A Literature review
Robert Pressley, Health Studies at the Centre for Nurse Education, Hilary House, Prospect Hill Douglas, Manchester Metropolitan University
Tutor Eileen O'Malley

If you wish to respond to the author, you may contact Robert Pressley at 'The Beeches', 2 Sartfell Road, Douglas, Isle of Man, United Kingdom IM2 3LZ or phone 44- 01624 629102

Abstract

In this paper I have explored the necessity of using nursing models in therapeutic recreation to enable registered nurses to provide individualised plans of care that are tailored to the individuals owns needs.

I have also suggested who is responsible for implementing, planning, assessing and evaluating therapeutic recreation in an elderly care environment. Along with clarifying the role differences and similarities between nurses and other health care professionals. Finally I have discussed some of the limited research available in relation to recreational activities

INDEX

1 - 2 Introduction

3 - 4 Nursing Models in Therapeutic Recreation

4 - 6 The Nurse and Therapeutic Recreation

6 - 7 Therapeutic Recreation

7 - 11 Research Discussion

12 - 13 Conclusion

14 - 15 References

Over the past six years I have been working as a Social Therapeutic and Recreational Nurse in an Elderly Persons Rehabilitation Unit. I have responsibility for assessing, planning, implementing and evaluating activities to aid in the rehabilitation process of the patients that are referred to the unit. As the unit is designated primarily an elderly care unit (65 years and over). I will limit the literature review to the benefits of that age group only.

There has been much research done in the field of therapeutic recreation on an international scale mainly America, Canada, Australia, and the United Kingdom (Buettner, L, L, Ferrario, J, (Date unknown). Barton, R. 1976. Goffman, E. 1961). The literature I am using for the purpose of this paper is from the United States of America and the United Kingdom.

The Recreational Therapist or Social Therapeutic and Recreation Nurse came into being in the United Kingdom in the early nineteen eighties through Theresa Brisco who was one of the first recreational therapists in the United Kingdom at this time. The concept of a social therapeutic and recreational nurse / recreational therapist was to utilise/use recreation as a way of promoting and maintaining an individuals social, psychological needs and increasing self-esteem (Vise, D. Murray, M. Scarth, M. Mills, S. and Forte, D. 1994). The aims and objectives of therapeutic recreation, in the care of the elderly setting, seen by Vise et al (1994), was in order to preserve and maintain self-esteem, motivation, mobility, challenge, social interaction and mental agility in elderly patients.

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This concept of therapeutic recreation is supported by Lowry, L, Ryan, A. (1993), who state that "Recreational therapy is a concept of meeting the patients psychological and social needs through meaningful daily activities". In this literature review I intend to discuss the use and importance of nursing models, in therapeutic recreation and the nurses role in relation to both the use of the model and participation in recreational therapy.

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The nursing profession has used the nursing process for a number of years in order to base care on an individual and holistic basis. The theory being that nursing care and intervention is tailored to meet the individuals needs. This approach to care is helped by using nursing models, such as Roper Logan and Tierney (1985) systems approach "Activities of Daily living" and Orem's (1991) developmental "Self care defecit model". Models are useful frameworks from which nurses can base their assessments of patients and decide and agree appropriate interventions from. Powers, B. A. Knapp, T. R. (1990) state:- "A model is a graphic and symbolic representation of a phenomenon that serves to objectify and present a certain perspective or point of view about its nature and/or function. The major nursing models identify concepts and describe their relationship to the phenomena of central concern to the discipline: person / client, environment, health, and nursing".

When using a model of nursing, nurses are expected to provide individualised plans of care aimed at identifying individual problems with the patient and agreeing interventions that will, hopefully, achieve resolution. All aspects, considered within the chosen model, need to be carefully thought about, including recreational needs. Roper et al. (1985) identifies twelve "Activities of Daily living" (appendix one). This Nursing model specifically includes recreation as one of the activities of daily living. Whereas Orem, D.(1991) in her self care defecit model, does not focus on recreation in such a direct manner. However the model does include time spent with others and time spent alone (appendix two). With using nursing documentation based on Orem's self care defecit model, it provides an opportunity for health care professionals to identify what self care abilities, and/or self care defecits, the elderly individual has.

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Whenever a nursing model is used the nurse, by virtue of the model framework, is accepting the responsibility of ensuring the individuals leisure/recreational needs are identified and documented and where a problem has been identified, an appropriate plan of care with realistic and achievable goals should be developed in conjunction with the individual. If the nurse fails to provide this they could be considered to be in breach of his/hers professional responsibilities, as stated in United Kingdom Central Council (1992) Code of Professional Conduct section two which states: "Ensure that no action or omission on your part, or within your sphere of responsibility, is detrimental to the interests, conditions or safety of patients and clients." and section five which states: "Work in an open and co-operative manner with patients, clients and their families, foster their independence and recognise and respect their involvement in the planning and delivery of care." It is therefore every nurses responsibility to consider activity along with all other aspects of the patients care.

