UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Continuity of identity through meaningful occupation : the experience of older adults living in long-term… Caron, Staci 2003

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-ubc_2003-0165.pdf [ 6.66MB ]
Metadata
JSON: 831-1.0090791.json
JSON-LD: 831-1.0090791-ld.json
RDF/XML (Pretty): 831-1.0090791-rdf.xml
RDF/JSON: 831-1.0090791-rdf.json
Turtle: 831-1.0090791-turtle.txt
N-Triples: 831-1.0090791-rdf-ntriples.txt
Original Record: 831-1.0090791-source.json
Full Text
831-1.0090791-fulltext.txt
Citation
831-1.0090791.ris

Full Text

CONTINUITY OF IDENTITY T H R O U G H M E A N I N G F U L OCCUPATION: THE EXPERIENCE OF OLDER A D U L T S LIVING IN L O N G - T E R M C A R E FACILITIES  BY  STACICARON, OT  B.Sc, The University of Western Ontario, 1994  A THESIS SUBMITTED IN PARTIAL FULLFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTERS OF SCIENCE in  THE FACULTY OF MEDICINE (School of Rehabilitation Sciences)  We accept this thesis as conforrjiipg Io_th£ require^ standard  The University of British Columbia April 2003 © Staci Caron, 2003  In  presenting  degree freely  at  this  the  available  copying  of  department publication  of  in  partial  fulfilment  University  of  British  Columbia,  for  this or  thesis  reference  thesis by  this  for  his thesis  and  study.  scholarly  or for  her  (2/88)  I further  of  the  gain  shall  requirements  agree  that  agree  purposes may  financial  The University of British C o l u m b i a Vancouver, Canada  DE-6  I  representatives.  permission.  Department  of  be  It not  that  the  be  Library  an  advanced  shall  permission for  granted  is  for  by  understood allowed  the  make  extensive  head  that  without  it  of  copying my  my or  written  Meaningful Engagement in Long-Term Care  ii  Abstract Disability often accompanies aging due to multiple impairments commonly experienced by older adults. Many older people admitted to Long-Term Care (LTC) facilities experience loneliness, helplessness, and boredom, which often lead to depression (Thomas, 1996). Yerxa (1998) explored the relationship between health and the human spirit for occupation, where occupation was considered the self-initiated, self-directed, productive daily activity that provides individuals with a sense of identity and purpose in life, which, in turn, contributes to their health.  Through qualitative research, this study aimed to contribute to the understanding of meaningful occupational engagement for older adults living in L T C facilities. A narrative approach using in-depth semi-structured interviews was used to explore the meaning of occupation for nine residential care facility residents, specifically through their current and past occupations and related perceptions of health, aging, and the L T C facility environment. Continuity theory and the emergent discipline of occupational science provided a conceptual approach to this research.  Findings of the study showed that the meaning of occupation was shaped within the context of participants' experience of living in a L T C facility, including their perceived losses, functional constraints, and afforded opportunities. Four themes of meaningful occupation emerged from the data; 1) reliance: maintaining a sense of independence within a supportive environment, 2) relationships: maintaining and fostering social relationships, 3) rewards: doing things that have purpose and contribute personally and socially, and 4) reflection: reflecting on life's experiences, accomplishments, and regrets. These themes were closely linked to an  Meaningful Engagement in Long-Term Care  iii  additional theme concerning the preservation and expression self-identity. Participants' chose to occupy themselves with activities that provided continuity with previous occupations, defining their sense of self. Rehabilitation therapists and other professionals who work with elderly residents are called to be innovative and flexible in designing programs and carrying out daily care activities within L T C facilities, in a manner that enables continuity for each resident and is tailored to fit with his or her sense of self.  Study findings have implications for occupational therapy practice and social planning for the aging population. Understanding the meaning that occupations have for older adults, and how engagement in them reflects a continuity of identity involves an appreciation of their "life contexts". Environments that provide opportunity for choice and self-determination can enable older adults to maintain necessary connections between their past, present, and future, engage in meaningful occupations, and in turn, foster healthy expressions of themselves as capable and worthy.  Meaningful Engagement in Long-Term Care  iv  Table of Contents  Abstract  ii  Table of Contents  iv  Acknowledgements  vii  CHAPTER 1: Introduction  1  Research objectives  5  Anticipated Significance  6  Conceptual Framework  6  Thesis Organization  8  CHAPTER 2: Literature Review Occupation  11 11  Defining Occupation  11  Occupation and Health  12  Occupation and Older Adults  15  Occupation and Older Adults Living in L T C Facilities  19  Conceptual Approach  20  Continuity Theory  21  Occupational Science  23  CHAPTER 3: Methodology  27  Narrative Approaches in Qualitative Research  27  Research Design  29  Pilot Interview  30  Criteria for Participant Selection  31  Recruitment  33  Data Collection / Interviews  35  Participant Profiles  36  Meaningful Engagement in Long-Term Care Data Analysis  38  Trustworthiness  39  CHAPTER 4: Life in a L T C Facility: A Story of Loss, Constraint, and Opportunity  47  Description of Participating L T C Facilities  48  Adjusting to Life in a Care Facility  50  Loss  51 Energy  52  Functional Abilities  55  Home  62  Constraint  67  Social Milieu  67  Physical Space  73  Institutional Routine and Resources  74  Opportunity  75  CHAPTER 5: Occupational Choices: A Time for Reliance, Relationships, Rewards, and Reflection  79  Participants' Current Daily Occupation  80  Reliance: Independence Through Control, Choice, and Dignity  81  A Balance Between Independence and Dependence  82  Control and Choice  83  Dignity  85  Relationships: The Importance of Family and Friends  88  Evolving Family Relationships  89  Missing Old Friends  92  Desiring Social Relationships With Co-Residents  93  Reward: Doing With Purpose and Contribution  94  Reflection: Reminiscing and Evaluating  98  Reminiscing  99  Meaningful Engagement in Long-Term Care Evaluating  vi 100  Self-Identity  103  CHAPTER 6: Discussion  105  Continuity of Identity Through Meaningful Occupation  105  Theoretical Considerations  106  Continuity  107  Self-Identity  109  Occupation  112  Environment  114  Implications for Occupational Therapy Practice  120  Implications for L T C Facility Practice  124  Study Limitations  126  Future Research Directions  127  Conclusion  129  References  131  Appendix A  Participant Consent Form  139  Appendix B  Letters of Recruitment  141  Appendix C  Interview Guide  142  Appendix D  Description of Participating L T C Facilities  145  Appendix E  Participants' Current Daily Occupations  147  Meaningful Engagement in Long-Term Care  vii  Acknowledgements For sharing their wisdom, stories, and time I am grateful to the eight women and two men who participated in this study. Their willingness to share their lives with me so freely was very much appreciated. Participants contributed to the understanding of what life is like when living in a LTC facility and the occupations that matter to the people who reside there. Their contribution provided a necessary base from which to move forward in planning positive opportunities for all nursing home residents.  I thank my thesis committee, Dr. Isabel Dyck, Dr. Anne Carswell, and Dr. Liz Drance for their support and guidance throughout this project. Their timely feedback and flexibility were integral to the completion of this study. Each member had a unique interest in the topic of the study that contributed to the quality of its outcome. Their continuous commitment to this study and ultimately my education is recognized.  I thank my friends and family for being uninterrupted sounding boards during the entire process and for getting excited with me at each project milestone. I am especially appreciative of Bradley, Robyn, Otto, and Trish who listened frequently. I thank Megan for her great editing. Special thanks goes to Robena for inspiring the topic of this paper.  This project has improved my knowledge and appreciation of the benefits of qualitative research in broadening our understanding of people's life experiences. As well, this endeavor has enhanced my passion for working with older adults. I hope the results of this study contribute to the quality of life for older adults who live in L T C facilities.  Meaningful Engagement in Long-Term Care  1  Chapter 1: Introduction The purpose of this study was to contribute to the understanding of meaningful occupational engagement for older adults who live in Long Term Care (LTC) facilities. By 2026, it is estimated that there will be over 7.8 million people over 65 years of age in Canada, representing over 20% of its population (Statistics Canada, 2000). Many older people with multiple impairments are admitted to Long-Term Care (LTC) facilities (residential care facilities also known as nursing homes) where they experience loneliness, helplessness, and boredom, which often lead to depression (Thomas, 1996). It is anticipated that the increasing numbers of the aging population will have a great impact on a LTC system, which is already in need of both financial and human resources (Beck & Chumbler, 1997). Along with the need for resources, L T C facilities are in need of a 'culture' change (Jirovec & Maxwell, 1993; Jones, 1996; Rader, 1995; Thomas, 1996). Nursing homes have traditionally been structured around the Western medical model and, thus, operated like a health-care institution, which has conflicted with a residential ambiance that has shown to correlate with residents' health and well-being (Jirovec & Maxwell, 1993; Jones, 1996; Rader, 1995; Thomas, 1996). Consequently, aspects of a home environment need to be incorporated into the structure of the typical nursing home (Jirovec & Maxwell, 1993; Jones, 1996; Rader, 1995; Thomas, 1996).  Health and well-being have also been positively correlated with engagement in meaningful activities. Yerxa (1998) explored the relationship between health and the human spirit for occupation, where occupation was considered the self-initiated, self-directed daily living activity that is productive for a person and contributes to others. Yerxa (1998) viewed health as a dynamic state of well-being, where aspects of adaptability, quality of life and  Meaningful Engagement in Long-Term Care  2  satisfaction are constantly interacting. Health is manifested in the ability to carry out daily living tasks, and occupation is a determinant of health (Rogers, 1984).  Engagement in occupation  satisfies individuals' self-interest, and the need for a healthful balance between daily activities (i.e. how time is spent) (Yerxa, 1998).  People who are no longer working and have no  organized leisure often become depressed, losing their sense of identity and purpose in life, as well as their health (Yerxa, 1998). These circumstances seem relevant to many retired seniors. Engagement in meaningful occupation contributes to health, thus meaningful occupation has been a central focus for the profession of Occupational Therapy.  Occupational therapy is a rehabilitation profession aimed at enabling people to choose and engage in meaningful occupations, which develop their personal and social resources for health (CAOT, 1994). Occupation is defined as "everything people do to occupy themselves, including looking after themselves (self-care), enjoying life (leisure), and contributing to the social and economic fabric of their communities (productivity)" (CAOT, 1997, p.34). Occupational therapists work in a variety of settings with people across the age span who experience any disability, injury, and/or illness, which affects their daily function in one or several areas of their lives. This includes older adults with mental illness.  My area of practice, throughout the course of this study, was in geriatric community mental health. That is, I work in a community-based health care setting with older adults who have severe mental illness. The role of occupational therapists, working as part of an interdisciplinary team, is enabling engagement in meaningful daily activities. Specific rehabilitation services for older adult clients include functional assessment and intervention,  Meaningful Engagement in Long-Term Care  3  addressing clients' social and leisure needs, designing and implementing environmental and behavioural strategies, providing education for family and caregivers regarding the rehabilitation needs of clients, and advocating for the development of relevant resources. Clients either live independently, in a mental health boarding home, or in a L T C facility.  Many clients living in a L T C facility are referred to the community mental health team for the treatment of depression. My initial assumption, as an occupational therapist aiming to optimize function, was that the onset of depression for these clients resulted from trying to cope with the loss of functional abilities and ultimate independence. It became apparent through practice however, that many of my clients expressed frustration in not being able to do the things that they felt capable of within the facility setting, rather than having difficulty coping with the functional losses which led to nursing home placement. In essence, many clients did not feel enabled within their environments to engage in meaningful activity. This reflection influenced my interest in this study area. I began to ask questions such as: how do residents want to spend their time when living in a care facility? How do they view their role within this environment? What meanings do these activities and roles hold for residents? Are residents doing what they would like to be doing? What are the sources of perceived choice and control in their lives? The philosophy of rehabilitation is to focus on individual strengths and capabilities, and to prepare people to participate to the fullest in life's activities (Trombly, 1995). How can this be achieved for older adults who live in a L T C facility setting?  My review of the literature for this study demonstrated that occupational therapy research is limited regarding the meaning and influence of occupation on the health of seniors with mental  Meaningful Engagement in Long-Term Care  4  illness, seniors with cognitive disabilities, and / or those living in L T C facilities. It is well documented that health influences what people do in their daily lives and, the things that people do influence their health (Law, M . , Steinwender, S., & Leclair, L., 1998). Much of the research involving occupation and older adults concerns healthy seniors living independently in the community and includes investigation of the relationship between daily time-use of seniors and their perceived health and well-being. Further, while there is considerable gerontological research exploring perceived quality of life and well-being for older persons, little of this focuses on older adults residing in L T C facilities (Engle, Fox-Hill, & Granery, 1998; Jirovec & Maxwell, 1993). Results of research concerning healthy older adults and /or those living independently in the community could not be generalized to older adults living in a L T C facility because of the declining health of older adults who live in LTC facilities, and its institutional environment. A n understanding of the meaning that occupation has for L T C facility residents therefore became the focus of this study. It was imperative that the meaning of occupation be explored from the perspective of the people living in institutions, if the findings were to meet the needs of the aging population within the L T C system. More specifically, it was important to learn from participants what occupational opportunities are important for their perceived health and well-being, and how current situations interfere with performance of those occupations (Law, Steinwender & Leclair, 1998).  Qualitative research is aimed at understanding or describing a particular phenomenon or event, specifically from the perspective of those involved (Hammersley & Atkinson, 1995; Mason, 1996; Morse & Field, 1995). It was therefore the chosen methodology to examine how older adults living in L T C facilities view 'occupation' in terms of its meaning in their daily life.  Meaningful Engagement in Long-Term Care This study used a narrative approach and semi-structured in-depth interviews to explore participants' meaning of occupation. Participants were asked to share stories about their occupational life.  Research objectives The intent of this study was to achieve a better understanding of what occupation means to older adults living in L T C facilities, in terms of how residents value spending their time. In this study, occupation was defined as, "everything people do to occupy themselves, including looking after themselves (self-care), enjoying life (leisure), and contributing to the social and economic fabric of their communities (productivity)" (CAOT, 1997, p. 34). In essence, an understanding of what a meaningful daily existence is for this population was sought. The research objectives were incorporated into interview questions, which guided the study. The objectives were to explore: 1. How the occupations of older adults are affected by change from independent to institutional living. 2. How older adults who live in L T C facilities spend their time (i.e. what are their occupations). 3. How older adults who live in L T C facilities want to spend their time (i.e. what they would like their occupations to be). 4. How the L T C facility environment (physical, social, cultural, and institutional,) influences the occupational choices of its residents.  Meaningful Engagement in Long-Term Care  6  Anticipated Significance Results of this study will add to the body of knowledge of occupation as it relates to older adults and their environment. Specifically, insights from this study will lead to a better understanding of occupation and its relevance to LTC facility residents. Study findings will be useful in understanding the needs of older adults who reside in L T C facilities, which will in turn serve in planning for the aging population and the health and L T C system that will serve them. For rehabilitation therapists and other health care professionals, the results will generate information regarding nursing home issues from the participants' point of view, including residents' quality of life, recreation programming, personal care regimes, and the social and physical environment.  The study findings will also be applicable to occupational therapists working with this population in their evaluation of the environment of a L T C facility, with regards to optimizing residents' function and quality of life through meaningful occupations. In addition, this study has also created further relevant research questions for occupational therapy practice, for example, regarding the discipline of occupational science, the meaning of environment, and meaningful occupation for people living in institutional settings and/or near the end of life.  Conceptual Approach The initial phase of designing a qualitative research study is to frame the study within a philosophical and theoretical framework that will guide the research process (Creswell, 1998). Continuity theory and the emergent discipline of occupational science provided the theoretical framework for this study. Continuity theory is a psychosocial theory of aging, described as an  Meaningful Engagement in Long-Term Care  7  adaptive strategy that suggests older people rely on past experience to meet daily living challenges associated with normal aging (Atchley, 1989). Continuity theory helps to explain the possible impact of institutionalization upon older adults as it highlights the importance of people's internal and external structures (i.e. personality and social network respectively), and stresses the need for those structures to continue in order to adapt to change and age successfully (Atchley, 1989). Continuity theory of aging helps to explain why an individual chooses or values the occupations that she or he does, because it considers the individual's personality and past life experience. As one's personality influences role activity and life satisfaction (Burbank, 1986), personal meanings are connected to the activities or occupations that one chooses. A n understanding of the role of occupation in achieving health and well-being was also required in order to enable meaningful engagement in daily life, especially for the many older adults who have difficulty adapting to the nursing home environment. This was provided within the framework of occupational science, which grew out of recognition of the significance of occupation to all people, and the need for a basic science to support occupational therapy practice (Yerxa et al., 1990).  Occupational science emphasizes the role that occupations play in affecting health and well-being, and highlights the importance of understanding the meaning of these occupations for those who engage in them (Jackson, J., Carlson, M . M . , Mandel, D., Zemke, R., & Clark, F., 1998). In order to appreciate the meaning of occupation for individuals, it is important to understand how people occupy their time, their satisfaction with the use of that time, and how well their values and goals are supported during that use of time (Yerxa et al., 1990). Occupational science allows for a better understanding of the dynamic between people's  Meaningful Engagement in Long-Term Care  8  occupation and their environments in maintaining health and well-being (Zemke & Clark, 1996). Together, concepts from continuity theory and the discipline of occupational science facilitated an understanding of the meaning of occupation for older adults living in L T C facilities, as it was related through participants' stories.  Organization of Thesis Chapter two addresses the literature related to occupation and health, occupation and older adults and, occupation and older adults living in L T C facilities. Relevant gerontology literature exploring, for example, perceived quality of life, control and choice, and depression for LTC facility residents is also included in the literature review. Chapter two will conclude with a discussion of the theoretical ideas that guided this study, focusing on the relevance of continuity theory and occupational science to the research.  Chapter three will discuss the chosen methodology for the study, examining the appropriateness of qualitative research, specifically a narrative approach and in-depth interviews, in achieving the research goal. Narrative approaches in research allow us to understand phenomena from an individual's perspective and experience, captured in a personal life story. In this study, narrative approaches were used to explore how the things older adults do (and have done) matter to them, within the context of life in a L T C facility. Specific elements of the research design and implementation are also reviewed in this chapter, including the research plan, participant selection, recruitment, research setting, data collection, and data analysis. The manner in which the study's trustworthiness was ensured is discussed at the end of this chapter.  Meaningful Engagement in Long-Term Care  9  Chapter four and five present the findings of the study. The identified themes emerging from analysis of the study transcripts are organized into two chapters, which demonstrate participants' life context and occupational choices respectively. Chapter four examines what life is like for an older adult living in a L T C facility. It was found that in order to understand the meaning that daily occupation has for participants an understanding of who they were and how they came to their facility was needed. Further, it was important to appreciate their perceived losses, constraints imposed by the L T C facility environment, and opportunities afforded by living in a care facility. Therefore, the three main contextual themes identified in chapter four are, 'loss', 'constraint' and 'opportunity'. The loss of energy, functional abilities, and home were evident in participants' transcripts. Daily occupations were constrained by the L T C facility's social environment, physical space, and institutional routines and resources. At the same time, participants' narratives revealed opportunities for them to contribute to and help others as well as feel safe and secure in day-to-day life. This study considers meaningful occupation for participants to be shaped in the context of their losses, constraints, and opportunities.  Through participants' narratives it became evident that the activities participants chose to engage in made up an occupation that is personally meaningful. Chapter five demonstrates the themes indicative of the occupations that were most meaningful for these older adults living in L T C facilities to engage in. While participants engaged in various activities, which differed from one another, they ultimately desired similar roles and opportunities in their life.  It was found  that residents desired to be as independent as possible and experienced similar benefits and frustrations in achieving self-reliance, which were imposed by their living environment. They also strived to foster relationships with friends and family and for the opportunity to contribute to  Meaningful Engagement in Long-Term Care  10  the people in their life and the world around them. Finally, participants appreciated opportunities to reflect and reminisce about their lives in this time that they perceived to be the final stage. Four main themes of meaningful occupation were identified and they are 'reliance', 'relationships', 'rewards', and 'reflection'. An additional theme, preserving and expressing selfidentity, was also evident as being personally meaningful. 'Self-Identity' was therefore organized as a separate theme, which is considered to act as a thread through all meaningful occupation. Emerging sub-themes, within both chapters, are also presented.  In chapter six, the final chapter, study findings are pulled together to discuss the meaning of occupation for older adults living in L T C facilities. The results are discussed in relation to the literature review, conceptual framework and methodology. Study results are also discussed as they relate to implications for occupational therapy practice and planning for the future of the aging population. To conclude, study limitations are examined and future research questions are proposed.  Meaningful Engagement in Long-Term Care  11  Chapter 2: Literature Review Occupation Defining Occupation Occupation is a concept underlying the core of occupational therapy. Evans (1987) defined occupation as an essential element of human nature, characterized by the active engagement in purposeful, goal-directed and intrinsically gratifying activity. It is goal-oriented behaviour related to daily living, which has been referred to as human doing (Rogers, 1984; Trombly, 1995). Occupation has been characterized by the development of skills and participation in the areas of self-care, work and leisure (Darnell & Heater, 1994, Law et al., 1998).  In this study, occupation was defined for participants as "everything people do to  occupy themselves, including looking after themselves (self-care), enjoying life (leisure), and contributing to the social and economic fabric of their communities (productivity)" (CAOT, 1997, p. 34). Occupations are simply the things people do during the course of everyday life.  In a study by Rudman, Cook and Polatajko (1996), the nature of occupation was described as the "doing that involves engagement" (p. 647). Nelson (1996) defined occupation as the relationship between occupational form and occupational performance. Occupational form was defined as " the composition of objective physical and socio-cultural circumstances external to the person that influences his or her occupational performance" (Nelson, 1996, p.776), and occupational performance as " the person's voluntary doing in the context of the occupational form" (Nelson, 1996, p.777). Yerxa et al. (1990) described occupation as a complex multidimensional phenomenon. The complexity of this construct lies in the value and meaning  Meaningful Engagement in Long-Term Care  12  that occupations have for people, and how engaging in occupation affects one's health and wellbeing.  Occupation and Health It is well documented that health influences what people do in their daily lives and, the things that people do influence their health (Law et al., 1998). A balance between self-care, productivity and leisure is essential for healthy living, and is fundamental to the practice of occupational therapy. The relationship between occupation and health is given much attention in the occupational therapy literature. Nevertheless, defining the nature of the relationship between occupation and health has been challenging, partly because the constructs themselves are difficult to define succinctly.  In the early 1960's, Reilly emphasized the individual's need for productive and creative occupation, and advocated that occupation can influence a person's state of health (Miller & Walker, 1993). Through occupation an individual comes to know of what he or she is capable, achieves a sense of competence, and establishes a balance between self-care, leisure, and productivity, and thus it contributes to health and well-being (Rogers, 1984). Occupation gives meaning to life, organizes behaviour, develops and changes over a lifetime, shapes and is shaped by environments, has therapeutic effectiveness and is an important determinant of health and well-being (CAOT, 1997).  For these reasons, occupational therapists use occupation, or daily activities, as a therapeutic medium to promote health when problems in occupational performance arise  Meaningful Engagement in Long-Term Care  13  (Rogers, 1984). Problems in performance may arise when injury or illness limits the individual's capacity and/or when the environment restricts the individual's opportunity to engage in occupation. Trombly (1995) explored occupation as a therapeutic medium and distinguished between its use as the goal of therapy (occupation-as-end) and as the change agent (occupationas-means). Both as an end and as a means, occupation's therapeutic value is achieved through purposefulness, in organizing behaviour, and meaningfulness, in motivating performance (Trombly, 1995).  Qualities such as perceived choice, importance, competency, challenge, success, and relevance have been used to describe how occupation is purposeful and meaningful (Trombly, 1995), demonstrating a connection between occupation and health and well-being. In a position statement on everyday occupations and health, the C A O T (1994) explained that healthy patterns of occupation need to be developed in order for people to take control of their health, and that an element of choice is needed for these patterns to be healthy. Furthermore, health and healthy patterns are shaped in the interaction between people and their environment (CAOT, 1994).  Hachey and Mercier (1993) reported that having an occupation (not necessarily paid work) contributed positively to the global perception of quality of life and perception of health. The authors of the study hypothesized that individual characteristics, living conditions and use of available services would positively affect quality of life of adults with psychiatric illness (Hachey & Mercier, 1993). They also predicted that individuals who received more rehabilitation services would demonstrate a better quality of life. The authors found that perceived difficulty with daily occupations negatively influenced quality of life (i.e. for global quality of life (r = -0.45, p <  Meaningful Engagement in Long-Term Care  14  0.05)) (Hachey & Mercier, 1993). Interestingly, the study showed that participants who used rehabilitation services perceived their quality of life towards occupation and daily activities as negative (r = - 0.15, p < 0.05). The more people used rehabilitation services, the more negative was their perception of their quality of life. The negative correlation between occupation and quality of life, for those who used rehabilitation services, may have been contributed to by the sense of difficulty or frustration with occupations that were practiced during rehabilitation. Perhaps the underlying reason for using rehabilitation services affected persons' perceived quality of life, or perhaps individuals with perceived good quality of life used less services (Hachey & Mercier, 1993). The authors called for more qualitative research, to explore the perception of quality of life in regards to the use of services.  