in the context of the Book Club meetings. The third step focused on contextualizing the emerging findings from the analysis and explored them in light of existing knowledge about occupations at nursing homes, nursing home culture, and occupational engagement. The conceptual areas explored were corresponding with the theoretical grounding of the authors and consequently with the interpretations presented in the findings section. The initial tentative interpretation ‘Growing and being more together’, for example, was interpreted in light of the literature as ‘Trying out different modes of engagement’, which later led to a final interpretation of the findings. Together these findings propose situated qualities of engagement and influence in relation to occupation of older adults living in a NH setting. The findings are presented with citations that stand out from the field work, followed by information of the situation to contextualize them, and finally followed by interpretations to invite the reader into possible understandings.

Trustworthiness was assured [54], by the extensive period spent in the setting, thick descriptions of the fieldwork and consequently a comprehensive data generation. Also, trustworthiness was enhanced by the positioning of the researchers understanding in constant dialog with the participants and regular peer debriefing through the analysis process. Of particular importance was to apply reflexivity [48], as the collaborative approach situated the researchers in multiple roles at the same time.

Findings

In the findings, the identified situated qualities of engagement and influence in occupation of older adults living in a NH setting are framed under headings to visualize various facets of these phenomena and how they are embedded in the everyday of the participants.

Altering the boundaries of everyday life

These findings illustrate how engagement and influence could take different expressions, sometimes through hesitation about what rules everyday life and other times fostered through reconnecting with ‘natural and refreshing’ social situations.

What rules everyday life?

The Book Club meetings seemed to be something relatively simple to start at the NH. One of the first surprising elements while setting up the Book Club was the insecurity about who was entitled to decide upon using the participants’ rented flats. When some of the participants involved in the project and the researchers were planning where to gather for the Book Club, one of the participants suddenly reflected:

‘But are you sure we can invite people to our flats?’ Yes, I am sure, replied the first author. ‘Well I think you need to check with the staff if it is possible anyway, I am not sure we can!’ was her reaction. Another resident participating in this conversation added: ‘It will be better if you ask if it is possible’, agreeing with this hesitation.

Somehow the idea of meeting at one of the participant’s flats was new not just to the participants, but also for the NH. This small change of the habitual routines at the NH turned out to be more controversial than anticipated. The day the Book Club was supposed to start, the first author went around reminding staff and participants about the time and place of the meeting. The nurse in charge held a meeting with the nurse assistants and expressed her concern about some residents having a cold and said:

‘About the Book Club, I am not sure if it is a good idea. One of the residents has a cold. I will be very upset if this cold is spread in the house! I really don’t think it is a good idea to be moving people, and going into each other’s flats!’

This was initially interpreted as opposition, and sounded at first very surprising to the research group, but was considered reasonable because many residents had frail health conditions and thereby the concern about spreading a cold was well grounded. On the other hand, it is possible to argue that there is a constant risk of contagion when residents and staff meet in the dining area and other common spaces and the staff walk in and out between the residents’ flats on a daily basis. Another possible interpretation of the nurses’ unwillingness towards this new activity was that it challenged the institutional order and that the proposed Book Club meetings lacked references and were not part of the ordinary everyday life within the institutional routines. The hesitation in the residents about being authorized to gather in their own flats could be interpreted as an embodied institutionalization that serves in adaptation at the NH but risks the resident’s integrity.

When engagement and influence become ‘natural and refreshing’

As the meetings continued to be held at one of the participants’ flats every week, one of the participants, Ann, acquired the role of hostess. Ann felt comfortable the first time she hosted the Book Club members and she wanted to continue doing so. Each time, she was thrilled to use her finest coffee cups and welcome the Book Club members into her flat. Ann was in need of using a cane or a walker, but despite this she welcomed each participant standing, and she waited to sit until everybody else was seated, making an obvious physical effort. She enjoyed telling stories about the family pictures and paintings on the walls, and she created a friendly and familiar atmosphere. She also offered coffee and some cake to each one of the participants; even if her hands were not steady enough to serve her guests the coffee, she attempted to. When the participants went back to their flats after one of the first Book Club meetings, Ann reflected:

‘It felt so natural to have these friends here.’ Ann was obviously touched when saying this, but also a bit surprised by her natural way of handling the situation and the experienced familiarity during the meeting.