The Nurse and Therapeutic Recreation

Lowry. et al (1993) state that the Social, Therapeutic and Recreational Nurse/ Recreational Therapist offers individuals opportunities to pursue their own choice of activities. Yet we should question who's responsibility this is, is it solely the responsibility of the Social, Therapeutic and Recreational Nurse/Recreational Therapist. to provide such therapy?. Roper et al (1985), in their "Activities of Daily living" model, identify recreation as one of the activities of daily living, while Orem's (1991) model includes time spent with others and time spent alone. This then, places the responsibility on the registered nurse to consider this within the nursing process to identify and develop plans to overcome any problems in this area with patients.

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Vise, D. et al.(1994) suggests that it is the responsibility of the Social Therapeutic and Recreational Nurse/ Recreational Therapist to educate others in the nursing profession on the use and benefits of therapeutic recreation. This is supported by Crump, A. (1991) who suggests that the concept of nurses becoming more actively involved in patient activities is receiving increased professional attention.

Even though there is evidence to suggest an increase in professional awareness regarding therapeutic recreation, Crump, A. (1991) goes on to argue that many nurses working with Elderly Patients still fail to provide purposeful activities for Elderly people and see the role of providing recreational therapies as the remit of other health care professionals such as Occupational Therapists. This argument is also supported by Armstrong-Esther, C. A. Browne, K. D. McAfee, J. G. (1994) who, through non-experimental research, observed that nurses only tended to have meaningful communications with patients when involved only in direct nursing care.

Crump, A. (1991) states that nurses place therapeutic recreation low on the priorities of nursing intervention and see the remit of providing therapeutic recreation as the role of other health care professionals such as Occupation Therapists and Physiotherapists. It is true that the Physiotherapist and the Occupational Therapist may both also have a part to play in helping individuals to develop a positive self image and adjust to disabilities. The College of Occupational Therapists (1990) defines Occupational therapy as: "The treatment of people with physical and psychiatric illness or disability through specific selected occupation for the purpose of enabling individuals to reach their maximum level of function and independence in all aspects of life."

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Through searching the World Wide Web on the Internet for information on the subject of therapeutic recreation I located 136,589 sites pertaining to this topic. Although I do not know the origin or amount of information in all the sites on the Internet, the magnitude of sites found certainly indicates an increased interest and awareness of this subject on an international scale.

Therapeutic Recreation

Recreation, play or work, no matter what word is used to describe activity, activities are an essential part of an individuals life. From an early age children play. This early stage of play has no structure, but it is vital for the child's social and intellectual development. Sulva, K. Lunt, I. (1982).

In adult life meaningful activities are just as vital as this early type of play to prevent boredom, isolation and aggression. Roper et al (1988). Throughout adult life we spend most of our time working to provide ourselves and family with shelter, warmth and food. Groenman, N. H. D'A Slevin, O. Buckenham, M. A. (1992). But alongside work we also need to relax.

This is achieved in many different forms which may be in isolation, or in groups of various sizes depending on the individual needs and activity involved. In the well adult this can be easily achieved by the individual themselves. Though in the sick this need for leisure activities can cause concern for individuals and may well prevent the individuals from having a meaningful life style which may ultimately affect recovery.

In latter years, the needs pertaining to leisure requirements in the elderly have been addressed by many businesses such as banks, by encouraging the individual to plan for retirement and providing courses to deal with the prospect of retirement.

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Many centres of adult learning now run courses for people who are planning to retire. One such place is the Isle of Man College of Further Education. Throughout adult life the individual is able to meet people, have a large circle of friends and choose their own activity, within their own interests and limitations. In retirement the individual has a much greater amount of time to fill, and without any meaningful activity, the individual may become increasingly bored and could well suffer from feelings of grief and increased boredom as a result of his/her retirement. This may cause the individual to sever all forms of activities in which they have been involved. This separation from the activities and friends they used to have is known as disengagement theory (Groenham et al 1992).

With the Elderly in a care environment, they may not be able to control their own recreational needs due to the routine of the institution, or the cushioning effect of the Nurses. This lack of control may cause the elderly individual to adopt a submissive outlook on his/her own needs. It is this which Goffman (1961) describes as institutionalisation. In this situation either the social therapeutic and recreational nurse /recreational therapist or registered nurse should enable elderly individuals to regain a feeling of self worth by assessing individual abilities and assisting individuals to participate in therapeutic recreation.

