Journal of Gerontological Nursing

Indoor Gardening and Older Adults: Effects on Socialization, Activities of Daily Living, and Loneliness

Victoria M Brown, PhD, RN, HNC; Aimee C Allen, BS; Marci Dwozan, BSN, RN; Ivey Mercer, BSN, RN; Kim Warren, BSN, RN

Abstract

ABSTRACT

This study examined the effects of indoor gardening on socialization, activities of daily living (ADLs), and perceptions of loneliness in elderly nursing home residents. A total of 66 residents from two nursing homes participated in this two-phase study. In phase one, experimental group 1 participated once a week for 5 weeks in gardening activities while a control group received a 20-minute visit. While no significant differences were found between groups in socialization or perceptions of loneliness, there were significant pretest-posttest differences within groups on loneliness and guidance, reassurance of worth, social integration, and reliable alliance. The results also demonstrated gardening interventions had a significant effect on three ADLs (transfer, eating, and toileting). Phase two examined differences in the effects of a 5-week versus a 2-week intervention program. Although no significant within-group differences were noted in socialization, loneliness, or ADLs, the 5-week program was more effective in increasing socialization and physical functioning.

Abstract

ABSTRACT

This study examined the effects of indoor gardening on socialization, activities of daily living (ADLs), and perceptions of loneliness in elderly nursing home residents. A total of 66 residents from two nursing homes participated in this two-phase study. In phase one, experimental group 1 participated once a week for 5 weeks in gardening activities while a control group received a 20-minute visit. While no significant differences were found between groups in socialization or perceptions of loneliness, there were significant pretest-posttest differences within groups on loneliness and guidance, reassurance of worth, social integration, and reliable alliance. The results also demonstrated gardening interventions had a significant effect on three ADLs (transfer, eating, and toileting). Phase two examined differences in the effects of a 5-week versus a 2-week intervention program. Although no significant within-group differences were noted in socialization, loneliness, or ADLs, the 5-week program was more effective in increasing socialization and physical functioning.

Chronic illness has a direct effect on an individual's ability to perform activities of daily living (ADLs) and maintain independent living conditions. Research indicates the effects of chronic illness contribute more to social, physical, and functional decline than aging (American Association of Retired Persons & Administration on Aging, 1999; Carballo, 1994; U.S. Department of Health and Human Services, 1998).

Eighty-five percent of elderly individuals have one or more chronic illnesses. The rapid increase in the incidence of chronic illness and the increasing number of elderly individuals is resulting in a rise in nursing home admissions (U.S. Department of Health and Human Services, 1 999; Ebersole & Hess, 1998; Kemper & Murtaugh, 1991).

While the majority of elderly individuals are not institutionalized, it has been estimated there is more than a 40% chance that individuals age 65 and older will spend time in a nursing home (Kemper & Murtaugh, 1991). Changes in the living environment can result in reduced socialization with family and community members, lack of stimulation, reduced physical activity, depression, loneliness, and decreased feelings of selfworth (Bondevik & Skogstad, 1998; D'Amico-Panomeritakis & Sommer, 1999).

Physical exercise, meaningful activities, and socialization strategies can reduce the incidence of chronic illness, functional disabilities, and social isolation (Demers, 1999). Healthy People 2010 specifies three target areas for successful aging (Rowe,2000):

* Prevention and treatment of chronic diseases.

* Maintenance of physical and cognitive functioning.

* Senescence or age-related reductions in functional capacity of the organs.

The Healthy Aging Project emphasizes the need to identify and evaluate strategies that will promote healthy lifestyles and reduce social and functional decline in older adults (U.S. Department of Health and Human Services, 1998).

Gardening has been identified as an activity that enhances physical and mental well-being in elderly individuals (Gillaspie, 1988). However, as Pender (1996) noted, "What is not clear is the extent of physical activity needed to influence health outcomes" (p. 187). Therefore, the purpose of this study was to examine the effects of indoor gardening on socialization, ADLs, and perceptions of loneliness in elderly individuals residing in nursing homes. In addition, the outcomes of participating in indoor gardening once a week for 5 weeks versus twice a week for 2 weeks were examined.