Rebeiro (1998) reviewed the psychosocial occupational therapy literature that examined the construct of occupation and mental health. However, there were few studies that directly examined the use of occupation as a means to mental health. She therefore conducted a qualitative exploration of the experience of engaging in occupation for participants involved in an occupation-based mental health group. Rebeiro (1998) reported that participants perceived improved self-confidence and self-competence through involvement in meaningful occupations (Rebeiro 1998). She called for future research to examine the construct of occupation as a means to mental health, in particular the meaning of engaging in occupation for consumers of mental health services.  Research has supported the notion that a lack of engagement in meaningful occupation may lead to poorer psychosocial functioning and negative perceptions of life satisfaction. People  Meaningful Engagement in Long-Term Care  15  who are not engaged in meaningful activity often become depressed, losing their sense of identity and purpose in life as well as their health (Yerxa, 1998).  Law et al. (1998) critically reviewed twenty-three studies that examined the relationship between occupation and health and well-being primarily in individuals without disability. Results of this meta-analysis provided evidence that occupation influenced people's perceived health and well-being, and withdrawal or changes in occupation significantly impacted their perception of health. Occupational therapists typically serve individuals with disabilities, especially chronic disabilities, therefore it is important to discover whether older adults with disabilities demonstrate differences in activity patterns and, the relationship between occupation and their perceived health and well-being (Law et al., 1998; Yerxa, 1998).  Occupation and Older Adults Rudman, D.L., Cook, J. V., & Polatajko, H. (1996) explored the characteristics and the potential of occupation for older adults living independently in the community. Results of the study characterized occupation as multi-dimensional, individualized and dynamic. They also supported the notion that occupation may exert a positive influence on perceived well-being in many ways, including a means to express and manage identity, a social connector, a time organizer, and a connector to past, present and future. (Rudman et al., 1996).  Clark et al. (1997) completed a randomized controlled trial evaluating the effectiveness of preventive occupational therapy for multi-ethnic older adults living independently in the community, called the 'Well Elderly Treatment Program'. Participants were randomized into  Meaningful Engagement in Long-Term Care  16  three groups. One group received an occupational therapy program whose services focused on occupation, a second group participated in a social activities program, and the third was a control group. Persons who received the occupational therapy program that focused on health through occupation (compared to those who received the social activities program and those who were not in either group) improved significantly in quality of interactions, life satisfaction, health perception, physical functioning, role limitations, vitality, social functioning and general mental health (Clark et al., 1997). Health outcomes, with the occupational therapy program in this study, included enhanced physical and mental health, improved occupational functioning and increased life satisfaction (Jackson, Carlson, Mandel, Zemke, & Clark., 1998).  Nine of the twenty-three studies reviewed by Law et al. (1998) focused on older adults, only one of which involved individuals living in a nursing home. Participants in these studies were primarily healthy seniors living independently in the community. Law et al. (1998) reviewed a study by Baum (1995), which revealed that people with Alzheimer's disease demonstrated fewer behavioural difficulties and required less assistance with self-care activities when they maintained involvement in daily occupation. Some of the studies reviewed focused on the relationship between occupation and physiological effects on seniors. One of these studies focused on psychosocial and metabolic effects when occupation was withdrawn, and the other on the relationship between plasma antioxidants and self-care abilities; the results both suggested that activity level may have influenced physiological measures, such as stress, and functional ability respectively. A cohort study by Widerlov et al. (as cited in Law et al., 1998: 1989) examined the physiological and functional effects of an activation program in nursing home residents with dementia, finding that "the group who received the programme improved  Meaningful Engagement in Long-Term Care  17  significantly in intellectual and self-care functioning, and had significantly increased levels of somatostatin in their cerebrospinal fluid" (p.88). The studies reviewed by Law et al. (1998) demonstrated that health and well-being were enhanced through engagement in occupation, that activity level may have influenced psychosocial and self-care functioning, and that having a safe and supportive environment to perform these occupations was important.  Much of the research involving occupation and older adults concerned the relationship between daily time-use of seniors and their perceived health and well-being. A general social survey conducted by Jones (1990) for Statistics Canada outlined how the elderly used their time in daily life. As one might expect, older retired adults had more free time than younger adults. Elderly people in this survey spent their time engaged in leisure pursuits, such as watching T.V., reading, engaging in hobbies, and walking, in personal care activities, such as sleeping and eating, and in family care (which included home management activities). The survey explored how these activities were balanced in terms of the number of hours in a day as compared to younger people (age 15 -64 years). Overall, a greater percentage of older people spent more time in leisure pursuits and personal care activities then did younger people, however family care activities took up approximately the same amount of time for both older and younger people (Jones, 1990). Retirement was found to be one of the main factors affecting time use of elderly people. Although daily occupation changes due to retirement, older adults continue to balance their time with meaningful activities.  Gregory (1983) studied the relationship between occupational behaviour and life satisfaction among retirees, where occupational behaviour was defined as the type, amount, and  Meaningful Engagement in Long-Term Care  18  meaningfulness of one's activity. The term "occupational behaviour" was used synonymously with "purposeful activity". Seventy-nine subjects from various senior-related settings completed a three-part questionnaire that addressed; demographic information; occupational behaviour (determined by adding the scores on an activity index and on meaningfulness of activity scale); and information concerning life satisfaction. Results demonstrated that occupational behaviour played a significant role in affecting life satisfaction among retirees (r = 0.38, p < 0.05). The occupational behaviour variables that correlated with life satisfaction were; the amount of activity (r = 0.43, p < 0.05), enjoyment in activity (r = 0.42, p < 0.05 ), autonomy (r = 0.43, p < 0.05), and meaningfulness of activity (r =0.29, p < 0.05). Guided by the Model of Human Occupation, Gregory (1983) emphasized that the meaning of activity was crucial in influencing satisfaction and helping people adapt to their environments.  Zuzanek and Box (1988) reviewed the life course and daily lives of older adults living in Canada, using a survey of time-budget and leisure participation. The authors examined relationships between uses of time and leisure participation, and life satisfaction of well elders. During development of their study, the authors found little empirical evidence supporting the use of time and leisure participation, as a function of advanced age (75 +). What the authors reported was that life satisfaction of older adults was more affected by their leisure interests and competencies than by their amounts of free time. McKinnon (1992) explored time use in selfcare, productivity, and leisure for elderly Canadians living independently. By prioritizing the use of their time, individuals in this study formed a balance in daily life activities that was positively related to their health status. McKinnon (1992) suggested that future research examine the  Meaningful Engagement in Long-Term Care  19  relationships between the quantity and quality of elderly people's time use and their subjective meaning of daily activities.  Jones (1990), Gregory (1983), Zuzanek and Box (1988) and, McKinnon (1992) highlighted that elements of activity such as choice, balance, diversity, interest, and competency, are important contributors to subjective well-being of older adults. Results of research concerning occupation for older adults living independently in the community cannot be generalized to those living in a L T C facility. What is clear is that the association between occupation and environment is important for older adults.  Occupation and Older Adults Living in L T C Facilities Jirovec and Maxwell (1993) found that nursing home residents desired more choice than they perceived they had while living in a facility, especially those residents who were less independent in their function. Thus residents who were more dependent for care perceived they had less control and they had lost the desire to control aspects of nursing home living. The significance of the environment on occupation was demonstrated in an ethnographic study by Jongbloed (1994), which explored one person's experience after a stroke. She found that the occupational performance was disrupted and influenced more by the physical and social environments than by the individual's residual physical abilities. A study by Leven and Jonsson (2002) explored how elderly residents perceived supports and constraints of the nursing home environment on their occupation performance, which is congruent with one of this study's objectives. Similar to the findings of this study, they identified continuity of activity as being important to the participants as well as the perception that the nursing home environment can  Meaningful Engagement in Long-Term Care  20  impose constraints on one's autonomy. The desire for social interaction, difficulty in making contact with co-residents and the importance of family were also similarly found, however an exploration of the meaning that occupation has for elderly nursing home residents was not explored. There has been considerable gerontology research exploring perceived quality of life and well-being for older persons, but few have focused on older adults who reside in L T C facilities (Engle, Fox-Hill, & Granery, 1998; Jirovec & Maxwell, 1993). Further, occupational therapy research is limited regarding the meaning of occupation for, and its influence on the health of, seniors with mental illness (Rebeiro, 1998), cognitive disabilities, and / or those living in L T C facilities.  Conceptual Approach The initial phase of designing a qualitative research study is to frame the study within a philosophical and theoretical framework that will guide the research process (Creswell, 1998). In qualitative, inductive research, theory can be derived from data and analysis or used to explain the collected data. In the former, theory is developed from the relationships and patterns interpreted in the data, which are then measured against data by testing hypotheses (Mason, 1996; Morse & Field, 1995). In the latter, developed theories are used to explain the data by relating analysis to a larger body of knowledge (Mason, 1996). While qualitative researchers play a significant role in the construction of theory, using developed theory provides a framework for the researcher to examine the data (Morse & Field, 1995). In this study, the role of theory was to guide the research process and demonstrate how theoretical concepts are grounded in the data (Morse & Field, 1995). Continuity theory and the emerging discipline of occupational science provided this study's theoretical framework.  Meaningful Engagement in Long-Term Care  21  Continuity Theory Continuity theory is a psychosocial theory of aging, described as an adaptive strategy that suggests older people rely on past experience to meet daily living challenges associated with normal aging (Atchley, 1989). The basic premise of continuity theory is that individuals attempt to adapt to and make choices concerning change by preserving existing structures and using strategies that are associated with their past experiences (Atchley, 1989; Hill, Thorn, Bowling, and Morrison, 2002; Jackson, 1996; Onega & Tripp-Reimer, 1997). According to this theory, older adults will essentially draw from their personal histories in making decisions about current and future problems in daily life (Hill & Thorn, 2002). For many older adults the extent to which they maintain a connectedness to their past, within new situations, will influence success as they age (Carlson, Clark, & Young, 1998).  Continuity is a subjective experience that is promoted by "individual preference and social approval" (Atchley, 1989, p. 183), and achieved by maintaining stability and connectedness with society (Jackson, 1996).  Older adults may vary in their need to maintain a sense of  connectedness to their past (Carlson, et al., 1998). Thus, some older adults living in L T C facilities may feel a balance between continuity and change (or sufficient internal and external continuity), while others experience severe discontinuities. Continuity can be described as being too little, too much or optimum (Onega & Tripp-Reimer, 1997). Having too little continuity exists when change has made life chaotic and unpredictable. Too much continuity may mean that life seems stagnant or lacks stimulation. Optimum continuity is achieved when change is congruent with a person's interests and coping abilities, and the social expectations or demands  Meaningful Engagement in Long-Term Care  22  (Onega & Tripp-Reimer, 1997). The goal is for people to adapt to change without causing discontinuity.  Continuity theory was supported in the qualitative study by Rudman et al. (1996), which explored seniors' perspectives on aging. The authors supported the proposition that successful aging was an individualized process characterized by different levels of activity (Rudman et al., 1996). Furthermore, they found that participants reported a sense of continuity and achievement of personal growth. The authors suggested the need for further exploration of seniors' perspectives of activity, for "a more in-depth understanding of the ways in which activity can be associated with a sense of continuity" (Rudman et al., 1996, p.647).  Continuity theory of aging may explain why an individual chooses or values the occupations that she/he does, because it considers the individual's personality and past life experience. Onega (1997) proposed that research identify ways in which interventions and services may be linked with personal meanings that provide individuals with continuity. As one's personality influences role activity and life satisfaction (Burbank, 1986), personal meanings are connected to the activities or occupations that one chooses. Exploring the meaning of occupation from the perspective of the older adults living in these institutions was therefore significant in meeting the needs of the aging population within the L T C system. To enable those who do experience discontinuities, an understanding of the role of occupation in achieving health and well-being is required, and provided within the framework of occupational science.  Meaningful Engagement in Long-Term Care  23  Occupational Science Occupational science grew out of the recognition that occupation is significant to all people and there is a need for a basic science to support occupational therapy practice (Yerxa et al., 1990). Yerxa et al. (1990, p.6) describes occupational science as "the study of the human as an occupational being including the need for and capacity to engage in and orchestrate daily occupations in the environment over the lifespan". Occupational science has also been defined as the "systematic study of form, function, and meaning of occupation" (Jackson, et al., 1998, p.327). Occupational science emphasizes the role that occupations play in affecting health and well-being, and highlights the importance of understanding the meaning of these occupations forthose who engage in them (Jackson, et al., 1998).  Within the science of occupation, occupations are defined as "chunks" of activity that are culturally and personally meaningful, and which interact with and evolve within the larger sociocultural and environmental context (Jackson, et al., 1998; Yerxa et al., 1990). Yerxa et al. (1990) described occupation as a complex multidimensional phenomenon. The complexity of this construct lies in the value and meaning that occupations have for people, and how engaging in occupation affects one's health and well-being. Health from an occupational perspective is defined, in part, as, "a balance of physical, mental, and social well-being attained through socially valued and individually meaningful occupation" (Wilcock, 1998, p.l 10). In order to appreciate the meaning of occupation for individuals, it is important to understand how people occupy their time, their satisfaction with the use of that time, and how well their values and goals are supported during that use of time (Yerxa, 1990). The meaning of an occupation is therefore, a personal, subjective experience that lies with the person who chooses the activity and is  Meaningful Engagement in Long-Term Care  24  influenced by the context in which it is performed (Henderson et al., 1991). Yerxa et al. (1990) claimed that the discipline of occupational science provides a framework for studying a person's experience of engaging in occupation. A n occupational science perspective demonstrates that enabling engagement in meaningful occupations can respond, at least in part, to the discontinuities that older adults experience living in a L T C facility.  Occupational science is grounded in the notion that individuals are occupational beings and thus are driven by the need for and capacity to be engaged in occupations (Wilcock, 1990; Yerxa, 1990; Zemke & Clark, 1996).  Occupations are embedded in people's lives and their  meanings depend on the context in which they are performed (Zemke & Clark, 1996). For instance, in the study of the 'Well Elderly Treatment Program', the authors employed occupational science principles presuming that the ability to experience meaning in the context's of one's occupation was key to successful aging (Jackson, et al., 1998). Further, in a qualitative study of the adaptive strategies of the elderly, Jackson (1996) found that the desire to be engaged in meaningful activity was expressed by all participants. According to Wilcock, (1998), engagement in occupation needs to have meaning and be flexible to evolve according to context and choice, for health and well-being to be experienced.  A second theme in occupational science is that identity is shaped by daily patterns of occupation, and that when there is a disruption, such as in the result of disability, individuals will redevelop meaningful lives by drawing on past occupations (Zemke & Clark, 1996). In this way people create continuity in their new situation. Thus occupational science and continuity theory are congruent when framing older adults' activity choices in L T C facilities.  Meaningful Engagement in Long-Term Care  25  That occupations can either facilitate or limit the capacity of the person to successfully adapt to the environmental challenges is a third theme within occupational science (Clark et al., 1991). A n understanding of the dynamic relationship between the person, as an occupational being, and the environment is fundamental to the science of occupation (Clark et al., 1991). The concept of 'flow' is significant to occupational science as it relates to the experience of engaging in occupation. 'Flow' is achieved when an activity is balanced between self-perceived environmental challenge and skill (Yerxa et al., 1990). It is therefore similar to the notion of balance, and when perceived balance in an activity is achieved, it is considered to provide people with the 'just right challenge', or an optimum state of engagement (Yerxa, 1990). Happiness and self-esteem, aspects of work and productivity and, the enjoyment of leisure and life satisfaction relate to the concept of flow (Clark et al., 1991), which suggests that when the 'just-right challenge' is provided during an activity, individuals are most satisfied, motivated, and feel a sense of efficacy and life affirmation (Yerxa et al., 1990).  If older adults living in L T C facilities achieve a sense of control over their daily occupations, their lives will be more meaningful and enjoyable (Carlson et al., 1998). The ability to exercise control over aspects of one's life was strongly correlated with good health, psychological well-being and life satisfaction (Carlson et al., 1998). Jackson (1996) explored adaptive strategies in the elderly and found that participants expressed the importance of maintaining autonomy as an adaptive strategy to aging. Control was also identified as a theme in Jirovec and Maxwell's (1993) study that found a relationship between perceived choice and functional dependence. Residents who were more dependent for care not only perceived they had less control, but also lost the desire to control aspects of nursing home living. A n  Meaningful Engagement in Long-Term Care  26  occupational science perspective provides insight into the importance of daily engagement in meaningful occupations for residents who may be trying to maintain continuity as they adapt to change in their functional abilities and living environment.  Together, occupational science and continuity theory offered a critical framework for examining aspects of function, quality of life, and 'normalcy' for older adults who reside in LTC facilities. Existing literature provides strong evidence that meaningful engagement in occupation (of choice) positively influences physical and mental health (CAOT, 1994; Clark et al., 1997; Gregory, 1983; Hachey & Mercier, 1993; Law et al., 1998; Rebeiro, 1998; Rudman et al., 1996; Yerxa, 1998). The significance of occupation lies in the perspective and meaning held by individuals in a particular context (Hachey & Mercier, 1998; Krefting, 1989). However, none of the studies have examined the meaning of occupation for L T C facility residents. A better understanding of the meaning and value of occupation for this population was necessary to enable personally meaningful engagement for residents, and in turn, promote their health and well-being.  Meaningful Engagement in Long-Term Care  27  Chapter 3: Methodology The purpose of this study was to better understand what meaningful occupational engagement is for older adults living in L T C facilities. Using qualitative methods, this study explored participants' occupational life history. Narrative approaches and semi-structured indepth interviews were used to explore participants' view of 'occupation', in terms of its meaning in their daily life. Analysis of participants' interviews demonstrated how their past and present occupations matter to them, and how engaging in these occupations is influenced by elements of the environment.  Narrative Approaches in Qualitative Research Qualitative research traditions have evolved from the concern of how to best study and represent human life and human action as meaningful, and therefore, broadly seek to answer questions that concern experience and meaning of social phenomena (Oreswell, 1998; Hammell, Carpenter, and Dyck, 2000; Morse & Field, 1995). Research within the qualitative paradigm is aimed at describing or understanding the meaning or experience of phenomena for particular people within a specific context. The fundamental concern of qualitative research is to understand and describe how people make sense of their lives, and thus it explores their perceptions and everyday realities (Hammell, Carpenter & Dyck, 2000). Because of its approach to the human sciences, qualitative inquiry has become popular within health research and is being used in occupational therapy practice. For instance, there has been an increasing interest in health professions to elicit stories from clients in order to appreciate the illness experience, and to further client-centered practice (Mattingly, 1991).  Meaningful Engagement in Long-Term Care  28  Qualitative methodology comprises various approaches and data collection techniques that can be used in investigating a research topic. While all methodologies conclude in an interpretation of particular phenomenon, choosing among them depends on the nature of the research problem, the philosophical and theoretical perspective, and what, specifically, the researcher wants to discover (i.e. the researcher may want to know about the participant's experience, meaning, practice or story about some phenomenon) (Creswell, 1998). The narrative approach is one methodology of qualitative research.  Narrative approaches to research allow us to understand phenomena from an individual's unique point of view or personal life story. Narrative is the means by which we shape our understanding and make sense of life experiences and events (Josselson and Lieblich, 1995). People's narratives, or stories, contain personal meaning and are constructed within the context of their lives, experiences, and positions in the world (Josselson and Lieblich, 1995). Narratives are a 'meaning making system' that allows an individual to make sense of a phenomenon, through the stories of their perceptions and experiences of that phenomenon. They are concerned with the likely connections among specific events and social meaning is contained in the depth and complexity within people's accounts and experiences (Mattingly, 1991; Mason, 1996). Further, narratives are shaped and reshaped or interpreted and reinterpreted throughout life (Josselson and Lieblich, 1995; Riessman, 1993). An individual's particular narrative is therefore a reflection of their story in the context of that time, or their story at that moment in time and place (I. Dyck, personal communication, September, 18, 2000a).  Meaningful Engagement in Long-Term Care  29  Narrative approaches are concerned with life as it is experienced now and on a continuum (Jean & Connelly, 2000). This study concerned elderly people who experienced a life transition from independent to institutional living, and therefore, narrative methodology worked well with its conceptual approach, continuity theory and occupational science, which provided a framework for understanding how these persons adapted to their new living environment and created meaningful experiences. In meeting the needs of the aging population within the L T C system, the meaning of occupation must be explored from the perspective of the people living in these institutions and can be achieved through qualitative research, using narrative approaches.  Research Design Hammersley and Atkinson (1995) described the study design as the pre-fieldwork phase of research but, according to the authors, the development of the research problem and the elements of design may not be completed before the fieldwork begins as the collection of primary data often shapes its development. During the design phase the researcher should become clear about what the essence of their inquiry is, that is what the nature of the phenomena being studied is (Mason, 1996). The researcher should also consider how the research questions and chosen methodology link with specific methods or techniques. Finally, considerations should be made so that the development of research questions, as well as data collection and analysis are carried out in an ethical manner (Mason, 1996). Specific considerations of design include formulating the research problem, choosing the methodology and methods, and selecting the research setting and cases. The research problem and chosen methodology are discussed above. This section will discuss the elements of this study's design, including criteria for participant selection, recruitment, interviews, participant profiles, data analysis, and trustworthiness of the findings.  Meaningful Engagement in Long-Term Care  30  Pilot Interview A pilot interview was conducted with one voluntary older adult who resided in a L T C facility and met the participant selection criteria. The purpose of the pilot interview was to ensure that the interview questions made sense for and were relevant to study participants. The pilot interview was helpful in developing the interview questions that were used in the study.  The pilot interviewee also attended the Vancouver Community Mental Health Services' Geriatric Rehabilitation Program (the Bright Spot), which is part of the Vancouver Coastal Health Authority. At the time of this pilot interview, the supervisor of the Bright Spot provided clients of the program with a written letter about the study and described to them the purpose of the pilot interview. Congruent with participant selection criteria, the program clients that were eligible for the pilot interview included older adults who resided in a L T C facility for no more than two years and could have participated in a semi-structured in-depth interview. As I worked with the Bright Spot program in my clinical practice, the potential participants for the pilot interview knew me but were not one of my direct clients. The participant that volunteered to engage in the pilot interview was understood its purpose and agreed to provide the researcher with feedback on the questions in the interview guide. This participant's feedback was that the questions were clear and understandable, relevant to her life experiences, and made sense regarding her understanding of the research purpose. She also reported that she enjoyed the process of the interview.  The pilot interview was not used in the analysis of the study because it was found that the interviewee lived in a facility for more than two years (two years and four months). Selection  Meaningful Engagement in Long-Term Care  31  criteria for the participants included individuals who have resided in a L T C facility for no more than 2 years. The rationale for this and other criterion will be discussed in the next section.  Criteria for Participant Selection Participants were older women and men over 65 years of age who resided in any L T C facility within the Vancouver region. Participants needed to have lived in a L T C facility for no more than two years of the date of their participation in this study (i.e. the date of the initial, 'screening', visit), with at least 3 months time to adjust to living in a facility. Thus, all participants had been living in a L T C facility (not necessarily their current facility) for no more than two years and no less than three months (i.e. between 3 months and two years). This criterion was intended to achieve some consistency across participants' construct of occupation, as the meaning of occupation for an individual will change over time. It was intended, through the interview questions, that during their interview, participants would conceptualize daily life when living independently and make comparisons with their current experience of living in an institutional setting (i.e. contrast what life is like living independently and in an assisted setting).  Participants could have had some degree of cognitive impairment but had to be able to participate in an interview with open-ended questions, for a minimum of 30 minutes at one time. Because cognitive impairment exists on a wide continuum and further, not all elderly people living in nursing homes have dementia, an ethical solution to interviewing older adults who reside in nursing homes is to "screen" participants in a pre-informal interview. It has been suggested that for participants whose mental capabilities are impaired or fluctuating, the researcher should include an assessment of mental status, in the procedures at the time consent is  Meaningful Engagement in Long-Term Care  32  obtained (Gift, 1993). Once a potential participant expressed interest and signed the consent form (Appendix A), eligibility of the interested participant was confirmed through an initial screen conducted by the researcher. This consisted of an informal meeting aimed at explaining the purpose and process of the study, as well as administering a cognitive screen, the Mini Mental State Examination (MMSE) (McDowell, Kristjansson, Hill, & Hebert, 1997). The screen aimed to determine the interested participant's cognitive capacity to participate in the study. The initial visit also helped to establish rapport and diminish potential anxiety that the participant might have prior to participating in the research interview.  