This issue’s Spotlight on
research has been provided by
Stephen Wey, Senior Lecturer at
York St John University. Stephen
is currently engaged in doctoral
studies related to ‘the dynamic
assessment of zones of proximal
development in the context of
dementia rehabilitation and
enablement’
This powerful and
challenging new paper by Wendy
Wood, Jenifer Womack and Barbara
Hooper, discusses selected
findings from a larger study
conducted by Wendy Wood into
opportunities for meaningful
occupation and use of time by
people with dementia resident in
two “Special care units” in the
United States. From this
standpoint it can be read as an
empathic and insightful study of
the occupational needs, and
striving for occupation, of
people with dementia in care
settings. As such it will be of
particular interest to those of
us who work with people who have
dementia. However, it would be a
mistake to see it as limited to
any one field of practice.
Anyone who is familiar with
Wendy Wood’s work will know that
she has carried out many studies
that explore the origins,
supports for, and limits of
occupation and occupational
behaviour; in particular, the
relationship between ecological
setting, occupational behaviour
and quality of life. So this
study is also of importance to
anyone interested in exploring
some of the central and
foundational questions of
occupational science.
“I’m dying of boredom”: Wood
describes in her field notes
from the study how she was
greeting with this statement by
Joseph, one of the residents,
and that it haunted her
throughout the study. The two
Special Care Units (SCUs), where
the study was conducted, were
each purpose built with the
needs of people with dementia in
mind. For methodological reasons
Wood chose two units that had
good reputations for quality of
care but that represented
divergent social and physical
environments. One was described
as more “homelike” with seven
residents, the other as a more
“traditional” nursing home
environment with 27 residents.
The methodology involved a
process of structured
observations using observers
trained to use a tool developed
by Wood. The tool used was the
Activity in Context and Time
(ACT) tool, which enabled
recording of residents’ use of
time, the immediate
socio-physical environmental
context, and the resident’s
affective state at the time.
Affect was used to inform
hypotheses regarding the
person’s well-being, in a manner
that appears broadly similar to
the approach used in the
Bradford Dementia Group’s
Well-Being Profiling and
Dementia Care Mapping tools. The
study discusses the findings of
these observations in relation
to several case examples, which
not only helps place the
findings in a human context but
also brings home some of the
emotional depth of the
residents’ experience.
The study focused on
meaningful use of time and
emotional well-being – both
issues that previous research
has shown strongly correlates
with the socio-cultural and
physical environment for people
with dementia. In particular it
discusses the concept of excess
disability (i.e. disability
beyond what is attributable to
disease process alone); such as
that which results from care
practices that do not support or
sustain existing skills or
provide activity opportunities
that tap into the person’s full
range of skills and capacities.
In each unit it was found that
individuals were spending
inordinately large periods of
time dozing or unengaged and
that only a small percentage
(5-6%) of time was spent
engaging in meaningful direct
interactions with staff members.
The study did not identify
significant differences between
the two settings, despite the
lower numbers of residents and
more “homelike” environment in
one setting.
One important finding was
that many everyday occupations
that people with dementia
themselves were attempting (not
always successfully) to engage
in were often seen but not
noticed. Additionally, in some
instances attempts at meaningful
occupations were pathologised;
for example a person seeking to
walk outside at night and
expressing anger at a locked
door was construed merely as
symptomatic of “sundowning”
rather than any attempt being
made to explore the unmet
occupational and emotional needs
being expressed. On the other
hand, people spending many hours
disengaged, withdrawn or asleep
was seen as normal.
The authors draw attention to
the fact that, like many care
settings here in the UK, there
is a notable absence of any
support for occupations of
people with dementia by
occupational therapists and end
with a plea for greater
involvement and suggestions for
future research.
This study is highly
recommended reading. It
demonstrates with great power
how actively observing, noticing
and building on the striving for
meaningful and relevant
occupation, and contact of
people with dementia themselves,
is an essential requirement for
creating opportunities for
enhancing quality of life and
overcoming excess disability for
this client group.
If you would like to read
this research article the
reference is:
Wood W, Womack J, Hooper B
(2009) Dying of Boredom: An
exploratory case study of time
use, apparent affect, and
routine activity situations on
two Alzheimer’s special care
units. American Journal of
Occupational Therapy, 63(3)
337-350
Stephen Wey, Senior Lecturer at
York St John University