Balance of Occupations of Older Adults in Residential Care

Deb Hearle, Dr Val Rees & Dr Jane Prince

Plan

Present overview of the context of methodologies

Explain Narrative in more depth

Explore methods of narrative analysis

THE STUDY

Stage 1: Using a narrative methodology, explored the differences and reasons for the differences in occupations between older adults in the community and in Residential Care.

MethodologyOpportunity sample of 22 older adults, Mean age = 83 years

4 males and 18 females (reflects the imbalance of men and women in this age group)

10 living independently in own homes, of which 3 regularly attend a local day centre

6 living at home in receipt of a full community care package

6 living in residential homes

Those receiving care matched for health status. In both groups, they had sensory, motor, respiratory and circulatory problems

Methodology ctd…

A design was employed eliciting life narratives, a relaxed and non-intrusive approach, to illuminate individual change over a lifespan.

‘Tell me about your life from as early as you can remember’

Stage 2: Using observation, explored the participation of older adults in residential care in occupations and their relationship to their environment.

Methodology & Data Analysis Stage 2

Single Case Study – 1 residential care home (23 residents, mean age 83 years)

Tools of data collection:Observation scheduleField notes

Analysed using descriptive statistics and presented in graphs. Field notes supported the discussion.

Stage 3 & 4: Using narrative and Interpretive phenomenological

analysis, explored the experiences of transition of older adults into residential care.

Future: Exploring possible selves in older adults: Facilitators and barriers

Narrative – What is it?

“If you want to know me you must know my story for my story defines who I am. And if I want to know myself, to gain insight into the meaning of my own life, I, too, must come to know my own story. I must come to see, in all its particulars, the narrative of the self - the personal myth that I have tactically, even unconsciously, composed over the course of my years. It is a story I continue to revise and tell to myself (and sometimes to others) as I go on living” (McAdams 1993 p 11).

What is a narrative?Human beings have personal, unique stories

A series of logically and chronologically related events

Gripping drama and believable history

Narrator + plot or theme with moral point

Meaningful stories which aim to understand social processes

Identifies large units of discourse (codes) with little direction from researcher (prompt questions only)

Narrative“A complex process - the plot is used to contextualise

and clarify life events”. Polkinghorne (1991)

“The individual is provided with a means of expressing past and present experiences and future aspirations from a unique perspective” (Clouston 2003)

“The use of narrative encapsulates the holistic and humanistic practice of occupational therapy” (Rees and Hearle 2004)

Advantagesallows ‘narrator’ to tell their story as they see it and

conceptualises stories as a whole – holistic

captures the richness, complexity and historical depth

provides a way of understanding human experience

allows a person a sense of self-worth in the present and confidence in the future

allows people with health problems to construct new maps and new perceptions of their relationships to the world.

lays disclosure at the feet of the narrator (lets them choose)Utilises strategies synonymous with older adults such as

reminiscence and validation, in an attempt to understand the life events which have shaped each individual.

Limitations

Ambiguity can mean unscientific and unconvincingTime consuming to transcribe and analyse dataNot useful for data collection from large numbersMethods of analysis can be subjective

Analysing the DataThematic Analysis ‘Patterns across narratives’

Content analysis ‘Frequencies’ (only part of content analysis)

Interpretative Phenomenological analysis (IPA)

‘Meaning behind the stories’

Thematic Analysis (Example 1)Themes Categories Codes Feelings Fear Anxious about future

Worried what staff would be like

What happens if doesn’t suitMood Felt that it was the end of

lifeWaiting for GodFelt happier now safe

Acceptance These things happencouldn’t manage on own

Others influence

Environment

Themes Categories

Historical Life Events Birth of child/Death of child Death of partner Retirement Transition to residential care

Family Children Grandchildren

Health Status Self Partner Children

Education & employment

Self Partner Children/Grandchildren

Interests/Activities

Self/As family

Care

Provision/Staff

Thematic analysis (Example 2)

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Observations of Patterns from Data

Residential Care Community Based

Narratives chronological and well rehearsed.

Past & present schemas relate to family, interests/ activities, health status and education.

Schema relating to provision of care in residential home.

Responses regarding current interests/activities negatively framed and self-deprecating.

Narratives move freely between past and present.

As in respondents in residential care.

Schema relating to provision in care package.

Responses lively & positive

for current interests and activities.

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The Model of Human OccupationVolition

Residential Care Community

Desires Sense of control

Balance of occupations

Belief in achievement

Compliant with procedures of institution.

Dependent, accepting.

Limited, pressed/ constrained by environment.

Not evident.

Translated into action.

Self-directing, empowered.

Varied and challenging.

Evident in all reported activities.

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The Model of Human OccupationHabituation

Residential Care Community

Roles

Use of Time Habits Adaptability

Sick role, dependent.

Constrained by organisation and imposed routine.

Passive,

conforming to residential identity.

Rigid compliance

with institutional organisation.

Active, varied. Self directed. Express sense of

self. Response to life’s

challenges.

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The Model of Human Occupation

Performance

Residential Care Community Productivity Functioning

Accepting, receiving rather than giving. Conforming to “sick” role.

Self-directing, caring/maintaining (with support). Dynamic mentally & physically within constraints of deficits.

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Frequencies of Codes in Past & Present Schemas

Residential Care Community Based More references to

negative life events. Few references to family

in present schema. Rich content in past

schema relating to interests/activities.

More references to illness,

deficit and incapacity

More references to

positive life events. Frequent references to

family. Schema for current and

possible interests rich. Few references to illness/

deficits as incapacitating.

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Frequencies of Codes in Schema Representing Past & Present

Past

Present Schema

Mean Frequency

Residential

Care

Community

& Care Package

Independent

& Day Centre

Independent

Mean Frequency

Residential

Care

Community

& Care Package

Independent

& Day Centre

Independent

Historical Life Events

32.25

45

23

24

37

Employment

9.75

16 8

3

12

Family

9.75

11 5

12

11

21

12

24

27

21

Education

10.25

20 5

6

10

5

6

5

9

Interests & Activities

16.5

36

9

12 9

19+

9- 6+

25

18

27

Health Status

6.0

10

5

3

6

8.25

15

9

3

6

8

Thoughts on Transition

Transition to residential care appears to be associated with closure.

Those participants in care retreated into the past, adopted passive, compliant roles and conformed with the organisation and procedures of the institution.

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Recommendations A role exists for occupational therapists within residential care The ecology of residential homes should be examined and changed to empower individuals Individual choice should be recognised

Balance of care is essential (holistic)

Residents should have a voice (advocacy)

Preparation for transition to care is essential

More research examining needs of older adults

17

Clouston, T. (2003) Narrative Methods. BJOT. 66 (4) pp136-42

Polkinghorne, D (1991) Narrative and Self Concept. J Narrative & Life history 1 pp 135-53

Rees, V. Hearle D. (2004) I’m not just sitting I’m thinking’ OTN March 2004 p30.

References

Thankyou for listening

Any Questions?