Journal of Gerontological Nursing

CNE Article 

Multisensory Installations in Residential Aged-Care Facilities: Increasing Novelty and Encouraging Social Engagement Through Modest Environmental Changes

Theresa L. Scott, PhD; Barbara M. Masser, PhD; Nancy A. Pachana, PhD

Abstract

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Instructions

1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

  • Read the article, “Multisensory Installations in Residential Aged-Care Facilities: Increasing Novelty and Encouraging Social Engagement Through Modest Environmental Changes” found on pages 20–31, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

    Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

    Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

    This activity is valid for continuing education credit until August 31, 2016.

    Contact Hours

    This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

    Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

    Activity Objectives

    Explore the benefits of indoor garden installations in aged-care facilities.

    Describe the study results of indoor garden installations on social engagement.

    Disclosure Statement

    Neither the planners nor the authors have any conflicts of interest to disclose.

    The current study examined the effect of an indoor simulated garden installation that included visual, auditory, and olfactory stimuli on resident well-being, compared to the effect elicited by a reminiscence installation and a control no-installation condition. A quasi-experimental ABA design was used (i.e., two intervention conditions plus a wait-list control condition). A survey instrument was administered to nursing home residents (N = 33) at three time points (pre-, during, and post intervention) over an 8-week period, which measured mood, behavior, health, and social interaction. Additionally, staff reports (N = 24) were collected. Both the nature-based and non-nature-based installations led to enhanced well-being and significantly more social benefits for residents because of their novel and aesthetic appeal, compared with the control condition. Residents in the nature-based installation condition reported more satisfaction with their living environment during the intervention phase than those in the comparison conditions. The results show that an indoor garden simulation is a relatively inexpensive way to transform a disused indoor area of an aged-care facility for the benefit of residents and staff. [Journal of Gerontological Nursing, 40(9), 20–31.]

    Dr. Scott is Postdoctoral Researcher, Dr. Masser is Associate Professor, and Dr. Pachana is Professor, School of Psychology, The University of Queensland, St. Lucia, Queensland, Australia. Dr. Pachana is also Co-Director, UQ Ageing Mind Initiative, The University of Queensland, St. Lucia, Queensland, Australia.

    The authors have disclosed no potential conflicts of interest, financial or otherwise. The authors thank the staff and residents who participated in this study.

    Address correspondence to Theresa L. Scott, PhD, Postdoctoral Researcher, School of Psychology, The University of Queensland, St. Lucia, Queensland 4072, Australia; e-mail: theresa.scott@uq.edu.au.

    Received: March 02, 2014
    Accepted: July 01, 2014

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    Abstract

    How to Obtain Contact Hours by Reading this Article
    Instructions

    1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

  • Read the article, “Multisensory Installations in Residential Aged-Care Facilities: Increasing Novelty and Encouraging Social Engagement Through Modest Environmental Changes” found on pages 20–31, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

    Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

    Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

    This activity is valid for continuing education credit until August 31, 2016.

    Contact Hours

    This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

    Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

    Activity Objectives

    Explore the benefits of indoor garden installations in aged-care facilities.

    Describe the study results of indoor garden installations on social engagement.

    Disclosure Statement

    Neither the planners nor the authors have any conflicts of interest to disclose.

    The current study examined the effect of an indoor simulated garden installation that included visual, auditory, and olfactory stimuli on resident well-being, compared to the effect elicited by a reminiscence installation and a control no-installation condition. A quasi-experimental ABA design was used (i.e., two intervention conditions plus a wait-list control condition). A survey instrument was administered to nursing home residents (N = 33) at three time points (pre-, during, and post intervention) over an 8-week period, which measured mood, behavior, health, and social interaction. Additionally, staff reports (N = 24) were collected. Both the nature-based and non-nature-based installations led to enhanced well-being and significantly more social benefits for residents because of their novel and aesthetic appeal, compared with the control condition. Residents in the nature-based installation condition reported more satisfaction with their living environment during the intervention phase than those in the comparison conditions. The results show that an indoor garden simulation is a relatively inexpensive way to transform a disused indoor area of an aged-care facility for the benefit of residents and staff. [Journal of Gerontological Nursing, 40(9), 20–31.]

    Dr. Scott is Postdoctoral Researcher, Dr. Masser is Associate Professor, and Dr. Pachana is Professor, School of Psychology, The University of Queensland, St. Lucia, Queensland, Australia. Dr. Pachana is also Co-Director, UQ Ageing Mind Initiative, The University of Queensland, St. Lucia, Queensland, Australia.

    The authors have disclosed no potential conflicts of interest, financial or otherwise. The authors thank the staff and residents who participated in this study.

    Address correspondence to Theresa L. Scott, PhD, Postdoctoral Researcher, School of Psychology, The University of Queensland, St. Lucia, Queensland 4072, Australia; e-mail: theresa.scott@uq.edu.au.