Even though there has been a lot of research in the field of therapeutic recreation it was difficult to locate any research on the beneficial effects of therapeutic recreation in the elderly. The four studies that I was able to locate were from the United Kingdom, the United States of America and Canada.

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Three of these studies were set in continuing care nursing homes (Beuttner, L.L. Ferrario, J. (date unknown), Dawe, D. Moore-Orr, R. 1995, Quattrochi-Tubin, S. Jason, L.A. 1979).

Armstrong-Esther, et al (1994) based their research in a hospital environment. All the studies were relatively small using between 20 and 99 subjects. Beuttner, L, L.., Ferrario, J. 1996 researched the effect of therapeutic intervention on nursing home residents with demetia. As the patients used in this study were mentally impaired I have decided not to use the study in this review.

Dawe, D. Moore-Orr, R. (1995) looked at the effect of single sessions of mild exercise in a group of cognitively unimpaired institutionalised elderly patients. The sample size of patients was 20, all of which were white and aged over 70 years, it is not known whether they were all male,female or mixed sex. In order to be eligible they had to fulfil the following criteria:

A) Alert

B) Did not suffer any cognitive impairment

C) Had resided in the home for more than 6 months.

D) Had a sedentary life style.

The residents were randomly assigned to an experimental group (exercise) or control group (video of exercise). There were 10 in each group.

Both the experimental and control group were given the same battery of questions and tasks both pre and post and 30 minutes after exercise to determine if cognitive performance increased in the experimental group.

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The outcome from the research did confirm that acute exercise benefits aspects of neuropsychological performance. This, the authors suggest, could prove a very beneficial and cheap intervention that could aid the promotion of independence, memory, self-esteem and quality of care of institutionalised elderly patients.

One of the main problems with this study is the selection criteria for inclusion in the study. Two of the four factors required were open to individual interpretation. These being 'alert' - there was no definition of the word and how it was to be applied and also sedentary lifestyle - there was no explanation of what this encompassed either.

Qualttrochi-Tubin, S. Jason, L. (1978) investigated the effectiveness of a stimulus controlled procedure (access to free coffee and biscuits) and its effect on attendance by residents at therapeutic recreation sessions in a nursing home. This study used a collection of data taken from behaviour observed during two minute time periods, pre and post stimulus, three days a week, by two independent observers, for a period of sixteen days, excluding the initial pilot experimental stage of four days. The recreational therapist was also asked to record their opinion of the performance of the residents during recreation sessions.

The study demonstrated that by offering elderly patients free coffee and biscuits in the lounge, only for a defined time period, the attendance at activity sessions and interaction of the elderly patients, with each other, increased. During the observation periods of this study it was noted that with the increase in activities and social interaction the elderly patients appeared to become less interested in the refreshments and more interested in what they were doing and whom they were with.

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The free refreshments were an incentive to help increase attendance at the activity sessions within the elderly care setting, providing a catalyst for improving a psychological sense of community in the elderly care setting. With the increase of community interaction it may be possible to assume the elderly patients felt more confident and may have an increased self-esteem.

Throughout this study the elderly patients were able to make the choice of attending activities for free refreshments or staying in their rooms. While this was also a means of allowing the elderly to take control over their own decisions, it could be said that they were given no choice but to join in as refreshments were not available elsewhere.

The research has several methodological flaws these including using the same residents for both the control and experimental conditions. The study would also have benefited by clearly identifying what was meant by social interaction, as the term is open to interpretation from each of the two independent observers. The short time period of the experimental phases of the study did not exclude the possible effect the novelty value of the stimuli may have had on the results. This study did not appear to be statistically analysed and so it cannot be known if the results are significant or not.

Because of the relatively small sample sizes within the above three research studies and the fact that they are limited to residents in a nursing home, it would not be possible to generalise the results from any of these studies to other areas. However it would be interesting to repeat the studies in a variety of other settings including my own, elderly rehabilitation.

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A slightly different view of patient activity was undertaken by Armstrong-Esther, et al (1994) whose research investigated the activities and interactions of elderly patients in an acute medical geriatric unit and a psychiatric unit. Twenty four patients were studied and divided into three groups of eight. The Clifton Assessment Procedures for the elderly were used to measure cognitive and behavioural functioning. The three groups were categorised as Lucid, Confused and Demented, information was gained by time sampling by non participant direct observation.

