You Can't Get There From Here: Reaching the Outdoors in Senior Housing

Predictors of change over time in satisfaction with outdoor activities ratings among long-term care services and supports recipients

OBJECTIVES

To identify predictors of change in older adults' satisfaction with outdoor activities ratings over the first two years of enrollment in long-term services and supports (LTSS).

METHODS

Self-rated satisfaction with outdoor activities (not at all satisfied to extremely satisfied) was the primary outcome of this secondary data analysis. Mixed-effects linear regression modeling with a backward elimination process was used for analyses.

RESULTS

In the final model (N = 453) older LTSS recipients at baseline had lower ratings of satisfaction with outdoor activities over time, whereas younger recipients had higher ratings over time. Those who moved into a residential facility at baseline had an increase in outdoor activity satisfaction ratings over time compared to older adults who received home and community-based services that had a decrease.

DISCUSSION

LTSS clinicians can use these findings to support older adults with decision-making around enrollment into LTSS, address preferences, and develop person-centered care interventions for outdoor activity.

Satisfaction With Outdoor Activities Among Northeastern U.S. Newly Enrolled Long-Term Services and Supports Recipients

Older adults receiving long-term services and supports (LTSS) experience barriers to outdoor activities and satisfaction ratings with such experiences are not well understood. Our study used cross-sectional data (n = 329) to (a) examine whether those new to LTSS were satisfied with their outdoor activities and (b) describe the characteristics and factors associated with satisfaction levels. Self-report of satisfaction with outdoor activities was the outcome variable. Multivariable linear regression modeling of the outcome was conducted. Fifty-nine percent were satisfied with their outdoor activities. More depressive symptoms (p < .001) and higher cognitive functioning (p = .011) were associated with lower ratings. Higher self-rated physical health (p = .009) and more independence with activities of daily living (p = .022) were associated with greater satisfaction. Findings suggest an unmet need among four in 10 new recipients of LTSS (41%) related to their outdoor activities. LTSS interdisciplinary teams can use these findings to inform their assessments, develop person-centered care plans, and address barriers.

Outdoor exposure and perceived outdoor environments correlated to fear of outdoor falling among assisted living residents

BACKGROUND

Fear of falling is a major health concern among older adults. Although several studies have addressed general fear of falling in relation to personal factors, little is known about the specific relationship between fear of outdoor falling and perceptions of the outdoor environments.

PURPOSE

This study is to identify perceived environmental factors and outdoor exposure associated with fear of outdoor falling among assisted living residents aged 65 or older stratified by the amount of time spent outdoors.

METHODS

This study used survey data collected from a multiregional study conducted in 2007 that surveyed residents in 68 assisted living facilities in Houston, Texas; Chicago, Illinois; and Seattle, Washington. Out of 1,043 total participants, this study used a subset of 907 residents who used outdoor areas at least five minutes a day. Multivariate logistic regression was used after controlling for covariates.

RESULTS

Approximately 31% of the participants reported having worried about falling while using the outdoor areas in their assisted living community. Multivariate analyses showed that adequately designed walkways (OR = 0.614, 95% CI = 0.405-0.931), comfort levels in using outdoor areas (OR = 0.657, 95% CI = 0.437-0.989), and frequency of outdoor usage (OR = 0.538, 95% CI = 0.368-0.787) were associated with decreased fear of outdoor falling after adjusting for individual factors (i.e. age, sex, health condition, fall history, vision problems, mobility aids).

CONCLUSION

Improved walkways and comfort levels when using outdoor areas, as well as the amount of time spent outdoors, would be helpful in reducing fear of outdoor falling, which can help promote healthy lifestyle among assisted living residents.

Understanding the Barriers and Enablers to Using Outdoor Spaces in Nursing Homes: A Systematic Review

BACKGROUND AND OBJECTIVES

Despite acknowledged benefits of residents in nursing homes spending time outdoors, little is known about factors related to their use of outdoor space. This systematic review summarizes reported barriers and enablers to nursing home residents' use of outdoor spaces.

RESEARCH DESIGN AND METHODS

Multiple databases were searched to May 2018. Qualitative or mixed methods studies describing barriers/enablers to use of outdoor areas by residents of nursing homes (aged 65 years and older), as reported by residents, staff, or family members were included. Study quality rating, thematic analysis, and stratified analyses were performed and confidence in findings assessed using GRADE-CERQual.

RESULTS

Twenty-four studies were included. Nineteen collected data from residents, 15 from staff/caregivers, 7 from families. Major themes and key findings concerned: design of the outdoor area (importance of garden greenery and built features), safety concerns and staffing issues, weather and seasons (appropriate shade and shelter), design of the main building (easy to open doors and nearby access points) and social activities.