    Received: March 02, 2014
    Accepted: July 01, 2014

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    The proximate visual environment has a profound effect on individuals’ psychological and physiological well-being (Dijkstra, Pieterse, & Pruyn, 2006; Ulrich, 1995). In a review of the literature, Dijkstra et al. (2006) found that health care environments could be transformed into psychologically healing environments through the incorporation of certain environmental stimuli, such as specific colors, sounds, odors, and seating, and the inclusion of natural features, such as plants. Perceiving the environment as more aesthetically pleasing was positively related to improved mood and well-being for residents and staff of aged-care facilities (Dijkstra et al., 2006). However, meeting the physical needs of residents often takes precedence over meeting their emotional and social needs. As such, the environmental design of nursing homes is usually based on the functional delivery of health care (Ulrich, 1995). To design a nursing “home” instead of a hospital, an enriched physical (Dijkstra et al., 2006) and social environment (Baltes, 1996) must be provided. The focus of the current study was to examine the effect of making positive changes to the indoor environment of aged-care facilities—specifically nature-based and reminiscence-based environmental enhancements—on the well-being of residents and staff.

    Social Engagement and Psychological Health

    It is vitally important to the well-being of older adults living in long-term care facilities that they develop social and emotional connections with staff and other residents (Baltes, 1996; Park, 2007; Street, Burge, Quadagno, & Barrett, 2007). For many older adults, coping with the loss of home and relationships precedes entry to a long-term care facility and can lead to the experience of isolation, loneliness, and chronic conditions (e.g., depression), which add another layer of complexity to their caring needs (Zarit, Dolan, & Leitsch, 1998). To counter the isolation that is often experienced within aged-care facilities (Drageset et al., 2009), where the inclination is to retreat into the private space of one’s own room (Hauge & Heggen, 2007), it is important to provide opportunities for interaction with other residents (Knight, Haslam, & Haslam, 2010). By providing a shared interest or activity, opportunity exists for residents to interact, establish new friendships, and obtain the critical social support necessary for the successful adjustment to living within an aged-care facility (Park, Zimmerman, Kinslow, Shin, & Roff, 2012).

    Reminiscence as a Therapeutic Tool

    Reminiscence therapy is an effective therapeutic tool used with older adults to enhance psychological well-being (Pinquart & Forstmeier, 2012). It can be a structured therapy, such as life review, which focuses on individuals reevaluating life events; or it can take the form of simple reminiscence, which is unstructured, more generally applied (Pinquart & Forstmeier, 2012), and can be conducted in a group or one-to-one sessions. To evoke memories, the facilitator may include prompts that make use of the senses (e.g., sight, smell, sound, taste) and photographs or music from a particular era or salient point in time for individuals (Pinquart & Forstmeier, 2012). In one study, collective recollection of the past resulted in an improvement in general cognitive ability and increased social identification among residents (Haslam et al., 2010).

    Horticulture as a Therapeutic Tool

    Horticulture therapy has also been used in health care settings to positively affect patient well-being. Resident-centered gardening programs provide activity that encourages socialization through a shared appreciation of the aesthetics of nature (Brown, Allen, Dwozan, Mercer, & Warren, 2004). Gardens and their natural elements stimulate the senses and encourage social interaction through mutual admiration of the associated sights and smells, as well as through shared recollections of favorite plants or past gardens. Gardens and their elements have broad appeal to residents of nursing homes because they provide a link to the past: plants can evoke memories of childhood gardens or a favorite childhood tree (Heliker, Chadwick, & O’Connell, 2001). Simply viewing nature through a window has significant healing benefits (Ulrich, 1984); listening to birdsong can reduce patient agitation (Whall et al., 1997); and plants, flowers, aquariums, or even wall murals of nature scenes have calming effects in health care environments in which individuals usually experience anxiety, such as dental waiting rooms and psychiatric units (Dijkstra et al., 2006; Pachana, McWha, & Arathoon, 2003).

    Theoretical Framework and Rationale

    According to biophilia theory, one explanation for the healing power of plants is that all humans have an inborn love of nature (Wilson, 1984). The theory suggests that individuals have evolved to prefer and appreciate natural environments and exposure to natural elements elicits a positive psychological and physiological response, such that in nature they are able to recover and restore from daily stressors. A key concept underpinning biophilia theory is the aesthetic experience of nature. Humans are genetically programmed to focus on and respond more positively to natural environments and their elements (Wilson, 1984).

    Compared with indoor gardening activities, accrued benefits manifest when large outdoor gardens are included in aged-care facilities (Heath & Gifford, 2001); however, not all facilities can support the inclusion of an outdoor garden. Some may lack the space or finances to provide such gardens. Further, although some nursing homes have outdoor gardens, many of the residents may not have direct or independent access to them for various reasons. Including some aspects of gardens indoors, such as flowers, potted plants, and pictures of gardens, should have a positive effect on resident and staff well-being by providing aesthetic pleasure and a shared interest, according to biophilia theory and accumulated research evidence.

    Current Study

    On the basis of biophilia theory and existing literature, the authors of the current article hypothesized that implementing environmental changes to the indoor environment of nursing homes (i.e., incorporating plants and natural elements) would positively impact resident and staff well-being. Biophilia theory proposes that humans have an innate inclination to connect with natural environments and their elements, opposed to man-made environments or their elements. To this end, two different installations were created indoors in separate aged-care facilities: one with a nature focus (i.e., biophilia installation) and, to contrast the effects of biophilia, the other with a non-living focus (i.e., reminiscence installation). The reminiscence installation included several man-made elements intended to evoke memories of the past for residents, such as music, magazines, and kitchenware. A third “no installation” control condition was also included. A number of measures were taken before, during, and after the interventions to examine the following hypotheses:

    • Hypothesis 1. The biophilia and reminiscence installations will provide novelty and aesthetic appeal, which would be positively appraised by residents and staff.