The participant's cognitive ability to participate in the study was determined by a designated cut-off score of the reliable and valid M M S E (McDowell, Kristjansson, Hill, & Hebert, 1997). Using the Mini Mental State Examination (MMSE), Phinney (1998) found that her research participants scored in a range (17-23 out of a maximum of 30) that was consistent with mild to moderate levels of dementia. She demonstrated that individuals with mild to moderate dementia could participate in a qualitative study concerning the experience of living with Dementia. Even within this range, there was variation in individuals' cognitive capacity. The cut-off score for this study was initially chosen based on findings of Phinney's (1998) study, and thus participants who scored above 17/30 were considered eligible. Except for one person, all participants scored 22 and above on the M M S E . Following administration of the M M S E with interested and potential participants, it was found that people who scored in the upper end of this range (i.e. 22 and above) understood the purpose of the study and were able to engage in a conversation based on a semi-structured interview. The one potential participant who scored 20 on the M M S E had difficulty with this, and had to be re-directed to the topic of conversation  Meaningful Engagement in Long-Term Care  33  several times during the screening visit. Thus, with agreement of the thesis committee, the eligibility cut-off score was reset at 22 and the participant who scored 20 was not considered eligible to continue with this study. More information regarding the profiles of the participants will be discussed below, in the section titled, "Participant Profiles". The intent was to interview up to ten participants, or until no new themes were emerging. Recruitment continued until nine participants were interviewed.  Recruitment Three letters of recruitment were devised; the first for the V C M H S Geriatric Service staff, the second for the L T C facility Directors of Care, and the third for potential participants/ L T C facility residents (Appendix B).  During the time of recruitment and data collection I practiced as an occupational therapist with the Vancouver Community Mental Health Services (VCMHS), of the Vancouver Coastal Health Authority. There are seven mental health teams in the Vancouver region that serve a specific geographic / catchment area. Each team has a geriatric service where outreach services are provided to older adults over 65 years of age, including those who reside in L T C facilities. Participants were recruited with the assistance of the V C M H S Geriatric Teams because of their relationships with the Vancouver region's L T C facilities. As I practiced with one of the seven teams, potential participants were not eligible i f they were current or previous clients of mine. The study was presented to the geriatric service staff of V C M H S and copies of a letter explaining the purpose and process of the study were handed out. The V C M H S Geriatric Service staff was  Meaningful Engagement in Long-Term Care  34  asked to share recruiting letters with the Directors of Care of the L T C facilities that they consult with, in addition to any of their clients who fit the study criteria.  Once the Directors of Care received the recruitment letter a follow-up telephone call by the researcher was made. As the Directors of Care were not being asked to participate in the study, there were no ethical concerns regarding direct contact by the researcher. Through this telephone contact, the Directors had the opportunity to ask any questions they had about the study and were asked to share the recruitment letters with residents in their facility (either by posting or handing out the letters). Interested participants were able to contact the researcher directly, through their V C M H S case manager, or a staff person in their L T C facility.  One month following the presentation to V C M H S staff there were no recruited participants. Upon discussion with V C M H S staff it was found that many people felt unable to assist in recruitment due to reported workload intensity. Thus, recruitment required that the researcher call many facility Directors' of Care who did not know of the study, and fax them the recruitment letters. This required additional follow-up telephone calls and ultimately residents were aware of the study and potential participants began to make contact with the researcher. Recruitment continued until nine participants were interviewed and no new themes were emerging from the data. The recruitment and data collection phase was approximately six months in duration.  Meaningful Engagement in Long-Term Care  35  Data Collection / Interviews Qualitative interviewing usually refers to in-depth, semi-structured or loosely structured forms of interviewing (Mason, 1996). Data in narrative approaches to research are the stories themselves and are typically collected via in-depth interviews (Riessman, 1993). Semistructured in-depth interviews were conducted with nine participants, between the period of July 6, 2001 and November 19, 2001. Interview questions were developed and used as a guide to facilitate the interview (Appendix C) however, during the interview, many responses were probed for added depth and understanding of the topic or issue being shared by the participant. Responses were also often paraphrased to clarify or confirm participants' reply to a question. Questions were phrased in everyday language and concerned the participants' experiences, thoughts, and feelings regarding their occupational engagement. Participants were asked about their occupational history, current daily occupations, and perceptions of health, aging and the LTC facility environment. The interviews were audiotaped and transcribed verbatim.  Data collected also included field notes, which included any relevant written descriptions made during the research process, for instance, to describe the interview process, context and, other relevant information not captured on audiotape (Morse & Field, 1995). Following each interview, I reflected upon my perception and impression of what occupation means to that participant and this was recorded within the field notes. During this process of reflection, I asked myself questions such as: What drives his or her current occupational choices? What does he/she designate most of their time to? What does he/she want to do at this point in his or her life?  Meaningful Engagement in Long-Term Care  36  Participants were offered the opportunity to be interviewed in the place where they reside (i.e. their care facility) or another environment of their choice. A l l participants had a private room within the facility, in which all of the research interviews were conducted. The interviews typically lasted one to two hours. If required, for example, because of fatigue, participants were offered the opportunity to conduct their interview over two sessions, but all participants completed their interview in one visit. With the initial screening visit, the in-depth interview, and an additional visit requested by two participants, there were a total of 20 visits with nine participants.  Participant Profiles A l l names used within the study findings are pseudonyms, chosen by the participants. Participants included 7 women and 2 men, between 72 and 94 years of age. Five different facilities are represented in the study, as participants lived in one of these five residences. Five additional people expressed interest in the study and three of them were met for a screening visit. These five residents did not meet the inclusion criteria because three of them were living in facility for over two years and the other two scored below the designated cut-off point of the MMSE.  A l l participants were widowed or divorced, except for one man who is married. His wife continues to reside in their home. Prior to moving into a care facility most participants had stayed in their homes or moved from home into a seniors' semi-independent living situation, and only one person moved in with a relative before living in a nursing home. The list of participants' impairments included loss or limitation in hearing, vision, strength, balance,  Meaningful Engagement in Long-Term Care  37  memory, and the presence of pain, shortness of breath, and bone fractures. The diagnoses they spoke of included Blindness, Cancer, Diabetes, Parkinson's, Heart Disease, Arthritis, and Osteoporosis. While none of the participants disclosed having a diagnosis of Dementia, a few spoke about their memory loss and difficulties with cognitive functions such as organizing and planning abilities. Despite their identified limitations, all participants were not significantly cognitively impaired and were physically mobile, some with the use of a walking aid or wheelchair.  Past vocations included nursing, homemaker, clerical worker, social worker, labour relations officer, store owner, hotel manager, construction worker and volunteer. Significant hobbies consisted of painting, singing, taichi, bridge, sewing, weaving, gardening, craft-work, and reading. Two participants spoke about their life-long involvement with a Church or religious affiliation. The following table highlights the profile of study participants.  Pseudonym  Age  Marion (pilot)  94  Time living in a facility 2 yrs 4 months  Margarita  85  5 months  Homemaker / music, choir  22  July 13, 01  Gormy  79  6 months  Labour relations officer / taichi, bridge  29  July 9, 01  Helen  84  3 months  Clerical / sewing  23  Oct 29, 01  Cayin  89  1.5 years  Social Work, missionary / pottery, weaving  29  Aug 6, 01  Gerry  78  1.5 years  Nurse / gardening, scrapbooks  28  Aug 8, 01 & Dec 5,01  Vocation / Hobby Nurse / painting  MMSE score 23  Interview Date June 11/01  Meaningful Engagement in Long-Term Care Anne  94  1 year and 4 months  Craft store owner and art teacher, formal volunteer / paper tolling, crafts  26  Aug 31, 01 & Sep 10, 01  Steven  84  1 year and 6 months  Hotel man. / reading  23  Sep 12, 01  Ben  72  9 months  24  Sep 23, 01  Doll  85  3 months  Construction / church deacon Clerical / formal volunteer  23  Nov 21, 01  38  Data Analysis Analysis of the data was thematic involving the search for and identification of common threads of meaning (Morse & Field, 1995). An interpretive, inductive analysis of the data was made through repeated listening to the audiotapes and thorough readings of the transcripts. Field notes were incorporated in the process of analysis. Throughout the analysis phase, notes, known as analytic memos, were kept to record thoughts and reflections about the data, and review and develop the analytic ideas that emerged through the process of data collection (Hammersley & Atkinson, 1995).  Manual methods were used to manage the data and its emerging themes, such as colorcoding the transcripts using highlighters and colored post-it notes, (Morse & Field, 1995). According to Jackson et al. (1998), themes of meaning are embedded within one's occupation as they guide the manner in which occupations are chosen and performed. Each transcript was manually coded listing the occupation talked about by the participant and his or her sentiment regarding the particular narrative. These codes were listed on computer and then collapsed into a shorter list, by grouping codes that were similar. In the collapsed list, the number of participants  Meaningful Engagement in Long-Term Care  39  who reflected the code (i.e. the particular occupation or sentiment) and the number of times it was initially coded was recorded. For instance, the code "independence" was reflected by all participants and was coded thirty times throughout the transcripts. Themes evolved from this coding process.  Five initial themes emerged and the codes from the collapsed list were grouped under one of five themes. Within the transcripts, participants' verbatim quotes, used to represent the five emerging themes, were bolded on computer and then color-coded with highlighters. The relative importance of the themes was made evident by the number of participants who spoke about the topic as well as by the emphasis given to it by each person. The final themes evolved during the process of writing the chapters about the study findings.  Trustworthiness Trustworthiness and credibility (truth value) were ensured by involvement of the participants and of the thesis supervising committee, because it is the researcher's responsibility to report the perspectives of the informants as clearly and accurately as possible, (Morse & Field, 1995; Krefting, 1991). The strategies for assessing the quality and merit of this research included, but are not limited to, researcher reflexivity, peer review, and revisits to participants, also known as 'member checking' (Carpenter & Hammell, 2000).  Researcher Reflexivity Current issues faced by qualitative researchers include the influences of their social position on their relationship with participants, and how data is constructed and interpreted  Meaningful Engagement in Long-Term Care  40  (Hammersley & Atkinson, 1995; Mason, 1996; Mishler, 1986). Becoming aware of the influences of one's social position is achieved through the notion of reflexivity. Reflexivity is based on the belief that the researcher cannot be neutral or separate from the knowledge or evidence generated, and therefore should try to understand her or his role in the research process (Mason, 1996). As stated by Jean and Connelly (2000) "we know what we know because of how we are positioned" (p. 17). Reflexivity is, essentially, self-awareness and awareness of the relationship between the researcher, participant and environment (Hutchinson & Wilson, 1994).  Throughout the research process, I have attempted to be reflexive about my position and how it influenced the collection and analysis of the study data. Issues that required reflection on included my professional values and interests as an occupational therapist, my assumptions about older people's experience living in a nursing home environment, the factors that influenced participants' consent to participate in the study and the stories they chose to tell me, and my ability to cope with the emotions elicited during the research process.  As an occupational therapist, I was influenced by my professional values and beliefs such as, occupations give meaning to life and are important determinants of health and well-being, and every person is unique, can make choices in life and both shape and is shaped by his or her environment (CAOT, 1997). Furthermore, practice should be client-centered, with the belief that clients have experience and knowledge about their occupations (CAOT, 1997). My clinical experience working in the field of geriatric mental health influenced my interest in contributing to this study topic, especially as I discerned that my clients who resided in L T C facilities were often not engaging in the activities that they reportedly desired and felt capable of. Five  Meaningful Engagement in Long-Term Care  41  assumptions based on my clinical experience and review of the literature supported the value for this study and required reflection. They are: 1. Occupations contribute to health 2. There is a dissonance between what people are used to doing and what they do when living in L T C facilities 3. The nursing home environment can construct daily barriers for elders to engage in meaningful occupations 4. Depression can result from the lack of opportunity, within the nursing home structure, to choose and engage in meaningful activities 5. An environment that enables elders to engage in meaningful occupations will positively influence health  These values, beliefs, interests, and assumptions shaped the areas of inquiry in the interviews (i.e. participants' occupational history, perceptions of health, aging and the L T C facility environment). Asking questions that I felt I knew the answers to, paraphrasing responses for clarity, and prompting responses for confirmation of participants' meaning are examples of how I tried not to let my own perspective impact what data I 'chose' to collect and how I interpreted its meaning. I tried also to facilitate the interviews so that participants were encouraged to choose the stories they wanted to share as well as guide the direction of the schedule. This strategy was important to ensure that participants' perspectives on the topic were sought versus confirmation of my own assumptions (O'Brien, unpublished thesis, 2001).  Meaningful Engagement in Long-Term Care  42  It needs to be acknowledged that older adults who reside in nursing homes may consent to participate in a qualitative study because of the perceived opportunity for social contact and to talk to someone that will listen. It was suggested that nursing homes are plagued with loneliness, helplessness, and boredom (Thomas, 1996). Mitchell and Radford (1996) explained that personal disclosures might result because "participants perceive an opportunity to unburden themselves of information that has been causing them grief (p.53). Higgins (1998) found that residents' loneliness, the need for intelligent conversation, and the need to talk about their aches and pains often led to long, intimate discussions, which provided her participants with much- . needed respite from nursing home routines. Consequently, the process of qualitative interviewing is in some ways parallel to therapeutic, counseling interviews and the relationship built between the researcher and interviewee was an ethical issue in that there was the potential for harm.  The intimacy of the relationship built in the process of the interviews provided me with an ethical responsibility to consider and handle potential harm of participants. Similar to a therapeutic interview, the components of a qualitative interview include interpersonal rapport, positive regard, trust, unconditional listening and a guaranteed anonymity (Denzin & Lincoln, 1994; Mitchell & Radford, 1996). Interviewing older adults about their occupational life history and how it relates to perceptions of their health, happiness, loss, and current situation were likely to evoke many emotions. Prior to conducting the interviews, I considered that participants may disclose personal information that caused them emotional pain and it was my responsibility to respond to participants' needs and emotions. If an interviewee risked mentioning a sensitive issue, it was my responsibility to acknowledge and explore it (Mitchell & Radford, 1996). The  Meaningful Engagement in Long-Term Care  43  therapeutic skills that I used included demonstrating empathy and support as well as making decisions such as when to stop the interview. While it was important for me to maintain my role as researcher, my skills as a therapist were beneficial in handling these potential emotions and responding to participants' needs (i.e. for more support of health care professionals or family, answers to practical questions and concerns, information about community resources). Fortunately, there were no serious related concerns noted during the interviews.  Other factors that may have influenced the stories participants chose to tell me included my relative youth, my gender, my experience and therefore, comfort with interviewing older people, and my "therapeutic use of s e l f (i.e. sharing my own experiences where appropriate in order to foster rapport). Throughout the research process, I reflected upon these issues and their impact on data collection, analysis, and presentation of the findings. I suspect that my young age was a barrier to what participants shared about their lives, at least in the beginning of the interviews, because it influenced what they believed I could appreciate about their experiences as older people. I also believe that being a woman with experience and comfort in interviewing older people eased participants' ability to share their stories and reflections with me. Further, as an occupational therapist I found myself, at times, switching into my professional mode of thinking and trying to assist participants in finding solutions to their needs and interests. As a result, the interviews were, for brief times, solution-focused, which impacted the direction of the interview until the next question was asked.  Meaningful Engagement in Long-Term Care  44  Peer Review Throughout the research process, the thesis committee provided feedback regarding data collection and analysis. M y thesis advisor has expert experience in qualitative research, and the two other committee members have expertise in research and the field of Geriatrics. M y thesis advisor reviewed two random interview transcripts, which helped me to clearly articulate my perspectives and reasoning, and define the categories that I interpreted in my analysis (Carpenter & Hammell, 2000). Coding methods were also discussed with my thesis advisor. A l l members of my thesis committee provided feedback on preliminary findings of the data. Furthermore, three research papers were completed as part of the thesis course work, which concerned aspects of the study, such as the theoretical framework used to guide the study, chosen methodology, and ethical considerations for doing qualitative research with this particular group of people. The feedback provided by the thesis advisor on all of these papers facilitated the study's rigour.  Member Checking A l l participants had the opportunity to provide feedback during the process and outcome of data analysis, in order see how their narratives were being used and to give feedback on this interpretation. In addition, participants were offered a copy of their interview transcript and the opportunity to review it, in order to clarify statements and add any additional information to their interview data. Three people requested a copy of their transcript and two asked for a follow-up visit to review, clarify, and add information to their interview data. Participants were also given the opportunity to meet and discuss the outcome of analysis, specifically with regard to how the findings reflect their own experiences (Dyck, personal communication, November 18, 2002).  Meaningful Engagement in Long-Term Care  45  Two participants expressed interest in doing so and were met individually after a draft of the study findings were written (approximately one year from the date of their research interview). A two-page summary of the study findings was written from the point of view of "the story that was told by participants" and a copy was given to Cayin and Anne, who participated in reviewing the data with me, one week prior to my visit with them. Both women were asked to read the summary and consider if and how the information reflected their own experiences. Cayin and Anne were in the main pleased with what they read regarding the study results. They felt that the information was thorough and a true reflection of their experiences. In particular, they both appreciated the themes of meaningful occupation. The feedback from these two participants varied regarding how the contextual themes of "loss", "constraint" and "opportunity," were important to their meaningful occupational engagement. For example, Cayin reported that she tries to forget her losses and not allow them to influence what is meaningful to her. In this way, she felt that the losses she has experienced did not significantly influence her occupational choices. Further, Anne did not agree that her facility environment imposes constraints on her ability to do what she chooses. She said that many fellow residents feel constrained because they possess a negative attitude about living in a nursing home and that having a positive attitude helps her to accept and enjoy living in a nursing home. She reported that her facility offers many opportunities and that "one needs only to take advantage of them". Both of these women expressed that a having a positive attitude helps them to cope with and accept their situation and, to some degree, sense independence.  Meaningful Engagement in Long-Term Care The process of reflexivity, combined with peer review and member checking have enhanced the rigour of this study and thus, the trustworthiness of the findings. The next two chapters present the study results, which are developed around identified themes.  Meaningful Engagement in Long-Term Care  47  Chapter 4: Life in a Long-Term Care Facility: A Story of Loss, Constraint, and Opportunity  And when I came here I found that, well I had to be ready to come in here. Doll  The women and men who participated in this study reflected on their lives during the interviews, by sharing and evaluating their life's experiences, roles, and relationships. When asked about their current daily occupations, participants primarily relayed stories of daily experiences and described their personal struggles and perceived opportunities.  Initially the focus of the study was to identify categories or themes of meaningful occupation, and then to explore how the LTC environment enables and/or constrains the ability for participants to engage in meaningful occupation. During the process of analysis however, it became evident that the meaning of occupation could only be understood within the context of participants' experience of living in a L T C facility. Participants described meaningful occupations as those that that they choose and desire to engage in, in relation to their age, abilities, and living environment. It was apparent that the occupations that they described as meaningful were influenced by their functional and environmental circumstances. As expressed by Henderson et al., (1991), the meaning of an occupation is a personal, subjective experience that lies with the person who chooses the activity, influenced by the context in which it is performed.  The research findings are presented in two chapters. This first chapter sets the context of what life is like for these older adults living in a L T C facility. It is organized into three main sections or contextual themes: loss, constraint, and opportunity, which together impacted  Meaningful Engagement in Long-Term Care  48  participants' adjustment to institutional living and influenced their occupational choices. The impact of various aspects of the L T C facility environment will be discussed within the context of their experienced losses, constraints and opportunities. Appreciating the position of L T C facility residents is vital for understanding the meaning that occupation has for them. The second chapter will demonstrate themes from the data concerning participants' meaningful occupation.  Description of Participating L T C Facilities A LTC facility is a residential care facility for people who have long-term health needs that are not possible to manage living at home. Residential care provides twenty-four hour professional care and supervision for day-to-day living and older adults are the primary residents of these L T C facilities. Types of residential care settings in the Vancouver Health region include Intermediate Care (IC) facilities, Special Care (SC) units, Extended Care (EC) hospitals, and multi-level care facilities including IC, SC and / or EC units. Each type of facility is funded according to the care needs of its residents, which are functionally focused. Most L T C facilities are of the IC type and they include three levels of care (IC1, IC2, and IC3) that reflect the daily support needs of the residents. Prior to being admitted to a nursing home, residents are assessed (by a L T C coordinator from their local health unit) to be at a particular level of care, which increases from IC1 to IC3 in correlation with the need for functional support. For instance, residents assessed as IC1 are independent for their basic personal care activities and require assistance with activities such as cooking, cleaning, and more complex or higher risk personalcare task such as bathing. At IC3, residents require some assistance with all daily activities including basic personal-care tasks. Special Care units exist in some IC facilities and are for people with permanent memory loss who are at risk for wandering or have other difficult  Meaningful Engagement in Long-Term Care  49  behaviours. Finally, E C hospitals are those that provide 24-hour care for people with physical impairments to independence, generally, these residents use wheelchairs and cannot transfer independently.  The nine participants resided in five different IC facilities that varied in their descriptions regarding size, levels of care, room description, community amenities, languages spoken, and cultural and religious affiliation (Appendix D). The residents that co-resided in a facility were: Gormy and Margaita, Cayin, Gerry, and Doll, and Anne and Steven. Ben and Helen were the only participants from their respective facilities. The number of residents (or facility beds) in each facility ranged from 53 to 144. These facilities varied in their structure regarding the level of care available and therefore, were Intermediate Care facilities only or multi-level care facilities including Intermediate Care, Extended Care, and/or a Special Care unit. The advantage of multilevel care facilities is that they enable people to grow older with increasing care needs without having to move. The concept that refers to this type of ability is known as 'aging in place', which is considered ideal for older people's health and well-being. In each of the five facilities, the rooms available varied in terms of being private or shared, however all study participants had a private, single room. Four facilities were within walking distance (i.e. a few blocks) to a public bus stop, shops and a city park, the fifth facility was within a 5 minute drive to the neighbourhood shops. Finally, the cultural and religious affiliations of the participating facilities included Anglican, Protestant, Jewish, German, and Italian, and included residents and staff who spoke English and the language(s) representative of the predominant cultural environment.  Meaningful Engagement in Long-Term Care  50  Adjusting to Life in a L T C Facility The transition from independent to institutional living was a difficult experience for many participants. It was hoped that during their interview participants would conceptualize daily life when living independently and make comparisons with their current experience of living in an institutional setting. In reviewing the transcripts of the participants, a sense of adjustment from independent to institutional living was apparent, specifically with regard to the experiences of loss, constraint, and opportunity. It was in this context that comparisons by participants between independent and institutional living were noticeable. Anne's comment aptly illustrates the tensions of adjustment: I had to adjust to having my meals that I did not make. And uh, there's a big difference. Even though I lived alone, I didn't consider myself alone. ...The days that I felt ok, I'd look around and I knew that I was benefiting ... by living here, but I ' d stop and think what am I doing here I feel alright? And I visualize my life again in my apartment. And then maybe the next day I wasn't feeling too well and I had pain and I thought, I'm thankful for being here. But it is a very great adjustment.  Loss of energy, functional abilities (including personal care and home-management activities, social and leisure pursuits, and volunteer work), and home were evident in all participants' transcripts. A l l participants experienced loss while living independently, however, progressive decline in function ultimately resulted in facility admission. Beyond their losses, participants discussed being constrained by the LTC facility's social environment, physical space, and institutional routines and resources.  Meaningful Engagement in Long-Term Care  51  Often participants' stories of daily occupation concerned the L T C facility environment itself. Many participants described the ways in which various aspects of the nursing home environment both enabled and constrained their ability to engage in meaningful occupations. The prominent influences of the social environment included participants' experience of isolation, limited meaningful relationships, social discomfort, and lack of stimulation. The physical environment imposed personal space constraints, especially for individual leisure pursuits. And the institutional setting of a care facility, which is designed around a daily routine of personal care and social activities, often constrained participants' ability to maintain the independence they had for certain meaningful activities.  Despite these barriers, many participants spoke positively about the opportunities afforded by living in a L T C facility. The opportunity to contribute to and help others as well as feel safe and secure in day-to-day life was very clear. Thus participants valued both support for daily living and their independence, and the meaning of occupation was influenced within the context of the losses, constraints and opportunities they experienced.  