Ann continued to hold the hostess role, and even if some days her dementia symptoms could be very disrupting, these meetings did not cease to trigger her natural sense of being a remarkable hostess. One possible interpretation of her engagement could be that her role in the Book Club gave her a chance to practice being a hostess and connected her with experiences she had mastered in her earlier life. Embodying this role again could then be seen as allowing her to temporarily cease being a resident at the NH, and in contrast connecting her with a well-known, natural, familiar, and comfortable embodied way of being in this situation, putting her in contact with the ordinariness and familiarity of the everyday life she lived before moving to the NH. The members of the Book Club expressed the same comfort and familiarity by the way they appropriated the room and the conversations and the relaxed way they started to connect to each other. When gathering some impressions after one of these meetings, one of the participants said:

‘We laughed so much today, it just felt so refreshing, so life-giving!’ pointing towards a clear distinction with other qualities in the occupations experienced at the NH.

The qualities of a refreshing familiarity, fellowship, and connectedness brought by the Book Club could be interpreted as altering the boundaries of the institutional routines and other occupations available at the NH.

Addressing the uncertain conditions for influence and engagement

These findings give new nuances to how engagement and influence can take different expressions. Engagement and influence could sometimes be threatened, limited, contained, created or nurtured through fellowship in this setting.

Influence and engagement as fragile and contingent

Some of the most popular and appreciated occupations for the participants at the NH, were those that allowed them to feel connected with the context outside the institution, both in a real and a symbolic sense. The Book Club group started to plan other activities together such as go walking in the neighborhood, museum visits, visits to small shopping centers. While preparing for one those outdoor activities, the nurse assistant asked one of the members, Karin, if she wanted to join the others:

‘Of course, I want to!’

‘Well, then it is good if you put your jacket on and some comfortable shoes to walk,’ the nurse assistant replied, and added: ‘don´t forget to bring your walker too!’

Karin reacted to this last part of the comment with energy: ‘I would rather take my cane. I have walked with it [the cane] for many years now, and I am sure I can use it today too if I want to.’

‘But you will get tired easily,’ the nurse assistant argued, trying to persuade Karin to use the walker.

‘Well, I will try this way anyway,’ was Karin’s final answer.

When the first author turned to see the reaction of the other women who were ready to go out, she saw that one of them was smiling with some kind of pride about what she just witnessed and that another woman was showing her approval by giving her a ‘thumbs up’. With this, the nurse assistant could not come up with anything more to say.

The situation described above shows how the Book Club group allowed the participants to enact resourceful dimensions of themselves in turns, even if this wasn’t in a constant flow. However, Karin’s and the other participants’ engagement could be seen as a response to the situation they were in, and their engagement could be described as being fragile and contingent in the sense that it was dependent on the conditions of the very moment and on others to be actualized. This engagement had the potential to arise, to disappear, to be encouraged, disregarded, or neutralized by others. This was also observed at the Book Club meetings on several occasions, sometimes in subtle ways and at other times more explicitly:

One of the women, Greta, was thanking the hostess for the coffee and for an enjoyable afternoon at the Book Club meeting. Greta asked out loud if she could be the hostess next time, at her flat. The other group members were approving this idea. She continued by assuring:

‘Then, I will call you all next week some days before the meeting to remind you.’ No one made notice that the use of a telephone between residents was not a possibility at the NH. Then, another woman in the group asked back, just getting along with the dialogue:

‘Do you need us to bring anything?’

Greta answered with joy: ‘Oh no, don’t worry, I am planning to do some baking myself, so just come as you are!’