    • Hypothesis 2. The biophilia and reminiscence installations will provide novelty and the impetus for increased social interaction compared with the control (no-installation) condition.

    • Hypothesis 3. The biophilia installation will provide greater opportunities for social exchange and satisfaction because of its dynamic and life-like qualities, compared with the non-nature-based installation and control conditions.

    Method

    Participants

    The facilities that agreed to participate were randomly assigned to the conditions using a simple lottery method; therefore, participants were assigned to one of three conditions based on the facility that they resided in: (a) the biophilia installation condition, (b) the reminiscence installation condition, and (c) the control condition. The facility managers were the first point of contact for potential participants.

    Recruitment. Facility managers briefed residents as a whole about the research being a “study about interiors and activities in residential care settings.” Facility managers fielded inquiries from residents and provided a list of names of residents who expressed their interest in “hearing more about the study” for follow-up contact by the researcher (T.L.S.). To avoid eliciting any feelings of coercion, participants were informed that they could withdraw their expression of interest at any point during the recruitment process and during the study itself. Expressions of interest were received from 47 residents across the three conditions. The researcher then contacted these residents to provide further information about the study and, if they consented to participate, to agree on a time to meet to conduct the first survey interview. Of the 47 residents who initially agreed to participate, formal consent to participate was obtained from 33 who met the criteria for inclusion in the study (i.e., not being confined to bed and having sufficient visual, cognitive, and language abilities to understand and answer the research questions). Twenty-four staff across the facilities also consented to participate in the study.

    Study Sites

    The aged-care facilities that agreed to participate were situated in South East Queensland, Australia. These facilities were fully accredited and owned and managed by the not-for-profit sector. The facilities were of similar average size (approximately 75 beds in total) and included both high- and low-care hostel and nursing home–style accommodation. Staff-to-resident ratio was equivalent across facilities; the majority of residents in each facility were women. Further descriptive information collected at baseline to establish the equivalence of social and environmental settings is reported below.

    Study Design

    The study used a quasi-experimental ABA design. Measurement of the variables of interest took place at baseline, during intervention, and return-to-baseline phases for the three conditions. The study duration was 8 weeks, and surveys were administered to participants and collected from staff on the following three occasions over the course of the study: (a) 2 weeks before the installations were put in place (T1), (b) during the 4-week period that they were in place (T2), and (c) 2 weeks after the installations were removed (T3). The researcher administered the questionnaires to residents. The staff questionnaires were distributed to staff, who completed them alone and then returned them to the researcher. Participants in the control condition were exposed to the same procedure and measurement variables as those in the biophilia and reminiscence groups at T1, T2, and T3; however, questions that related to the installations were excluded. The survey contained several measures to examine the use of the enhanced environment and changes in resident behavior. These measures included satisfaction with the new décor and indoor environment, as well as social engagement. In addition, data were collected relating to the social milieu of the facility, residents’ general health, and residents’ daily living activities.

    Nature-Based Environmental Enhancement. A nature-based environmental enhancement was used to recreate a garden environment indoors. The environmental enhancement was a small, indoor, garden-based feature (i.e., biophilia intervention) that was installed inside an austere common area of the residence (Figure 1). This nature-based enhancement was designed specifically to be multisensory. Therefore, the biophilia installation included a garden bench seat; a large wall mural of a tree canopy; potted plants that were chosen because they were non-toxic, hardy, and aesthetically pleasing; an aroma diffuser emitting garden scents; audio of birdsong, which came from speakers hidden behind the planters; and a table, which provided a place to include a scrap-book with photographs of gardens. The garden ornaments (i.e., gnomes) were meant to evoke memories of past (i.e., domestic) gardens.

    The indoor space (A) before and (B) after the multisensory biophilia installation was put in place.

    Figure 1.

    The indoor space (A) before and (B) after the multisensory biophilia installation was put in place.

    Non-Nature-Based Environmental Enhancement. A reminiscence-based environmental enhancement was used to compare the nature-based environment with a built (i.e., homelike) environment. This environment included several original items from 1920 through 1950 (the period during which most of the residents were young adults) and included display tables, chairs for seating, kitchenware, china pieces, period books and magazines, and a large wall mural depicting a family scene from the early 1950s. In addition, an old radio was set up so that it appeared to be playing an old radio program, which was actually a recording coming from hidden speakers under the table. An aroma diffuser was included, which emitted cinnamon scents (Figure 2).

    The indoor space (A) before and (B) after the multisensory reminiscence-based installation was put in place.

    Figure 2.

    The indoor space (A) before and (B) after the multisensory reminiscence-based installation was put in place.

    Control Facility. The indoor environment of the facility chosen as the control condition did not change during the study (i.e., no installation was provided during the period that the facility acted as a control: T1, T2, and T3). However, the measurement instruments administered to residents and staff participants in the control condition were identical to those in the experimental and comparison conditions, with the exception of reference to “installations.” Participants were informed that the researcher was exploring variables related to social and physical environments of residential care facilities.