Loss The notion that people will experience loss as they age seems reasonable. Older people commonly experience declining functional ability, age related illness and, the death of friends and family members (Harvey, 2002; Thompson, 1998). When older adults experience health problems compounded by the loss of support networks of relatives and friends and changes in life roles, such as the role of parent, spouse or worker, they can become marginalized within society (Harvey, 2002). Believed stereotypes of older people often result in a minimized value  Meaningful Engagement in Long-Term Care  52  for older persons (Harvey, 2002). It seems understandable, therefore, that the aging process sometimes involves the loss of meaning, health and hope (Harvey, 2002). Participants in this study provided insight into how the experience of such losses is shaped in the context of a L T C facility. When talking about their daily occupations all participants spoke about their experiences with loss, specifically including loss of energy, functional abilities, and home.  Energy A pervasive element of loss among all participants was the loss of energy they felt, and its effect on their daily lives. The increasing need for rest was reported so consistently across interviews that an occupational theme of 'rest' was initially interpreted. As Cayin reported, "I'm realizing that you can sleep all day and still sleep at night. I'm sleeping a lot more than I did." She also felt that she should do more activity in her day when she said: "So I always have things either I should do or I can do or I want to do. But now I am getting too lazy. .. .1 think I'm wearing out." As the analysis progressed, it became apparent that the loss of energy experienced by participants interfered with their ability to engage in meaningful occupations and in this way rest was more a necessary activity than it was a chosen one. Margarita explained how her lack of energy limits her ability to garden, an activity she was very fond of, when she stated: Oh I used to have a little garden at home and used to love patching in that. We do have a gardening day here you know where you can join in. I did a couple of plants on the front balcony. ... I find I just haven't got the energy to do it now. Most participants plainly stated that they do not have the energy levels that they once did. For instance, when Gormy was asked about a current typical day, she said, "You can see that I don't  Meaningful Engagement in Long-Term Care  53  have energy." In response to a similar question Steven replied, "Well you don't have the same level of energy anymore. At least I haven't."  Energy levels also varied from day to day, affecting the ability to plan for occupational involvement. Cayin, Gerry, Anne, and Gormy described how their daily occupation was dictated by their energy level, on that given day. If she had the energy Cayin would do her weaving, Gerry would join the gardening group or work on her scrap books, and both Anne and Gormy would join the leisure activities offered in their respective facilities. These days were considered good days as emphasized by Cayin who said: Weaving has been a wonderful thing for me because it's been a time for contemplation as well as a time for considering colors and the aspect of weaving, and all the rest of it. And I think that has kept me from going mad because I have enjoyed the weaving so much and I have so many years of it and I've had a lot of appreciation. ... I'm really not doing anything. If I get myself energized in the morning to starting something and get this out and get wool, I have a wonderful day because I think 'Oh, I've got it out, now I can work at it' and I do a lot of work.  Decreasing energy levels inhibited the ability for many participants to engage in their leisure interests, at least to the degree that they were accustomed to. As described previously, Margarita attributed a decline in energy level to the difficulty she had with gardening. Gerry was also limited in her ability to garden because of declining energy, as well as an additional limitation of "stalling", related to Parkinson's disease. Gerry explained that "stalling" is a symptom of Parkinson's that interferes with the ability to initiate purposeful movement.  Meaningful Engagement in Long-Term Care  54  Increased experience of stalling reportedly inhibited Gerry's involvement in many activities including gardening. She described one incident where she was "stuck" outside while gardening: Well before I moved in ... I'd do the gardening and I would be fine. And near the end, when I was home I would do the gardening outside, out the front. And of course I have to get to the back and I had to ... bring the garbage to the garbage can, and I got to the stall and I just couldn't move so I prayed and hoped to heavens that the neighbours were all in the house. And I ' d get to a certain spot where I could crawl, and I'd crawl and leave the garbage and my son, he could help. Cayin described her weaving as taking up most of her retirement activity. She displayed her work at craft shows and subsequently took orders for weaving projects. Cayin described how "slowing down on the weaving came very gradually", and she felt that she was "getting too lazy" and "wearing out".  As a result of declining energy levels, the increasing need for rest was reported. Participants accepted, to varying degrees, their need for increased rest. Two participants emphasized their struggle with being less active. Anne, who had been a life long volunteer and once an entrepreneur, described feeling sorry for herself when she said, "I get very tired, and then I have to rest. And then I feel very sorry for myself, why should I rest?" Similarly Cayin, who pursued mission work overseas, an academic career, an influential work position, and volunteer work, struggled with feeling content to sit and not be busy. She stated, "I'm getting to the place where I just like to sit here and that bothers me, that I'm so content."  Meaningful Engagement in Long-Term Care  55  Two participants however expressed genuine content with doing less activity. When asked to describe a typical day, Gormy replied, "I'm just a lazy, just a lazy person in a care home. But I'm enjoying things here." And Steven stated, "I do nothing but I do very well." A l l participants emphasized how their decreased physical energy related to a decline in occupational pursuits. Declining functional abilities related to the loss of energy also significantly impacted daily life.  Functional Abilities A l l participants described deteriorating functional abilities, which impacted daily life. For most participants, functional changes occurred after retirement, as they aged. A l l interviewees pursued an active retirement lifestyle, which included taking care of themselves and their home, familial involvement, social and leisure pursuits, and for some, traveling and volunteer work. Except for Gerry and Ben, who respectively experienced illness and injury before retirement, participants experienced declining functional abilities in their later retirement years.  Participants described how their function had declined over time, for many people the changes seemed gradual but for some they were abrupt. A l l underwent severe changes in daily occupational pursuits in the few years prior to L T C facility admission. The functional losses associated with diminished abilities and resulting impairments included changes in independence for personal care and home-management activities, social and leisure pursuits, and volunteer work.  Meaningful Engagement in Long-Term Care  56  Personal Care and Home-Management Activities A l l participants talked about their loss of independence in daily personal care and homemanagement activities, which preceded their admission to L T C . For Gormy, Cayin, Anne and Gerry, a loss of independent mobility was the primary reason for needing support. Gormy suffered from decreased strength and balance resulting from a broken hip, while Cayin's strength and balance deteriorated gradually. Anne endured extreme osteoporosis since her early adult years, which became increasingly painful and limiting over time. And for Gerry, the progression of Parkinson's disease led to her loss of safety and ability for independent living. For Doll and Helen, progressive blindness was their primary difficulty with daily living. Margarita and Steve needed assistance with daily home-management because of cognitive limitations, such as memory loss. And finally, Ben, who was living with his spouse, explained that his wife felt unable to provide him with the daily support that he needed because of her own current limitations. Ben suffered with the loss of function on one side of his body resulting from a tumour in his brain, which was operated on before his retirement years.  At the time of the interviews, most participants required varying degrees of assistance with personal care activities, such as dressing, bathing, going to the toilet. It ranged from full physical assistance to minimal support, and was primarily related to participants' physical limitations, such as mobility, hand function, and blindness. For instance Gormy and Gerry required help with getting out of bed, dressing and going to the toilet, while Ben required help fastening the buttons of his shirt, and Helen needed help picking out her clothes.  Meaningful Engagement in Long-Term Care  57  Participants such as Doll, Steven, Gormy, Cayin, Helen, and Margarita spoke about the help they appreciated with tasks such as managing medication regimes, cleaning, laundering, housekeeping, shopping, and cooking. Helen, for example, stated, "I appreciate the medical. They give me the pills I have to take and the eye drops, and that helps. I appreciate the laundry done. I appreciate them cleaning my apartment." Similarly, Doll said, "It's such a relief to know that I'm taken care of." These participants reported that they could not live independently because they are unable to manage these activities without daily support. For instance, when asked why she moved into a care facility, Helen reported, " I needed to have food. I couldn't cook for myself." And, when asked to describe what she likes about living in a care facility, Gormy said, "I think I'm lucky, because I couldn't look after myself." A l l of these changes occurred when living independently and all led to the need for support levels that are provided by a L T C facility. Participants' ability to pursue social and leisure interests was also lost due to the same impairments that rendered them unable to independently manage their personal care and home management activities.  Social and Leisure Pursuits For many participants, deteriorating functional abilities interfered with their social and leisure interests. Leisure interests included individual activities such as gardening, knitting, weaving, painting and doing picture puzzles, as well as social activities such as playing bridge and chess. A few participants reported being involved with community seniors' centers, while others described visiting with friends and family as a social pursuit.  Meaningful Engagement in Long-Term Care  58  In addition to the previously described loss of energy, declining cognitive abilities also caused participants to diminish their involvement in leisure occupations. In addition to declining energy levels, Cayin attributed a decline in social and leisure activity to memory loss. She said: I'm losing my memory and that slows me down. I start to do something and then I don't remember how to do it. I have to search a little bit for the method, or give it up and do something else and then come back to it. It takes the interest out of some things. Similarly, Anne described her concern about memory loss and its impact on social engagement when she said, "One thing that worries me greatly, I can't remember names. I have difficulty. I can be introduced to someone, many people around me, I look at them and I say, oh, why can't I remember their names?" While Steven's memory impairment impeded his ability for living independently, he attributed his poor vision and his loss of physical mobility to the decline in reading and going for walks respectively. He said, "Well, I did a lot of reading and I did a lot of walking and ... your eyes don't last forever and that's the only reason I'm not reading much anymore." And when asked about walking he said, "Not a great deal, no, because, uh, my legs like the rest of me aren't, ain't what they used to be."  The ability to pursue social and leisure interests was limited further by moving from home into a care facility. Moving away from home seemed to cause a significant sense of loss regarding social and leisure pursuits, even more so than participants' declining functional abilities. Perhaps this is because, for most people, the functional changes that affected their social and leisure engagement occurred gradually and/or participants adapted or altered their pursuits with their given abilities. The move from home into a care facility would have occurred more abruptly. Anne captured this sentiment when asked how moving into a care facility  Meaningful Engagement in Long-Term Care  59  affected the things that she was doing before. She said, "And urn, my interest was in getting together with a lot of friends and playing card games. There was good contact there. ... Well it's, it's a great adjustment. On the positive side with regard to Anne's' contact with friends, she reported, "I have wonderful friends that keep in touch with me and I feel that, that I'm not forgotten."  Like Anne, Cayin described herself as being a social person who enjoyed entertaining friends. The loss of this role was evident and for Cayin, living in a care facility impeded her ability to entertain because of the need to plan for and prepare refreshments, which was difficult because of declining independence. She expressed missing this activity very much when she said: I have a friend over here and she comes to see me and I invite her in. Once or twice I've taken her upstairs and we've had tea, but I haven't had anything to have with tea, unless I plan ahead. It is so different. If I am going to do any entertaining, I have to plan ahead to get somebody to get me whatever I need and all the rest of it. .. .1 find one thing that really affected me being in a place like this is that I can't entertain. I can't offer a cup of coffee and I can't do the things that I took as a natural way of living. The barriers to social and leisure occupations that are specifically imposed within the environment of a care facility, such as physical space limitations, will be discussed in the second main section titled, "Constraint".  Meaningful Engagement in Long-Term Care  60  Volunteer Work Declining functional abilities forced many participants to give up the volunteer work that they pursued during their retirement. Anne, Doll, Ben, and Helen talked about their passion for volunteering. Anne began her volunteer career in her early 20's when she worked with an orphanage, teaching basic life skills to young orphaned girls. She then became active in Brownies, and finally, worked with seniors. Doll has been a volunteer since retiring from the workforce. Her twenty-five years of formal volunteering included work with the Red Cross, a cancer clinic, and a hospital palliative care and hospice program. In addition to the work she did with health care agencies, Doll was an active volunteer with her church. In reflecting upon her role as a volunteer, she said, "I loved the work, I love work." Currently Doll assumes her volunteer role by providing companionship and listening support to fellow residents. Doll reports, "They give me a free hand because of my hospice experience. I can help them in here, I help them here everyday in here working."  Like Doll, Ben volunteered with his church for many years. He and his wife were church deacons until his operation, after which he was "unable to stand and turn around." Ben then taught Sunday school in his church. Since his move into a care home, Ben has tried to befriend fellow residents with acts of kindness such as by offering someone a sweater when they seem cold, and via a chess club, which he formed with the aim "to know the person." According to Ben, this has been his way of "helping other people," as he has been taught through his connection with his church. Contrary to Doll's sentiment however, Ben does not feel empowered with a volunteer role within the care facility, which is indicated by his comment, "I really thought if there was a chance that I could do something up here, I would offer my services  Meaningful Engagement in Long-Term Care  61  but I don't know what that would be." In continuity with his volunteer role, Ben expressed that he would "like to teach [his] grandchildren as much as [he] can." He tries to do so currently by through the stories he tells them during their phone calls or visits to the facility. He stated, "I try to, sometimes I phone, tell them, tell them stories about experiences". Finally, Helen began her volunteer role in retirement, at age 62. She started out working with a group of retirees who contributed by making clothing and crafts, and then moved onto to helping with nursery school aged children. Helen did most of her volunteering in the United States before moving up to Canada to be closer to her son.  While none of these four participants provided specific reasons for giving up volunteer work specifically, each of their transcripts revealed that their formal volunteer roles diminished concurrently with decline in function and increased need for support. For instance, Anne lost her volunteer role indirectly because of increasing limitations related to Osteoporosis. Both Doll and Helen are no longer formally volunteering because of progressive blindness. And Ben gave up his volunteer role at church because of decreased balance and energy. Ben also relied on support from his wife to pursue volunteer work, which has diminished as she is experiencing her own growing functional difficulties.  Anne, Doll and Ben all spoke about how they revised, or have tried to adapt, their formal volunteer roles into ways in which they help fellow residents. In varying ways, Anne, Doll, and Ben continue to actively pursue helping others in their facility. The opportunity for L T C facility residents to continue to help other people will be addressed in the third main section titled, "Opportunity". In summary, functional changes experienced by participants during retirement  Meaningful Engagement in Long-Term Care  62  significantly impacted their daily occupations, including volunteer pursuits. The loss of independence experienced by participants influenced changes in their living environment, because eventually they required a level of daily support that could not be provided at home. Loss of functional abilities ultimately resulted in the loss of home.  Home For all participants, a loss of independent function was the main reason for moving into a care facility. During their retirement years, all participants' lived alone in their own homes or apartments, except for Ben who lived with his wife and Cayin who lived with her son. In the few years prior to moving into a care facility all participants had to make changes in their living situation in order to function safely and independently. Family and friends, home support services, private care-aids, and / or adaptive medical aids provided additional support to all participants. Growing difficulties with personal care and home-management activities eventually led to the loss of safe independent functioning. Six participants moved into a care facility from their own homes, however Anne, Gerry, Gormy, and Doll had all had recent hospitalizations that preceded their move. When it became too difficult to live at home safely, Helen and Doll moved into congregate living environments, where meals were provided and 24-hour assistance was available if needed.  Finally, Cayin was the only participant to have moved in with family prior  to a care home, however she was not the only person to talk about feeling a burden to the children.  Familial involvement increased during the time preceding admission to a L T C facility. For many participants the perceived burden of their care on family influenced their decision to  Meaningful Engagement in Long-Term Care  63  move into a care home. Ben reported that his decision to move into a nursing home was based on the difficulty that his wife had in caring for him. He explained, "The reason I'm here is because she told the social worker she couldn't have me because she herself has back problems, that's the reason I came." Anne described a pivotal moment, which influenced her decision to move from her apartment. Her decision came following an evening when her children had to stay with her through the night, missing work the following day. Anne said, "And I realized then, what am I doing to myself, and my children? I better be interested in coming into the [name of facility]. I wasn't fair to them and that made my decision." Participants reported that relying on their children for daily support is "unfair" or "not right", and makes them "feel bad". Both Helen and Cayin felt that living with their children would be the wrong choice for both their children and themselves. Helen talked about how she felt her presence would interfere with her children and their family's space: And the kids talked about me living with them, and I said I really don't think it would be good for either one of us, because the kids were younger then. You know, if you get another person in your home, and it might be that at some ages it would be alright,but I don't feel like that I should live with them. You know, "be quiet your grandmother's sleeping", or "be quiet grandma is here". No. I don't want them to feel obligated to. I thought it would be alright if I came and lived in the same town you know. But there's been so many trips to the doctor and things. I feel bad about that sometimes. I think well, at least you're not living with them. Similarly, Cayin said:  Meaningful Engagement in Long-Term Care  64  I appreciate most is a place where I am taken care of and I'm not a nuisance to my son. That was one of my biggest things was to get out from under there for that reason. They still have to look after me but I don't feel that I'm cutting down their life quite as much. It was apparent that an added concern about health care needs was involved in Cayin's decision to move from her son's home, which was in a small town in a rural location within the province, when she said: I didn't think it was right to stay there with my son, for his sake as well as for mine. I told him that I really needed to be closer to something that could help me in a minute's notice. And I needed it since I have been here so I know it was right.  Home is a space where our sense of security, intimacy and autonomy are integral and where self-identity should be protected (Segal & Baumohl, 1988). For participants, home represented a place of independence, privacy, freedom and safety. When the home became unsafe with regards to being able to carry out everyday activities and self-care,i these meanings were also lost for many participants. The meanings associated with home, as evident in participants' narratives, represented the varying losses experienced by participants when having to move. Home represented achievements that were displayed within the home and by the physical home itself. Furthermore, for some participants, their home, which was decorated with belongings and memorabilia, expressed their identity. When talking about the time preceding her move into a care facility Gerry said: I still was intent on staying in my home. Just 'cause your things are around you, and I'd worked hard on the house.  ... It was nothing, the house was nothing when people  passed, but it was mine. And I had, surrounded with my things.  Meaningful Engagement in Long-Term Care  65  To cope in part with her loss, Gerry began making scrapbooks of her life. In her words: it's a good activity when you come into a place like this because otherwise you sort of feel that you left everything behind. Similarly, Anne said, "Even after my hospital, my husband passed away 14 years ago, I still wanted to keep my attachment to my home. I had a lovely apartment, it was large and comfortable."  The sense of recreating home within a facility room was shared amongst two participants. Anne described her effort in recreating a sense of home in her facility room, as she "brought with [her] only the things that [she] can use". She said: So I've made a home this way. This is my bedroom, my plants and my plant stand is my patio, this is my dining room, this is my living room, where I have my cupboard there belonging to my kitchen. My fridge is my kitchen, my clothes closet, my bathroom, this is my four bedroom, my four roomed apartment. She followed up by stating: Sometimes I feel its empty, but it's only what I need. While Gerry did not emphasize a lack of space in her room, like Anne she expressed an expectation of recreating a sense of home within the facility. In Gerry's home, furniture and other items were sufficient for her to get around her living space. She said, "the house was little so there was always something there." In the facility, "there is quite a distance from one spot to the other without a grab bar", thus when she moved into the facility, grab bars and a hospital bed were installed in her room. Reflecting on these environmental adaptations in her room, Gerry said, "Well, it doesn't look like a home." Gerry also stated that putting up pictures and photographs around her room "helps a lot". While only Anne and Gerry described purposefully recreating their sense of home within in their new physical space, many other participants displayed their  Meaningful Engagement in Long-Term Care  66  life's memorabilia around their facility room and took interest in talking about these items with this writer.  Moving from home also included the loss of community, neighbourhood, and proximity to friends. Gerry spoke about her leisure activities involving neighbours she'd known for fifty years. When asked about how she would like to spend her time she replied, "Once in a while just, like I'd like to go across the street and play a game of "hand and foot" with my neighbours, and uh, but that would be my occupation now. But it doesn't work out." As mentioned, Cayin and Anne also expressed their lost involvement with friends since moving into a facility. Furthermore, Ben and Steven explained that while their friends come to the facility to see them, getting out to visit with them is difficult.  Most participants didn't want to leave their attachment to their home, and all never imagined or planned for nursing home living. Participants, such as Anne, Doll, and Ben immediately liked nursing home living, Steven, Helen, and Margarita merely accepted it, and participants such as Gormy and Cayin appreciated it. On some level, all participants' continue to adjust to life in a facility. The following statements describe the range of sentiments participants had about losing their homes and moving into a L T C facility; "I came here and the minute I stepped across the door I knew it was the place for me", "I fought like tooth and nail not to come in here", "I appreciate that I am here and if anything happens, there is somebody to look after me", and finally, "I'd rather not be here but, .. .if I go out of here I've got no place to go now".  Meaningful Engagement in Long-Term Care  67  In summary, while the meaning of being independent varied among participants, the sense of loss and struggle to maintain it was evident in their description of daily occupation. The loss of energy and functional abilities meant that participants had to adapt and make changes in the way they lived from day to day. However, with the additional loss of home, participants described new constraints to meaningful occupation, which were specifically imposed by the L T C facility environment.  Constraint Beyond the losses incurred because of functional changes, participants disclosed the constraints within the nursing home environment that they experienced in doing what they felt capable of. For many participants, daily personal care, home management routines, and social pursuits were further inhibited by their new home. In exploring participants' current occupation, all spoke about how the L T C facility's social environment, physical space, and institutional routines and resources constrained their ability to do some of the things that matter to them.  Social Milieu The influence of the social milieu was a very prevalent concern conveyed by participants. Many participants described feeling socially isolated despite living in an environment of "peers". Participants described isolating themselves in their rooms for a variety of reasons. Participants expressed a lack of attachment to fellow residents while desire for companionship was apparent. Some participants expressed a sense of social discomfort in the facility, causing one person to leave the facility when possible in order to escape the social environment. Finally, some contributors expressed a lack of stimulation offered by the social activities program. Thus,  Meaningful Engagement in Long-Term Care  68  isolation, limited significant relationships, social discomfort, and a lack of stimulation were evident amongst many participants as environmental constraints on their social well-being.  Many participants expressed a sense of being socially isolated. In this study, participants were not significantly cognitively impaired and were physically able to get around their facility. However, three participants reported spending a lot of time in their rooms. Cayin's observation was that, "People come up from their meal and go to the rooms and that's it. They must all have something to do in their rooms because you don't see many of them out in the halls or anything." Steven and Gerry also reported spending quite a bit of time in their room. Steven said, "I'd just like to get out, I'm pretty much confined to the suite now and that I don't like but I can't do anything about it." Steven attributed memory impairment and the potential to getting lost as reasons for being "confined in his room". Gerry's physical limitations contributed to her sense of isolation. Gerry's difficulty joining leisure opportunities stemmed from Parkinson's disease and subsequent impairment with functional movement. While she could ambulate independently using her wheelchair, she described her difficulty in coordinating her participation in leisure activities with her medications. She said: No, I've always stayed in my room. Well I try to go out, and I do go out. The trouble with the pills is it uh, it is calculated to coincide with ... in other words it shouldn't compete, its ok, at 7:15 its ok, at 7:161 might not be able to go to bed and get back up. Gerry also articulated her sense of isolation amongst residents in general when she said: I think people have very much of a lost feeling. ... Close the door, hear a click, people feel like they're going to prison, and key turns in the lock. When I was in respite, I was downstairs, and I was, I was walking, I was on the far wall. And I had to get to the  Meaningful Engagement in Long-Term Care  69  bathroom which wasn't very far along, but I really couldn't move and I couldn't call anybody, I didn't have anything. And uh, I, you feel more lost there. A couple of times since I've lived here I heard people call and I usually put my eye out there. Reports of spending time alone were only one indication of social isolation. Being socially isolated was also expressed as having few significant attachments with fellow residents. For Cayin, spending time alone related to the lack of meaningful relationships she had with people living in her facility. Cayin described how she does not sit in the common areas because other residents, who are more disabled than she, tend to sleep in these areas. She described not wanting to disrupt this trend because she is more capable of getting around and engaging herself. She said: When I first came I spent quite a lot of time down there and I would make myself a cup of tea and read the paper or magazine or something and have a chance to talk to people. Now I don't go down and I am ashamed of myself for not doing it but it is partly because there are people lying down and sleeping and taking up quite a bit of room. They have rearranged the room so it is not as easy to find a place that is comfortable to sit. So I don't go down there. They are out of their rooms in their wheelchairs with their feet out on something, all spread out. And if that is the place where they are comfortable I think they should be considered because they don't have as much ability to look after themselves as I do. I can fix myself up. And I can be quite comfortable here. I'm just not meeting people. Steven described the lack of attachment to residents as true friends when he said, "They're not really close friends, they're just friends, the only close friend I have left... when he's in town he comes out to see me." While Gormy reported an interest in meeting people, she expressed  Meaningful Engagement in Long-Term Care  70  resistance to developing friendships with residents when she said, "But you know you don't want to force yourself on people. They're weary, and you don't want to bother them." Helen, who desired companionship from fellow residents, said: I thought it would be a great place to get to know some of these people because you have time. .. .1 don't have to have companions day and night but I do like to know somebody, somebody that I can talk to.  