Delivering Preference-Congruent Recreational Care in Nursing Homes
What is preference-congruent care?
Preference-congruent care honors a person’s individual preferences. One way to deliver preference-congruent care is to tailor leisure and recreational activities to an individual’s unique preferences, strengths, needs and wishes.
What is preference-congruent recreational care?
Recreational congruent care is the alignment of recreational care with one’s preferences. Recreational care includes all activities a person engages in one-on-one, independently, and within small or large groups, such as listening to music, playing games, or reading. Recreational care can stimulate an individual socially, intellectually, and physically.
Why should we deliver Preference-Congruent Recreational Care to older adults in Nursing Homes?
Delivering preference-congruent recreational care has been linked to improved well-being for older adults in nursing homes1-3. Greater attendance in congruent activities is linked to better functional well-being and less pain. Choosing not to attend activities by individuals is linked to more depressive symptoms.
How do we deliver and track Preference-Congruent Recreational Care for older adults in Nursing Homes?
Step 1: Plan
- Form a team who will help champion the effort to develop a system to assess, deliver and evaluate preference-congruent care. This will include leadership, recreation, nursing (i.e., CNAs, RNs), Information Technology (IT), and quality improvement staff.
- Learn what a person prefers. Assess preferences using the Preferences for Everyday Living Inventory (PELI) or data collected from the MDS 3.0 Section F: Preferences for Customary Routine and Activities on comprehensive assessments. See PELI—How to Get Started Tipsheet.4
- Document important preferences in a person’s care plan and/or in an easy-to-read care information sheet (i.e., PAL Card or an All About Me Sheet5-6) to ensure communication of preferences across shifts.
- Use a data-driven approach and reference the important preferences reported by residents in your organization. Prioritize which preferences will be monitored for recreational activity congruence. For example, you might select 10 preferences that were most endorsed by residents to evaluate preference congruence.
- Create a list of activities offered and align them with stated preferences. For example, a music performance event may satisfy a preference for listening to music one likes but also satisfy a preference to do things with a group of people. A current event activity may align with a preference to keep up with the news.7
- Set up a system (i.e., the Preference Match Tracker7) to record the activities a person attends each day and which activities a person chooses not to attend. Collaborate with your organization’s IT team for a solution on how to demonstrate residents are attending preferred activities (i.e., setting up a new field in the electronic medical record or using an Access or Excel database).
Step 2: Do
Identify which activities match a person’s preferences. Offer activities to each resident that align with their preferences. Track attendance and when people decide not to attend activities over a specific period of time (e.g., 3 months).
Step 3: Study
Review the data to determine how well you are meeting resident preferences. Are you meeting a person’s stated preferences at least once a week? How about 2 times a week? Are you meeting all the preferences of a person? Or only a few? Analyze any trends in the preference congruence data on a neighborhood or community-wide basis to see where there might be gaps.
Step 4: Act
Share the gaps in individual or community level care with the appropriate clinical staff (e.g., in care team meetings). Clinical staff can brainstorm innovative approaches to ensure that each person is given an opportunity to engage in activities that align with stated preferences. Offer more activities that are preferred, offer activities at different times, extend person-specific invitations to preferred activities, or identify new ways to engage individuals.
Example #1: A resident is depressed and not coming to activities. The staff looks at the person’s specific preferences to see how best to engage the individual. The staff sees an interest in gardening and develops a plan to have this individual follow a plant watering plan within the nursing home. The staff might also engage a buddy system to encourage the residents to engage or the staff might want to explore further the barriers to a person’s attendance.
Example #2: The staff sees a trend in the reporting that a group of residents have a shared interest in gardening that is unmet. The staff develops a new horticultural program that allows participants to do regular planting and maintenance of plants within the nursing home.
Example #3: A family member reported that it was always important to their loved one living with dementia to “volunteer their time”. In a huddle the care team brainstormed ways to address the resident’s increased restlessness with this preference in mind. The activities staff recommended that they enlist the help of this resident to distribute the newspaper each day.
Tips and Tricks from Providers, Residents, and Families
Staff approach
Having a staff person in the community that serves as a true “champion” of the effort to provide preference-based care matters to residents, families, and the care community.
Ensure that activities are not just preferred, but that the residents are approached by staff with a positive intent to create positive interactions. Engagement in preferred activities supports meaningful opportunities for socialization.
Clinical staff may need to teach families and residents about how preferred activities are designed to promote quality of life and a positive mood.
Personal invitations by staff to participate in activities go a long way. It shows a personal interest in the individual and can demonstrate a willingness to meet one’s preferences.
If all is going well tracking recreational care preference-congruence, consider expanding your tracking to include personal care preferences (i.e., what time a person likes to wake up in the morning) and ways to meet these preferences.
Considering resident demographic attributes
• Younger male residents may be more likely to choose not to attend activities that are offered. Individual efforts to reach out to these individuals may be needed to ensure that preferences are met.
• As you get to know a person, consider a person’s personality and prior preferences. Provide invitations to activities and activity options that appeal to the person.
• There are a lot of reasons why a person may choose not to participate in a given preferred activity or change their mind about a once preferred activity (i.e., feeling ill, has an appointment, weather), consider exploring these with the resident.8
Considering resident clinical attributes
• Individuals who are choosing not to attend activities may be more likely to be depressed. Get creative in finding ways to engage these residents in participating in preferred activities. Mental health services and support may be needed to engage residents through therapy.
• Individuals experiencing pain may find it harder to engage in activities – work with the clinical team to ensure that pain is managed and then invite the individual to participate in activities. You may get a better response.
Example: “I think there’s three things that have come to my light. You need a sense of purpose. You need to move your body, and you need to move your mind. And I would say that would help you feel less pain because you focus less on decline and more on possibilities.” – Family Member
• Individuals new to the nursing home may be more depressed and/or experiencing more pain. Individuals may also come into the community with a predisposition to being social or not which can impact engagement in activities. The transitional period to a nursing home is often focused on clinical symptoms and associated with an experience of loss. Ask yourself, how are we welcoming those to our community? If the new resident is more cognitively capable, are we providing programs where they would feel challenged? Can we pair a new person with a neighbor or peer that they have something in common with?
Example: “When someone else asks her to go, she usually goes. There were times when a lot of the women in her area were going out one night a week to go out to a different dining hall. She did do that, and she had a lot more to talk about because she got out of her room and got out of her comfort zone.” – Family member
• Ensure that activities are modified to meet a person’s cognitive and functional capacities. Consider leveling programs by functional ability to maximize participation.
Example: A person may prefer to play a specific card game but now feels she cannot do it. A new game may need to be purchased, or a card holder might need to be used, or a similar game may need to be introduced (i.e., Rummy instead of Bridge) to engage. It might also be important to help residents learn how to participate in certain activities that they have never done before (i.e., never did art before, learn how to engage).
Example: A resident shared that when she attends a preferred activity, she makes a special effort with her self-care (e.g., dress, make-up, hair) which promotes her functional independence.