    Materials

    A survey containing several standardized scales and a range of open-ended and closed questions constructed for the study was administered to residents before, during, and post intervention; it was distributed to participating staff to complete alone. The questionnaire administered at T1, T2, and T3 to residents and staff assessed identical constructs to allow comparison across the time points, with the exception of demographic information, which was not repeated. Sex, age, length of residency, quality of life (i.e., physical health, energy level, mood), former occupation, and hobbies and interests were collected just once at T1 from residents .

    Resident Questionnaire. This questionnaire, developed for the current study, focused on residents’ satisfaction with the physical environment of the residence; satisfaction with opportunities for keeping occupied; social engagement; mood; and liking for the environmental enhancement (as appropriate). A visual analog scale was constructed and used to help residents answer the Likert-type questions as a visual cue to the scale options (1 = strongly agree to 5 = strongly disagree). In addition, participants were allowed time to discuss their feelings and thoughts with the researcher. General information about residents’ cognitive status, dependency, and their usual daytime location (i.e., where most time was spent) and whether they went outdoors was collected from facility records or nurse reports, as appropriate.

    Cognitive Ability. The Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) is a widely used, valid measure of cognitive function in older adults. Residents’ most recent MMSE scores were used to screen participants and identify individuals with possible cognitive impairment. These scores were not disclosed to the researcher and are therefore not reported.

    Geriatric Depression Scale (GDS). Self-reported depressive symptoms were measured at T1, T2, and T3 using the short-form of the GDS-5 (Yesavage et al., 1983), a dichotomous (yes/no), self-report assessment that was administered by the researcher. A score of 2 or higher indicates possible depression. The GDS-5 has been shown to have high internal consistency in previous studies. Within the current sample, the internal reliability of this scale was acceptable, with Cronbach’s alphas ranging from 0.71 to 0.74 across the three measurement points.

    Geriatric Anxiety Inventory (GAI). The short (5-item) version of the GAI (Byrne & Pachana, 2011) was used to measure self-reported anxiety symptoms at T1, T2, and T3. Participants agree or disagree with five statements (e.g., “I often feel nervous.”). A cutoff score of ≥3 indicates possible clinical level of anxiety. The scale has high internal consistency, with Cronbach’s alphas ranging from 0.85 to 0.90 in the current sample.

    Quality of Life. A number of items were adapted from the Quality of Life in Alzheimer’s Disease (QoL-AD) Life Satisfaction Assessment tool (Logsdon, Gibbons, McCurry, & Teri, 1999) and administered only at baseline to allow for comparison across groups. These items related to self-perceived physical health, energy level, mood, and memory; participants were asked to self-report these individual variables as poor, fair, good, or excellent.

    Environmental Satisfaction. Satisfaction with the living environment was measured at T1, T2, and T3 with the item, “I would rather live here than move to another home,” according to Knight et al. (2010). Participants responded using a Likert scale of 1 (strongly agree) to 5 (strongly disagree).

    Satisfaction with Opportunities for Keeping Occupied. Two separate items were included to measure residents’ satisfaction with activities and opportunities for keeping occupied at T1, T2, and T3: (a) “I find that I can keep myself occupied on most days,” and (b) “I get satisfaction from the things done in the home.” Participants responded using a Likert scale of 1 (strongly agree) to 5 (strongly disagree).

    Well-Being and Engagement. Well-being and engagement was assessed at T1, T2, and T3, with six items constructed for the study on a Likert-type scale of 1 (strongly agree) to 5 (strongly disagree). The items included:

    • “In the past week, I have felt a sense of closeness to the other residents.”
    • “In the past week, I have felt supported by the other residents.”
    • “In the past week, I have shared conversations with the other residents.”
    • “In the past week, the quality of my life has improved.”
    • “In the past week, I have been in high spirits.”
    • “In the past week, I have felt that the home is a pleasant place in which to live.”

    The internal reliability of the six items measuring well-being and engagement was assessed and found to be acceptable (i.e., Cronbach’s alphas ranging from 0.81 to 0.87) at each time point.

    Staff Questionnaire. The staff questionnaire was administered at T1, T2, and T3. The questions, which were constructed for the study, focused on the staff member’s social interaction with residents (e.g., “In the past week, I have shared conversation with the residents”); appraisal of the environmental transformation, where appropriate (e.g., “Do you enjoy the new décor?”); appraisal of residents’ liking for the environmental transformation (e.g., “Do you think that the residents liked the new décor?”); and appraisal of whether the environmental transformation recreated memories for the residents (e.g., “Do you think that the new décor brought back any memories for the residents?” and “If yes, what makes you think so?”). General demographic information about participating staff, such as age, sex, duration of employment, and job position, was collected at T1.

    Facility Information. In addition to general demographic details of the facilities, information was collected from an appropriate staff member about the social climate of the facility using the Ward Atmosphere Scale (WAS; Moos & Houts, 1968) at baseline only. The range of the facilities’ public and private spaces was measured with items taken from the Gradation of Space Scale (GSS; Parker et al., 2004) at baseline only. This information was used to describe and compare the facilities at baseline.