Two participants expressed discomfort in being around many older people who are sick or disabled. Cayin found it difficult to be reminded by the impairments of other residents of what she can become functionally. She explained: I'm getting to the place where I'm not very comfortable. I'm comfortable but I'm realizing, how I'm, now this is hard to say, the people that I am with, I'm with old people. And I've always been with people much younger than myself. I get into an elevator and it's all wheelchairs and walkers. There is one woman there who is talkative. Isn't it a nice day, all full of cheer. And usually when you get into an elevator in a private place it is probable that nobody will say anything but if somebody does then it can bring a little life to it. The rest of them don't look unhappy, they just look busy. And here, but I think one of the reasons that it is so bothersome is that you see what you might become. For Doll, getting out on the bus trips affords her a break from seeing the limitations of those around her. She said: I sure enjoy the [name of coffee shop]. ... I always feel better when I come back ... from seeing the people that can't go. They have to stay home, they're too sick to go. And I can get away from that for a little while.  Meaningful Engagement in Long-Term Care  71  Beyond social relationships, some participants desired a more stimulating social environment in terms of their activity level. The social environment in care facilities is typically designed around an activities program, which offers residents the opportunity to engage in a myriad of organized leisure activities that are scheduled throughout the day. Interestingly, participants almost never mentioned the activities program as a meaningful part of their day while discussing their daily occupations. Steven, Gormy, Helen, and Cayin expressed that they are "not doing anything", frustration with "nothing to do", and "a lack of stimulation". Helen reported, "I don't have enough to do to occupy my mind or physical or anything else. Moreover, one of the barriers to an activities program that is routinely scheduled is that the timing is not conducive to all potential partakers." At the time of the interview, Gerry described the importance for her to do her own dressing despite how long it takes her. This requires planning her medication regime with her daily schedule. Joining a gardening group that starts at 9:30 A M meant that Gerry must begin her day at 5:00 A M . The ability for Gerry to join in the gardening group was difficult because of the time that it is scheduled, indicated by her explanation, "I i  joined the gardening group, which is fine but I can't, can't get dressed on time. I get up at five ...so I've only gone twice. But it was good to get into gardening." Cayin disclosed that she primarily spends her leisure time in her room because of the lack of stimulation that she gets in trying to engage with other residents and / or in the social activities program. Cayin reported, "If I feel I have to go, want to go, I can go. But I don't get much stimulation when I go. I get more stimulation here because I enjoy doing things, handwork, writing letters, and all sorts of things."  Two participants spoke of the constraints of the facility's staffing resources to provide them with the individual support they would need to engage in their chosen activities. For  Meaningful Engagement in Long-Term Care  72  instance, Helen reported that she would need the support to go for a walk because she is nearly blind. However she reported that, "there is nobody here that does that" as often as she would like. And Gerry expressed a desire to go outside on the patio. She relayed a story when she accomplished this task independently but with great difficulty. Within her story she reported that she went outside alone because the staff would be unable to spend the time she wanted outside. She said, "They couldn't, they got work to do down here so I knew they couldn't stay the staff were too busy to leave." It seemed evident that the number of staff working in Gerry's L T C facility is limited in enabling meaningful individual engagement for residents.  Not every participant expressed such negative influences on their social well-being. Margarita felt that if she were bored she could "go out any other time" or join the "different programs" where she could get outside and help with the gardening. Doll spoke positively about the social environment when she said, "I'm interested in not laying down and dying. I'm interested in everything that goes on around here, and when I can participate, I do. .. .They make our life very full." Doll had also been an active volunteer, a role that was re-afforded to her by the living in a L T C facility. For participants who had been active volunteers or described themselves as being "interested in people," the social environment provided them the opportunity to help others. This will be discussed further in the section titled, "Opportunity". However, social and leisure involvement was also constrained by aspects of the physical environment, which were accounted in participants' narratives.  Meaningful Engagement in Long-Term Care  73  Physical Space For some participants, the lack of physical space to pursue individual hobbies was a clear barrier. These participants mainly felt constrained by the physical space they considered private or personal despite having access to areas in the facility outside of their rooms. This was evident in the interviews, when participants identified the size of their rooms as their main physical space issue. The rooms were typically sized for a single bed, dresser, and desk or small table. They also included either a full bathroom or a washroom with a sink and toilet only.  Weaving and paper-tolling are types of craft-work once pursued by Cayin and Anne respectively. They identified these hobbies as their main individual leisure interests that were inhibited because of limited physical space. Cayin articulated space as a significant constraint on her ability to weave when she said: Of course, in here, space is another thing. Like this, I have my easel over there under the bed and then I think "Oh, I'd like to weave" and I have to get it out from under the bed, you know. It is too much work. Not enough space and my room is smaller than most. Moreover, the main spatial barrier for Cayin was the inability to keep her weaving set-up in order to spontaneously engage in it. The need to have the equipment set-up was how Cayin adapted her weaving to the lack of energy that she experienced, as she was able to engage in it for brief periods of time without exerting effort in its set-up. Cayin explained: I used to have it set up all the time. Sometimes I'd spent 10-15 minutes sometimes I'd spend two hours. It was there and I could do it. Cramped quarters here. When I was up in Merritt I could it. I had it set up all the time. I did a fair amount up there. ... I would  Meaningful Engagement in Long-Term Care  74  like to have my weaving and my easel right there. So when you leave I can go and sit there and weave a little bit. That would please me and take quite a bit of time. As a result Cayin believes that she should "find something else to do that wouldn't take up so much room". Similarly, Anne who reportedly brought to the facility only what she felt she needed because of space limitations, described leaving her art supplies at home. When asked what she would like to do, she replied, "I'd love to get back to my art." Although, when she thought further about this, Anne reported feeling unable to do her craft because of the limitations imposed by her arthritis. Beyond craft-work, Anne and Margarita described the lack of space as inhibitors to keeping a library of books, despite their strong interest in reading. For instance, Margarita reported that extra books "clutter up" her space because she hasn't "got a lot of room". Overall, participants' perceived social and physical barriers captured aspects of the institutional setting.  Institutional Routines and Resources The institutional routines and resources within a LTC facility encompass aspects of the social and physical environment. In the interviews, participants described how their personal and social routines had changed after moving into a care facility. For some, these changes were expected and/or accepted. However, for others the facilities' institutional routines and resources constrained their ability to maintain the independence they had for certain meaningful occupations. Social and leisure involvement were the most prevalent articulated occupations to be constrained by the environment. However personal care activities were also constrained by living in an institutional setting. For instance both Cayin and Margarita described missing the opportunity to bathe daily, and both felt able to do this independently. Furthermore, maintaining  Meaningful Engagement in Long-Term Care  75  independence with dignity and pride was integral for participants, such as Gormy, Gerry and Doll who expressed their feelings about the institutional practices of  care.  Routines of personal care and leisure activities are structured throughout the day, resulting in limited spontaneity for participants to engage in these activities. Some participants described the loss of ability to be spontaneous as interfering with their independence, which was reportedly inhibited by both their functional capacity and living environment. Examples of how the institutional environment has created barriers to meaningful occupational engagement include the lack of human resources available to assist participants in pursuing individual activities, the routine timing of leisure activities that, for some participants, inhibited leisure pursuits and, the lack of space required to keep belongings and set-up individual hobbies. In conclusion, the L T C facility is an institutional environment, which evidently both constrains and enables occupation for its residents. The losses and constraints experienced by participants impacted their occupation in terms of what they can and want to do. At the same time, a new living environment provided them with innovative, positive opportunities.  Opportunity The opportunity within a L T C facility for participants to "help" other residents and feel personal safety and security was evident in several of their stories. For participants who had been active volunteers, the physical proximity to people afforded them the opportunity to maintain or re-engage in their helping role. Participants such as Doll, Anne, Ben, and Margarita described a sense of pride in their ability to contribute to other people's lives. Anne volunteers at her facility by sending residents greeting cards, on occasions such as when they are new to the facility, have  Meaningful Engagement in Long-Term Care  76  had a loved one pass away, or are ill. Doll supports fellow residents by providing them companionship when they are ill or anxious. During the interview, she told a story about a time when she sat with one resident for many hours until she passed away. Doll's sentiment about her opportunity to help was, "And I'm so thankful that I have had the privilege of helping people. And now I have the privilege of helping them in here." Similarly, Ben recounted a story of helping a fellow resident when he seemed cold. He stated: And one day he was sitting, I think it was at breakfast and he shakes, he was cold so I said come with me to my room and I'll give you a sweater because I've been taught to share. I have two sweaters and to him always I can see it's quite unbelievable that somebody would ... but we have been taught to help people where we can and share whatever it is. Finally, Margarita described playing piano as her contribution to herself and others, when she said: I played the piano here quite a few times. ... It gives people pleasure. ... It sort of gets you out of a rut really. To play the piano, things like that. ... I bring out people when I go out.  For Cayin, the opportunity to contribute to aspects of the environment and/or programming in her facility was valued. She said: Somebody here, and I can't remember names, one of the workers here is starting to ... try and find out what people would like and how they would like them [a residents' council meeting or focus group]. I think that is good. I'm trying to contribute to that. ... It is good whether anything comes of it or not, it makes us think. And for Gormy, the opportunity to try new activities was appreciated. Gormy, who described herself as an innovator and leader throughout her working career, welcomed the opportunity to challenge herself and others around her while learning something new. She said:  Meaningful Engagement in Long-Term Care  77  I'm just a lazy ... person in a care home. But I'm enjoying things here. I never studied the bible and that, but they have a Minister here. And just recently he started having these meetings about the spirit world you know. So it's fascinating. And I don't want to be critical of these people, but its been fascinating though that I challenge some of the things.  The opportunity to feel safe and secure by living in a facility was clearly appreciated by many participants. Seven participants reported that they appreciated the "consideration and care," "being taken care of," "being looked after," having "somebody there," as well as assistance with daily activities such as medication management, laundry, and cleaning. The following statements demonstrate participants' sentiments: Doll stated, "There's a warmth and security in this place" and Anne said, "I appreciate the consideration and the care. I never feel neglected and if I need any help its there for me. And I feel that everyone, right down to the least detail, I can say I'm well cared for." Similarly Cayin asserted, "I appreciate that I am here and if anything happens, there is somebody to look after me. .. .That assurance, I feel safe." Finally Helen declared: Well I appreciate the medical. They give me the pills I have to take and the eye drops I have to take, and that helps. Helps to remember. I help them remember what's going on, and that's something that I need now, I can't read the labels and this type of thing. We have the best nurse that oversees this. ... I appreciate the laundry done. I appreciate them cleaning my apartment.  Meaningful Engagement in Long-Term Care  78  It was apparent that for some participants the opportunity to feel safe and secure allowed them to build confidence and recreate some sense of independence. For instance, by moving into a facility Gerry was able to focus on safely and independently managing her personal care. Anne, Ben, and Doll were able to resume their independence for volunteering. Steve and Margarita were able to "take it easy" and enjoy life, without living at risk. Lastly, Gormy was able to get back into life without "worrying about everything under the sun". She further affirmed, "I think I'm normal. I'm normal, I'm not great but.. .I'm working on trying to concentrate on my hands, make them stronger. You can improve."  In summary, the combination of losses, constraints, and opportunities make up the context of participants' lives, which in turn influences meaningful occupation. As participants adjusted to the many changes in their lives, their experiences influenced daily life and occupational choices. Study participants revealed how they were spending their time and the meaning behind these occupations became evident upon analysis. The focus of the next chapter will be on the identified themes of meaningful occupation.  Meaningful Engagement in Long-Term Care  79  Chapter 5: Occupational Choices: A Time For Reliance, Relationships, Rewards, and Reflection I'm interested in not laying down and dying. (Doll)  In order to appreciate the meaning that occupation has for individuals, it is important to understand how people occupy their time, their satisfaction with the use of that time, and how their values and goals are supported during that use of time (Yerxa, 1990). The meaning of occupation for the study participants was shaped in the context of their identified losses, constraints, and opportunities, which were involved in the experience of living in a L T C facility.  Through participants' narratives it also became evident that the activities they chose to engage in made up an occupation that is personally meaningful. While participants engaged in different activities from one another, four main themes of meaningful occupation emerged from the data; 1) maintaining a sense of independence, 2) maintaining and fostering relationships, 3) doing things that have purpose and contribute personally and socially, and 4) reflecting on life's experiences, accomplishments, and regrets. These four occupational themes have been respectively titled: reliance, relationships, reward, and reflection, and are presented in order of importance to the participants. Together these four occupational themes framed and gave meaning to daily life for participants.  An additional theme, preserving and expressing self-identity, was also evident as being personally meaningful. Participants disclosed a sense of themselves when they described their past, current, and desired occupations. Thus, each person's identity was recognized within the context of his or her chosen occupation. For instance, Ben told several stories about helping  Meaningful Engagement in Long-Term Care  80  others, and the activities that he engaged in were reportedly aimed at contributing to and/or getting to know fellow residents. At the same time, Ben's transcript revealed his life long connection to his Church and value for "living the good life". In this way, it is conceivable that people conveyed the meaning of what they do through stories that reflected their identity. In this study, self-identity is organized as a separate theme, and it is connected with all meaningful occupation.  Participants' Current Daily Occupations The occupations that participants pursued, living in a care facility, reflected the identified themes of meaningful occupation; that is, their daily engagement represented their desire for a sense of self-reliance, social relationships, personal rewards and reflections. Participants engaged in similar and different activities from one another throughout their current typical days (Appendix E). Similar activities included personal care, attending and eating meals in the dining room, watching or participating in entertainment opportunities such as listening to a musical concert in the facility, visiting with friends and family, reading, and resting. Because of the loss of energy they experienced, participants spent much of each day resting in their rooms or in the common areas. Individual pursuits amongst participants included weaving, writing greeting cards to co-residents and their families, working on scrapbooks, playing piano, listening to the hockey game on the radio, walking, and playing chess.  Participants' current daily occupations also included activities that were not desired or chosen but a result of health or environmental circumstances, such as resting, taking medications, and having a weekly bath (versus a daily shower). Furthermore, as previously stated, a L T C  Meaningful Engagement in Long-Term Care  81  facility is typically structured around a daily routine of personal care and leisure activities. "Free time," therefore, is generally available at specific times of the day. For instance, Cayin explained that the time available between breakfast and lunch is not enough for her to set up and engage in her hobby of weaving, indicating that the time between scheduled meals can dictate residents' occupational pursuits. When asked to describe a typical day Cayin said: Well, I get up and get dressed, go for breakfast, then I come back and I read the paper. And then I do something after that. If I'm going to be bored I'm often bored then because there isn't enough time to get out all the equipment for weaving. Similarly, Gerry talked about the constraints between meal times in doing her scrapbooks. She said, "Well the energy level is different with the Parkinson's and you get everything out and its supper time, and gosh it was just lunch time." For Cayin, the barrier to engaging in her weaving concerned the lack of space to keep her materials set up and for Gerry, the barrier primarily related to her functional abilities. For both women, loss of energy and endurance impeded their daily engagement.  Reliance: Independence Through Control, Choice, and Dignity While the meaning of being independent varied among participants the sense of its loss was evident in their description of day-to-day life. Terms such as "loss of freedom", "loss of independence", and "feeling lost" were used by three participants when describing their abilities. Furthermore, all participants described an increased reliance on family during the years just prior to moving into a care facility, which resulted from the loss of functional independence they experienced. This will be discussed in the next section titled, "Relationships". This section will demonstrate how maintaining a sense of independence was important to all participants and the  Meaningful Engagement in Long-Term Care  82  elements of control, choice and dignity are integral to achieving self-reliance. Study participants struggled to maintain a sense of independence while, at the same time, accepting the comfort and security they perceived by living in a L T C facility.  A Balance Between Independence and Dependence A balance between independence and dependence often related to participants' ability to do the things that they felt capable of without living in fear. For many participants, loss of independence contributed to safety concerns and a sense of fear while living alone. For instance, accepting support meant minimizing fear and optimizing safety for Gormy, who also admitted that she accepted the daily support provided in a LTC facility rather than the alternative of living alone. She states: Everybody wants to live on his or her own, well I don't want to live alone. ... I'm glad that uh, even if you needed changing and you'd be in bed for hours its better than lying on the floor with a broken hip.  Gerry, Ben, Doll, Helen, Anne, and Cayin used terms such as, appreciate, safe, assurance, thankful, consideration, and wonderful to describe what they like about living in a care home. At the same time, all of these participants desired their independence and/or yearned to do the things they felt capable of before moving into a care facility. For instance, Gerry explained that it is important for her to continue to dress herself no matter how long it takes her, while at the same time, she reported moving into a care facility to minimize her responsibilities. The importance for Gerry to conserve energy in order to maintain her independence for personal care activities was evident when she said:  Meaningful Engagement in Long-Term Care  83  I don't do much, but I planned on doing is getting myself dressed, say by 10 o'clock. It's taking me a lot of time but... I have a pill at 5:00 so I have to wake up, but then after that I uh, take my time. ... The energy level is different with the Parkinson's ... I came here to try and get less done. Despite declining functional abilities that forced Ben, Doll, Helen, and Anne to give up their formal volunteer roles, they were interested in pursuing their ability to assist staff and help fellow residents with various acts of kindness and support. Furthermore, despite decreasing energy levels and declining cognitive difficulties, Anne and Cayin wished to maintain their involvement in individual and social hobbies. Gerry represented the tension between independence and dependence, for older people living in L T C facilities when she said: I was visualizing what sometimes happens when people get older. It really affects everybody's whose come in, unless they happen to like being looked after. Those that don't really like being looked after want to do it themselves. But uh, I think its there for comfort... you're getting older anyway.  Participants' struggle to define independence within L T C facility living was evident in their narratives. What was clear, was their value for the elements of control, choice, and dignity to be inherent in their sense of independence.  Control and Choice Participants' overall sense of independence was greatly affected by the sense of control and choice that they perceived over their functional abilities and daily activities. For Cayin, a  Meaningful Engagement in Long-Term Care  84  loss of control over her abilities, specifically memory, negatively impacted her independence for engagement and interest in her hobbies. She explained: I start to do something and then I don't remember how to do it. I have to search a little bit for the method or give it up and do something else and then come back to it. It takes the interest out of some things. Similarly, Ben described how his difficulty with continence (and his experience of wearing adult pads) impedes him from engaging in leisure pursuits. He stated: And I have another problem, sometimes they have tours here and I can't go, I have to stay close to the washroom because I have a problem, I have to go to the washroom quite often and if I go, I don't want to go. ... It's very awkward. Moreover, Gerry described the loss of control over her mobility as interfering with her independence when she said, "I think I haven't got the same independence that I'd like to. I think it's a lovely day, I'd like to go for a walk, just go down to Granville Island or something ... near by." When asked why she does not do this she responded, "Cause I couldn't bring myself back. I could stall right there and not be able to move." In addition, perceived control over one's abilities was influenced by having the confidence to engage in daily activities. Gormy, for instance, related improvements in her confidence or "nerve" to do things on her own with a gained sense of control. She said: Just 'til I really feel that I'm controlling everything in my life I'll never be the same as I was. ... But I have in the last week got a little more nerve and gone out on the deck. You're always afraid that you'll get locked out. And Steven said, "Whether you like to believe it or not, some of your freedom is gone, not because of the place, because I have reached an age where I can't do what I want."  Meaningful Engagement in Long-Term Care  85  Independence was also represented as having choices about day-to-day time use and, some participants experienced a sense of choice while others did not. For instance, Anne described having choices within her day, when she said, "Yes, I can come and go as I wish. I think that I can make use of every hour I guess. I don't, it's my choice." Helen also expressed a sense of choice by stating, "Oh, I could do my own thing. They even let me take a shower by myself." In contrast, Steven reported the inability to choose how and where to spend his time. He reported, I don't have, no, uh, I live from day to day and what will be will be, Que sera sera, that's it. ... It's not what I want but I have no choice at my age, I'm just glad to be here or anywhere else. And, Cayin explained that she would be more independent in her self-care if she had the choice to take showers because having to take tub baths meant that she relied on assistance for set up and had limited control over when she could bathe, due to scheduling issues. She said, "If there were showers that I could take every day I wouldn't bother with a tub shower."  In this study, participants' meaning of independence was significantly influenced by their perception of control and choice over their abilities and daily activities. For these nursing home residents, aspects of control and choice in the provision of care also concerned their sense of dignity, which in turn, impacted feelings towards reliance.  Dignity Feeling dignified while receiving support with personal care activities was extremely important to participants' positive view of their autonomy and hence, self-reliance. For two  Meaningful Engagement in Long-Term Care  86  participants, a sense of dignity correlated with physical vulnerability. Gormy described issues of dignity and vulnerability (including control and independence) in her description of receiving support, when she reported: You uh, act like a baby just put a diaper on. You have to uh, especially when you go to bed you have to uh ... they strip you down all your slacks and everything, they take everything off and you're sitting on the toilet. Then they take your sweaters off and your shirt and uh, undershirt and uh, and uh, ... Its just too indecent to be talking about it. ... I think the people here are, the workers, are very well trained you know and, .. .does something that affects my body you know then I'll get into a shouting match. ... I'm getting better but I had so many anxieties and worries uh and things when I'm in here and mainly tying ... it into all the pills and no control over your body functions. .. .They're trying to look after you but, they're used to it, they come in there asking if you want help going to the toilet but I don't want to depend on anybody. I, you know, I uh, cause that's how I got hurt. But there are improvements in my health, not worrying about everything under the sun. Similarly, Doll highlighted issues of dignity and physical vulnerability, when she described a positive experience receiving personal care. She stated: And the staff in here are absolutely wonderful. The nurses, we couldn't ask for more caring people then the people here. And the care people that assist the nurses, like yesterday I was so sick and I had vomit all down and they came in here, men you know, I wasn't embarrassed by them coming. And they stripped me and washed me and put on a new nightie, and they stripped my bed. And no problem at all, in some ways it was like a pleasure for them. They never make you feel embarrassed.  Meaningful Engagement in Long-Term Care  87  Likewise, Gerry described her initial reaction to being cared for by a male care-aid. Like Doll, Gerry also found that she was cared for with dignity, by not being made to feel embarrassed. She said: You just about die when you first come here because you have a male care-aid in there. ... I knew somebody who practically went into the cupboard to get changed. When it first happened to me, you knew you had to get up and go to the bathroom and you'd try to be ... I don't know its like looking out a window and somebody looking in. ... Its like he's looking out a window, when he's caring for you. I mean he's not making you feel embarrassed.  Further, in relation to support and dignity, Doll articulated, "It is important because in some ways I suppose I'm a problem and I like to pride in the way I appear. I like to look decent." Finally, for Helen, maintaining a sense of dignity and pride was integral for her to get involved in leisure pursuits. When discussing her leisure involvement, Helen explained that while she recognized the need for assistance she does not want to ask for help. Helen stated, "Nobody had asked me too and I'm not going to say, "Will someone help me?" .. .They might think they had to, you see if, and that wouldn't be any fun." For most participants, having a sense of control, choice and dignity were important aspects of independence.  Overcoming barriers and accomplishing tasks independently also were a part of a sense of self-reliance. For instance Gormy and Gerry described the ability to go outside and get back in independently as contributing to their sense of independence. For both women, this task was not  Meaningful Engagement in Long-Term Care  88  simple because of anxiety and physical disability that they respectively experienced. Both Doll and Ben expressed satisfaction with their ability to dress themselves. Doll said: Well, well I think its very satisfying that I can dress myself, and that I can take a taxi and go over to London Drugs and a girl over there comes and helps me, guides me to everything, and then I take a taxi home. And I like to do that. I like to be independent. Similarly, Ben reported: I think I'm better off than ninety-five percent of the people that live here. Some they have to be in a wheelchair or they have to be fed and so on but I can help myself undress and dress in the morning up to a certain, I call the nurse. ... I try to help when I can, and I'm trying not to be a burden to anybody.  In summary, participants' struggle to balance the desire for independence with acknowledged need for daily support was demonstrated within their accounts of day-to-day occupations. Meaningful occupation encompassed activities that enabled a sense of independence, which involved elements of control, choice and, dignity. By some means, all participants aspired to optimize self-reliance within the context of a dependent living situation. Living in an institutional setting also had an impact on participants' familial and social relationships.  