The study found that all patients, irrespective of their cognitive state, spent 95% of their time sitting during the observational periods. Lucid patients spent the majority of their time interacting with others and only 7% of the time interacting with the staff.

All the nurses involved in the survey saw talking to patients as the most rewarding and enjoyable aspect of their job. However as can be seen above a very small proportion of their time was spent interacting with the patients. The author of this study suggests that nurses are either missing or ignoring the opportunity to engage and involve elderly patients in activities that could maintain their independence and social skills. They also conclude that it is the needs of the institution that are given greater importance that those of the patients they serve.

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Conclusion

It is essential that nurses use a nursing model to guide their assessment of the patient. Using the information gained from the assessment to develop meaningful and realistic plans of care. The ultimate aim being to improve the quality of nursing interventions and subsequent outcomes for patients.

In terms of therapeutic recreation I have shown the importance of this aspect of patient care within this literature review. The benefits of therapeutic recreation have been discussed and this remains important whether or not a social therapeutic and recreation nurse/recreational therapist is available or not. Physiotherapists, Occupational therapists and Registered Nurses all have a responsibility, to a greater or lesser extent, in considering and providing patient activity and interaction.

Armstrong-Esther et al (1994) state that:- "An objective for nursing care is to ensure that their level of function (Lucid Patients) is at least maintained and does not deteriorate. Hence engaging them in conversation or structuring activities with other patients that will stimulate psychosocial activities and skills must be seen as an important and worthwhile nursing activity, enjoying the same status as the administration of medicines. In fact it is not unreasonable to suggest that with more therapeutic and recreational activities, nurses could extend their range of skills from the present model of custodial care for elderly patients to one that has a restorative focus".

They further conclude that :- "Nurses need to acquire a repertoire of skills that embraces psychosocial and physical rehabilitation, to ensure that the focus of care of the elderly moves from custodial to the restorative. The elderly must regain, wherever possible, some of their independence by being encouraged and assisted to acquire or retain the skill of self-care".

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Within my own practice this is what I have aimed towards within my role as social therapeutic and recreational nurse. The challenge to me now is to persuade other Registered Nurses that they too need to acquire a repertoire of skills to assist not only with physical rehabilitation but also psychosocial rehabilitation.

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REFERENCES

Armstrong-Esther, C. A. Browne, K. D. McAfee, J. G. (1994) Elderly Patients: Still Clean and Sitting Quietly. Journal of Advanced Nursing, 19: 264-271

Barton, R. (1976) Institutional Neurosis, (3rd edition) Wright and Son, Bristol

Buettner, L. L. Ferrario, J. (date unknown) Therapeutic Recreation-Nursing Team: A Therapeutic Intervention for Nursing Home Residents with Dementia. Alzheimer's Disease Assistance centre, Decker School of Nursing, Binghamton University, Binghamton, N Y 13902-6000. Internet address: http://www.recreationtherapy.com/re-dem.htm

College of Occupational Therapists (1990) Standards, Policies and Proceedings: Statement on Occupational Therapy Definition, College of Occupational Therapists Ltd: 6/8 Marshalsea Road, London SE1 1HL

Crump, A. (1991) Promoting Self-esteem; Nursing the Elderly 3, 19-21.

Dawe, D. Moore-Orr, R. (1995) Low-Intensity, Range-of-Motion Exercise: Invaluable Nursing Care for Elderly Patients, Journal of Advanced Nursing 21,675 - 681

Goffman, E. (1961) Asylums. Penguin, London.

Groenman, N. H. D'A Slevin, O. Buckenham, M. A. (1992) Social and Behavioural Sciences for Nurses: P 147-149: Campion Press Ltd, Edinburgh.

Lowry, L. Ryan, A. (1993) Recreation is not a Luxury; Elderly Care 5, 6, 24-26

Orem, D. (1991) Nursing Concepts of Practice (4th edition) Mosby.

Powers, B. A. Knapp, T. R. (1990) A Dictionary of Nursing Theory and Research, Sage Publication

Quattrochi-Tubin, S. Jason, L.A. (1979) Enhancing Social Interactions and Activities Among the Elderly Through Stimulus Control, Journal of Applied Behaviour, 1, 13, 159 - 163.

Roper, N. Logan, W. W. Tierney A. J. (1985) The Elements of Nursing, Churchill Livingstone, Edinburgh.

Sulva, K. Lunt, I. (1982) Child Development: A First Course. P157-172 Grant McIntyre, London

United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) Code of Professional Conduct.

Vise, D. Murray, M. Scarth, M. Mills, S. and Forte, D. (1994) Social Therapeutic and Recreational Nursing Fact Pack., R.C.N. Publication

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