    Statistical Analyses

    Data were screened for missing values and outliers and to ensure that the data met the various assumptions of the proposed statistical analyses; no violations of assumptions were discovered. Quantitative analyses were conducted using SPSS version 18 and included descriptive statistics to describe demographic data and frequency distributions to show the distribution of cases into the different categories of variables (e.g., percentage of staff reports of “liking” for the installations). As with other studies of a similar design (Brown et al., 2004; Cohen-Mansfield & Werner, 1998), analysis of variance and multivariate analysis of variance (MANOVA) were used to assess the effects of the installations by comparing the outcome measures across groups at T1, T2, and T3. Follow-up comparison t tests were used to examine group differences. Where appropriate, the Bonferroni correction was applied to minimize the risk of making a Type 1 error.

    Results

    Resident Characteristics

    Data were obtained from 33 resident participants (22 women, 11 men) ages 68 to 98 (mean = 82.7, SD = 7.9 years). Tests were conducted to examine whether any differences existed in sample characteristics across the three groups (i.e., biophilia, reminiscence, and control). Sociodemographic details of the resident sample are shown in Table 1. Approximately 80% of the resident participants were born in Australia (n = 27); of these, 18.5% were of Aboriginal or Torres Strait Islander descent (n = 5). The remaining participants were born in the United Kingdom (n = 3) and Europe (n = 3). No significant differences were noted among the three groups for baseline measures of depression, anxiety, and QoL-AD items (i.e., self-perceived physical health, energy level, mood, and memory) (Table 1); satisfaction with the environment; and satisfaction with opportunities for keeping occupied (Table 2), which indicated comparability among the groups prior to the interventions commencing. By the study’s end, resident attrition due to ill health, hospitalization, and death was approximately equal across the biophilia, reminiscence, and control groups: 13%, 13%, and 10%, respectively.

    Sociodemographic Characteristics of Participants Across Conditions

    Table 1:

    Sociodemographic Characteristics of Participants Across Conditions

    Social Engagement and Mood Measures Across Conditions and Groups

    Table 2:

    Social Engagement and Mood Measures Across Conditions and Groups

    A total of 24 staff members completed questionnaires (19 women, 5 men), ranging in age from 24 to 63 (mean = 46, SD = 12.3 years). Staff members’ positions included: volunteer (n = 1); student nurses, nursing assistants, and senior nurses (n = 12); diversional therapists and aides (n = 4); allied health (n = 2); pastoral care workers (n = 2); and administrators (n = 3). The demographic details of staff by group are shown in Table 1.

    Facility Characteristics

    No significant differences were noted between the facilities on the WAS. Therefore, the facilities did not differ at baseline on measures of social climate. The range of public and private spaces, as measured by the GSS, was equivalent across facilities.

    Appraisal of the Installations

    Resident Appraisal. To test the hypothesis that the biophilia and reminiscence installations would be positively received by residents and staff, the authors first examined the frequencies of residents’ responses to the question “Do you like the new décor?” There was 100% agreement among the residents in the biophilia and reminiscence installation conditions.

    Specifically, respondents in the biophilia group commented favorably about the audio of the birdsong that was featured in the display and the large wall mural of a tree, which was familiar to the residents because the tree grows in many of the public parks in the locality. They reported liking the pleasant look, the naturalness, the freshness, and the smell of the plants in the display, commenting that they preferred the living plants to the plastic plants that existed in other parts of the facility.

    Respondents in the reminiscence group commented on the novelty of the display, reporting it was most appealing because, for example, “it was something new to look at.” They made particular mention of the audio sounds (the 1950s radio program and music that appeared to be broadcasting from the old radio in the display) and the large wall mural because it contained many familiar images and items.

    Staff Appraisal. In response to the question “Do you like the new décor?”, staff responded as follows. For the biophilia installation group, 90% of staff (n = 9) said yes. In particular, they liked the birdsong. Overall, the comments were that the biophilia installation created a feeling of openness and naturalness and that it was a relaxing place to sit and talk. One respondent commented, “It makes the place feel less institutionalized.” The majority of staff in the reminiscence group reported liking the installation, with 87.5% (n = 7) responding yes to this item. Further comments were related to the novelty and attractiveness of the reminiscence installation: for example, it made the place “look more homely” and “warmer.” There was 100% agreement by staff, in both the biophilia and reminiscence conditions, to the question “Do you think that the residents liked the new décor?”

    Residents’ Evaluations

    Social Engagement. To test the effect of the installations on social engagement, multivariate analyses were conducted. The composite social engagement scales were created using the group average of scores at each time point (i.e., T1, T2, and T3). Lower scores on this scale indicated greater social engagement. A mixed MANOVA, with scores on the social engagement scale as a within-subjects factor and condition as a between-subjects factor, was conducted. The results indicated a significant interaction effect, such that responses differed as a function of group condition (e.g., biophilia, reminiscence, control) and time (i.e., pre-, during, and post intervention), F(2,22) = 2.85, p < 0.05, η2p = 0.21.

    Follow-up analyses revealed significant differences in social engagement among the groups. At T1, the groups did not differ significantly (Table 2). However, at T2, the results showed that social engagement was significantly greater for the biophilia group (mean = 2.17) and the reminiscence group (mean = 2.42) compared with the control group (mean = 2.98), where 1 indicated strongly agree. At T3, a similar effect was found: social engagement was significantly greater for the biophilia group (mean = 2.72) and the reminiscence group (mean = 2.69) compared with the control group (mean = 3.20).

