Older adults in poor health may experience life crises because they need to move into nursing homes away from their families and depend on staff members rather than relatives (Choi, Ransom, & Wyllie, 2008; Hunter & Gillen, 2009; Tsai & Tsai, 2008). Older adults residing in nursing homes frequently experience life adaptation problems. Studies have indicated that chronic health problems, living without families, and life maladaptation are severe stressors for nursing home residents (Choi et al., 2008; Hunter & Gillen, 2009). Nursing home residents have been reported to experience higher levels of stress than community-dwelling older adults (Yulitasari, Amatayakul, & Karuncharerernpanit, 2015). Stress reduces quality of life (de Frias & Whyne, 2015), leads to depression (Tsai, Chi, & Wang, 2015), and increases mortality risk (Vasunilashorn, Glei, Weinstein, & Goldman, 2013). Therefore, managing stress is crucial for improving quality of life, preventing depression, and increasing longevity in nursing home residents.
Although effects of stress are extensive, specific methods can prevent, moderate, and reduce these effects. Previous studies have suggested that self-determination and social support are two basic needs and satisfaction of these needs can contribute to stress reduction in older adults (Sikma, 2009; Tak, Hong, & Kennedy, 2007; Weinstein & Ryan, 2011). Self-determination refers to free choice and initiative in activities, whereas social support corresponds to receiving adequate support from family and friends. Participation in leisure activities can provide older adults with opportunities to exercise self-determination (Chang, 2012). Leisure for older adults is also vital because it can afford opportunities to interact with family and friends and receive social support (Burnett-Wolle & Godbey, 2007). Thus, participation in leisure activities appears to be crucial to enhance levels of self-determination and social support and reduce stress in older adults (Chang, 2015).
Coleman and Iso-Ahola (1993) indicated that promoting self-determination through leisure activities refers to leisure self-determination and that receiving social support from family and friends in leisure contexts refers to leisure social support. Leisure self-determination means having free choice and initiative in the leisure activities in which one decides to participate. For example, an individual decides, rather than is informed, to practice yoga. Leisure social support pertains to receiving adequate support from leisure companions (e.g., family, friends) when the recipient needs it. For example, when a man would like to play croquet, his friends invite him to participate in the game. Praising his activity performance is also a type of leisure social support. Leisure self-determination and leisure social support have been observed to correlate with stress reduction in community-dwelling older adults (Chang, 2017). However, stressors nursing home residents may experience, such as living arrangement and loneliness (Hunter & Gillen, 2009), are different from those community-dwelling older adults may experience. Therefore, it is necessary to examine whether leisure self-determination and leisure social support are related to stress reduction in nursing home residents.
In practice, arranging everything for nursing home residents may lead to residents becoming overdependent on other individuals. Opportunities to make decisions decrease when nursing home residents have excessive help. Because providing help is also a type of social support in leisure contexts, excess leisure social support may hinder maintenance of leisure self-determination in nursing home residents. Although no evidence suggests any relationships exist between leisure self-determination and leisure social support, research by Jansen et al. (2014) indicated a nonlinear relationship between autonomy and social support. Jansen et al. (2014) recruited 166 individuals receiving dialysis to examine effects of various types of support on autonomy, self-esteem, and personal control regarding illness. Data related to support, autonomy, self-esteem, and personal control were examined using regression analysis. Results demonstrated that general support was positively related to autonomy and that overprotection was negatively associated with autonomy; the negative association between overprotection and autonomy was stronger in individuals with high personal control. The role of support in autonomy appeared to depend on personal control, whereas the role of support in self-esteem did not. These findings imply that leisure self-determination decreases when leisure social support increases. Furthermore, lower levels of leisure self-determination lead to higher levels of stress in older adults (Chang, 2015); therefore, higher levels of leisure social support may moderate a relationship between leisure self-determination and stress reduction in nursing home residents. However, any assertions regarding such a relationship must be further investigated.
Social support can be divided into two major types: emotional and instrumental (Ramirez-Valles, Dirkes, & Barrett, 2014). Emotional support is the offering of affection, concern, empathy, encouragement, love, or trust. Instrumental support (also called tangible support) is the provision of financial assistance, material goods, or services. However, no studies have analyzed the relationships between leisure self-determination and the two types of leisure social support in nursing home residents and their stress. Therefore, the current study examined the main and interaction effects of leisure self-determination and leisure social support (emotional and instrumental) on stress in nursing home residents. The results contribute to a more comprehensive understanding of the relationship between leisure and stress.