Relationships: The Importance of Family and Friends For many participants, meaningful occupation included activities that sought to maintain and foster relationships with people. A l l participants described the impact of living in a care facility on their familial and social relationships. Evolving family relationships, missing old  Meaningful Engagement in Long-Term Care  89  friends, and fostering social relationships with residents were the most prevalent themes in participants' narratives.  Evolving Family Relationships Study participants expressed the importance of family in their account of changing family dynamics, which occurred as they aged and lost independence. Early on in the interviews, most participants told stories of times shared with family and many expressed being proud parents. For example, Cayin's expression of her children's accomplishments demonstrated her pride as a parent when she said, "I've had real rewards. I have three sons and they have all done very well." Similarly, Gormy stated, "My son's been a good, done a good job, the best he could possibly." Having dinner with family and knitting clothes for children and grandchildren are examples of memories shared by Gormy and Helen respectively. Due to declining function, cooking and knitting were 'normal' activities that these women were no longer able to do independently.  The support received by participants from their children was a significant topic within the interviews. Participants had an increased reliance on close relatives, especially in the recent time period before moving into a care facility. Help with shopping, money management, taking medications, and mobility are examples of the support provided by family. Both Helen and Cayin had changed cities in order to be closer to their sons, a move which had been initiated by their children. For instance, Helen explained: Well John wanted me to move up here .. .after I was retired and I really needed someone to help me out, I was, well it wasn't that I didn't have anything to do but I, he felt like that I should move up here so he could look after me, my eyesight was failing.  Meaningful Engagement in Long-Term Care  90  Some participants expressed feeling "lucky" and "thankful" when speaking about their family "being there" for them. For instance, Cayin accounted: They're all wonderful to me. My oldest son looks after me. He sort of kept his eye on me and was the main, "raison d'etre" for me. And then my second son, I've been living with him for a number of years and now my youngest son and his wife look after me here. So they have been wonderful to me. Similarly Anne reported, "I have a wonderful family, really, I am very, very lucky and fortunate. ... They encourage this with me and are interested in what I do. And I relate to them." Anne also connected her family involvement with a sense of security. She said, "Well each day my contact with my children, or their contact with me has been an important start of the day, so I can start out each day feeling secure". And, Ben spoke about his wife's support following his operation for a brain tumour. He said, "Well, of course I have to adjust to life, after an operation like that you have to start slowly, and I have a wonderful wife." He also spoke of his relatives and said, "I have wonderful relatives, they help, are amazing. Whenever I needed something they're willing to chip in and help." Throughout the interview, Ben also spoke highly of his children, including their support of him. While the support of family was appreciated, many participants did not want to be a burden to their children. As stated in the previous chapter, the perceived burden of their care on family influenced the decision for participants such as Cayin, Ben, Anne, and Helen to move into a care home.  For many participants, the move into a facility also meant less time spent with family. The desire for participants to be with their family but not depend on them was emphasized in their narratives. Gormy, Ben, and Gerry expressed the desire to spend more time with family.  Meaningful Engagement in Long-Term Care  91  When Gormy was asked to describe how she spent her time before moving into a care home, she said, "One day I was very much involved with family and uh we were always together. ... So that would be one ... of my activities." Gormy also reported that one of the things that she misses most since moving into a care home is going out on Sundays with the family, however her anxiety and difficulties with continence impeded outings from the facility. Similarly, When Ben was asked how he would like to spend his time at this point in his life, he said, "I like to teach my grandchildren as much as I can, even if I'm not a teacher." And, Gerry reported that she would like to spend more time with family when she stated, "Well, if I had good health I'd like to be spending with D. I'd like to, I like to ... be with the kids or laugh and stuff like that."  In summary, as participants' stories progressed from parenting memories to being cared for by their children the exchange between parent and child, in the role of care-giving, was evident in the transcripts. Family relationships primarily changed because of participants increased reliance on their children for day-to-day living, and while participants appreciated their children's support they resented being a burden to their family. Moving into a care facility was one way to decrease the perceived burden, however it often resulted in less time spent with family than desired. For participants, meaningful occupation included sustaining relationships with family by spending time with them. Moreover, participants expressed the desire for this time to involve contribution to their family, which will be discussed in the section titled, "Reward".  Meaningful Engagement in Long-Term Care  92  Missing Old Friends A few participants talked about old friends and missing their engagement with them. For these people, meaningful occupation included spending more time socializing with old friends, which was difficult to do mainly because of declining health and limited community mobility. When asked about what she did to enjoy her self, Gerry reminisced about a group of girlfriends she grew up with. She said: There were 6 of us all together we grew up since grade 1. ... We lost one a couple of years ago, she died of cancer. But uh the other ones ... we kind of phone. .. .Well it's hard. ... When we were kids we used to celebrate every Friday night, we'd have a ball. Gerry also spoke about her friendship with her neighbours of fifty years. When asked what her current occupations were, she replied, "Once in a while ... I'd like to go across the street and play a game of hand and foot with my neighbours, ... that would be my occupation now. But it doesn't work out." In comparison, Cayin reported, "I'd like to have more of my friends around." During the interview Cayin reported that she "very much" misses entertaining her friends. As demonstrated in the previous chapter, Cayin expressed difficulty maintaining her role as an entertainer while living in a care facility because of the need to plan ahead for refreshments. Similarly, Helen found it difficult to correspond with her friends. She said, "So we enjoyed, you know, corresponding and telling about our families and so forth. But uh, it got such a task." Like Cayin, Helen expressed missing this activity.  In contrast, two participants felt satisfied with their contact with friends, however both relied on their friends to keep in touch. Anne reported, "I have wonderful friends that keep in touch with me and I feel that, that I'm not forgotten." And Steven said, "One of my close friends  Meaningful Engagement in Long-Term Care  93  who lived in Vancouver ... we saw a great deal of one another and, ... he's out of the country now I think but when he's here, ... he makes sure that he sees me.  Desiring Social Relationships With Co-Residents As discussed in the previous chapter, being socially isolated was expressed as having few significant attachments with fellow residents. Many participants, such as Helen, Cayin, Gormy, and Ben, desired companionship with people living in their facility. During the interview, Helen expressed that she misses living in her previous seniors semi-independent housing situation because "of the people there" who she "could understand". With regard to her current living environment she said, "I can't sit down and talk with someone, there's no way. ... There's only one woman here that I can really talk to." When asked to describe the barriers, she replied, "Well ... we do talk together because ... you say, "Pardon me?" and they repeat. And you say, "Spell it" and they spell it. You make a kind of game out of it." For Helen, difficulty communicating and socializing seemed frustrating for her and hence, a significant barrier. Similarly, Cayin expressed the desire to meet people but felt that she was not. She reportedly found more stimulation in her room, engaging in activities of her choice, than in the common areas where most people were reportedly sleeping. Cayin also stated, "I do things here that interest me. I don't have any contact with anybody else. That bothers me to a certain degree". Gormy also wanted to know her fellow residents but was concerned about "forcing" herself on people and "bothering" them. While the reasons that participants felt a lack of attachment to fellow residents varied the desire for social relationships with people living in their facility was commonly expressed.  Meaningful Engagement in Long-Term Care  94  Ben formed a chess club primarily to meet residents and "get to know" the person he is playing with, however, in his experience, the people he had played with had "different rules" than he did and cared more about winning the game than socializing. Ben said, "Even though I know everyone wants to win, to me its important that I get to know the person and if we enjoying playing we'll get together some other time to play." Despite his experience playing chess, Ben's facility environment provided him with positive cultural connections. He reported with apparent pleasure, " Well I have met people that talk like me in Low German and I have met people that sort of make me feel... when I had my birthday, all of a sudden they came behind me and they sang happy birthday."  Thus, meaningful occupation involved relationships with family, friends, and fellow residents. Being connected with people was also expressed within the context of doing things that were considered productive and contributed to others.  Reward: Doing With Purpose and Contribution For seven participants, being meaningfully occupied included activities that had purpose and contributed to family, friends, fellow residents and/or the community at large. The rewards inherent in activities considered "productive", "purposeful", and/or "helpful" included a "healthy feeling", "not rotting", having "better days" and, "giving pleasure". Examples provided by participants of these type of activities were playing piano and making greeting cards for fellow residents, teaching one's grandchildren, offering friendly gestures, helping facility staff with daily tasks and, doing craft-work to give to someone else.  Meaningful Engagement in Long-Term Care  95  Some participants were enabled, through opportunities in their facility, to engage in such activities. As stated in the previous chapter, participants such as Doll, Anne, Ben, and Margarita felt enabled to contribute to other people's lives. As participants who had been active volunteers, the physical proximity to people afforded them the opportunity to maintain or re-engage in their helping role. However, other participants expressed a lack of productive occupation in their life.  Gormy, Margarita, Cayin, Helen, and Gerry expressed a lack of productive occupation in their lives. Gormy identified herself as a hard worker who was a leader or innovator within her career. She reflected on this role as she considered her current daily occupation. Gormy reported: I feel I worked for a lot of things, .. .1 had good ideas and I'd be enthusiastic about people and they'd sort of follow you know, they'd be glad to let me sort of direct them. I also think that if I had good ideas that I could get involved in things.  ... I'm not doing  anything now. Similarly, Margarita reported having been a hard worker who is feeling a lack of meaningful daily engagement. She said, "Well I'm strongly not productive, I don't know, my daughter says I have worked hard all my life and it is time I took things easy." Cayin also spoke about her sense of productivity and touched upon her experience living in a facility, with regard to the opportunity to do things for herself and for others as well as her sense of isolation. She stated: Productive, me productive? Oh, I'd love to be productive. I should be. ... I should do something that satisfies me that is productive. That's a wonderful word. I don't do it. ... It's something I just normally do, and I don't do enough of it. ... I think being productive is something that contributes to other people. ... I don't do anything like that. Everything  Meaningful Engagement in Long-Term Care  96  is done for us. ... It would be nice to know that you were doing something for someone else. While Cayin spoke about her lack of productive activity she expressed the importance of occupation when she said, "I don't think I have any special occupations except take up space. I'd feel better if I had ... I keep thinking there is something I have to do today. The days that I do have an occupation are much better." Likewise, Helen addressed the significance of occupation for both mental and physical health when she stated, "I don't have enough to do to occupy my mind or physical or anything else. ... That I don't enjoy? There's nothing to do." Finally, Gerry reported, "I do nothing but look out the window. You mean today, what I do today? ... I've been here about a year and a half and I put all my scrapbooks. ... So that sort of got me going, scrapbooks. Gerry also demonstrated the role of occupation, specifically on motivation, when she expressed that her scrapbooks, "got her going". Similarly, Margarita expressed the benefits of meaningful occupation when she was asked to explain how it is important for her to do the things that she wants to do. She replied, "It sort of gets you out of a rut really."  Towards the end of each interview participants were asked, in various ways, what they would like to do or what was important for them to do at that point in their life. Participants, such as Anne, Gerry, Cayin, Ben, Helen, and Doll, spoke about things they would like to do to be meaningfully engaged. Some of these individuals felt that their choices were not realistic because of their current abilities and living situation, while others expressed a sense possibility if given assistance. A l l of their choices involved personal rewards related to giving and doing. For instance, Anne reported:  Meaningful Engagement in Long-Term Care  97  I think I'd go back to volunteer work, its satisfying, its helpful. It's doing something not only to the, the recipient, but the one whose giving of herself too. ... I think that it contributes to a healthy feeling. Doing something worth living for. Gerry said, "If I could plan today? I'd plan to get out and garden. ... So you accomplish something you see. If I could do what today I would garden. And Cayin expressed: Weaving has been a wonderful thing for me because it's been a time for considering colors .. .and all the rest of it. And I think that has kept me from going mad because I have enjoyed the weaving so much and I have so many years of it and I've had a lot of appreciation. ... I would like to have my weaving and my easel right there. So when you leave I can go and sit there and weave a little bit. That would please me and take quite a bit of time. I don't worry now about a product because if I could keep myself busy that would be great. Ben reported that he would like to teach his grandchildren as much as he can, as well as help others. He stated, "I try to do my best in helping other people we were taught that in our church." Helen is blind and hearing impaired and, when asked what was important to her at this time in her life she replied, "I'd like to be able to walk down the street with people", and have "somebody that I can talk to." Finally, when Doll was asked the same question she replied, "Help others. And listen to the hockey game!"  For Steven, living day-to-day seemed to be his primary occupation. Despite having described his losses, Steven expressed a sense of contentment throughout the interview. He attributed his attitude to his ability to positively cope with change and loss. When asked how he wanted to spend his time at this point in his life, he replied, "I don't think it makes a big deal of  Meaningful Engagement in Long-Term Care  98  difference between you and I and the telephone post, if I've got a newspaper, I can read that all day so I, I still do a fair amount of reading." Outside of reading, Steven reported that he would engage in most activities or opportunities offered to him.  In summary, many participants described a lack of productive or meaningful activity in daily life. For many participants, productivity related to humanity in the sense that being productive involved a connection with or contribution to other people. Four participants expressed benefits of meaningful occupation on their emotional and physical health and wellbeing. Cayin poignantly stated, "I think if I didn't do things I'd rot." Likewise, when Doll was asked why she participates in the many activities that she described doing she said, "I'm interested in people, and I'm interested in not laying down and dying."  Reflection: Reminiscing and Evaluating Reflection was identified as a meaningful occupation, which, for participants, regarded reminiscing about and evaluating life. Many participants specifically mentioned reminiscing as a meaningful past time to remember and connect with others. The importance of reflection as a meaningful occupation was demonstrated by many participants who stated that they were grateful for the opportunity to review and evaluate their lives, within the context of their research interview. Further, through the interview process, some participants reflected on end of life issues.  Meaningful Engagement in Long-Term Care  99  Reminiscing Reminiscing was demonstrated as both an independent and social occupation. Examples of independent reminiscing were making scrapbooks with photos and memorabilia, re-reading old letters and, thinking about the past. Gerry, who was engaged in making scrapbooks, described its importance when she said: Well, sometimes when you feel sick you think, darn I'm not even looking forward to those scraps. But you, you do the job because you, well you're putting the pieces of your past together, you got on a certain length or something, and you sort of relive that, you reminisce but not everyone would like to do that its just something that I like to do. ... It's a good activity when you come into a place like this because otherwise you sort of feel that you left everything behind. ... So that's why I keep saying that I got a picture of this and I got a picture of that. You can see that it is important to me to have those things ... because it is an interesting part of your life. When considering what she might do next Gerry said explained that she would like to spend some of her time re-reading old letters. Gerry said: But I know I've got a little box like this full of letters. And I could phone somebody I haven't seen for years. ... Reread them and remind me of when I used to pick raspberries. My cousin phoned me the other day ... I have letters that she sent, so that would take certainly the time. When discussing the roles in Anne's life, she said, "They've all been important,... they've been a stepping-stone, let's say, in each area of my life. Something to look back at and try to remember, and feel that I've been with it. In this way, Anne considered her roles in her life as a means of reflection.  Meaningful Engagement in Long-Term Care  100  Reminiscing socially involved sharing memories and past experiences with other residents. The opportunity to reminisce about life was described, by a couple of participants, as one of the reasons social relationships with residents were desired. For instance, Ben said, "I would like to meet other people here ... to exchange and to talk about their past experiences." Like wise, when talking about her relationship with fellow residents, Anne explained: Well while I'm in [name of facility]... I feel that they are all friends. So I've made a bit of closer friends with some, and we may visit, exchange experiences and have a nice time just talking together. .. .We each explore our pasts a little bit, and um, it's good to learn about others. ... Yes, it's good to live a little bit in the past, just to remember.  Evaluating Participants reported that the opportunity to look back on their lives, throughout the interview, was a meaningful experience. Cayin said, at the end of her interview, "The only thing I would like to add is that I've enjoyed this very much." And Anne reported, "Looking past and reviewing so much with you, I can say right now, I can put it all into one word. Thankful." Reflective thoughts by participants were also about significant memories, regrets, faith and, end of life. A few participants reflected on their most rewarding experience in life. For Gormy, it was being with her mother before she died. She explained: I think the one of my best experiences is being with my mother, getting to see her...I'm not Catholic, but she was at Mount St. Joseph's before she died. We both sat there when my mother died ... we knew it was happening. ... I was able to tell her she was the best mom. So that was a good experience.  Meaningful Engagement in Long-Term Care  101  Similarly, Doll recounted a significant memory regarding her mother, when she was young and they were in Church. She stated, "When the altar call came ... my mother went up and she was a changed woman. I never witnessed anybody as marvelous as she was." And for Cayin, her most meaningful time was when her family "was whole". She described: It was a good life. That was the time I had with my husband of course. My family was whole and the children naturally were a big part of my life, especially when it changed so abruptly and suddenly. But uh, it was a wonderful life. Moreover, a small number of participants reflected on their life's regrets. For instance, Margarita admitted that she wished she had finished nursing school when she reported: I was going in to be a nurse and I had done 11 months of my training. We had three years to do and then you became a general nurse, four if you were doing you know um, midwifery. ... No, I didn't [finish nursing school]. And I regretted it. ... I did really in a way when I look back on my life you know, I should have sort of made myself stick it out. Ben admitted his regret regarding his education when he said, "Well sometimes I wish I had better education but that was not to be had, I don't, I went to school for five years and then the war came to our... and then my education was over. And, one or two participants reflected on their faith. For instance, Ben reflected on how his life was guided by his faith when he said: Well I look at it this way, we've been taught everything that happens to us, the Lord Jesus knows, he is, or if you want to call it God, he has planned our path and I try to do my best in helping other people, we were taught that in our church. ... In other words I believe whatever happens to me is sent to test my faith.  Meaningful Engagement in Long-Term Care  102  During the interview, some participants took the opportunity to reflect, and share their thoughts, about the 'end of life'. For Ben the connection to faith and God were apparently important in his view of death. He stated, "That's the way I feel, people that don't pray, to me that's unbelievable because we're at that stage where we could die anytime. ... People at this place don't care, they just exist so to speak, and I can't understand that." Likewise, Doll's faith guided her evaluation about her life and about dying, when she said: I've had a full life. And I'm happy with, maybe its coming to an end but I'm ready when God calls me. Because I feel that, I feel like, like Paul said in the bible, "he finished his course, he's kept the faith, and he went on to heaven". And I feel that, that'll be me, when I finish my course here and I keep the faith, I can look forward to going on into the new life, like Jesus. Gerry described the importance of time in life when she said: I'd like to uh, perhaps special a little bit. But that's when you, you think of those sort of things when you're fifty, and you don't realize that you're not planning. ... Of course then you're in the middle of the night you don't think you're going to be here that long anyway. You should make use of the time you have. Finally, Steven explained that his motto for living life when he said, "So staying alive is very important because, uh, I could kick the bucket tomorrow. Yeah, I live for today. .. .My dad, uh, lived the same way."  In summary, reflecting was done individually and socially and included, reminiscing for the sake of remembering and sharing the past and, reviewing for the purpose of evaluating life's experiences. It was evident that the act of reflection was a meaningful experience for all  Meaningful Engagement in Long-Term Care  103  participants and for some an active occupation, including talking with other residents, creating scrapbooks and, spending time thinking.  Self-Identity This study identified that participants told stories about their occupations that reflected their selfidentity. For instance, as stated above, Ben told several stories about helping others, and the activities that he engaged in were reportedly aimed at contributing to and/or getting to know fellow residents. At the same time, Ben talked of his life long connection to his Church and value for "living the good life". Doll also told many stories about helping others. She described her experience volunteering with various health care agencies as "interesting" and a learning tool to the "hurts of others". Her faith and connection to God has, like Ben, guided her occupations. Margarita recounted several stories about how she devoted her life to her children and husband. When asked about her experiences and choices in life, she often replied that they made others happy or were chosen because someone dear in her life thought it was a good idea. One of Margarita's most proud occupations currently involves playing the piano for fellow residents. Like Doll and Margarita, Anne devoted most of her life to volunteer roles and her family respectively. The importance for Anne to feel "with it" throughout her life and pursue her "interest in people" was evident in her chosen occupations, both past and present.  Cayin was a missionary and artist throughout her life. Independently coming up with creative ideas that resolve current barriers was evidently important to Cayin and, being innovative, productive, and creative were the qualities guiding her occupations. Similar to Cayin, Gormy was a woman who broke barriers for women in the workforce. Both Cayin and  Meaningful Engagement in Long-Term Care  104  Gormy held positions in university and government respectively, which were new for women in the workforce. Being innovative and a leader were important dimensions of Gormy's identity, and she continued to apply these abilities in her involvement in and evaluation of her L T C facility.  Helen was a single parent who pursued higher education later in life, in order to work and support her family. Helen's desire to be treated with dignity reflected her independent quality, which guided her life long occupations. Specifically, Helen expressed that a subtle approach to providing assistance with daily activities to persons with disabilities can contribute to their sense of dignity. And finally, Steven was a bachelor who lived his life with a care-free, "what-will-bewill-be" attitude. Steven's occupational choice to "live life for today" and take advantage of whatever opportunity is available to him was a clear reflection of his identity.  In conclusion, meaningful occupation for LTC facility residents was identified as the activities that enable self-reliance, social relationships, rewards and, reflection. Regardless of the specific activity in which they engaged, participants demonstrated that opportunities to maintain a sense of independence, foster familial and social relationships, be productive and contribute to others and, reflect back on their lives was necessary for a meaningful existence in a L T C facility. Each participant's identity was reflected within his or her chosen activities, thus acting as a "thread" through meaningful occupation. The last chapter will discuss how this study's results relate to the literature and theoretical framework, as well as the implications they have for occupational therapy and L T C facility practice. Study limitations and relevant future research directions will also be presented.  Meaningful Engagement in Long-Term Care  105  Chapter 6: Discussion The purpose of this study was to contribute to the understanding of meaningful occupational engagement for older adults who live in LTC facilities. Its topic was influenced by my clinical practice where I discerned that many older adult clients who reside in L T C facilities do not engage in the activities that they desire and feel capable of doing. The research objectives were to explore what meaningful daily occupation was to the study participants, and how the environment of a L T C facility enabled and /or constrained their ability to engage in such personally meaningful occupations.  Continuity of Identity Through Meaningful Occupation The meaning of occupation for participants in this study was shaped within the context of their occupational life histories, self-identities, and experiences of living in a L T C facility. The study participants' narratives depicted their occupational life history and self-identities as they reflected on and expressed their life's experiences, roles, and relationships. Their accounts revealed a contextual story of losses, constraints, and opportunities, which influenced meaningful daily occupational engagement. Losses of energy, functional capacity, and home were clearly evident in participants' narratives and current daily occupations were reportedly constrained by the L T C facility's social environment, physical space, and institutional routines and resources. At the same time, participants described that living in a L T C facility affords them new opportunities to contribute to and help others, as well as feelings of safety and security in day-today life. Participants expressed a sense that moving from independent to institutional living was "a great adjustment," which they have made to varying degrees.  Meaningful Engagement in Long-Term Care  106  Through the study participants' stories it became evident that the activities they chose to engage in made up an occupation that is personally meaningful. While participants engaged in different activities from one another, four main themes of meaningful occupation emerged from the data that together framed and gave meaning to daily life, these were; 1) maintaining a sense of independence within a supportive environment, 2) maintaining and fostering social relationships, 3) doing things that have purpose and contribute personally and socially, and 4) reflecting on life's experiences, accomplishments, and regrets. For all participants, engagement in meaningful occupations contributed to their preservation and expression of self-identity, as capable and worthy individuals, thus an additional theme, self-identity, was also evident. Participants disclosed a sense of themselves when they described their past, current, and desired occupations and the ability for them to express their self-identity was found to underlie all of their meaningful occupations.  Theoretical Considerations The theoretical ideas from continuity theory and the discipline of occupational science provided the framework for exploring the meaning that occupation has for elderly people who have experienced a recent change in their living environment. The concepts of continuity, selfidentity, occupation, and environment dynamically influenced meaningful occupation and therefore, served as the framework for discussion of study results. Aspects of the aging experience, including associated losses, will be discussed within the context of these four constructs, which interact to mediate the meaning of occupational engagement for participants.  