LITERATURE REVIEW

Research on the health practices of older adults has increased significantly in the past 10 years. The results have demonstrated the importance of cognitive stimulation, physical activity, and social interaction (Kocken & Voorham, 1998; Rowe, 2000). Slangen-De Kort, Midden, and Van Wagenberg (1998) found the more resources that elderly individuals had to choose from, the more likely they were to engage proactively in adapting to changes in physical abilities and the environment.

The relationship between the socioeconomic, marital, and health status of older adults and participation in health promotion activities has been validated in several studies (Adelmann, 1994; Kim, Bramlett, Wright, & Poon, 1998). Using Pender's health promotion model, Duffy (1993) conducted a study of 477 older adults (age 65 to 99 years) to determine the degree to which age, gender, race, educational level, marital status, financial income, perceptions of health locus of control, self-esteem, and health status explained engaging in health promotion practices such as nutrition, exercise, stress management, interpersonal support, self-actualization, and health responsibility. Findings indicated participants who reported having higher self-esteem and good health were more likely to practice self-actualization, nutrition, exercise, and stress management. In addition, participants who were married and had higher annual incomes were more likely to engage in regular health promotion practices such as exercise and stress management but not in interpersonal support activities.

A positive relationship between functional health status and the performance of instrumental ADLs has been documented (Upchurch, 1999). In a descriptive study by Whittle and Goldenberg (1996), three functional status variables were significant (.001) with instrumental ADL performance: social functioning (r = -0.60), health perception (r = -0.69), and physical functioning (r - -0.66). These variables were good indicators of overall health status. A decline in each variable was found to cause an increase in instrumental ADL dependency.

Other studies focusing the relationship of social support and health promotion of older adults reported similar findings (Kocken & Voorham, 1998). Tadlock's (1991) findings indicated that if older adults possess adequate social support and increased practice of health promotion activities, they may be more likely to remain independent and live at home.

The influence of social contacts and ADLs on the loneliness and social relationships of elderly individuals was studied by Bondevik and Skogstad (1998). Significant relationships were found between continence, toileting, and transferring and emotional loneliness (p = .02, p = .01, and p =. 01, respectively). Toileting and transferring were also significantly related to social loneliness (p = .03 and p = .02, respectively).

The frequency of social contacts with the family showed a significant relationship with emotional loneliness (p = .001). Low frequency of social contacts with friends, neighbors, or both was associated with high levels of emotional loneliness (p = .000), while medium or high frequency of social contacts in combination with dependence or independence regarding toileting showed significantly lower levels of social loneliness compared to other groups (p = .001).

The results of this study indicate dependence in carrying out ADLs may not be associated with emotional and social loneliness. Because many of the participants were dependent on assistance with their ADLs, they received regular social contact from caregivers, which may be seen as significant social contacts. Therefore, Bondevik and Skogstad (1998) suggested:

Functional dependence in performance of ADL functions may facilitate social contacts and thereby reduce or prevent the experience of loneliness, (p. 340)

Ryan (1998) conducted a longitudinal correlational study to examine the prevalence of loneliness and depression in older men and women at hospital admission and the interactive effect of loneliness, social support, and decline in cognitive function during hospitalization. Findings suggested patients with higher loneliness scores had a lower cognitive status on hospital admission. Five days after admission, cognitive status improved slightly in these patients (p = .07). This may have been a result of interactions with health-care providers and visitors or improvements in their physical health. The results indicated a strong positive relationship between cognitive status and high levels of social support (p = .005). However, cognitive status declined significantly in these patients 5 days later (p = ≤.05). This may have resulted from a decrease in their social contacts with friends and relatives during hospitalization.

Another important finding was the significant difference in social support scores of patients younger than age 75 and those older than age 75 at admission (p < .001) and after 5 days (p < .05). Ryan (1998) suggested this confirms "that the constellation of social supports and contacts shrink with increasing age" (p. 24). The changes in levels of significance between admission and during hospitalization may add evidence that interactions with health-care providers has a positive impact on elderly individuals with lower perceptions of social support.

