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Increasing the attendance of nursing home residents at group recreation activities
BEHAVIOR THERAPY 13, 283--290 (1982)
Increasing the Attendance of Nursing Home Residents at Group Recreation Activities ANDREW L. REITZ ROBERT P . H A W K I N S
West Virginia University This study examines the effects of several prompting procedures--signs, loudspeaker announcements, personal invitations from the recreation director, and direct prompts from the nursing staff on the attendance at recreation activities of 20 nursing home residents. Results indicated that signs and loudspeaker announcements were generally ineffective in improving attendance at the sessions (averaging less than 10% of the residents per session), while the personal invitations resulted in marked increases in attendance (averaging just under 50% of the residents per session). Additional increases in attendance were initially obtained when the Center's nursing staff was encouraged to prompt the residents to attend, but staff prompts and, consequently, resident attendance quickly decreased to very low levels. Prominently displaying the number of residents attending each day's sessior~, however, successfully maintained staff prompting and generated the highest levels of attendance during the study (averaging 60% of the residents per session).
The literature on aging is replete with articles stressing the need for increased participation of nursing home residents in recreational and social activities (Bonner, 1969; Kurasik & O'Connor, 1966; McClannahan, 1973; Melin & Gotestam, 1981). McClannahan describes the reason for this emphasis when she refers to substantial evidence that "environmental intervention programs that reinforce high levels of activity can retard the degenerative processes associated with aging, and can help to maintain verbal and self-care skills" (p. 425). While many nursing homes now conduct structured recreational proThis project was supported in part by Grant Number 90-A-661 from the Administration on Aging, Department of Health, Education, and Welfare. Points of view or opinions stated in the paper do not necessarily represent the official position or policy of the Department of Health, Education, and Welfare. Special thanks go to Ms. Bonnie Levine, Ms. Geri Botwinick, and the rest of the staff and residents of the Morgan Manor Convalescent Center. Without their cooperation this project could never have been completed. Requests for reprints should be sent to Andrew L. Reitz, Pressley Ridge School, 530 Marshall Avenue, Pittsburgh, PA 15214.
283 0005-7894/82/0283-029051.00/0 Copyright1982by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any formreserved.
284
REITZ AND HAWKINS
grams for their residents, generating and maintaining participation in these activities remains a widespread, serious problem. Research in this area has focused mainly on stimulus control procedures. For example, resident participation in activities has been studied as a function of the location of activity areas (Koncelik & Snyder, 1971), the variety of activities available (Pierce, 1975), the difficulty level and types of activities available (Fox, 1970), various types of announcements for activities (McClannahan & Risley, 1974), the availability of recreational materials (McClannahan & Risley, 1975), and prompts to use recreational materials (McClannahan & Risley, 1975). Token and monetary reinforcers have also been used to increase participation in social and recreational activities (McClannahan & Risley, 1974; Mueller & Atlas, 1972). Although the above studies all demonstrated increases in resident attendance and/or participation in recreational activities, the positive effects have generally been limited to small portions of the targeted population. Furthermore, some studies used interventions that involved resources not available in most nursing homes. The present study evaluated the relative effectiveness of several prompting procedures on the attendance of nursing home residents at recreational activities and generated large increases in the residents' attendance using only those resources generally available in nursing home settings.