    The level of social engagement within the control condition did not differ across time points, F(2,12) = 1.68, p > 0.05. A significant difference was noted in the level of social engagement across T1, T2, and T3 within the biophilia condition, F(2,18) = 13.82, p < 0.001. Follow-up comparison analyses revealed significant differences at T2 compared to T1, t(13) = 5.00, p < 0.001; and at T3 compared to T1, t(9) = 4.26, p < 0.01, where 1 indicated strongly agree. A significant difference was noted in the level of social engagement across T1, T2, and T3 within the reminiscence condition, F(2,14) = 3.62, p < 0.05. Follow-up comparison analyses revealed significant differences at T2 compared to T1, t(7) = 4.33, p < 0.01; and at T3 compared to T1, t(8) = 2.48, p < 0.05, where 1 indicated strongly agree. All means, SDs, and significance levels are shown in Table 2.

    Satisfaction With the Living Environment, Opportunities for Keeping Occupied, Depression, and Anxiety. Analysis of these satisfaction and mood measures showed no significant effects of time or condition (all F < 1.35, all p > 0.05) (Table 2). However, although traditional levels of statistical significance were not met, the pattern of responses across the measures “satisfaction with the living environment” and “opportunities for keeping occupied” were similar to those observed on the measure of social engagement for the biophilia condition, which was a trend toward increased levels of satisfaction for the biophilia condition during the time that the installations were in place. This pattern was not evident for the reminiscence or control groups.

    Staff Evaluations

    Staff Social Engagement With Residents. The effect of the installations on social interaction between residents and staff was assessed via staff self-report. Analysis of the item “In the past week, I have shared conversation with the residents” across the conditions and phases of the study indicated no significant effects, F(2,14) = 0.25,p > 0.05 (Table 2). However, staff self-report of this item was high at T1 baseline across all conditions (mean = 1.25, SD = 0.33, where 1 indicates strongly agree) and remained so at T2 (mean = 1.39, SD = 0.61) and T3 (mean = 1.52, SD = 0.84).

    Recreation of Memories: Staff Proxy Reports

    To test whether the biophilia installation had recreated memories of past gardens for residents, staff responses were examined: 60% (n = 6) replied yes, they thought the garden installation had brought back memories for participants when it was in place. According to one staff member, “Some residents made comments about the gardens they used to have” during the time the biophilia installation was in place. The reminiscence installation had a similar effect, such that 100% (n = 8) of staff indicated that it had recreated memories of the past for residents.

    Discussion

    The current study examined whether positive changes to the indoor environment of residential aged-care facilities would benefit the well-being of residents and staff. Participants in the biophilia and reminiscence installation interventions acknowledged their favorability toward the changes to the indoor environment of their facility. The most salient effect of the changes was through the aesthetic appeal, novelty, and sensory stimulation that the biophilia and reminiscence installations provided. Further, these installations significantly enhanced overall well-being and engagement for these older adults while the installations were in place. Social engagement and well-being were significantly greater in the biophilia and reminiscence groups than in the control group while the installations were in place. The effect was also found within the biophilia and reminiscence groups, such that social engagement was significantly increased while the installations were in place, compared to 2 weeks before (i.e., baseline) and 2 weeks after removal (i.e., post intervention). However, the biophilia and reminiscence groups did not differ significantly from one another in terms of social engagement while the installations were in place.

    Consistent with the results of other studies, enhancing the indoor physical environment had a positive effect on the well-being of residents and staff of these residential aged-care facilities (Calkins, 2001; Cohen-Mansfield & Werner, 1998; Dijkstra et al., 2006). Given the static indoor environment of many residential care homes, any environmental change, no matter how small, was likely to be noticed by residents (Calkins, 2001). The changes to the indoor environment in both the biophilia and reminiscence intervention groups were noticed and valued by the residents and staff. Residents and staff reported that the changes engendered a more “home-like” space. Creating a less hospital-like environment for older adults living in long-term care facilities is theorized to be an important contributing factor to their quality of life and adjustment to their new surroundings (Dijkstra et al., 2006). Furthermore, the multisensory quality of the biophilia installation, which was intended to make the installation a more sensory experience, was highlighted by residents as one of the most satisfying aspects of its appeal. According to residents and staff, one of the most salient enjoyable features of the installation was the audio of birdsong, which had also been found to decrease patient agitation in other health care environments (Whall et al., 1997). The scent of the plants, the aroma emanating from the diffuser, and the visual aesthetic of the plants and the mural of trees were suggested as the features that made the environment feel more “homely” to residents, whether they were sitting on the garden bench or simply viewing the space from a distance.

    Staff self-reports and their secondary reports of resident satisfaction also affirmed the benefits of the interventions. The overwhelming majority reported that they and the residents appraised the indoor environment as more aesthetically pleasing, warmer, and, in general, more home-like while the installations were in place. This finding is noteworthy because the physical environment and atmosphere of the care facility can have a positive impact on staff morale and efficacy (Pachana, 2002); therefore, environmental enhancements of this kind could serve as an effective way to increase staff well-being and, in turn, their positive interactions with residents. Although no evidence was noted of this suggestion in the current study, the authors suggest that the effect of changes to the physical environment on staff morale is an important future consideration for studies of this kind.