Environmental factors such as gardening have been found to impact the ability of individuals to maintain a healthy lifestyle and independence in ADLs (Roberts, Dunkle, & Haug, 1994; Ulrich, 1994). Studies have indicated a relationship between gardening and reduced blood pressure, relaxed emotional states, shorter hospital stays, and improved quality of life (Borret, 1997; ReIf, McDaniel, & Butterfield, 1992; Waliczek, Mattson, & Zajicek, 1996).

In a national survey of community gardeners, Waliczek et al. (1996) found all racial and ethnic groups reported gardening to be important to their quality of life. These individuals indicated gardening positively contributed to their physiological, safety, social, self-esteem, and self-actualization needs.

Research has indicated changes in lifestyles can occur in elderly individuals that can prevent social, physical, and functional disabilities and reverse the effects of aging (Kocken & Voorham, 1998; Rowe, 2000; SlangenDe Kort et al., 1998). The majority of these studies have been conducted with non-institutionalized individuals. More studies are needed to examine the impact of interventions on these variables with individuals in institutional settings.

CONCEPTUAL FRAMEWORK

Pender's revised health promotion model was used as the organizing framework for this study (Figure). The revised health promotion model uses constructs from expectancy value theory and social-cognitive theory to describe the complexity of holistic human functioning. Pender (1996) states the revised health promotion model is

an attempt to depict the multidimensional nature of persons interacting with their environment as they pursue health, (p. 53)

The model views health as a positive state of being, emphasizing the strengths, resiliencies, resources, potentials, and capabilities of the individual rather than focusing on existing pathology.

The revised health promotion model suggests individual characteristics and experiences combined with behavior-specific cognitions and affects result in behavioral outcomes. Individual characteristics and experiences consist of prior related behaviors and personal factors including biological, psychological, and sociocultural factors. Behavior-specific cognitions and affects are composed of perceived benefits of action, perceived barriers to action, perceived self-efficacy, and activity-related affect. Personal biological, psychological, and sociocultural factors are impacted by interpersonal influences such as family, peers, and health-care providers. Other situational influences involved include options, demand characteristics, and aesthetics. Behavioral outcomes are dependent on the individual's commitment to a plan of action, health-promoting behaviors, and immediate competing demands and preferences (Pender, 1996).

Active involvement of older adults in activities that maximize independence and life satisfaction promotes self-care behaviors and productive living. Regular physical activity enhances physiological stability and high-level functioning. In addition to physical activity, social interaction with others and the environment affects mental, social, and physical well-being by providing comfort, assistance, encouragement, and information (Pender, 1996). Interventions that build on prior physical and social activity habits and preferences while being sensitive to physical, mental, and sensory changes that may occur with aging provide opportunities for enhanced wellbeing, personal fulfillment, and selfactualization (Duffy, 1993; Pender, 1996).

Gardening activities are one form of physical activity that can be included in the plan of action to promote individuals' physical abilities, mental stability, and socialization skills (Gillaspie, 1988). Physical benefits may include increased muscular strength, improved fine motor skills, and improved balance. Self-esteem and attention span are improved or enhanced by gardening therapy.

The benefits of gardening on the social level can be seen in increased responsibility and independence, development of cooperation, and ability to learn new skills (Gillaspie, 1988). Activities such as gardening provide opportunities that keep the mind active and promote independent living (Administration on Aging, 1998; Borrett, 1997; Macneil, 1998; ReIf, 1981).

METHOD

Hypotheses

The two hypotheses examined in this study were:

* The use of indoor gardening will increase socialization, increase independence with ADLs, and decrease perceptions of loneliness in elderly individuals residing in nursing homes.

* The use of indoor gardening once a week for 5 weeks will be more effective than use of indoor gardening twice a week for 2 weeks.

Design

A quasi-experimental pretestposttest control group design was used for this study. Approval for the study was obtained from the University Institutional Review Board, the Ethics Committee of each nursing home, and the corporate administrator. A team of nursing home staff including the director of nursing, social worker, a certified nurse assistant, and the activity director evaluated individual residents for participation in the study.

Nursing home residents were considered as potential participants for the study if their current health status did not preclude participation and they met the following criteria:

Aimee Allen and resident discuss gardening.

Aimee Allen and resident discuss gardening.

* Were age 60 or older.

* Could speak and understand English.

* Could cognitively comprehend and answer questions.