METHOD
Subjects and Setting The study was conducted in a nursing home and convalescent center in Morgantown, West Virginia. The Center has a capacity of just under 100 residents, with the population generally ranging between 80 and 95 residents. The majority of these residents are admitted to the Center for short periods of convalescence and physical therapy (6 months or less), although a small proportion are admitted on a long term basis. Recreation sessions were conducted in the Center's recreation room or in one of the large lounge areas. Generalization data were collected in all areas of the Center. Participants included in the study were (a) at least 65 years of age, (b) physically capable of engaging in a variety of recreational activities (as judged by the recreational and physical therapists), (c) mobile within the Center so that they could attend the recreation activities without being assisted, and (d) expected to remain in the Center long enough to complete the study. Participation was on a voluntary basis. Of the 34 residents who met the initial criteria for inclusion, 14 improved sufficiently to be discharged prior to the conclusion of the study. All data presented here are taken from those 20 residents who were present throughout the entire project. The 8 males and 12 females ranged in age from 65 to 92 years, with a mean age of 74.5 years. The primary admitting diagnoses included chronic brain syndrome, characterized by
A T T E N D A N C E AT R E C R E A T I O N A C T I V I T I E S
285
periods of anxiety, confusion, and disorientation (n = 7); broken hips or legs (n = 6); partial paralysis resulting from strokes (n = 5); and severe depression, characterized by an almost total lack of interaction with others, long periods of motionless sitting, and frequent crying for no apparent reason (n = 2). Nine of the residents were confined to wheelchairs, four used walkers, and the remaining seven were ambulatory. Several of the residents lacked bladder and/or bowel control and all needed assistance with many routine daily activities.
Dependent Variables and Recording Procedures Resident attendance. The primary dependent variable in the study was the residents' attendance at recreation sessions. These sessions, held at 2:00 p.m. each weekday, consisted of a variety of activities (e.g., arts and crafts, card games, food and drink parties, bingo, and exercises). To be scored as attending a session, a resident had to arrive in the designated activity area prior to 2:15 p.m. and remain in the area a minimum of 15 min. While residents did not have to participate in any activity to meet the attendance criterion, informal observations indicated that very few residents ever attended without participating to some extent in the activity. Staff prompts. During experimental conditions when staff members prompted the residents to attend the recreation sessions, data were collected on the number of residents prompted. A prompt consisted of any verbal reminder, invitation, request, or direction given to a resident to attend the recreation activity. Physical prompts, such as pushing someone's wheelchair into the recreation area, were also scored as prompts even if they were not accompanied by verbal prompts. The only prompts scored were those given during the 15 min immediately following the loudspeaker announcement of the activity.
Reliability For the attendance data, inter-observer agreement was assessed for each session by comparing the data recorded by the recreation director with those of the experimenter, dividing the smaller number by the larger, and multiplying by 100%. Inter-observer agreement for the prompt data was assessed for approximately one-third of the sessions, with a minimum of three checks during each experimental condition. The experimenter served as the reliability checker throughout the study. Inter-observer agreement was calculated by the same method employed with the attendance data.
Procedure A within-subject withdrawal design was used to analyze the data from the group as a whole. Using the notation of Hersen and Barlow (1976), the design used was an A/BCBC/DEDE design. The successive condi-
286
REITZ AND HAWKINS
tions were signs (A), loudspeaker announcements (B), personal invitations (C), staff prompts (D), and staff prompts with feedback (E). These interventions were selected on the basis of their administrative and economic feasibility within most nursing home settings and their probable effectiveness. Signs. During this condition, the only announcement of the daily recreation session consisted of three prominently placed signs, one in each of the large lounge areas and one at the entrance to the dining room. The brightly lettered 1 m by 1½ m signs contained information regarding the type of activity planned, as well as the time and place the activity was scheduled. Loudspeaker announcements. During these conditions the signs were removed and the only announcement of the recreation sessions was a loudspeaker announcement made by the recreation director 5 min before the activity was to begin. These announcements, clearly audible throughout the Center, included the same information that had been conveyed by the signs as well as an invitation for all residents to attend the session. Personal invitations. During these conditions the recreation director continued to make the loudspeaker announcements, but immediately following the announcement, she also sought out each participant (as well as other residents) and personally invited him/her to attend the session. The content of these invitations was standardized and consisted of a greeting, description of the activity, information regarding the place, and an invitation to attend. The recreation director then excused herself " t o invite some other people," thereby limiting further conversation. Staff prompts. At the beginning of the first staff prompts condition, the director of the Center and the recreation director sent a memo to all Center staff. This memo described the important role that participating in recreational activities can play in a resident's rehabilitation, reaffirmed the Center's stand that the recreation program was an integral part of the overall treatment program, and directed all staff to encourage the residents to participate in the recreational program. In addition, the loudspeaker announcement of each day's activity now included a request that all Center staff encourage residents to attend the day's activity. No personal invitations were given by the recreation director. Following the loudspeaker announcement, the recreation director returned immediately to the recreation area and waited for the residents to arrive. No attempts were made to control either the frequency or the content of the staff prompts. Staff prompts with feedback. These conditions were identical to the staff prompts conditions described above except that, following each day's session, the staff received feedback on the number of residents who had attended the activity. Two large signs, posted at the Center's two nursing stations, thanked the staff for their assistance and prominently displayed the number of residents attending the day's recreation session.