Sampling and Participants
Two nursing homes in Taichung City, Taiwan, were randomly selected for the current study. The directors of the two nursing homes were requested to assist with recruiting residents. Sampling was conducted after directors had given permission. Participants were required to meet three eligibility criteria: (a) age 65 or older, (b) able to participate in leisure activities, and (c) free from mental health conditions (e.g., dementia, depression). Prospective participants were excluded if the director of their nursing home reported that a physician had diagnosed them with a mental health condition. A total of 139 nursing home residents were recruited. Each received a small gift (i.e., a pair of stainless steel eco-chopsticks) and filled out a consent form before the study began. Participants were ages 65 to 90, with a mean age of 79.4 years (SD = 7.1 years). Most participants were female and widowed and had completed primary school (Table 1).
Characteristics of Participants (N = 139)
Although 68.3% of participants could read a questionnaire, many had visual impairment and disliked reading. For consistency, face-to-face interviews were conducted. A research assistant (RA) read the questionnaire items to all participants. All items were scored on a 5-point interval scale and participants' responses were coded. Each interview lasted approximately 35 minutes. Before beginning each interview, the RA explained the purpose of the study, rights of participants, anonymity of their identity, and confidentiality of all responses. Participants who were literate signed a detailed informed consent form to affirm their participation was voluntary. If participants who were illiterate doubted the form content, they could ask their adult children or relatives for assistance. After agreeing to enroll in the study, participants signed their name on the form. Each interview was conducted in a private place, such as a conference or living room.
Leisure self-determination was measured using the six-item scale developed by Chang (2015), which measures older adults' perceived levels of freedom to make choices regarding leisure activities; for example, two items on the scale are “I freely choose my leisure activities” and “I perceive freedom when participating in leisure activities.” Participants were asked to rate the degrees to which they agreed with each item on a 5-point Likert scale, from 1 (not at all) to 5 (completely). Potential scores of the scale ranged from 6 to 30, with higher scores indicating greater perceived leisure self-determination. Reliability of the scale was assessed through a preliminary investigation involving 120 older adults. Results indicated that the scale had an acceptable alpha reliability coefficient of 0.83.
Leisure emotional support and leisure instrumental support were measured using two subscales of the Leisure Social Support Scale (Iwasaki & Mannell, 2000), which was used in a previous study to investigate older adults in Taiwan (Chang, 2017). The two subscales measure the degree to which older adults feel adequately supported by their leisure companions in terms of emotional and instrumental dimensions. The eight-item leisure emotional support subscale focuses on emotional and esteem support, whereas the eight-item leisure instrumental support subscale focuses on informational support and perceived aid. Examples of items on each of the subscales are “I feel emotionally supported by my leisure companions,” and “My leisure companions will lend me things if I need to borrow them,” respectively. Participants were asked to rate the degree to which they agreed with each of the items on a 5-point Likert scale, from 1 (not at all) to 5 (completely). Potential scores of the two subscales ranged from 8 to 40, with higher scores indicating higher perceived leisure emotional support and leisure instrumental support. Reliabilities of the subscales were assessed and results indicated that the subscales had acceptable alpha reliability coefficients of 0.89 (leisure emotional support) and 0.80 (leisure instrumental support).
The 14-item Perceived Stress Scale developed by Cohen, Kamarck, and Mermelstein (1983) was adopted to measure stress in participants. This scale was used in Yulitasari et al. (2015) to investigate nursing home residents. Two examples of items on this scale are “In the last month, how often have you successfully coped with life hassles?” (reverse item), and “In the last month, how often have you felt that you were unable to control the important things in your life?” Participants were asked to rate their degree of stress regarding each of the items on a 5-point Likert scale from 1 (never) to 5 (always). Potential scores of this scale ranged from 14 to 70, with higher scores indicating higher levels of stress. Reliability of the scale was assessed. Results indicated that the scale had an acceptable alpha reliability coefficient of 0.90.
Descriptive statistics were used to describe characteristics of participants. Normal probability plots were inspected prior to all analyses to ensure that data were normally distributed. A correlation analysis was performed to examine interrelationships among leisure self-determination, leisure emotional support, leisure instrumental support, and stress. Finally, a hierarchical regression analysis was performed to determine the main and interaction effects of leisure self-determination and leisure social support (emotional and instrumental) on stress and examine whether demographic variables were significantly related to stress.