* Could communicate verbally or in writing.

* Were willing to participate in indoor gardening activities for 6 weeks.

Consent to participate in the study was obtained from residents or their guardian. All data collection instruments and consent forms were coded to ensure confidentiality.

Table

TABLE 1AGE DISTRIBUTION FOR STUDY PARTICIPANTS

TABLE 1

AGE DISTRIBUTION FOR STUDY PARTICIPANTS

Setting

The study was conducted at two rural nursing homes in the southeastern United States. Both nursing homes were public facilities. Nursing home A was a 98-bed facility, and nursing home B was a 100-bed facility.

Procedure

There were two phases in this study. In phase one, residents of nursing home A comprised experimental group 1 and participated in an indoor gardening project once a week for 5 weeks. Residents of nursing home B comprised the control group and received 20-minute visits over the same 5 week period. A coin toss was used to determine the assignment of each nursing home to the experimental and control group in phase one. During the second phase of the study, the residents of nursing home B became experìmental group 2 and participated in indoor gardening twice a week for 2 weeks.

Data Analysis

Data were analyzed using descriptive statistics to describe the sample. Analysis of variance (ANOVA) was used in phase one to determine the differences between the experimental and control groups, pretest-posttest differences within groups, and the interactive effects of gardening on loneliness, socialization, and physical functioning.

Multivariate analysis of variance (MANOVA) was used to examine the differences between the posttest data of the control group in phase one and the experimental group in phase two. The MANOVA also was used to determine the effects of indoor gardening performed once a week for 5 weeks compared to twice a week for 2 weeks. Statistical Package for Social Sciences software (SPSS Inc., Chicago, IL) was used to conduct data analysis.

Instruments

* The instruments used for this study were:

* Demographic data sheet.

* UCLA Loneliness Scale (Version 3).

* Revised Social Provisions Scale.

* Minimum Data Set for ADLs.

Demographic data sheet. This tool was used to determine sample characteristics including educational level, sources of financial income, involvement in nursing home activities, frequency of social contacts with family members and friends, and previous interest in gardening activities.

UCLA Loneliness Scale. This scale is documented in the literature as the standard scale for measuring loneliness. In Version 3, a total of 20 items are assessed using 9 positively worded items and 11 negatively worded items. Reliability testing has indicated the scale has an internal consistency ranging from 0.89 to 0.94 and a test-retest reliability of 0.73. Convergent validity has been demonstrated by a significant correlation with the NYU Loneliness Scale (0.65) and the Differential Loneliness Scale (0.72) (Russell, 1996).

Revised Social Provision Scale. This scale includes six subscales: guidance, reassurance of worth, social integration, attachment, nurturance, and reliable alliance. Each subscale consists of two positively worded and two negatively worded items. Studies have demonstrated reliability with alpha coefficients ranging from 0.65 to 0.76. Factor analysis has revealed item loadings on the respective factors to be statistically significant (ranging from 0.38 to 0.79), indicating each item represents the construct it was designed to assess (Cutrona & Russell, 1987).

Minimum Data Set Physical Functioning Scale. This scale was used to assess the participants' physical functioning relative to performing ADLs. At the time of the study, this instrument was being used at both nursing homes to assess residents' ability to perform six ADLs (transfer, locomotion, grooming, bathing, dressing, and eating). Therefore, this scale was used for the study to provide additional assessment data. Participants were rated according to five categories: independent, supervision, limited assistance, extensive assistance, and total dependence. Reliability testing for the total score of the six subscales revealed coefficients ranging from 0.75 to 0.81.

Phase One

Phase one of the study was conducted for a 7-week period. During the first week, the study was described to each potential participant in the control and experimental groups and consent forms were signed.

After obtaining signed consent forms, charts were reviewed to collect demographic information, and investigators conducted one-to-one sessions to complete pretest questionnaires. Five participants completed the questionnaires independently with the investigator available for questions. The questionnaires were read to the remaining participants at their request, and the verbal answers were recorded by the investigator. Rest periods were taken between the administration of each questionnaire if participants appeared fatigued or restless. Prior to the study, interrater reliability was tested. Pretest and posttest data for each subject was obtained by the same investigator for consistency of data collection.