ATTENDANCE
Signs
LA-1
20
I
I
I R ?
I
t'~
18
I
LA-2
RECREATION
PI-2
1
I
~
l
287
ACTIVITIES
i
SP-I
SPF-1
SP-2 t / I
'6, ¢!1 ij' ~t
I
,N ~4
AT
I SPF-2 I
I I
I
70 8
j Z
f,,Jl
...... , ........
~. . . . . . .
Ii
20
illlLLiiill~l
~1
~, ,,/NDING ..................
SESSIONS
FIG. I. Number of residents attending ( 0 0 ) and prompted to attend (© ©) recreation activities during the Signs, Loudspeaker Announcement (LA), Persona] Invitation (PI), Staff Prompts (SP), and Staff Prompts with Feedback (SPF) conditions. Prompts are shown only for those conditions in which individual residents were prompted by staff.
RESULTS Inter-observer agreement on the number of residents attending the recreation sessions averaged 96.6% (range, 67% to 100%). Nearly all errors resulted from one observer failing to note that someone who came to the session left before the required 15 min had elapsed. Inter-observer agreement on the number of residents prompted to attend the sessions averaged 91.3% (range, 83% to 100%). Fig. 1 shows the data on resident attendance at the recreation sessions. Attendance during the signs condition averaged less than one person per session and increased only slightly during the first loudspeaker announcement condition. Adding individual invitations from the recreation director increased attendance to a mean of 9.2 residents per session. A return to the loudspeaker announcement condition resulted in a decline to previous low levels of attendance, while reinstating the personal invitations increased attendance again to a mean of 8.6 per session. Introducing the staff prompts resulted in an immediate increase in the number of residents attending to 16, but attendance steadily decreased to a low of 2, with an overall mean of 7.7 per session. Adding feedback to the staff on the number of residents attending the sessions increased attendance to a mean of 10.4 residents per session. Discontinuing the feedback resulted in a decrease in attendance to 7.6 residents per session, but its reinstatement resulted in an increase to 11.6, the highest attendance during any condition.
288
REITZ AND H A W K I N S
Fig. 1 also shows the number of prompts given during the two personal invitation conditions and the four staff prompts conditions. During the personal invitation conditions, the number of residents prompted averaged 18.4 and 18.9, respectively. When the staff prompts condition was initiated, the number of residents prompted was high for the first three sessions (mean = 18.0), but it dropped to a mean of only 3.7 during the last three sessions. Incorporating feedback to the staff gradually increased the number of residents prompted to a mean of 14.6 per session. Discontinuing the feedback decreased the number of prompts to a mean of 10.9. Reinstating the feedback increased the number of residents prompted to a mean of 14.5 per session.