    Effects of Installations

    Social Engagement. The biophilia installation introduced a novel stimulus in the environment, which alone may explain the positive effects. However, in addition to novelty, participants may have responded well to this intervention because it was nature-based (Wilson, 1984); biophilia theory proposes that humans not only have a love of living things, but they also have an innate appreciation for the aesthetics of nature and an inbuilt positive response to natural elements.

    Participants responded well to the reminiscence installation. Simple reminiscence, which involves remembering positive events from one’s past, is an effective way to enhance well-being and increase social interaction for older adults living in residential care (Haslam et al., 2010; Pinquart & Forstmeier, 2012). The period items that were included in the installation, such as the postwar music, magazines, and old wares, may have provided the stimulus for remembering the past and thus promoted conversation around shared recollections. Installations of this type may provide novel, noticeable changes to the indoor environment and stimulate conversation among residents, thus making this an important beginning study.

    Social engagement increased significantly for residents in the biophilia and reminiscence groups compared with the control group, at T2 and T3. Social engagement scores were greatest during the time that the installations were in place; however, some evidence existed of sustained engagement at posttest measurement (i.e., 2 weeks after the installations were removed). This finding is important because social relationships within the residence are important to resident well-being, quality of life, and to their feeling at home (Street et al., 2007). The quality of the relationship will have an important bearing on well-being, and the ability to develop quality relationships is affected by numerous variables, such as individuals’ hearing problems, cognition, and physical limitations (Park et al., 2012); however, these relationships begin with the opportunity to interact. The significance of the biophilia and reminiscence installations is that the presence of these installations led to greater social engagement, perhaps through providing the impetus and novelty for starting a conversation.

    Mood Measures. Although the installations led to increased social engagement, the intervention did not have a significant effect on the measures of depression and anxiety symptoms. On average, the participants’ scores on the GDS and GAI were elevated compared with normative data, indicating the presence of possible depression and anxiety (Byrne & Pachana, 2011; Hoyl et al., 1999). Although variability existed within and between the scores across time points, the absence of any significant effect is perhaps not surprising given the nature and course of depression and anxiety; that is, late life depression is difficult to treat (Fiske, Wetherell, & Gatz, 2009), anxiety disorders are common among older adults (Kessler et al., 2005), and depression is more severe when combined with anxiety (Beattie, Pachana, & Franklin, 2010). Depression is one of the most common psychiatric disorders in older adults. The incidence of depression is higher for older adults in long-term care; however, it often goes unnoticed and undiagnosed in these settings (Snowdon, 2010; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001). One suggestion for the high incidence of depression and anxiety among the population of older adults in long-term care, compared with community samples, is that the environment of long-term care facilities is often depressogenic (Zeiss, 2005). An alternative approach is to adapt an environment more reminiscent of home and include natural elements to reduce the overall incidence and prevalence of depression (Alvermann, 1979; Bergman-Evans, 2004). Therefore, although the biophilia and reminiscence installations were not potent enough to establish changes in mood in a 6-week period, the aesthetics and novelty of these types of environmental transformations may be a step toward improving environmental quality. Further research that examines the effect of different types of environmental enhancements on resident outcomes is needed.

    Limitations

    Much has been written about the design and analysis challenges of social ecological research in the context of residential aged-care. These challenges, including staff issues (e.g., motivation, time, turnover) and resident characteristics (e.g., mental and physical acuity, motivation, attrition) (Mentes & Tripp-Reimer, 2002), are often not encountered in other contexts; however, these factors affected the current study. The main limitations of the study were the short intervention time and sample size, which was further affected by attrition throughout the study protocol, as participants became unwell, were confined to their beds, were hospitalized, or passed away. Staff attrition was roughly equivalent across the facilities, particularly at T3 of the study, at which time motivation to complete the questionnaires was possibly depleted due to competing work demands. Initial projections of sample size were greatly diminished in practice, such that baseline measures could not be taken in the short 2-week lead time for some participants who were unwell or heavily medicated during that initial period. The relatively short time for evaluation of the interventions was necessary, as participant attrition issues heavily affect longitudinal studies in residential aged-care, as discussed above. In addition, social desirability effects have been found to be a source of bias in previous research with older adults, particularly with satisfaction measures. A limitation of the current study was the potential for participants to provide socially desirable responses due to the researcher’s involvement in all phases of the study, from set up of the installations through to data collection. Although an attempt was made to offset this effect by including a control condition, the findings must be considered with this limitation in mind.

    A strength of the study was the inclusion of a control condition, which addressed a limitation of prior studies (Cohen-Mansfield & Werner, 1998). The inability to blind participants to treatment conditions may sometimes result in a Hawthorne effect, and to eliminate this effect as much as possible, the participants were blinded to the true characteristics of the study (i.e., they were not made aware of the existence of other conditions). Furthermore, the amount of contact between the researcher and the participants in each of the conditions (i.e., biophilia, reminiscence, and control) was carefully monitored for equivalence.

