“Life is More than Activities. It is Engagement.”

In the quote from Gawande’s book, BEING MORTAL, that I posted last week, I included the paragraph below.  Quite simply and succinctly Gawande addresses two major issues:  purpose and meaning in later life and “activities” as experienced in most nursing homes to this day.

“There was so much more she felt she could do in her life. ‘I want to be helpful, play a role,’ she said. She used to make her own jewelry, volunteer at the library. Now her main activities were bingo, DVD movies, and other forms of passive group entertainment. The things she missed most, she told me, were her friendships, privacy, and a purpose to her days.  Nursing homes have come a long way from the firetrap warehouses of neglect they used to be. But it seems we’ve succumbed to a belief that once you lose your physical independence, a life of worth and freedom is simply not possible.”

The challenge is presented:  how do we transform that aspect of nursing home culture which defines “activities” as what are really primarily generic activities, not related to personal interests (Bingo and DVD movies), and “forms of passive group entertainment.”  Carter Williams, social worker, advocate and activist, noted in her convening address to the Pioneer Network Conference in 2013 that “life is more than activities. It is engagement.”

A few years ago I visited Perham Living, a nursing home in Perham, MN, an onsite visit during the Pioneer Network Conference. An outstanding memory of that visit some seven years ago is of a woman who was growing African Violets in her room. It was something she had done for years. There were quite a number of these beautiful plants. We were told that the workmen had installed a deep wooden shelf near the window, as she had requested. It allowed this woman to engage in life, to continue familiar routines that were meaningful and pleasurable. This nurturer of violets was in her late nineties at this time.

There is a breadth and depth of implications and consequences for moving beyond activities to engagement. Federal Regulations called the Minimum Standards (yes, minimum) mandate that nursing homes learn what specific interests each resident has and to build “activities” around those interests.  The tragic reality is that even with these standards in place, surveyors by and large ignore the spirit and meaning of the minimum standards for “Activities”.

There are, of course, implications of cost and of outcomes for the transformation of activities that are generic and/or passive group entertainment.   In the case of the woman with her violets, research indicates such involvement enhances emotional and mental health. The sense of well-being can heighten one’s immune system, in contrast to a state of depression, isolation and loneliness all too common in too many nursing homes. Theoretically, then, this woman raising her African Violets was less likely to contract diseases that cannot be fought with a weakened immune system. She was also delivered from the insidious prescription of anti-depressants.  In all of this, no expense item has been noted, only the avoidance of possible expensive medications with an accompanying lowered quality of life.

The cost to the nursing home for this intervention, this facilitating quality of life, purpose and meaning?  The board to hold the plants. And maybe an hour’s labor from an employee in the maintenance department.

What if the interests, routines, and preferences of each resident in an Assisted Living or in a nursing home community were known, really known by the staff?  Would there be engagement? Would we find that the word “Activities” does not describe what is happening as residents engage?  I believe it would. We are moving to that reality when we describe the person responsible for this engagement as a Life Enrichment Director rather than an Activities Director.