DISCUSSION This study evaluated the effects of several different procedures for prompting nursing home residents' attendance at recreation activities. Two of these procedures--announcing activities with large signs and making loudspeaker announcements--resulted in extremely low levels of attendance, while two other procedures--personal invitations and staff prompts--greatly increased resident attendance at activities. While the personal invitation procedure resulted in substantially increased attendance, it appeared to have reached maximum effectiveness even though nearly half of the residents were unaffected. Three difficulties with this procedure were identified: (a) the relatively low ratio of residents attending to residents prompted, (b) the recreation director's occasional absence from the recreation area when participants arrived for the session, and (c) the continued isolation of the recreation program from other Center staff and activities. The staff prompts procedure was implemented in an attempt to overcome these problems. However, while the staff prompts were highly effective and did solve the problems cited above, it proved difficult to maintain the staff's prompting at acceptable levels. Implementing a feedback condition effectively maintained staff prompting at satisfactory levels and resulted in approximately 60% of the study participants attending the recreation sessions each day. Although several possible explanations exist for the relatively greater effectiveness of the staff prompts, the content of the prompts appears the most plausible. As previously described, the content of the prompts was strictly controlled during the personal invitation conditions. During the staff prompts conditions, however, the content of the prompts was not controlled. Anecdotal observations indicated that the staff used a wide variety of procedures, such as persuading residents, giving directions, and physically prompting residents, while the recreation director only gave information about the activity and an invitation. While large increases in attendance were obtained, comparisons between the personal invitation and staff prompts conditions must be made with some caution. The participants' experiences with previous conditions and the order in which the conditions were presented may have
ATTENDANCE AT RECREATION ACTIVITIES
289
influenced these results. Studies using counterbalanced or group designs could control for these effects. Attendance was selected as the dependent variable in the study because of the nature of the problem in this setting. Observations made prior to the study indicated that the targeted residents were easily induced to participate in most activities by the recreation director. The problem was to develop an efficient means of using the recreation director's time to get the most activities to the most residents. Previous attempts to "take the activities to the residents" had been abandoned because they reached only a few residents at a time, and because many desirable activities were not sufficiently portable. The most efficient solution to the problem was to get the residents to come to the recreation area, making attendance at the sessions the logical dependent variable. 1 Data were also collected to assess resident activity levels at times of the day when no recreational activities were scheduled. These data showed only minor fluctuations throughout the study, indicating that generalization of treatment effects during these times was minimal at best. 2 Further work in nursing home settings might systematically evaluate the impact of (a) varying the frequency of feedback to staff, (b) using different types of prompts, and (c) selecting residents, rather than staff, to deliver the prompts. Regardless of the specific procedures studied, however, attention should be directed toward achieving generalization and maintenance of behavioral gains.
REFERENCE NOTE 1. Reitz, A. L., & Hawkins, R. P. Using volunteer staff to increase activity levels of severely debilitated nursing home residents. Paper presented at the meeting of the Association for Behavior Analysis, Dearborn, MI, June, 1979.
REFERENCES Bonner, C . D . Rehabilitation instead of bed rest? Geriatrics, 1969, 24, 109-118. Fox, E. Does it have to be bingo? Nursing Homes, 1970, 19, 17-19. Hersen, M., & Barlow, D . H . Single case experimental designs: Strategies fi)r studying behavior change. New York: Pergamon, 1976. Koncelik, J. A., & Snyder, L. The role of design in behavior manipulation within longterm care facilities. Nursing Homes, 1971, 20, 6-23. Kurasik, S., & O'Connor, R. Why recreation in hospitals, nursing homes, and homes for the aged? Journal of the American Geriatrics Society, 1966, 14, 643-646. McClannahan, L. E. Therapeutic and prosthetic living environments for nursing home residents. The Gerontologist, 1973, 13, 424-429. 1 Another group of Center residents, which rarely participated in activities even when attending recreation sessions, was also identified. A second study evaluated procedures aimed at increasing these residents' participation levels during recreational activities (Reitz & Hawkins, Note 1). Complete information on the generalization data are available from the first author on request.