The mean leisure self-determination score of 13.39 (SD = 3.20) was lower than the average score of 18 on a 6 to 30 scale; the mean leisure emotional support and leisure instrumental support scores of 19.29 (SD = 4.97) and 19.81 (SD = 5.60), respectively, were also lower than the average scores of 24 on an 8 to 40 scale; however, the mean stress score of 47.09 (SD = 11.74) was higher than the average score of 42 on a 14 to 70 scale.
Results of correlation analysis indicated that leisure self-determination, leisure emotional support, leisure instrumental support, and stress were all significantly correlated (Table 2). Moreover, the hierarchical regression analysis produced three main results. First, demographic variables were not significantly correlated with stress. Second, leisure self-determination (ß = −0.34, p < 0.01) and leisure emotional support (ß = −0.28, p < 0.05) were significantly and negatively correlated with stress, whereas leisure instrumental support (ß = 0.05, p > 0.05) was not. Third, leisure emotional support (ß = 0.27, p > 0.05) did not significantly moderate the effect of leisure self-determination on stress, whereas leisure instrumental support (ß = 0.56, p < 0.01) did have an effect. The F and R2 values of the stress model were 3.86 and 0.21, respectively (Table 3). In addition, a regression analysis plot revealed that stress significantly decreased when leisure self-determination increased on lower levels of leisure instrumental support. However, stress did not significantly decrease when leisure self-determination increased on higher levels of leisure instrumental support (Figure).
Correlation Analysis of Variables
Hierarchical Regression Analysis for Variables Predicting Stress
Effects of leisure self-determination on stress on different levels of leisure instrumental support.
Note. Higher scores of leisure self-determination and stress indicate greater perceived leisure self-determination and higher levels of stress, respectively.
Consistent with findings of previous gerontological studies (Chang, 2015, 2017), results of the current study indicated that leisure self-determination and leisure emotional support were significantly and negatively correlated with stress in participants. Therefore, higher levels of leisure self-determination and leisure emotional support are believed to be associated with lower levels of stress in nursing home residents.
Leisure instrumental support was not significantly correlated with stress in the regression model, which is inconsistent with findings of Iwasaki and Mannell (2000), likely because of the multicollinearity problem between leisure emotional support and leisure instrumental support in the current regression model. The multicollinearity phenomenon denotes that leisure instrumental support predicts stress through leisure emotional support in the regression model. In other words, leisure emotional support may be more crucial than leisure instrumental support for reducing stress in nursing home residents.
Results demonstrated that higher levels of leisure instrumental support decreased the relationship between leisure self-determination and stress reduction. Results correlate with findings of Jansen et al. (2014). Thus, providing excessive leisure instrumental support to nursing home residents should be avoided.
Results of the current study highlight several implications for nursing home resident care. First, stressors faced by many nursing home residents, such as living arrangement and loneliness, are ongoing (Hunter & Gillen, 2009). Although such stressors cannot be eliminated, emotion-focused methods can help reduce stress (Ong & Bergeman, 2004). Studies have reported that leisure self-determination can facilitate full emotional processing of stressful events over time and reduce stress in older adults by promoting emotional health (Chang, 2015), and that leisure social support can reduce stress through emotion-focused comfort from leisure companions (Chang, 2017). Notably, leisure social support was specifically identified as leisure emotional support in the current study. Therefore, enhancing leisure self-determination and leisure emotional support appears to be an effective emotion-focused means of reducing stress in nursing home residents.
Second, leisure self-determination is related to stress reduction on lower levels of leisure instrumental support, whereas leisure self-determination is not related to stress reduction on higher levels of leisure instrumental support. These findings imply that much leisure instrumental support is not necessary. In practice, caregivers and friends do not need to provide nursing home residents with leisure instrumental support (i.e., activity suggestions) when they do not ask for help.