Meaningful Engagement in Long-Term Care  107  Continuity Growing old involves a variety of life changes that force people to either adapt or be overcome by stress (Williamson & Dooley, 2001). For older adults, adaptation to loss is often a subtle and continuous challenge involving a variety of resources and change in the structure of daily activities (Jackson, 1996). This study revealed that participants experienced many changes to the internal and external structures of their lives, such as the loss of their functional capacity and home. The lack of continuity experienced by participants between their past and current state of affairs was evident in many of their stories, and the activities that they chose to engage in reflected their desire for meaningful connections.  The acts of reflection and engaging in normal everyday activities are considered effective ways of establishing a sense of continuity (Harvey, 2002; Williamson & Dooley, 2001). Reflection is one recognized strategy for coping with loss and change (Harvey, 2002), and was identified in this study as a theme of meaningful occupation for participants. This study suggests that the acts of reminiscing and life review could be the means by which participants attempt to cope with their many reported losses.  Maintaining engagement in normal activities is another coping strategy that promotes successful adaptation and/or effective functioning in older adulthood (Williamson & Dooley, 2001). The daily activities that participants reported to be worthwhile ways of spending their time were found to be related to their past occupations. That is, participants found it meaningful to do the things that they used to do or that relate to what they did in their past. Like findings in Jackson's (1996) study, participants in this study often linked past and present activities through  Meaningful Engagement in Long-Term Care  108  personal themes of meaning, such as religion and family relationships. These themes were considered building blocks to an evolving self-identity (Jackson, 1996). In Jackson's study, the theme of religion guided participants' occupational experiences. The identified themes of occupation in this study reflected participants' desire for meaningful connections with previous personal, familial, and societal relationships. For instance, Doll's desire to help out in the facility demonstrates continuity with her life-long volunteer role. Making scrapbooks was Gerry's way of maintaining continuity with her nursing identity, and family and social relationships. Finally, Ben's interest in teaching his grandchildren shows a connectedness with his role as a Sunday school teacher.  For the study participants, meaningful occupational engagement involved a connectedness to their past occupations and social relationships. Coping with loss and change seems positively influenced by the ability to maintain normal activities and/or engage in activities that connect the past and present. Rudman et al. (1996) suggested the need for further exploration of seniors' perspectives of activity for a deeper understanding of the association between activity and a sense of continuity. Maintaining identity and autonomy is one of the most difficult challenges for older adults who live in nursing homes, and this is related to the ability to maintain internal continuity within a new setting and changing abilities (Hill & Thorn, 2002). This study suggests that older adults who live in LTC facilities may cope more effectively with experienced losses and adapt to changes in life if they are enabled to continue engagement in activities that reflect their past occupations and identities, than if they experience severe lack of continuity in these activities. Despite the many losses experienced by participants, maintaining  Meaningful Engagement in Long-Term Care  109  continuity in the form of activities, memories, and friendships can offer them perceived stability and a healthy connection with the world (Jackson, 1996).  Hill and Thorn (2002, p.32) discussed the role of L T C facilities in promoting continuity for residents, they stated, "residential care facilities can help residents maintain a sense of continuity in their environment by providing ample opportunities and encouragement to participate in valued roles and activities or develop new ones that can be valued within the longterm care context." This study supports that nursing home residents who are enabled with a sense of continuity may be empowered with a sense of self-efficacy, which will impact meaningful engagement and contribute to quality of life.  Self-Identity The meaning ascribed to the concept of aging is constructed within a society based on its cultural norms (Dyck & Jongbloed, 2000; Gillepsie and Gerhardt, 1995; O'Brien, Dyck, Caron, and Mortenson, 2002). And, as O'Brien et al. (2002, p.231) comment, "in Western society, biomedicine is a dominant and authoritative system of knowledge about the body that exerts considerable power in defining what is normal and not normal." The social construction of aging conveys negative ideas about older peoples' competence, in part, because of their associated losses and functional changes that result in deviations from the norms of 'ableness' (Harvey, 2002; O'Brien et al., 2002). Dominant ideological assumptions about aging result in the characteristic of dehumanization, where older people are often regarded as "less than fully human" and as a homogenous group where all people think and function in the same way (Thompson, 1998, p.697). Furthermore, there exists a stereotyped ideology that views old age as  Meaningful Engagement in Long-Term Care  110  a time of no future, preparation for death, and thus, active withdrawal from life (Thompson, 1998). Social attitudes towards aging therefore often result in a stigmatized identity for many older adults, especially for those living in a L T C facility.  Environmental barriers coupled with social attitudes can, as O'Brien et al. (2002) state, constrain activities and participation in society. Participants in this study reported many perceived barriers to engaging in meaningful occupations, both within themselves and in their physical and social environments. While participants did not speak directly to a sense of discrimination, their desire to express themselves as capable and worthy individuals was evident in their chosen occupations, which were a reflection of past interests and accomplishments.  Identity is shaped by daily patterns of occupation, and when there is a disruption individuals will redevelop meaningful lives by drawing on past occupations (Zemke & Clark, 1996). In a study by Dyck (2000b) exploring the experiences of women with multiple sclerosis, it was found that continuing to work helped them to express their identities as competent and healthy individuals, identities that were threatened through disclosure of their illness at their place of employment. In studies by Dyck and Jongbloed (2000) and VrkJan & Miller-Polgar (2001), it was found that a change in functional capacity experienced by participants disrupted their daily routines, which in turn, challenged their identities as competent, healthy, and worthy individuals. Similar findings were found for participants in this study, where age associated losses that resulted in a decline in functional capacity disrupted their occupational routines, which in turn, challenged their identities as capable and healthy individuals.  Meaningful Engagement in Long-Term Care  111  Relocating from home into a L T C facility can further challenge elderly persons' ability to engage in those occupations that they find meaningful (VrkJan & Miller-Polgar, 2001), which was found to be true for participants in this study. One general principle of loss and adaptation to loss is the experience of identity change, thus people who experience major loss may lose a sense of who they are (Harvey, 2002). The study participants' losses in their functional capacity and living environment challenged them to reconstruct their identities, and in doing so, most drew from their former activities. By engaging in familiar activities participants were able to cope with loss as well as reconnect with and express a perceived competent and worthy identity.  Individuals in this study maintained their self-worth through the celebration of their occupations (Jackson, 1996). In Jackson's (1996) study, participants shared weekly occupational events with each other as a means of celebrating their self-worth and identities as older people who warrant notice of their accomplishments. In this study, participants' accounts of their life's experiences, roles and relationships clearly reflected who they were, and their stories and chosen daily activities represented who they are and what is meaningful to them. For example, Gerry did her scrapbooks because it was a way to celebrate her life and to connect with her self-identity. It was a reportedly good activity because according to her, you could "lose yourself moving into a care facility. Thus, the themes of meaningful occupation identified in this study were a symbolic reflection of the participants' self-identity. In this study, people's self-identity was expressed in and connected to what they do, and in turn, the things they do were an expression of who they are.  Meaningful Engagement in Long-Term Care  112  Occupation The literature regarding the construct of occupation supports the notion that occupation is an important determinant of health that gives meaning to life (Law et al., 1998; Jackson et al., 1998; VrkJan & Miller-Polgar, 2001, Wilcock, 1998). Many older people, especially those living in LTC facilities, suffer from loneliness, anxiety, low self-esteem, helplessness, and boredom, which all negatively impact health (Harvey, 2002; Thomas, 1996). Evidence also suggests that, for the elderly, chronic illness, physical decline in function, and loss of autonomy associated with residential care placement contributes to high rates of depression and anxiety (Hill & Thorn, 2002). Research that has explored the experience of occupational engagement for a particular group of people and/or occupation as a means to enhancing physical and/or psychosocial health has broadened our knowledge about occupation and understanding of what makes occupation meaningful. Findings of this study suggest that engagement in meaningful occupation promotes continuity and the expression of a competent and worthy self-identity, which are positively correlated with psychological health (Hill & Thorn, 2002; Rebeiro, 1998). Thus, according to the study findings, enabling nursing home residents to be self-reliant, foster relationships, make a contribution, and engage in reminiscence and life review can in turn, contribute to their health.  The emerging discipline of occupational science is, in the main, concerned with the role of occupation in human life, including its meaning (Carlson et al., 1998). One core belief within the discipline of occupational science and occupational therapy practice is that "occupation is a basic human need which is directly related to the meaning and quality of one's life" (Rebeiro, 1998, p.15). As proponents of occupational science, Jackson et al., (1998) reported their assumptions about occupation and its role in human life, they are; 1) Individuals are occupational  Meaningful Engagement in Long-Term Care  113  beings; 2) Individuals make choices about daily occupations. The choices create the occupational being and are influenced in the social historical context in which they are chosen; 3) People create meaning about what they do (i.e. they "do occupations" for reasons); 4) People have the capacity to respond to challenges in life and recreate a life that is meaningful to them and society; 5) The environment acts to enable or constrain occupational engagement. These assumptions are used to demonstrate how occupation is meaningful for participants in this study  Participants demonstrated their desire to continue to engage in daily life to the best of their abilities, hence demonstrating themselves as occupational beings. A sense of wanting to withdraw from society was not evident in participants' narratives. In fact, participants desired more social stimulation and welcomed opportunities to be active and contribute to their facility and its residents.  Study findings support the conceptualization of occupation as a personal subjective experience that lies with the person who chooses the activity, but which is influenced by the context in which it is performed (Henderson et al., 1991; Zemke & Clark, 1996). Reasons for participants' choices of their occupations was found to include a desire for a sense of selfreliance, to foster familial and social relationships, to do things that have purpose and contribute to themselves and other people, and for reflection on life. Hence, the occupational themes identified were titled; reliance, relationships, reward, and reflection. At the same time, participants' choices about their daily occupation were influenced by their losses, constraints, and opportunities, which were identified as themes that make up the context of what life is like for a person living in a L T C facility. Appreciation of the participants' experience of loss, constraint  Meaningful Engagement in Long-Term Care  114  and opportunity was important in achieving an understanding of how the person came to choose his or her particular meaningful occupation.  The study findings demonstrate that occupation can play an important role in connecting an individual's past with their present and future as well as allowing a person to express his or her self-identity, which is similar to findings in a study by Rudman et al. (1996). However, in this study, the enabling and constraining aspects of the nursing home environment clearly impacted participants' occupational engagement, they are discussed in the following section.  Environment Both occupational science and the Canadian Model of Occupational Performance (CMOP) view the environment as being dynamic and having enabling and constraining influences on the performance of occupations (CAOT, 1997; Zemke & Clark, 1996). The C M O P defines the environment as having social, cultural, physical, and institutional elements, which can impact a person's ability to perform their occupations (CAOT, 1997). Further, the environmental elements of nursing home facilities can affect a resident's functional ability, social interaction and psychological well-being (Hill & Thorn, 2002). According to the study findings, the enabling and constraining elements of the residential care facility's social milieu, physical space, and institutional routines and resources, as described in chapter four, interacted and impacted participants' engagement in meaningful occupation.  Meaningful Engagement in Long-Term Care  115  The Social Environment While it is known that the different environmental components impact people's experience of disability, the social environment has recently received greater attention in the literature as an important factor in human occupation (Dyck & Jongbloed, 2000; Rebeiro & Cook, 1999; Rebeiro, 2001). Dyck and Jongbloed (2000) studied identity and employment issues, such as disclosure of diagnosis in the workplace, for women with Multiple Sclerosis, highlighting the importance of a supportive social environment in shaping positive workplace experiences for women with Multiple Sclerosis. In the studies of occupational engagement for women with mental illness, Rebeiro and Cook (1999) and Rebeiro (2001) demonstrated that when participants were affirmed within their social environment as being valued persons, they were enabled to experiment with a variety of occupations and that without such an environment, participants lacked confidence in trying new things. Further, for the participants in Rebeiro and Cook's (1999) and Rebeiro's (2001) studies, successful participation in these occupations confirmed their sense of self-worth, which in turn, served to foster an evolving self-identity as capable and worthy individuals. These studies demonstrate that the opportunities and support afforded to people within their environments greatly impact meaningful occupational engagement and thus, a supportive social environment is important in shaping identity and enabling the engagement in occupations for people in a particular setting (Dyck & Jongbloed, 2000; Rebeiro & Cook, 1999; Rebeiro, 2001).  The social environment in care facilities is typically designed around a recreation program that offers residents the opportunity to engage in a myriad of organized social and leisure activities that are scheduled throughout the day. Leisure involvement can be a significant  Meaningful Engagement in Long-Term Care  116  occupation for nursing home residents, especially in a living environment where they typically require assistance with self-care activities and most home-management activities are taken care of for them by staff or family. Interestingly, when participants discussed their daily occupations including what they did to enjoy themselves they rarely mentioned the activities program as a meaningful part of their day. While participants generally considered the activities to be enjoyable ways of spending time or filling the day, the occupations that they described as personally meaningful did not include those offered in the recreation programs. Furthermore, despite living in a social environment that is filled with people and activity opportunities, participants expressed the sense of isolation, wanting more meaningful connections with people, and lacking sufficient stimulation.  The personally meaningful occupations for participants were connected to their past interests and pursuits and, desired connections with fellow residents were made when these occupations were enabled by the facility staff and/or environment. For example, Doll and Anne connected with residents as helpers within their facility, which gave them a sense of reconnecting with their meaningful volunteer roles. Bingo games and other common residential care activities will only appeal to those who enjoyed participating in these pursuits earlier in their lives (Hill & Thorn, 2002). Making connections with people is evidently difficult to accomplish in organized leisure activities that do not bear personal meaning. In this way, the social environment in a nursing home has a role in promoting continuity for residents by affording personally meaningful roles and opportunities.  Meaningful Engagement in Long-Term Care  117  The opportunities for choice and self-determination within the L T C facility's social and physical environment were often lacking for participants in this study, especially with regard to their engagement in social and leisure pursuits. The elements of choice and self-determination were found to be integral for women with mental health problems in constructing a social environment in which they felt a sense of belonging (Rebeiro, 2001). These elements are supported as enablers of social well-being and meaningful engagement for nursing home residents. One way to empower residents within their environment is to ensure that residents are informed about the recreation activities and can make choices regarding their involvement in these programs (Hill & Thorn, 2002). Findings of this study propose that residents be involved in the ongoing development of facility recreation programs and that activity opportunities provide ways for residents to maintain as sense of self-reliance, foster social relationships, contribute to themselves and others, and reflect on their lives. The leisure opportunities afforded within L T C facilities can offer more than diversionary activities and can enable residents to engage in personally meaningful occupations that in turn, express a worthy and capable identity.  The Physical Environment Within the physical environment, study participants identified the lack of space to set up and pursue individual hobbies as the main barrier. Specifically, limited space to safely keep materials such as weaving and painting supplies in small private rooms or activity and common areas constrained participants' ability to engage in past individual leisure interests. Physical space requirements that are conducive to enabling residents' occupational engagement are issues of design and organization that have fiscal and policy implications for the institutional setting, which is discussed in the next section.  Meaningful Engagement in Long-Term Care  118  The Institutional Environment The institutional environment of a L T C facility is comprised of both a physical structure and organizational routines and practices, which further affect residents' occupational performance and expression of self. According to C A O T (1997) and within the CMOP, the institutional environment is described as having economic, legal, and political elements that have a strong influence on everyday life. The economic, legal and political impact within the environment includes policies, decision-making processes, procedures, accessibility and other organizational practices (CAOT, 1997). For instance, the traditional model of nursing home care is designed upon the principles of the medical / hospital model and its funding is based on the medical care needs of its residents (Rader, 1995). These factors impact aspects of the institutional setting such as the staff-to-resident ratios, the daily care-giving practices, activity opportunities, and staff philosophy of care. The medical model guiding nursing home care is not designed to address the needs of residents with regards to enabling choice, dignity, and normalcy in daily life (Jones, 1996; Rader, 1995). Findings of this study demonstrate that the institutional setting of a LTC facility is comprised of physical and social elements, which are collectively impacted by economic, legal, and political factors.  The institutional environment of nursing homes impose organizational practices, resources and policies, which influence the meaning that occupations have for participants and can serve to compromise their ability to pursue engagement in these occupations. The structure and environment of many L T C facilities often negatively affects residents' well-being (Hill & Thorn, 2002). The closed social system of a L T C facility can limit opportunities for interpersonal interaction, and the low staff-to-resident ratio combined with daily regiments and  Meaningful Engagement in Long-Term Care  119  routines "can limit individualized attention and treatment, decrease a sense of privacy and autonomy, and stifle individual initiative" (Hill & Thorn, 2002, p.210). In this study, the institutional environment of a L T C facility was found to be full of contradictions with regards to participants' function and well-being. For instance, while many participants appreciated the comfort and security provided by living in a care facility they missed the independence they sensed by living in their own home. Further, declines in perceived self-efficacy were demonstrated in participants' narratives despite their hope to maintain a sense of independence with the help provided by staff and available services in a care facility. Another contradiction is found within the social element with regard to participants sense of isolated and desire for social stimulation, despite living in an environment filled with people and organized leisure opportunities.  The constraints imposed and opportunities afforded in the L T C facility environment play a significant role in respectively constraining or enabling engagement in meaningful occupation for residents. Institutional elements of the L T C facility environment, such as regimented routines and physical design, can compromise individuality and in turn, self-identity. The lack of opportunity within the social, physical, and institutional setting to make choices and determine for themselves what, when, and how to perform daily activities impacted participants' occupational engagement and in turn, expression of self. Environments that provide opportunities and affirm people as worthy and capable individuals can empower self-efficacy and engagement in meaningful occupation (Hill & Thorn, 2002; Rebeiro, 2001). Thus the dynamic  Meaningful Engagement in Long-Term Care  120  environment significantly impacts engagement human occupation and construction of selfidentity.  This study considers meaningful occupational engagement to be influenced by the dynamic between participants' identity, chosen occupations and environmental context. Occupational therapists have an important "role in advocating and enabling the experience of meaningful occupational engagement for older adults who reside in L T C facilities.  Implications for Occupational Therapy Practice Study results generated information regarding the meaning of occupation and the impact of social and physical elements of the institutional environment on participants' occupational engagement. They bear implications for clinical practice, specifically when working with the older adults who either reside in nursing homes or are preparing to move from a private residence to assisted living. The study findings are also relevant for rehabilitation therapists who work with clients who reside in institutional settings such as a L T C facility.  This study aimed for a better understanding of occupational engagement for L T C facility residents. It was evident through the process of analysis that an understanding of the participants "life context" was integral to an understanding of the meaning that occupation has for them, and leads to the first implication, which is that therapists explore client's perceived losses, and the barriers to and opportunities for their occupational engagement. Enabling meaningful occupation for clients, especially elderly clients must involve an appreciation of where the individual is "coming from" and sense of "what life has been like" for that person. In this way, the client's  Meaningful Engagement in Long-Term Care  121  context may include but extends beyond the impact of his or her current living environment and community.  The second implication concerns the elements of continuity and identity, which are important for enabling clients to cope with transitions, life changes and challenges. Findings demonstrated that a lack of continuity (of both internal and external structures) negatively impacted participants' adjustment to living in a nursing home. Furthermore, findings suggest that participants chose occupations that in some way connected their past with the present and were an expression of their self-identity as capable and worthy. Clinicians can support clients as they adjust to the changes imposed by injury, illness, and/or disability and to achieve a sense of self-efficacy and/or reconstruct a self-competent identity. This can be achieved by collaborating with clients to foster their sense of continuity regarding occupation and by providing opportunities within their environment for self-expression. Promoting continuity for clients who reside in nursing homes begins with an understanding of the client's personal history, experiences, and interests, specifically from the perspective of that person. Occupational therapists then need to advocate for long-term care organizations to be flexible in designing programs and carrying out daily care activities in a manner that is tailored to fit with the resident's sense of self (Hill & Thorn, 2002).  A third implication concerns the definition of meaningful occupation as a fundamental concept within occupational therapy practice. One aim of occupational therapy practice is to enable clients to engage in "meaningful occupation," and in assessment, to identify barriers to clients' engagement in occupations that are meaningful to them. This study explored the  Meaningful Engagement in Long-Term Care  122  subjective meaning that occupation has for older adults who live in L T C facilities. Findings suggest that meaningful occupation includes a variety of activities that collectively have personal meaning for a person, and engagement in these activities can be symbolic of his or her identity. The expression of identity may therefore be one reason why a particular occupation is meaningful to a person. Conversely, one's identity can be shaped by the occupations he or she chooses to engage in. As stated by Clark et al. (1991), "when we attempt to explain occupation simply as an activity unsaturated with meaning, we miss its essence" (p.302). Occupational therapists need to consider the experience of the collective activities that their clients choose and engage in, both past and present, in order to appreciate the meaning that these occupations have for them. Further, enabling clients to perform their chosen activities can, in turn, enable expression of their identity. According to this study, older adults who live in nursing home environments will, when given the opportunity, choose occupations that enable a sense of self-reliance, foster social relationships, allow them to contribute in a significant way, and encourage reflection on life. Therapists working with nursing home residents, or people who are comparable in age or who live in similar institutional settings may want to explore how their clients' daily occupations serves to facilitate these areas.  The fourth implication concerns the impact of the environment in enabling engagement in meaningful occupation. This study supports Rebeiro's (1999) finding that "environments that provide opportunity, and not prescription are more conducive to fostering occupational performance" and give the client a sense of authority within their occupational therapy involvement (p. 176). Environments that provide opportunity including elements of choice and self-determination can enable older adult clients to maintain necessary connections between their  Meaningful Engagement in Long-Term Care  123  past, present and future, engage in meaningful occupations, and in turn, foster healthy expression of themselves as capable and worthy.  The fifth implication also pertains to the environment and concerns the advocacy role of occupational therapists in regards to housing issues for seniors, including physical environments and activity opportunities. As Dyck and Jongbloed (2000) stated, clinicians take on a role as advocates for clients regarding the planning of their environments, especially when they consider the significant impact of institutional environments on peoples' occupational engagement. Taking the environment into account in analyzing participant's experience of occupational engagement provides the foundation for advocacy roles in the built environment and associated social policy of L T C facilities for seniors. This study suggests that occupational therapists have a role in advocating for built and organizational environments in which their clients live that are conducive to fostering clients' optimal occupational engagement.  Using narrative approaches to understand meaning for elderly clients and to elicit their goals is the sixth implication of the study results. Dyck (2000), Mattingly (1991), and Helfrich and Kielhofner (1993) have highlighted the benefits of using narrative approaches in occupational therapy research and practice. This study suggests that older people are keen to talk with other people, share their stories, reminiscence, and reflect on life. Older adults may not be familiar with setting and articulating goals, especially within the context of traditional, formal occupational therapy assessments. This does not mean however, that our clients do not know what matters to them and what they want to achieve in their life. Using narrative approaches and  Meaningful Engagement in Long-Term Care  124  in-depth interviewing techniques in practice can be beneficial to understand clients' meaning in everyday life and elicit their occupational interests, needs, and goals.  Implications for LTC Facility Practice In British Columbia, the profile of people who are moving into L T C facilities is changing because of new policies created to reflect both the needs and growth of the aging population and the limited resourced L T C system. On April 15, 2002, the new provincial policy on access to LTC facilities was implemented (htt://admin.moh.hnet.bc.ca/acc/homecc/index.html). The particular criteria that a person now has to meet in order to be eligible to move into a facility are that he or she; 1) has complex care needs that cannot be planned for by a home care nurse or other home-care professional, 2) has exhausted all available community resources that can keep him or her safe at home (e.g. Adult Day Centre and Home Support Services), and 3) requires placement within the next three months. The changes to L T C facility access also include the elimination of a 'wait-list', which allowed people to plan and choose their preferred facility. Today, older adults can visit any facility and identify a preference, but when the above admission criteria are in place, choice will not be guaranteed. People will have the opportunity to move into the first 'bed' available in the system and then put their name on a list to be transferred to the preferred facility, if and when a bed becomes available. The idea behind these changes is to manage the existing waitlists, which are long and "blocked" and the changes are intended to offer older adults the safety of care when they need it (Anne Bullock, personal communication, January 21, 2003). These changes also reflect a rise in the acuity of care needs of elderly adults residing in the community. Soon L T C facilities will no longer care for people who are assessed as Intermediate Care level 1 or 2, a trend that is already being seen in Vancouver facilities.  