290
REITZ AND HAWKINS
McClannahan, L. E., & Risley, T. R. Design of living environments for nursing home residents. The Gerontologist, 1974, 14, 236-240. McClannahan, L. E., & Risley, T. R. Design of living environments for nursing home residents: Additional strategies for increasing attendance and participation in group activities. Journal of Applied Behavior Analysis, 1975, 8, 261-268. Melin, L., & Gotestam, K . G . The effects of rearranging ward routines on communication and eating behaviors of psychogeriatric patients. Journal of Applied Behavior Anlaysis, 1981, 14, 47-51. Mueller, D. J., & Atlas, L. Resocialization of depressed elderly residents: A behavioral management approach. Journal of Gerontology, 1972, 27, 390-392. Pierce, C. Recreation for the elderly: Activity participation at a senior citizen center. The Gerontologist, 1975, 15, 202-205. RECEIVED: July 7, 1981 FINAL ACCEPTANCE" February 5, 1982
Increasing the Attendance of Nursing Home Residents at Group Recreation Activities ANDREW L. REITZ ROBERT P . H A W K I N S
West Virginia University This study examines the effects of several prompting procedures--signs, loudspeaker announcements, personal invitations from the recreation director, and direct prompts from the nursing staff on the attendance at recreation activities of 20 nursing home residents. Results indicated that signs and loudspeaker announcements were generally ineffective in improving attendance at the sessions (averaging less than 10% of the residents per session), while the personal invitations resulted in marked increases in attendance (averaging just under 50% of the residents per session). Additional increases in attendance were initially obtained when the Center's nursing staff was encouraged to prompt the residents to attend, but staff prompts and, consequently, resident attendance quickly decreased to very low levels. Prominently displaying the number of residents attending each day's sessior~, however, successfully maintained staff prompting and generated the highest levels of attendance during the study (averaging 60% of the residents per session).
The literature on aging is replete with articles stressing the need for increased participation of nursing home residents in recreational and social activities (Bonner, 1969; Kurasik & O'Connor, 1966; McClannahan, 1973; Melin & Gotestam, 1981). McClannahan describes the reason for this emphasis when she refers to substantial evidence that "environmental intervention programs that reinforce high levels of activity can retard the degenerative processes associated with aging, and can help to maintain verbal and self-care skills" (p. 425). While many nursing homes now conduct structured recreational proThis project was supported in part by Grant Number 90-A-661 from the Administration on Aging, Department of Health, Education, and Welfare. Points of view or opinions stated in the paper do not necessarily represent the official position or policy of the Department of Health, Education, and Welfare. Special thanks go to Ms. Bonnie Levine, Ms. Geri Botwinick, and the rest of the staff and residents of the Morgan Manor Convalescent Center. Without their cooperation this project could never have been completed. Requests for reprints should be sent to Andrew L. Reitz, Pressley Ridge School, 530 Marshall Avenue, Pittsburgh, PA 15214.
283 0005-7894/82/0283-029051.00/0 Copyright1982by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any formreserved.
284
REITZ AND HAWKINS
grams for their residents, generating and maintaining participation in these activities remains a widespread, serious problem. Research in this area has focused mainly on stimulus control procedures. For example, resident participation in activities has been studied as a function of the location of activity areas (Koncelik & Snyder, 1971), the variety of activities available (Pierce, 1975), the difficulty level and types of activities available (Fox, 1970), various types of announcements for activities (McClannahan & Risley, 1974), the availability of recreational materials (McClannahan & Risley, 1975), and prompts to use recreational materials (McClannahan & Risley, 1975). Token and monetary reinforcers have also been used to increase participation in social and recreational activities (McClannahan & Risley, 1974; Mueller & Atlas, 1972). Although the above studies all demonstrated increases in resident attendance and/or participation in recreational activities, the positive effects have generally been limited to small portions of the targeted population. Furthermore, some studies used interventions that involved resources not available in most nursing homes. The present study evaluated the relative effectiveness of several prompting procedures on the attendance of nursing home residents at recreational activities and generated large increases in the residents' attendance using only those resources generally available in nursing home settings.
METHOD
Subjects and Setting The study was conducted in a nursing home and convalescent center in Morgantown, West Virginia. The Center has a capacity of just under 100 residents, with the population generally ranging between 80 and 95 residents. The majority of these residents are admitted to the Center for short periods of convalescence and physical therapy (6 months or less), although a small proportion are admitted on a long term basis. Recreation sessions were conducted in the Center's recreation room or in one of the large lounge areas. Generalization data were collected in all areas of the Center. Participants included in the study were (a) at least 65 years of age, (b) physically capable of engaging in a variety of recreational activities (as judged by the recreational and physical therapists), (c) mobile within the Center so that they could attend the recreation activities without being assisted, and (d) expected to remain in the Center long enough to complete the study. Participation was on a voluntary basis. Of the 34 residents who met the initial criteria for inclusion, 14 improved sufficiently to be discharged prior to the conclusion of the study. All data presented here are taken from those 20 residents who were present throughout the entire project. The 8 males and 12 females ranged in age from 65 to 92 years, with a mean age of 74.5 years. The primary admitting diagnoses included chronic brain syndrome, characterized by
A T T E N D A N C E AT R E C R E A T I O N A C T I V I T I E S
285
periods of anxiety, confusion, and disorientation (n = 7); broken hips or legs (n = 6); partial paralysis resulting from strokes (n = 5); and severe depression, characterized by an almost total lack of interaction with others, long periods of motionless sitting, and frequent crying for no apparent reason (n = 2). Nine of the residents were confined to wheelchairs, four used walkers, and the remaining seven were ambulatory. Several of the residents lacked bladder and/or bowel control and all needed assistance with many routine daily activities.