Third, leisure not only enhances overall life satisfaction (Cheng, Stebbins, & Packer, 2017), but also provides a key context for experiencing autonomy, competence, and relatedness, all of which are core attributes of self-determination (Iwasaki, Coyle, & Shank, 2010; Iwasaki, Coyle, Shank, Messina, & Porter, 2013; Porter, Iwasaki, & Shank, 2010). Similar perspectives suggest that leisure can provide older adults with opportunities to exercise self-determination (Chang, 2015) and that leisure creates an avenue for older adults to interact with family and friends and receive leisure social support (Burnett-Wolle & Godbey, 2007). Deci and Ryan (2008) asserted that satisfaction gained from self-determination and social support can fuel intrinsic motivation for activity engagement. If leisure helps individuals enhance self-determination and receive social support, benefits acquired from leisure can assist them in continuing to participate in leisure activities (Iwasaki et al., 2010; Porter et al., 2010). In other words, older adults continually gain self-determination and social support in leisure contexts. Enhanced leisure self-determination and leisure social support that older adults experience through leisure can reduce stress (Chang, 2017).
Leisure education can be provided through an organized program designed to improve leisure attitudes, knowledge, and skills of participants and thereby allow them to use their leisure time more effectively (Dattilo & Williams, 2012; Sivan & Stebbins, 2011), and leisure education has been reported to significantly promote leisure self-determination and leisure social support (Dattilo, 2015). Therefore, encouraging nursing home residents to engage in leisure education is necessary.
Strengths, Limitations, and Recommendations
The current study had two key strengths. First, the study examined the critical topics of leisure and coping with stress. Although previous studies have examined the relationships between leisure self-determination and leisure social support in older adults and their stress (Chang, 2015, 2017), no studies have determined the main or interaction effects of leisure self-determination and leisure social support (emotional and instrumental) on stress in nursing home residents. In particular, the current study demonstrated that higher levels of leisure instrumental support changed the relationship between leisure self-determination and stress; this outcome had previously been overlooked. Second, participants were recruited from nursing homes. Because leisure activities of this population are studied much less than those of community-dwelling older adults, the results provide important information for the field of gerontology.
The current study has limitations to acknowledge. First, cause and effect conclusions cannot be drawn from the results because of the correlational design of the study. Second, the sample size was not large; however, it was not significantly smaller than sample sizes of other leisure studies that recruited participants from nursing homes (Altintas, De Benedetto, & Gallouj, 2017; Kalinowski et al., 2012). Sampling was also not random. The results may not be generalizable to all nursing home residents. Third, several factors, such as depression (Zautra & Smith, 2001) and locus of control (Pilisuk, Montgomery, Parks, & Acredolo, 1993), are related to stress in older adults. However, the current study did not include these factors in the stress model. In addition, a scale of specific stress perceptions of nursing home residents was not developed in the study. Therefore, the stress model cannot account for 100% of variance. Although limitations exist, the results provide a starting point for understanding relationships between leisure self-determination and leisure social support (emotional and instrumental) and stress in nursing home residents.
Based on these limitations, future studies should complete the following tasks to ensure robust conclusions. First, the main and interaction effects of leisure self-determination and leisure social support (emotional and instrumental) on stress should be determined using an experimental design, and any causal relationships between leisure variables and stress should be identified. Second, the main and interaction effects should be evaluated based on a large random sample. Third, relationships between more factors and specific stress should be examined.
The current study suggests that leisure self-determination and leisure emotional support are significantly and negatively correlated with stress in nursing home residents, and that higher levels of leisure instrumental support moderate the effects of leisure self-determination on stress.
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Characteristics of Participants (N = 139)
| Female||88 (63.3)|
| Male||51 (36.7)|
| Illiterate||44 (31.7)|
| Primary school graduate||66 (47.5)|
| High school graduate||15 (10.8)|
| University degree and above||14 (10)|
| Widowed||101 (72.7)|
| Unmarried||15 (10.8)|
| Divorced||12 (8.6)|
| Married||11 (7.9)|
Correlation Analysis of Variables
|Variable||Leisure Self-Determination||Leisure Emotional Support||Leisure Instrumental Support||Stress|
|Leisure emotional support||0.33**||—|
|Leisure instrumental support||0.41**||0.75**||—|
|Range||6 to 30||8 to 40||8 to 40||14 to 70|
|Mean (SD)||13.39 (3.20)||19.29 (4.97)||19.81 (5.60)||47.09 (11.74)|
Hierarchical Regression Analysis for Variables Predicting Stress
|Statistic||Model 1||Model 2|
|Leisure emotional support||−0.65||0.28||−0.28*|
|Leisure instrumental support||0.11||0.27||0.05|
|Interaction between leisure self-determination and leisure emotional support||−0.16||0.11||0.27|
|Interaction between leisure self-determination and leisure instrumental support||0.23||0.08||0.56**|