Table

TABLE 2DEMOGRAPHICS OF STUDY PARTICIPANTS

TABLE 2

DEMOGRAPHICS OF STUDY PARTICIPANTS

Experimental group 1. Once a week for the next 5 weeks, experimental group 1 participated in indoor gardening projects. Investigators encouraged participants to meet in a group but met with participants individually if the participant desired. Gardening projects included:

* Decorating flower pots and planting bulbs of their choice.

* Choosing and transplanting colorful flowering plants.

* Discussing proper care of the plants.

* Viewing a video on gardening.

* Arranging various plants in a hanging basket.

* Arranging fresh cut flowers and greenery.

The last week was spent completing posttest data collection and achieving closure of the project.

Control group. Pretest and posttest data were collected for the control group using the same procedure as for experimental group 1. Participants in this group received 20-minute visits during the 5-week intervention period to control for the social interaction and potential Hawthorne effect produced by the presence of the investigators with the participants in experimental group 1.

Phase Two

To further differentiate the effects of a 20-minute visit and participation in gardening activities, participants from nursing home B who were in the control group during phase one were invited to participate in a second phase of the study. This provided an opportunity to determine if the social interaction provided by the 20-minute visits with the investigators during phase one or the gardening interventions provided in phase two had a significant effect on the dependent variables.

Table

TABLE 3DIFFERENCES IN GROUPS RECEIVING 5-WEEK AND 2-WEEK GARDENING INTERVENTIONS

TABLE 3

DIFFERENCES IN GROUPS RECEIVING 5-WEEK AND 2-WEEK GARDENING INTERVENTIONS

RESULTS

Phase One

Thirty-three residents from nursing home A composed experimental group 1, and 33 residents from nursing home B composed control group 1. Eighty-two percent were women and 18% were men. Participants ranged in age from 60 to 96 (mean age, 81 years) (Table 1).

The majority of participants were White (85%) and widowed (70%). Seventy-two percent of the participants had completed junior high school or high school. Eighty-eight percent of the participants received financial support through Medicaid or Medicare; only 12% had secondary insurance or were private pay. The majority of participants (78%) had resided in the nursing home for 5 years or less (Table 2).

Ninety-one percent of participants had family and friends who lived within 30 miles of the nursing home and visited them in the nursing home. Seventy-five percent of the residents participated in gardening activities prior to entering the nursing home.

No significant differences were found between the experimental and control groups for any of the dependent variables. This indicated there were no significant differences in the physical functioning, socialization, and perceived loneliness of the participants receiving the gardening intervention and the participants receiving the 20-minute visits once a week for 5 weeks.

There was significant pretest-posttest difference within the groups for several variables. Social interaction with or without the gardening intervention was associated with less loneliness (F = 21.31, p = .00) and enhanced socialization measures such as guidance (F = 24.84, p = .00), reassurance of worth (F= 19.33, p = .00), social integration (F = 28.15, p = .00), and reliable alliance (F = 28.55, p = .00). Within group differences also indicated residents who participated in indoor gardening had significant improvements in three measurements of ADLs involving upper body movements including transferring (F= 7.87, p = .00), eating (F = 5.44, p = .02), and toileting (F=62S,p = .01).

Phase Two

Experimental group 2 consisted of 12 nursing home B residents. Characteristics of experimental group 2 were comparable to those for experimental group 1 (Tables 1 and 2). All of the participants had family and friends who lived nearby and visited participants regularly. Ten of the 12 participants had gardened previously.

The posttest data from phase one and the posttest data from phase two of the participants in nursing home B were analyzed using MANOVA to determine the effects of gardening on socialization, activities of daily living, and perceptions of loneliness. No significant differences were found within the group for any of the dependent variables.

MANOVA also was used to examine differences in the effect of a 5-week intervention program compared to a 2-week intervention program. The results indicated there was no significant influence on loneliness or socialization total score on the Revised Social Provisions Scale. However, there was a significant difference between the 5-week and 2week programs on four socialization subscales (guidance, social integration, reassurance of worth, reliable alliance) and two physical functioning measurements (transfer and walk in corridor) on the Minimum Data Set comparing 5 weeks versus 2 weeks (Table 3). These significant differences indicated an intervention program conducted once a week for 5 weeks was more effective than a program conducted twice a week for 2 weeks.