Dependent Variables and Recording Procedures Resident attendance. The primary dependent variable in the study was the residents' attendance at recreation sessions. These sessions, held at 2:00 p.m. each weekday, consisted of a variety of activities (e.g., arts and crafts, card games, food and drink parties, bingo, and exercises). To be scored as attending a session, a resident had to arrive in the designated activity area prior to 2:15 p.m. and remain in the area a minimum of 15 min. While residents did not have to participate in any activity to meet the attendance criterion, informal observations indicated that very few residents ever attended without participating to some extent in the activity. Staff prompts. During experimental conditions when staff members prompted the residents to attend the recreation sessions, data were collected on the number of residents prompted. A prompt consisted of any verbal reminder, invitation, request, or direction given to a resident to attend the recreation activity. Physical prompts, such as pushing someone's wheelchair into the recreation area, were also scored as prompts even if they were not accompanied by verbal prompts. The only prompts scored were those given during the 15 min immediately following the loudspeaker announcement of the activity.
Reliability For the attendance data, inter-observer agreement was assessed for each session by comparing the data recorded by the recreation director with those of the experimenter, dividing the smaller number by the larger, and multiplying by 100%. Inter-observer agreement for the prompt data was assessed for approximately one-third of the sessions, with a minimum of three checks during each experimental condition. The experimenter served as the reliability checker throughout the study. Inter-observer agreement was calculated by the same method employed with the attendance data.
Procedure A within-subject withdrawal design was used to analyze the data from the group as a whole. Using the notation of Hersen and Barlow (1976), the design used was an A/BCBC/DEDE design. The successive condi-
286
REITZ AND HAWKINS
tions were signs (A), loudspeaker announcements (B), personal invitations (C), staff prompts (D), and staff prompts with feedback (E). These interventions were selected on the basis of their administrative and economic feasibility within most nursing home settings and their probable effectiveness. Signs. During this condition, the only announcement of the daily recreation session consisted of three prominently placed signs, one in each of the large lounge areas and one at the entrance to the dining room. The brightly lettered 1 m by 1½ m signs contained information regarding the type of activity planned, as well as the time and place the activity was scheduled. Loudspeaker announcements. During these conditions the signs were removed and the only announcement of the recreation sessions was a loudspeaker announcement made by the recreation director 5 min before the activity was to begin. These announcements, clearly audible throughout the Center, included the same information that had been conveyed by the signs as well as an invitation for all residents to attend the session. Personal invitations. During these conditions the recreation director continued to make the loudspeaker announcements, but immediately following the announcement, she also sought out each participant (as well as other residents) and personally invited him/her to attend the session. The content of these invitations was standardized and consisted of a greeting, description of the activity, information regarding the place, and an invitation to attend. The recreation director then excused herself " t o invite some other people," thereby limiting further conversation. Staff prompts. At the beginning of the first staff prompts condition, the director of the Center and the recreation director sent a memo to all Center staff. This memo described the important role that participating in recreational activities can play in a resident's rehabilitation, reaffirmed the Center's stand that the recreation program was an integral part of the overall treatment program, and directed all staff to encourage the residents to participate in the recreational program. In addition, the loudspeaker announcement of each day's activity now included a request that all Center staff encourage residents to attend the day's activity. No personal invitations were given by the recreation director. Following the loudspeaker announcement, the recreation director returned immediately to the recreation area and waited for the residents to arrive. No attempts were made to control either the frequency or the content of the staff prompts. Staff prompts with feedback. These conditions were identical to the staff prompts conditions described above except that, following each day's session, the staff received feedback on the number of residents who had attended the activity. Two large signs, posted at the Center's two nursing stations, thanked the staff for their assistance and prominently displayed the number of residents attending the day's recreation session.