The nurse assistant interrupted the dialogue, this time in an effort to mark the boundaries of this emergent initiative:

‘But you can’t bake here, Greta!’ she said.

Then the whole group reacted and mumbled as a sign of complaining and opposition about this statement, until one of the participants stated: ‘But for sure it is possible to bake here, isn’t it?’ Thus, appealing to the rest of the group members and challenging the nurse assistants’ view.

This could also be seen as an example of contingent engagement, and we can question whether the Book Club’s response would have been the same without the group’s history together. The quality of engagement could in this example be seen as telling about the necessary conditions to start up such a response, in this case the fellowship and connection experienced at the Book Club. On the other hand, as exemplified here, the contingent quality of engagement can emerge in ordinary and unpredictable situations.

When engagement turns into dangerous enthusiasm

The enthusiasm of being part of the Book Club expressed by the participants could evolve and endure for some days; however, according to the nurse assistants this could turn problematic. One day when the Book Club gathered, one participant of the group was missing and another member of the group, Astrid, asked for her and wondered why she wasn’t there. Astrid got the following response from a nurse assistant:

‘You know it is difficult with her because after these meetings she gets very excited and she starts asking all the time and every day when the next meeting is going to be. Some nurse assistants consider this too difficult to manage’.

Then Astrid reflected and asked back: ‘So she is not invited anymore?’

The nurse assistant answered with a lower tone in her voice: ‘At least not today’, as if she was realizing how her explanation did not match the Book Club participants’ expectations.

This remarkable and unexpected finding about preventing and endangering participation at the Book Club meeting to the missing lady, could be understood as presenting the fragile nature of engagement in this context and the need to uphold it not just by the participants, but also by the institutional practices imbedded in the NH culture. Another possible interpretation is that the lady’s enthusiasm is somehow labeled as endangering the institutional order by the staff in this case. This makes visible that in an institutionalized setting engagement in an occupation is at risk of being pathologized and therefore in need of being contained. In addition, this finding raises the question about what types of values the NH strives for. This understanding could be seen as endangering the chances of older adults living at the NH to hope for and pursue a meaningful everyday life and engagement in an occupation on their own terms.

Setting engagement, influence, and fellowship in motion

The resourceful dimensions of the participants, as described in this study, can easily pass unseen in the every day. This resourcefulness was observed, for example, when the participants, depending on the topic of the day, could flourish and show previously unseen expertise about a specific period of time, a part of the city or a particular topic. The reading of well-known persons’ biographies and the use of books with pictures opened up for engagement in diverse dialogs. These dialogs were about the group members’ personal lives, world visions, and experiences contextualized in their current situation. In contrast to flourishing, some participants also dared to share their current struggling. In one of the Book Club meetings, one of the participants triggered by a dialog about a picture in a book said:

‘I can’t remember how to cook anymore. Imagine! I was a professional cook once and now I can´t even follow a recipe!’

One of the ladies comforted him by saying: ‘Don´t worry about that, nowadays there is all kind of ready-to-eat food, you just have to heat it! You don´t need to know how to cook anymore!’

The man then said: ‘Well, maybe I have to start thinking like that’. The man remained mostly in silence, but apparently less anxious and able to engage with the group during the rest of the meeting by looking at the illustrations of cars in some books.

It was interesting to notice how the dialog presented above was not about practicalities but about existential reflections about changes in life. This dialog could be seen as exemplifying the expertise of living an everyday life, the losing of control, and, despite their frailty, being able to console, support, and encourage each other. This could also be understood as a shift in the traditional NH roles, of not just being a passive recipient of care, but also having the possibility to care about others, a seldom highlighted aspect of older adults in this context. This interpretation was strengthened by the nurse assistant who actively participated along with the Book Club, and when reflecting back she noticed this resourcefulness and fellowship:

‘For me the most surprising of all was to see that they are more together, that they light up together, the way they grow together. I didn´t expect to see this kind of support for each other here [at the NH]’.