    Implications for Nurses

    The current study demonstrates that relatively low-cost, simple, environmental changes to the indoor environment can have a positive impact with minimum effort. Improving environmental quality through the introduction of reminiscence displays of period elements—which can be sourced secondhand or by appealing for donations from families—may serve to create an indoor environment that is more reminiscent of “home” for residents. Including visual, olfactory, and auditory features, as well as rotating installation elements, will ensure that installations are dynamic and sustain interest so that older adults do not habituate to the displays. Plants and natural elements may be more readily sourced, and bringing them indoors provides residents with important contact with nature and the stimulus for social exchange. Plants will grow, flower, wither, and die; however, replacing them will create novelty and sustain interest. Including comfortable cushions on the garden bench and audio of nature (e.g., birdsong), as well as positioning the display in a quiet and neglected area of the facility (e.g., away from the nurses station or recreational area), will have the most value to residents and staff. Elements such as an atrium or a birdcage, an aquarium, and various plants and wall murals (which can be rotated) could further increase the dynamic effects of a biophilia installation. Increasing the hands-on aspect of the biophilia installation, such as allowing participants to plant seedlings or propagate plants, might also encourage repeat interactions among residents.

    Conclusion

    Emerging evidence for the effectiveness of cognitive and behavioral interventions to treat depression and anxiety disorders in frail older adults in nursing homes highlights the importance and difficulty of including more pleasurable activities (Konnert, Dobson, & Stelmach, 2009). Including these types of nature-based interventions and making them more hands-on to promote socialization may be an important adjunct to other psychological therapies, such as cognitive-behavioral therapy.

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    Sociodemographic Characteristics of Participants Across Conditions

    Resident Characteristic Biophilia (n = 15) Reminiscence (n =10) Control (n = 8)
    Age (mean, SD) (years) 82.20 (8.90) 83.30 (8.60) 83.30 (5.70)
    Sex (n)
      Female 10 6 6
      Male 5 4 2
    GDS T1 (mean, SD) 1.80 (1.87) 3.00 (1.91) 2.17 (2.04)
    GAI T1 (mean, SD) 1.00 (1.50) 2.57 (2.07) 2.67 (2.16)
    QoL-AD items
      Physical health 2.20 2.07 2.00
      Energy level 2.20 2.13 2.29
      Mood 2.67 2.67 2.29
      Memory 2.73 2.73 2.43
    Daytime location of resident (%)
      In own room 56 60 50
      In lounges/common area 44 40 50
    Staff Characteristic Biophilia (n = 10) Reminiscence (n = 8) Control (n = 6)
    Age (mean, SD) (years) 45.30 (11.10) 46.60 (13.20) 46.50 (16.70)
    Sex (n)
      Female 7 6 6
      Male 3 2 0
    Duration of employment (mean, SD) (years) 3.41 (2.12) 3.31 (2.61) 10.22 (8.19)

    Social Engagement and Mood Measures Across Conditions and Groups

    Mean (SD)
    Resident Measure T1 T2 T3
    Social engagement scale
      Biophilia 2.85b (0.51) 2.17a (0.33)*** 2.72a (0.29)**
      Reminiscence 2.96b (0.72) 2.42a (0.66)** 2.69a (0.57)*
      Control 2.95 (0.60) 2.98 (0.55) 3.20 (0.54)
    Satisfaction with the living environment
      Biophilia 2.30 (1.06) 1.70 (0.49) 2.20 (0.63)
      Reminiscence 2.13 (0.35) 2.13 (0.35) 2.13 (0.35)
      Control 2.14 (0.38) 2.14 (0.39) 2.29 (0.49)
    Satisfaction with opportunities for keeping occupied
      Biophilia 2.10 (0.32) 1.90 (0.32) 2.20 (0.42)
      Reminiscence 2.38 (0.74) 2.38 (0.74) 2.75 (1.04)
      Control 2.57 (0.79) 2.43 (0.54) 2.42 (0.54)
    GDS
      Biophilia 1.80 (1.87) 2.00 (0.94) 2.00 (1.41)
      Reminiscence 3.00 (1.91) 2.57 (1.27) 2.86 (1.07)
      Control 2.17 (2.04) 2.17 (1.33) 2.50 (1.22)
    GAI
      Biophilia 1.00 (1.50) 1.20 (1.75) 1.90 (1.72)
      Reminiscence 2.57 (2.07) 1.86 (2.12) 2.00 (2.00)
      Control 2.67 (2.16) 3.16 (2.14) 2.83 (2.22)
    Staff Measure T1 T2 T3
    Staff –resident interaction
      Biophilia 1.50 (0.53) 1.50 (0.53) 1.89 (1.23)
      Reminiscence 1.25 (0.46) 1.43 (0.79) 1.43 (0.79)
      Control 1.00 (0.01) 1.25 (0.50) 1.25 (0.50)

    Keypoints

    Scott, T.L., Masser, B.M. & Pachana, N.A. (2014). Multisensory Installations in Residential Aged-Care Facilities: Increasing Novelty and Encouraging Social Engagement Through Modest Environmental Changes. Journal of Gerontological Nursing, 40(9), 20–31.

    1. It is important to the well-being of older adults living in long-term care facilities that they develop social and emotional connections with the home and other residents and staff.

    2. The results of the current study show that simple changes to the indoors can create an environment that is more reminiscent of home and provide the stimulus for social exchange

    3. An indoor garden simulation or a reminiscence installation is an affordable way to transform an indoor area of an aged-care facility for the benefit of residents and staff.

    10.3928/00989134-20140731-01

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