ATTENDANCE
Signs
LA-1
20
I
I
I R ?
I
t'~
18
I
LA-2
RECREATION
PI-2
1
I
~
l
287
ACTIVITIES
i
SP-I
SPF-1
SP-2 t / I
'6, ¢!1 ij' ~t
I
,N ~4
AT
I SPF-2 I
I I
I
70 8
j Z
f,,Jl
...... , ........
~. . . . . . .
Ii
20
illlLLiiill~l
~1
~, ,,/NDING ..................
SESSIONS
FIG. I. Number of residents attending ( 0 0 ) and prompted to attend (© ©) recreation activities during the Signs, Loudspeaker Announcement (LA), Persona] Invitation (PI), Staff Prompts (SP), and Staff Prompts with Feedback (SPF) conditions. Prompts are shown only for those conditions in which individual residents were prompted by staff.
RESULTS Inter-observer agreement on the number of residents attending the recreation sessions averaged 96.6% (range, 67% to 100%). Nearly all errors resulted from one observer failing to note that someone who came to the session left before the required 15 min had elapsed. Inter-observer agreement on the number of residents prompted to attend the sessions averaged 91.3% (range, 83% to 100%). Fig. 1 shows the data on resident attendance at the recreation sessions. Attendance during the signs condition averaged less than one person per session and increased only slightly during the first loudspeaker announcement condition. Adding individual invitations from the recreation director increased attendance to a mean of 9.2 residents per session. A return to the loudspeaker announcement condition resulted in a decline to previous low levels of attendance, while reinstating the personal invitations increased attendance again to a mean of 8.6 per session. Introducing the staff prompts resulted in an immediate increase in the number of residents attending to 16, but attendance steadily decreased to a low of 2, with an overall mean of 7.7 per session. Adding feedback to the staff on the number of residents attending the sessions increased attendance to a mean of 10.4 residents per session. Discontinuing the feedback resulted in a decrease in attendance to 7.6 residents per session, but its reinstatement resulted in an increase to 11.6, the highest attendance during any condition.
288
REITZ AND H A W K I N S
Fig. 1 also shows the number of prompts given during the two personal invitation conditions and the four staff prompts conditions. During the personal invitation conditions, the number of residents prompted averaged 18.4 and 18.9, respectively. When the staff prompts condition was initiated, the number of residents prompted was high for the first three sessions (mean = 18.0), but it dropped to a mean of only 3.7 during the last three sessions. Incorporating feedback to the staff gradually increased the number of residents prompted to a mean of 14.6 per session. Discontinuing the feedback decreased the number of prompts to a mean of 10.9. Reinstating the feedback increased the number of residents prompted to a mean of 14.5 per session.