The surprise of the nurse assistant could be understood as the rarity of paying attention to older adults taking care of each other and fostering fellowships in contexts such as NHs.

In summary, both Altering the boundaries and Addressing the uncertain conditions for influence and engagement inform about how older adults’ engagement and influence in an occupation emerged in everyday life through doing together in a NH setting. Altering the boundaries refers to the creation of a third space, the Book Club, and the entering into a new territory of action that brings about distinctive qualities to everyday life. Distinctive qualities such as enjoyment, fellowship, and a sense of familiarity and normality refer to a way of being seen, met, sensed, understood, and cared for at the NH. In other words, to be seen and encountered by others as persons, and not just as residents at the NH, by being enabled to enact influence and by doing so to alter institutional boundaries. The finding Addressing the uncertain conditions for influence and engagement in an occupation refers to the actions performed by the participants in everyday practices as a response to the institutional order. These actions were facilitated by a new situatedness, a new social context, given by the Book Club meetings. These actions could be seen as challenging the traditional view of engagement in this context.

Discussion

As identified in this study, qualities such as enjoyment, fellowship, a sense of familiarity and normality were regained when the occupation was aligned with mundane aspects of everyday life. Qualities such as ordinariness, familiarity, fellowship, and connectedness were actualized by the residents by engaging in the Book Club. In contrast, if occupations are seen instrumentally, as fulfilling specific but limited purposes such as training memory or activating certain body functions, everyday life could be seen as being at risk of losing its vital function of giving sense and meaning to life [26,62]. This understanding of everyday life is in line with previous research showing that older adults engage in occupations that promote a sense of familiarity and that are ingrained in their identities [2,14,21,43,63]. These qualities present a clear contrast with restricted possibilities to enact influence at the NH whose culture is still rooted in a medical model. It is possible to argue that the understanding of everyday life in an institutional culture frames the types of activities that are emphasized and enabled. This framing of activities imprints its contents, qualities, and forms [25,35,64].

The findings presented in Altering the boundaries of everyday life might be useful knowledge for understanding the actual possibilities of transforming traditional care practices into more inclusive and meaningful ones. When the participants were enabled to engage in the Book Club meetings, they could enact alternative practices that were grounded in their values and capabilities. This has been addressed as a key issue for good care quality at NHs [2,65] but has also been framed as a challenge in clinical and research practices [11,25,63]. In order to enable this type of engagement in this occupation, it was a necessary precondition to address power positions and to redefine the role of the participants as experts in their own everyday life at the NH [27,59,66]. This understanding facilitated interactions where the participants could enact resourceful and insightful dimensions of themselves together in the Book Club meetings. As expressed by the nurse assistant involved with the project, this resourceful side of the participants is seldom seen in action and is not sufficiently highlighted in research regarding older adults [27,66]. Connecting with other older adults through doing and co-creating could be seen as promising for the enactment of influence over their everyday life and occupation.

The resourcefulness triggered by doing together [39] tells us about the emergent nature of engagement and could, for example, be identified in the hostess role adopted by one of the participants. Her familiarity with the role could be seen as reconnecting with embodied dimensions in a social context. This way of understanding could be related to habits [67] referring to how the social is both incorporated and constitutive of our identity and subjectivity [15]. Habits have been referred as having a practical sense, as a know-how sense of enacting in familiar social situations. In other words, this familiarity of being the hostess could be understood as an internalized and embodied history, that is actualized through engagement in a new occupation at the NH. The fellowship that was built into the Book Club could be interpreted as an engaging occupation that enabled the participants to experience other qualities in everyday life, such as a sense of reconnection with the social dimensions of being a person and not just a resident at the NH. This reconnection with well-known social forms could be seen as helping older adults to reclaim a sense of ordinariness in everyday life.