CONCLUSIONS AND IMPLICATIONS

Providing gardens with seasonal plants and interactive features, weather protected seating, manageable doors at accessible thresholds, planned social activities, and appropriate clothing are fundamental to facilitate nursing home residents' access to the outdoors. Cultural change at an organizational level, addressing perceptions of safety as a barrier is important. Incorporation of the recommendations in this review by architects, facility managers, and policy makers in the design and management of nursing homes, may increase use of outdoor areas and improve the quality of life of residents.

REGISTRATION

The protocol is registered in Prospero (CRD42018100249).

Evidence-Based Landscape Architecture for Human Health and Well-Being

More than 80% of the people in the USA and Canada live in cities. Urban development replaces natural environments with built environments resulting in limited access to outdoor environments which are critical to human health and well-being. In addition, many urban open spaces are unused because of poor design. This paper describes case studies where traditional landscape architectural design approaches would have compromised design success, while evidence-based landscape architecture (EBLA) resulted in a successful product. Examples range from school-yard design that provides safe levels of solar radiation for children, to neighborhood parks and sidewalks that encourage people to walk and enjoy nearby nature. Common characteristics for integrating EBLA into private, public, and academic landscape architecture practice are outlined along with a discussion of some of the opportunities and barriers to implementation.

Residents' use and perceptions of residential care facility gardens: A behaviour mapping and conversation study

AIM

To describe the gardens and their use by individuals living at residential care facilities (RCFs) with high ratings on restorative values.

BACKGROUND

Being outdoors has been described as important to older people's well-being. Use of outdoor gardens may increase residents' well-being through experiences of restorative qualities such as being away and fascination. Thus far, there has been little research on restorative experiences of gardens in the care of older people.

DESIGN

A descriptive design using behaviour mapping observations integrated with qualitative field notes and recorded conversations.

METHODS

A criterion sampling of two gardens (out of a total of 87) was made based on residents' ratings of restorative values; the two with the highest values were chosen. Eleven residents at the two RCFs took part. Data were collected through behaviour mapping observations, field notes and conversations on five occasions in the respective facilities during residents' visits to the garden.

RESULTS

The observations revealed that the main uses of the gardens were to socialise and relax. The conversations also showed that the garden stimulated residents' senses and evoked memories from the past. These restorative values were interpreted as a sense of being away and fascination. Not having opportunities for outdoor visits was reported to result in disappointment and reduced well-being.

CONCLUSIONS

The findings showed that two basic gardens with different characteristics and views could stimulate residents' senses and evoke memories from the past; this supports the call for residents to be able to spend time in gardens to promote their well-being.

IMPLICATIONS FOR PRACTICE

First-line managers, nurses and healthcare staff in the care of older people should consider that regular opportunities to spend time outdoors may promote older people's well-being through feelings of being away and fascination.

The Experience and Meaning of Physical Activity in Assisted Living Facility Residents

Assisted living (AL) residents engage in very low levels of physical activity (PA), placing them at increased risk for mobility disability and frailty. But many residents in AL may not perceive the need to increase their PA. This study explored the experience, meaning, and perceptions of PA in 20 older adults in AL. The factors associated with PA were also examined. Qualitative data were collected using semistructured interviews and analyzed using phenomenological methodology. Six themes were identified: PA was experienced as planned exercise, activities of daily living, and social activities based on a schedule or routine; PA meant independence and confidence in the future; residents perceived themselves as being physically active; social comparisons influenced perception of PA; personal health influenced PA; motivations and preferences influenced PA. The findings highlight the importance of residents' personal perceptions of PA and effects of the social milieu in the congregate setting on PA.

The Seniors' Outdoor Survey: An Observational Tool for Assessing Outdoor Environments at Long-Term Care Settings

PURPOSE OF THE STUDY

To describe the development and psychometric testing of the Seniors' Outdoor Survey (SOS), an instrument for evaluating how well the outdoor space in a long-term care setting supports the preferences and outdoor usage of residents.

DESIGN AND METHODS

Content validity of the main SOS items initially was based on relevant literature and preliminary studies in diverse long-term care settings. After conducting a multiregional pilot study with 152 outdoor spaces at 68 assisted living facilities, the instrument was substantially revised and tested for interrater and test-retest reliability with 22 outdoor spaces at 12 long-term care settings, using 2 raters. Validity was examined using content analysis of resident survey responses (N = 1,128) from the multiregional study and specific item validation by subject matter experts (N = 53).

RESULTS

The final instrument contains 60 ratable items organized in 5 domains: access to nature (14 items), outdoor comfort and safety (15 items), walking and outdoor activities (14 items), indoor-outdoor connection (11 items), and connection to the world (6 items). Intraclass correlation coefficient (ICC) estimates of interrater reliability were .91 for the overall instrument, ranging from .83 to .98 for the 5 domains. Interrater reliability (ICC) was above .70 for more than 79% of individual items. Test-retest reliability (ICC) was .92, ranging from .81 to .98 for domains.

IMPLICATIONS

The SOS tool fills a gap in the available environmental assessment instruments, providing a reliable way for researchers, providers, and designers to evaluate and compare the supportive potential of outdoor spaces for long-term care residents.