DISCUSSION

Pender (1996) suggests self-care and independent living is enhanced by physical activities. Gardening was identified by the majority of the study participants as an activity of interest to them prior to entering the nursing home. In this study, there were no significant differences between the residents who participated in gardening and those who received 20-minute visits.

The oldest participants in this study had been in the nursing home the least amount of time and were older than age 80. These participants may have maintained independent living conditions because they remained physically active and participated in social activities. A possible explanation for the lack of pretest -posttest difference could be that the participants had not been in the nursing home long enough to have increased perceptions of loneliness and decreased socialization. Therefore, gardening had no significant impact on these variables.

The findings in phase one indicated there was a significant interaction effect of the gardening intervention on the three subscales measuring ADLs including transferring, eating, and toileting. These three physical functions require primarily upper body movements. The indoor gardening activities were done in a sitting position and included activities such as selecting, lifting, positioning, and watering plants. Similar fine and gross motor movements are required for transferring, toileting, and eating. These findings provide support for the relationship between indoor gardening and physical functioning required for ADLs.

The significant decrease in perceived loneliness and increase in socialization in the areas of guidance, reassurance of worth, social integration, and reliable alliance in the combined experimental and control groups suggests the social interaction with the investigators was sufficient to improve these behavioral outcomes. Previous research has demonstrated that frequent social contacts by health-care providers or family increased socialization and decreased perceptions of loneliness (Bondevik & Skogstad, 1998).

It was interesting that the socialization subscales for nurturance and attachment were not significantly different. This indicated the participants continued to feel they were not needed or able to take care of others (nurturance subscale) and they did not feel their relationship with other individuals had changed from the beginning to the end of the study (attachment subscale).

There were no significant differences within groups from the posttest data of the control group in phase one and the posttest data of experimental group 2 in phase two on socialization, loneliness, and physical functioning subscales. However, in phase one of the study, the control group did have significant outcomes indicating the 20-minute visits once a week for 5 weeks had a positive impact on loneliness and several socialization measures. Implementation of the gardening intervention twice a week for 2 weeks with these same participants had no significant effect in phase two. This may have been due to the previous changes that occurred during phase one prior to implementation of the gardening activities or to the short time frame in which the gardening intervention was conducted.

The comparison of the 5-week gardening intervention program with the 2-week program revealed the 5-week program to be more effective. The participants receiving the gardening intervention once a week for 5 weeks for a total of five interventions had significant differences in four socialization and two physical functioning measurements. Although the control group had a comparable number of four gardening interventions, they were implemented in a shorter time period. This supports previous studies that indicated it takes approximately 5 to 6 weeks to determine a significant effect of an intervention.

LIMITATIONS AND FUTURE RESEARCH

Limitations of this study included the small sample size, the short length of time for evaluation of the gardening intervention, and the lack of a control group receiving no social visits. Replication of this study would benefit by having a control group that receives no visits from the investigators.

Longitudinal studies are needed to examine the effects of interventions such as indoor gardening on cognitive functioning, severity of depression, and use of antidepressant medication, as well as socialization, loneliness, and physical functioning. Replication studies also are needed using larger sample sizes comparing individual interventions and group interventions. Likewise, studies are needed to determine whether individuals who garden during their lifetime maintain physical functioning, thereby reducing the need for assisted care facilities.

CONCLUSION

Independence in performing ADLs is important to elderly individuals to facilitate social contacts and reduce the experience or incidence of loneliness (Bondevik & Skogstad, 1998). Jones and Jones (1997) suggested health-care providers should offer prescriptions for physical activity that include frequency, duration, type, and progression of the activity. Gardening is one form of physical activity that offers older adults the opportunity to promote health by encouraging physical functioning and socialization.

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TABLE 1

AGE DISTRIBUTION FOR STUDY PARTICIPANTS

TABLE 2

DEMOGRAPHICS OF STUDY PARTICIPANTS

TABLE 3

DIFFERENCES IN GROUPS RECEIVING 5-WEEK AND 2-WEEK GARDENING INTERVENTIONS

10.3928/0098-9134-20041001-10

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