The findings of this study suggest that when collaborating with older adults in a NH on co-creating an occupation that is grounded in their interests and desires, everyday life might shift from a medicalized tone towards a mundane, ordinary, and familiar tone for older adults. However, the understanding of everyday life focuses almost exclusively on the provision of care activities that set an institutional tone and dynamic in everyday life [10,35]. In line with this logic, the dominant view in research about occupations in this field has been limited to symptomatic management and other health outcomes [2], and not as a fundamental dimension of life and meaning making [13,24,26,43,45]. The dominant view of occupations in this field could then be seen as endangering social aspects of identity and subjectivity, aspects that are at stake for older adults living in a NH. Returning to the story of the lady missing the Book Club meeting because of her excitement, this could be showing the collision between the institutional culture logic and influence enacted as enthusiasm for the Book Club meetings. In this case, this enthusiasm in the institutional logic was labeled as dysfunctional behavior and pathologized and therefore seen as in need of being managed. This perspective on this particular occupation could be seen as privileging the institutional order but failing to acknowledge the value that older adults assign to other qualities brought by a meaningful occupation into everyday life [26].

The findings presented in Addressing the uncertain conditions for influence and engagement supports the claim that everyday life has a dynamic nature [26], however they also point to the adaptation and alignment in practice [44] which does not happen by itself but emerges through openings created by engagement in occupation. The findings of this study suggest that, engagement of older adults will require practices that notice and acknowledge significant events and that put them in dialog with others to actively facilitate influence in a given occupation [11,59]. This was the case of the Book Club that served as an arena to enact engagement in occupation and to gain influence in everyday life.

Finally, the findings of this study urge us to critically reflect on how everyday life in NHs might mirror policies of participation, influence, and empowerment of older adults as guiding frameworks both locally [19] and worldwide [68]. Furthermore, these findings also urge occupational therapist to reposition the relevance of occupation, everyday life and the role of the profession in this field.

Methodological discussion

A strength of this study is the active effort to include older adults in research despite their frailty [65,68]. The methodology used, framed as a third space, served to get nuanced and situated knowledge about one occupation, engagement and everyday life for older adults living in a NH and at the same time had a function in the participants’ setting. However, more research is needed in order to get a broader understanding of occupations in this kind of settings. The participants of this project were only a small group of the total population of older adults living in NHs in Sweden, and the authors are aware that occupations might vary in other NHs. Nevertheless, this is an important group exemplifying the challenges of people in this vulnerable age living in an institutional setting. The chosen approach situated the researchers within multiple roles in the setting, which could create both challenges and possibilities [48]. This required a constant attention to ethical issues applying a reflective attitude in order to involve the participants as much as possible in all stages of the research project. Special consideration was needed when finalizing the research project, in particular regarding dialog with the participants about the withdrawal of the researchers. The length of the Book club was not established in advance. Initially the focus was on how the Book Club was received by the participants and the NH community. Once this was clarified, the duration was determined in collaboration with the participants based on sustainability criteria as is characteristic in collaborative approaches [48]. A detailed presentation of both the setting and the analysis was given, striving for trustworthiness by inviting the reader to engage in the context and logic of the analysis and findings [58]. The collaborative nature of the approach served to formulate the multiple steps in dialog with the participants, and other initiatives were formulated as a result of this approach. This collaboration also helped to inform future research questions, for example, for a coming study that focuses on the NH staffs’ understanding of occupations grounded on the older adults’ interests and capabilities.

Conclusions

This study shows that older adults’ engagement and influence in an everyday life occupation in a NH setting is possible when enabling partnerships and resourcefulness among the residents. These findings suggest that engagement and influence on occupation is fragile and contingent, and therefore in need to be consciously enabled by the NH community. This study also indicates that if a given occupation is grounded in older adults’ values and interests, the institutional order can be challenged. An important consequence of this approach, is that it can provide a positive impact on older adults’ identities and integrity. Taking these findings together, we can conclude that engagement in an occupation, can challenge stereotyped views of older adults living in NHs, and could make practices more representative of the policy framework regarding participation.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Swedish Research Council for Health, FORTE (2014-04980) and Vårdalstiftelsen (idéprovning 2012).