DISCUSSION This study evaluated the effects of several different procedures for prompting nursing home residents' attendance at recreation activities. Two of these procedures--announcing activities with large signs and making loudspeaker announcements--resulted in extremely low levels of attendance, while two other procedures--personal invitations and staff prompts--greatly increased resident attendance at activities. While the personal invitation procedure resulted in substantially increased attendance, it appeared to have reached maximum effectiveness even though nearly half of the residents were unaffected. Three difficulties with this procedure were identified: (a) the relatively low ratio of residents attending to residents prompted, (b) the recreation director's occasional absence from the recreation area when participants arrived for the session, and (c) the continued isolation of the recreation program from other Center staff and activities. The staff prompts procedure was implemented in an attempt to overcome these problems. However, while the staff prompts were highly effective and did solve the problems cited above, it proved difficult to maintain the staff's prompting at acceptable levels. Implementing a feedback condition effectively maintained staff prompting at satisfactory levels and resulted in approximately 60% of the study participants attending the recreation sessions each day. Although several possible explanations exist for the relatively greater effectiveness of the staff prompts, the content of the prompts appears the most plausible. As previously described, the content of the prompts was strictly controlled during the personal invitation conditions. During the staff prompts conditions, however, the content of the prompts was not controlled. Anecdotal observations indicated that the staff used a wide variety of procedures, such as persuading residents, giving directions, and physically prompting residents, while the recreation director only gave information about the activity and an invitation. While large increases in attendance were obtained, comparisons between the personal invitation and staff prompts conditions must be made with some caution. The participants' experiences with previous conditions and the order in which the conditions were presented may have
ATTENDANCE AT RECREATION ACTIVITIES
289
influenced these results. Studies using counterbalanced or group designs could control for these effects. Attendance was selected as the dependent variable in the study because of the nature of the problem in this setting. Observations made prior to the study indicated that the targeted residents were easily induced to participate in most activities by the recreation director. The problem was to develop an efficient means of using the recreation director's time to get the most activities to the most residents. Previous attempts to "take the activities to the residents" had been abandoned because they reached only a few residents at a time, and because many desirable activities were not sufficiently portable. The most efficient solution to the problem was to get the residents to come to the recreation area, making attendance at the sessions the logical dependent variable. 1 Data were also collected to assess resident activity levels at times of the day when no recreational activities were scheduled. These data showed only minor fluctuations throughout the study, indicating that generalization of treatment effects during these times was minimal at best. 2 Further work in nursing home settings might systematically evaluate the impact of (a) varying the frequency of feedback to staff, (b) using different types of prompts, and (c) selecting residents, rather than staff, to deliver the prompts. Regardless of the specific procedures studied, however, attention should be directed toward achieving generalization and maintenance of behavioral gains.
REFERENCE NOTE 1. Reitz, A. L., & Hawkins, R. P. Using volunteer staff to increase activity levels of severely debilitated nursing home residents. Paper presented at the meeting of the Association for Behavior Analysis, Dearborn, MI, June, 1979.
REFERENCES Bonner, C . D . Rehabilitation instead of bed rest? Geriatrics, 1969, 24, 109-118. Fox, E. Does it have to be bingo? Nursing Homes, 1970, 19, 17-19. Hersen, M., & Barlow, D . H . Single case experimental designs: Strategies fi)r studying behavior change. New York: Pergamon, 1976. Koncelik, J. A., & Snyder, L. The role of design in behavior manipulation within longterm care facilities. Nursing Homes, 1971, 20, 6-23. Kurasik, S., & O'Connor, R. Why recreation in hospitals, nursing homes, and homes for the aged? Journal of the American Geriatrics Society, 1966, 14, 643-646. McClannahan, L. E. Therapeutic and prosthetic living environments for nursing home residents. The Gerontologist, 1973, 13, 424-429. 1 Another group of Center residents, which rarely participated in activities even when attending recreation sessions, was also identified. A second study evaluated procedures aimed at increasing these residents' participation levels during recreational activities (Reitz & Hawkins, Note 1). Complete information on the generalization data are available from the first author on request.
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McClannahan, L. E., & Risley, T. R. Design of living environments for nursing home residents. The Gerontologist, 1974, 14, 236-240. McClannahan, L. E., & Risley, T. R. Design of living environments for nursing home residents: Additional strategies for increasing attendance and participation in group activities. Journal of Applied Behavior Analysis, 1975, 8, 261-268. Melin, L., & Gotestam, K . G . The effects of rearranging ward routines on communication and eating behaviors of psychogeriatric patients. Journal of Applied Behavior Anlaysis, 1981, 14, 47-51. Mueller, D. J., & Atlas, L. Resocialization of depressed elderly residents: A behavioral management approach. Journal of Gerontology, 1972, 27, 390-392. Pierce, C. Recreation for the elderly: Activity participation at a senior citizen center. The Gerontologist, 1975, 15, 202-205. RECEIVED: July 7, 1981 FINAL ACCEPTANCE" February 5, 1982