Meaningful Engagement in Long-Term Care  125  The findings of this study suggest that older adults currently in L T C facilities choose occupations that provide a sense of continuity, representing their self-identity. The importance of enabling continuity for persons living in L T C facilities may increase significantly with changes to LTC access, as their move to the residence will occur in times of personal stress and extreme discontinuity. Further, effectively enabling continuity may also become more difficult within the facilities. Gathering of information about the persons' losses, and consideration of the environmental constraints and afforded opportunities will therefore be central to meeting the needs of the future resident. However, if the older adults living in nursing homes are increasingly impaired, especially cognitively, then the manner in which we gather information about the resident may need to change. Using narrative approaches with residents to gather their personal histories, needs, and interests may not be viable and it is likely that there will be an increased reliance on family and friends for collateral information.  This study's identified occupational themes; reliance, relationships, rewards and reflection, will continue to be relevant to the nursing home resident, although the activities that an older person has the capacity to engage in may change. For instance, if in the future, all of the elderly people residing in L T C facilities are severely cognitively and/or physically frail, it may not be appropriate to offer any resident the responsibility of writing and delivering greeting cards to co-residents (as Anne currently does). However, the need to enable residents' sense of contribution and reward will remain very important (however insignificant that contribution may seem to other people). The activity programming in residential care will need to be reviewed in light of the increasingly frail resident. Employment of skilled professionals, training for support staff, and improved built environments will be necessary for the future of L T C . The L T C  Meaningful Engagement in Long-Term Care  126  management and staff will need to be innovative and flexible in designing programs and carrying out daily care activities tailored to fit with the 'new' resident's sense of self.  Study Limitations Four limitations have been identified with regards to this study. The first concerns the generalization of results to L T C facility residents. The small number of participants, as in most qualitative studies, does not permit generalization of findings to all people who fall within the identified group. In particular to this study, the participants were cognitively able to engage in an in-depth interview, which is not representative of the many significantly cognitively impaired nursing home residents. Study findings are potentially limited to a better understanding of meaningful occupation for nursing home residents who are cognitively intact, which may currently be a minority. Conversely, the participants may have represented the needs and interests of those who are unable to effectively communicate them. A second limitation concerns the fact that, as per the study design, only one interview was conducted with each participant. It was evident that a more in depth understanding of daily occupational engagement for participants could have been gained with an additional interview or by additionally using the method of participant observation. A third limitation concerns issues of transcription. The soft voices of many participants resulted in difficulty deciphering some words or phrases when listening to the audiotapes. The use of a collar-microphone is suggested for future qualitative study with this population. A final limitation regarded aspects of recruitment. In this study, recruitment of participants was accomplished following all ethical standards and participation was voluntary but residents who had the opportunity to participate in the study were selected by the respective facility Director of Care. Letters were given to the directors asking them to post as well as share  Meaningful Engagement in Long-Term Care  127  a recruitment letter geared towards potential participants. Unfortunately posting up the letter did not elicit any participants. The implied limitation concerns the director's bias in regards to choosing residents that he or she believed could and/or would like to participate in the study. However, it is important to note that the study criteria included participants who had been living in a facility for no more then two years. This criterion would have influenced, and perhaps limited, which resident(s) a director could have asked.  Future Research Directions A better understanding of the meaning that occupation has for older adults who reside in L T C facilities was achieved through this study, however many new questions and avenues for exploration emerged from the findings. Meaningful occupation for the participants was influenced by their perceived losses, constraints, and opportunities and, motivated by the expression of their self-identity. The following suggestions are primarily made to broaden the . understanding of meaningful occupational engagement, particularly for older people.  The study findings suggest three directions for future research concerning the concept of self-identity. First, this study highlighted the significance of one's identity as a connecting factor throughout life's occupations. Participants chose occupations that were connected with their past in order to convey their self-identity while living in an environment that can compromise individual expression. Further exploration of the dynamic between continuity, identity, occupation, and environment is warranted. For example, how is one's self-identity affected by a disruption in daily occupation? How is a sense of continuity achieved for people who have  Meaningful Engagement in Long-Term Care  128  experienced a change in both their daily occupations and living environment? And, how does a sense of continuity impact occupational engagement?  Identity is known to evolve as a person goes through life and be reconstructed in light of his or her present circumstances (Dyck, 2000; Jackson, 1996); however, it was not clear how participants' identity evolved during older adulthood and in what way it had changed in their perception. Thus, exploration of how one's self-identity is constructed in different situations is the second suggestion for future research. For instance, how do older adults who live in L T C facilities perceive their self-identity? And how is it different from their perception when they lived independently? In connection, further examination of the relationship between older adults' identity and their roles in life is also warranted. What are L T C facility residents' perceived roles in life? And how do they develop or maintain significant roles living in a L T C facility? Finally, how can L T C facility management and staff enable residents to construct meaningful roles, in the context of residents' experienced losses and, within their perceived constraints in and opportunities for occupational engagement?  The concept of identity has a third implication for research in regard to occupational therapy theory and practice. There seems to be a paucity of research regarding the concept of person as it relates to the person-occupation-environment relationship. Related research questions can include: How does identity, as a concept, fit with the C M O P , specifically the component of person? What is the relationship between identity and person? What is the relationship between identity and spirituality?  Meaningful Engagement in Long-Term Care  129  This study highlighted that the institutional setting of a L T C facility comprises social and physical environments that are influenced by economic, legal, and political elements. Residential settings, such as nursing homes, are institutional systems that often segregate residents from the rest of society. People who live in these institutions do not need to leave the facility to complete most daily activities. Furthermore, for these residents, typical community appointments are also met inside the facility, such as seeing the doctor or hair stylist. Essentially, residents' daily life primarily occurs within the facility, which limits opportunities for community integration. Further examination of the institutional elements of a residential care environment is warranted, specifically involving its impact on residents' daily life and meaningful occupational engagement.  Finally, the role of leisure as a meaningful occupation for older adults who live in nursing facilities deserves further study. According to Rebeiro and Cook (1999), diversionary activities and a sense of fun can offer a necessary escape from physical, cognitive and social problems, provide respite from negative thinking, and focus on a person's capabilities. Why then was the activities program not identified by participants as a meaningful part of their day? How are current activities programs relevant to L T C facility residents?  Conclusion Results of this study add to the body of knowledge of occupation for older adults living in a LTC facility. Specifically, findings offer a better understanding of what occupation means to LTC facility residents and how the (institutional) environment impacts their occupational engagement. According to this study, older peoples experienced losses, perceived constraints and afforded opportunities greatly influence their chosen occupations. L T C facility residents will  Meaningful Engagement in Long-Term Care  130  choose occupations that allow for a sense of self-reliance, social relationships, reward through contribution, and time for reflection. Further, the occupations that are personally meaningful to elderly residents include those that allow them to express themselves and their self-identity.  Study results have implications for occupational therapy and L T C facility practice with older adults who reside in L T C facilities, specifically regarding issues such as the initial assessment of the resident, recreation programming, provision of personal care, and the development of the physical and social setting. The connection between older adults' occupation and their self-identity can be enabled through meaningful environmental opportunities. Rehabilitation therapists and other professionals who work with elderly residents are called to be innovative and flexible in designing programs and carrying out daily care activities within L T C facilities, in a manner that enables continuity for each resident and is tailored to fit with his or her sense of self.  Meaningful Engagement in Long-Term Care  131  References Atchley, R. C. (1989). A continuity theory of normal aging. Gerontologist. 29(7.V 183-190.  Beck, C , & Chumbler, N . (1997). Planning for the future in long-term care: Consumers, providers, and purchasers. Journal of Gerontological Nursing, 23(8). 6-13.  Bullock, A. Personal communication. January 21, 2003.  Burbank, P. M . (1986). Psychosocial theories of aging: A critical evaluation. Advances in Nursing Science. 9 (1). 73-86.  Canadian Association of Occupational Therapists (1997). Enabling occupation: A n occupational therapy perspective. Ottawa, ON: Author.  Canadian Association of Occupational Therapists (1994). Positive statement on everyday occupations and health. Canadian Journal of Occupational Therapy, 61(5), 294-295.  Carlson, M . , Clark, F., & Young, B. (1998). Practical contributions of occupational science to the art of successful aging: How to sculpt a meaningful life in older adulthood. Journal of Occupational Science. 5(3). 107-118.  Carpenter, C , & Hammell, K . (2000). Evaluating qualitative research.  In: Hammell,  K.W., Carpenter, C. & Dyck, I. (Eds.), Using qualitative research: A practical introduction for occupational and physical therapists, (pp. 107-119). London, U K : Churchill Livingstone.  Clark, F., Carlson, M . , Zemke, R., Frank, G., Patterson, K., Ennevor, B.L., RankinMartinez, A., Hobson, L., Crandall, J., Mandel, D., & Lipson, L (1996). Life domains and adaptive strategies of a group of low-income well older adults. American Journal of Occupational Therapy, 50 (2), 99-109.  Meaningful Engagement in Long-Term Care  132  Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M . , Mandel, D., Hay, J., Josephson, K., Cherry, B., Hessel, C , Palmer, J., & Lipson, L. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial. Journal of the American Medical Association, 278 (16). 1321-1326.  Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five traditions. London, U K : Sage Publications.  Darnell, J. L., & Heater, S. L . (1994). Occupational therapist or activity therapist, which do you choose to be? American Journal of Occupational Therapy, 48(5), 467-468.  Dyck, I. Personal communication, September 18, 2000a.  Dyck, I. (2000b). Working with theory in qualitative research: A n example from a study of women with chronic illness (multiple sclerosis). In K. W. Hammell, C. Carpenter, & I. Dyck (Eds.), Using qualitative research: A practical introduction for occupational and physical therapists (pp. 85-95). London, U K : Churchill Livingstone.  Dyck, I., & Jongbloed, L. (2000). Women with multiple sclerosis and employment issues: A focus on social and institutional environments. Canadian Journal of Occupational Therapy. 67(5). 337-346.  Dyck, I. Personal communication, November 18, 2002.  Engle, F., Fox-Hill, E., & Graney, M . (1998). The experience of living and dying in a nursing home: Self-reports of black and white older adults. Journal of American Geriatric Society, 46(9), 1091-96.  Epp, J. (1986). Achieving health for all: A framework for health promotion. Health Canada, Ottawa, Canada.  Meaningful Engagement in Long-Term Care  133  Evans, K . A . (1987). Definition of occupation as the core concept of occupational therapy. American Journal of Occupational therapy, 41, 627-628.  Gregory, M . D. (1983). Occupational behavior and life satisfaction among retirees. American Journal of Occupational Therapy, 37(8), 548-553.  Hachey, R., & Mercier, C. (1993). The impact of rehabilitation services on the quality of life of chronic mental patients. Occupational Therapy in Mental Health, 12 (2), 1-25.  Hammell, K . W., Carpenter, C , & Dyck, I. (2000). Using qualitative research: A practical introduction for occupational and physical therapists. London, U K : Churchill Livingstone.  Hammersley, M . , & Atkinson, P. (1995). Ethnography: Principles in practice, 2nd Ed. London, U K : Routledge.  Harvey, J. H . (2002). Perspectives on loss and trauma: Assaults on the self. California, US: Sage Publications.  Helfrich, C , & Kielhofner, G. (1993). Volitional narratives and the meaning of therapy. American Journal of Occupational Therapy, 48 (4), 319-326.  Higgins, I. (1998). Pearls, pith and provocation: Reflections on conducting qualitative research with elderly people. Qualitative Health Research, 8(6), 858-66.  Hill, R., & Thorn, B . (2002). Geriatric residential care: A population at risk. Mahwah, NJ: Lawrence Erlbaum Associates.  Meaningful Engagement in Long-Term Care  134  Hutchinson, S., & Wilson, H . (1994). Research and therapeutic interviews: A poststructuralist perspective. In J. M . Morse (Ed.), Critical issues in qualitative research methods (pp. 300-315). Pennsylvania, US: S A G E Publications.  Jackson, J. (1996). Living a meaningful existence in old age. In R., Zemke, & F. Clark (Eds.), Occupational science: The evolving discipline (pp. 339-361). Philadelphia, US: F.A. Davis Company.  Jackson, J., Carlson, M . M . , Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign: The well elderly study occupational therapy program. American Journal of Occupational Therapy. 52 (5). 326-336.  Jean, C. D., & Connelly, F. M . (2000). Narrative inquiry: Experience and story in qualitative research. San Francisco, C A : Jossey-Bass Inc.  Jirovec, M . M . , & Maxwell, B. A. (1993). Nursing home residents functional ability and perceptions of choice. Journal of Gerontological Nursing [September], 10-14.  Jones, M . (1990). Time use and the elderly. Canadian social trends: Statistics Canada, [summer], 28-30.  Jones, M . (1996). Gentlecare. Moyra Jones Resources: Chelsea Printers.  Josselson, R., & Lieblich, A. (1995). Interpreting experience: The narrative study of lives. London, U K : Sage Publications.  Jongbloed, L. (1994). Adaptation to a stroke: The experience of one couple. American Journal of Occupational Therapy. 48 f 1 \ 1006-1013.  Meaningful Engagement in Long-Term Care  135  Krefting, L. (1989). Disability ethnography: A methodological approach for occupational therapy research. Canadian Journal of Occupational Therapy, 56, 61-66.  Krefting, L. (1991). Rigor in qualitative research: The assessment of trustworthiness. American Journal of Occupational Therapy, 45(3), 214-222.  Law, M . , Steinwender, S., & Leclair, L. (1998). Occupation, health, and well being. Canadian Journal of Occupational Therapy, 65 (2), 81-91.  Lewis, S. C. (1989). Elder care in occupational therapy. Thorofare, NJ: S L A C K Inc.  Mason, J. (1996). Qualitative researching. London, U K : S A G E Publications.  Mattingly, C. (1991). What is Clinical Reasoning? The American Journal of Occupational Therapy, 45(11), 979-986.  McDowell, B., Kristjansson, G., Hill, B., & Hebert, H. (1997). Community Screening for Dementia: The mini mental state exam (MMSE) and modified mini mental state exam (3MS) compared. Journal of Clinical Epidemiology, 50(4), 377-383.  McKinnon, A. L . (1992). Time use for self-care, productivity, and leisure among elderly Canadians. Canadian Journal of Occupational Therapy, 59(2), 102-110.  Miller, R.J., & Walker, K.F. (Eds.). (1993). Perspectives on theory for the practice of occupational therapy. Gaithersburg, M D : Aspen Publishers.  Ministry of Health Services for BC. (2003). Home and community care policy manual. htt://admin.moh.hnet.bc.ca/acc/homecc/index.html.  Meaningful Engagement in Long-Term Care  136  Mishler, E. G. (1986). Research interviewing: Context and narrative. USA: President and Fellows of Harvard College.  Mitchell, T. L., & Radford, J. L . (1996). Rethinking research relationships in qualitative research. Canadian Journal of Community Mental Health, 15(1), 49-60.  Morse, J. . M . , & Field, P. A . (1995). Qualitative research methods for health professionals (2 ed.). Thousand Oaks, C A : S A G E Publications. nd  Nelson, D. L . (1996). Therapeutic occupation: A definition. American Journal of Occupational Therapy, 50(10), 775-782.  O'Brien, P. (2001). Change and Continuity: The Experience of living with a terminal illness. Unpublished Masters of Science Thesis, School of Rehabilitation Sciences.  O'Brien, P., Dyck, I., Caron, S., & Mortenson, P. (2002). Environmental analysis: Insights from sociological and geographical perspectives. Canadian Journal of Occupational Therapy, 69(4), 229-238.  Onega L. L., & Tripp-Reimer T. (1997). Expanding the scope of continuity theory: Application to gerontological nursing. Journal of Gerontological Nursing, 23(6), 29-35.  Phinney, A . (1998). Living with dementia from the patient's perspective. Journal of Gerontological Nursing, [June!, 8-15.  Rader, J. (1995). Individualized dementia care: Creative and compassionate approaches. New York: Springer Publishing Company.  Rebeiro, K . L . (1998). Occupation as a means to mental health: A review of the literature, and a call for research. Canadian Journal of Occupational Therapy, 65(1), 12-19.  Meaningful Engagement in Long-Term Care  137  Rebeiro, K . L . (2001). Enabling occupation: The importance of an affirming environment. Canadian Journal of Occupational Therapy. 68(2). 80- 89.  Rebeiro, K . L., & Cook, J. V . (1999). Opportunity not prescription: A n exploratory study of the experience of occupational engagement. Canadian Journal of Occupational Therapy, 66(4), 176-187.  Riessman, C. K . (1993). Narrative Analysis. Thousand Oaks, C A : S A G E Publications.  Rogers, J. C. (1984). Why study human occupation? American Journal of Occupational Therapy, 38, 47-49.  Rudman, D.L., Cook, J. V., & Polatajko, H. (1996). Understanding the potential of occupation: A qualitative exploration of senior's perspective on activity. American Journal of Occupational Therapy, 51(8), 640-650.  Segal, S., & Baumohl, J. (1988). No place like home: Reflections on sheltering a diverse population. In C. Smith, & J. Giggs (Eds.), Location and stigma, (pp 249-263). Boston: Unwinhyman.  Sheppard, K . F., Jensen, G. M . , Schmoll, B. F., Hack, L . M . , & Gwyer, J. (1993). Alternative approaches to research in physical therapy: Positivism and phenomenology. Physical Therapy, 73. 88-101.  Statistics Canada: Canadian Census data from the Internet. (2000).  Thomas, W. H . (1996). Life worth living: How someone vou love can still eniov life in a nursing home. Acton, M A : VanderWyk & Burnham.  Meaningful Engagement in Long-Term Care  138  Trombly, C. A . (1995). Occupation: Purposefulness and meaningfulness as therapeutic mechanisms. American Journal of Occupational Therapy, 49(10), 960-972.  VrkJan, B. & Miller-Polgar, J. (2001). Meaning of occupational engagement in lifethreatening illness: A qualitative pilot project. Canadian Journal of Occupational Therapy, 68(4), 237-246.  Wilcock, A. A . (1998). Occupational science. British Journal of Occupational Science, 54(8), 297-300.  Williamson, G. M . , & Dooley, W. K . (2001). Aging and coping: The activity solution. In C. R. Snyder (Ed.), Coping with stress: Effective people and processes (pp. 240-258). New York: Oxford University Press.  Yerxa, E. J., Clark, F., Frank, G., Jackson, J., Parham, D., Pierce, D., Stein, C , & Zemke, R. (1990). A n introduction to occupational science, a foundation for occupational therapy in the 21 century. Occupational Therapy in Health Care, 6, 1-17. st  Yerxa, E . J . (1998). Health and the human spirit for occupation. American Journal of Occupational Therapy, 52(6), 412-418.  Zemke, R., & Clark, F. (1996). Occupational science: The evolving discipline. Philadelphia: F.A. Davis Company.  Zuzanek, J., & Box, S.J. (1988). Life course and the daily lives of older adults in Canada. In K. Altergott (Ed.), Daily lives in later life (pp. 147-185). California: S A G E Publications.  Meaningful Engagement in Long-Term Care  APPENDIX A Participant Consent Form  139  Meaningful Engagement in Long-Term Care  140  Forward to Appendix A  In the Participant Consent Form, Dr. Anne Carswell is identified as the principal investigator. At the time of participant recruitment, Dr. Carswell was the thesis advisor for this study. Following the phase of data collection, a change in advisor, between committee members, was made because Dr. Carswell suggested that Dr. Isabel Dyck as an expert in the area of qualitative research and therefore better suited as this study's thesis advisor. A l l committee members and myself were in agreement.  THE  UNIVERSITY  OF BRITISH  COLUMBIA  School of Rehabilitation Sciences Faculty of Medicine T325 - 2211 Wesbrook Mall Vancouver. B.C. Canada V6T 2B5  rintp-  Mav  1 9001  Tel: (604) 822-7392  Date. M a y l , z u u i  F a x :( 6 0 4 ) 8 2 2  .  7 6 2 4  Website: www.rehab.ubc.ca  PARTICIPANT INFORMATION AND CONSENT FORM  The Meaning of 'Occupation' for Older Adults Living in Long-Term Care Facilities Principal Investigator: Anne Carswell, Ph D. Dr. Anne Carswell will be the principal investigator of the study in the capacity of academic advisor to the co-investigator. Co-Investigator:  Staci Caron, BSc OT  Staci Caron is an occupational therapist (OT) working in the area of geriatric mental health and, working towards a Masters Degree in Rehabilitation Sciences. Staci Caron will be conducting this study in partial fulfillment of her Master's Degree. Introduction I understand that I am being invited to participate as a volunteer in this study because I am an older adult who is living in a Long-Term Care facility. Purpose of Study The purpose of this study is to explore the meaning of 'occupation' to older adults who are living in Long-Term Care facilities. 'Occupation' includes all the things that people do in their lives, such as eating, socializing, caring for family members, enjoying themselves, and taking care of their home. This study will explore how occupation matters to participants, by talking about what they did in their life and what they are currently doing. Results of this study may provide useful insights into how Long-Term Care facility routines and, the social and physical environment, affect residents' function and quality of life. The researcher of this study believes that older adults 1 of 3  Meaningful Engagement in Long-Term Care  APPENDIX B Letters of Recruitment  THE  UNIVERSITY  OF B R I T I S H  COLUMBIA  School of Rehabilitation Sciences Faculty of Medicine T325 - 22I1 Wesbrook Mall Vancouver, B.C. Canada V6T 2B5  Date: May 1,2001  Tel: (604) 822-7392 Fax: (604) 822-7624 Website: www.rehab.ubc.ca  Dear Participant, If you are an older adult who is living in a Long-Term Care facility, you are invited to participate in a qualitative study titled, The Meaning of 'Occupation' for Older Adults Living in Long-Term Care Facilities  The purpose of this study is to explore the meaning of 'occupation' to older adults who are living in Long-Term Care facilities. 'Occupation' includes all the things that people do in their lives, such as eating, socializing, caring for family members, enjoying themselves, working, and taking care of their home. If you participate in this study, Staci Caron, will interview you. The interview will regard your involvement in day-to-day activities and what those activities mean to you. The interview will explore what you did throughout your life and your interests in how you want to be spending your time when living in a nursing home. There will be two visits from the researcher. The first will be to meet you and answer any questions you might have about the study, as well as to ask you to participate in a brief assessment to confirm your ability to participate in an interview. The second visit will involve an interview about how the things that you have done and currently do in your life matter to you. The interview is expected to take 1 to 2 hours, and can be broken up into shorter visits, if you prefer. It will be audio-taped and scheduled at your convenience with respect to time and location. You may also withdraw from the study at any time during the interview. Results of this study may provide useful insights into how Long-Term Care facility routines and, the social and physical environment, affect residents' function and quality of life. The researcher of this study believes that you and your facility  1 of 2  Meaningful Engagement in Long-Term Care  APPENDIX C Interview Guide  Meaningful Engagement in Long-Term Care  143  Interview Guide  Defining Occupation When I ask about your occupations or daily living activities during the interview, I am referring to all the things (such as dressing, eating, socializing) that you do in your life. Occupational Life History (tapping into self-identity) Tell me about what you did for a living, before retirement? What activities did you do for work (i.e. paid job, taking care of your family)? What activities did you do for your own enjoyment? I.e. Hobbies / interests Which of the roles in your life were most important to you (e.g. being a mother /father, spouse, daughter, worker, volunteer)? Which of these continue to be important? If someone asked you today, "What do you do for a living?", how would you answer?  A Typical Day of Current Occupations Describe typical day for you before you moved into a care facility? Which of these activities do you continue to do now that you are living in this environment? Describe a present typical day for you? What do you do and whom do you do these activities with? What activities do you do for yourself, personally (i.e. to take care of yourself)? To enjoy yourself? To relax or rest? To be productive? Of all the things that you do in a day, which do you enjoy doing? Describe the things you don't enjoy doing?  Perceptions of Health and Aging Tell me about your health. What does "being well" mean to you? Do you feel that you are well today? If not, describe what that would look like for you? How do you feel your health contributes to your current daily living activities?  Meaningful Engagement in Long-Term Care How do you feel your current daily living activities contribute to your health? How has growing older affected your occupations or the things that you do everyday? How has your mental health affected your occupations or the things that you do everyday? Occupations and the LTC Facility Environment How has living in a care facility affected your occupations / daily living activities? How would you like to be spending your time at this time in your life? If you could plan to do what ever you wanted in a day, what would you plan to do? Describe what you like / appreciate about living in a care facility? Describe what you dislike about living in a care facility? What do you miss most since moving into a facility? What is important for you to do now?  Would you like to add anything else? Did I miss any important information regarding what occupation means to you?  Meaningful Engagement in Long-Term Care  APPENDIX D Description of Participating L T C Facilities  145  p  to  td  o  H?  CD  3  CD  a  o o  >  n CO  CD CD  CD  C Cu U.  3  o  3 kS> co  I 1 CD  1 / 5  3H-  S  O H 3" i g CD co H - IS 4^n> 2 tr. co  ^I  4*. 4^  £- B ON K 9 & 3 o CD 3* i-i P  3  4^  to ON  X  CD  co  CL CD CL  CD  O  £  CD  3 3  CD CL  o  w O N>  CD  CD cr  co  3  C  ft g  3 p C l  4^ 2- "8 <3a*  ON  O  . .  n  .N>  e ?p a>  P  to  co  § ^  3  CL  £  2.  <:  O  cr n> CD 5 cr  5.  CD ><  HH-  H?  -O  4^  CL  3  P  3  £  60  co  CO  3  ~  U, P 3 C  CD P P  CD  3 co  3  H^. P m  M-  O  CO  CL  o era 3 CD  CL  3  cr  co  P 3  O  I  cl I Hi  CD  n o O o o « 3 CO 2- 3 CD 5 o Oq 3 CT 3 v; 3 CD CO  3-  3  3  5' a o o  o  co  H"  P.  CL  <  H  CD D C D co O  4^  CT CD  a.  CL  CO K..  §  If °  O 3 S •  R 3 o o § 3 3 HJ  I  CD \  3  D  CD  c 3. 3. CL O w CD  3  net o' 3  O  Ht>  •-a  I.  co  p  ^  ^ v5 H;.  era  00  CD  I3  era W 3  era p era CD CD 3  o  !r  s C2D LJCt HT  ^  E5  CL  y. CD ft' o cr . - ^ ft ft" HT » p & " S o 3 HJ cr 3- 3 - H* • p» ^ CD 3 era S o era - 3 c?  3  cT  &  ^  o  h  lO C£  CL  O P 3 cr " S. ^ |$ era  —  & O cl  •i- O 3 O  CD  u . h-i  5  n  CC L (O 3.  B * >  CT  Hf  HH  xD C  CT < CD 2.  CO  5"  CD  00 HJ  CD CD  O cT o 3 3 o 3  S co CT  (-f Ht-  3  3  3  i §  3  co 3  3  .J^.  >  co  5' ^  < H-i C D 2. ft O S3, C L C L cT CD P . co CO CO 3* CD P ' o 5' 3' 'rt 3 p 5 D CO iL ° C L CO3 3 9 C 8 3 3 < o oo e g p CD (Z) a; p co 00 T 3 CD co rT CO CD C ? C&D ' 'o 3 tO 3 o r- cr 3 - CO 3 CD  CD  o a * a s o  S*  cT O CL C D 3* CD C L CD CL CL O % P CD 3  fjq  3 CTQ  5«  P O M c o 3 X O 3 ° to CD °co CD W S-' T3 3 3 _ C D o 3. CDn 3 2. CD M C D , o O CD P CL p n p  g  2  p  CL  "a 3  n P oD C co  ^. " 8  ^3-3g* CD O o K) CL Cl n > 3. CD 3  P  3  H> CTQ  3  co  8,8 Sg  a ft 3  CD  3  H|  P  CO CD  H- £ , " 0 O  p  3 CTQ  co  CL  <"> I p  B . 3  2-  3  B-  >—»• rt-  3 o  3  3  -  ft  1  5" *-f 5 . CD cr. CL  CL  •  I5? | a>  co  H ?  i'  CO  cr CD  H-J  ~  CTQ 1  co  CD T3 CD O 3- ^ S—  Et  «g  CO  -r  S ^ HJ CD CD op CD CD 3 CD O CL £ Et co T 2 n C C D a 3  °ss § S. i i g s-  i . CO  3"  "T3  <-H  CO  H|  >  o era o 2. < O C S 2 HJ 3D 5' S epra 33 3 3_ CD g. n' o* P 3 &  o' 3 c 3 CL CO CD CL cl 3 CD O 3 p  O  CO  Hi O  CD CL  H^ d 3 § 3 & 2. P hi S 3 CD p P Hrt d . era o* CD %  3  -  3 S3 £3  CO  era '  2  CO  Hi.  era  CD  3 p  eCD ra > O  a cf  « tra  o 3 BP  Ht> p p 0  C2 3 cr  rp  3 & " c  3->• 3> M <  3  on-  c  eCD ra  s  5J  W  ° § era  31  T3  *J  2-  <§' o'  c  4^ ON  Meaningful Engagement in Long-Term Care  APPENDIX E Participants' Current Daily Occupations  147  <  13  CD  3  5' fJQ 3 3 a ~ 3. co 3*  3 > 2 S 2. cr. n>3 3  Ccn TQ  CD  3  > 2  13  CL  cn O 3  CD  cf 5 > ? S O S CD n  o  P  H  CD "-I  g g g. ° T3 3 ° : co  22  3  CD  O 2  ^  CD  3," E O 5 ft  3  3  K  2 »  C<o  13  CD i-t cn O O  1 c  3  8- C  £J  C  o  Cn  K' i-. »  a cn  «  3 3  o  5-3  C coD  a g. §• s 3  o-  CD  3  £.  CO  o  °- 2  3  r-t-  C  3  3  13  3 K § o Q £ a o' o £  2 cn O 3 K. o CD  3  CTQ  o f—i 3* L. O  cn  Cd c  CO  13  i-l cn O 3 EL o  O 3  ~ g 3 o-  a  CD  CO  3  3  CD  3  CD  KM  P  1  8  U  3  L^ 3. n '-io n>pi EJ- N cn rv CT> ST cn  3' 3 w  CD  cn O  <—»•  5'  trq  CO  CD  3  CD  13 >  00  8 8  3 o 8 3  K' N  CD  50  CD  ^ O  0 1  3 g  & 8  3  ~  ^  2  3  >-i cn O 3 SL o  3 CD cr. s CTQ  o  > 3 3  CD CD  CD  D. CD  S C/3  *0 CD  C?  13  CD cn 00 | O CD 3 03  < CD  3 Cn  O  3"  <  in  C/3  PS  C D Q3 co D- co co o ~ CDI  13  ° 3 ' t L K a , - g c D C 3 —-EL O p N S »• ff 5' a n S ST r[3 O N CD cn cn l CD  CD  i-t co O 3 SL o  3 CL  3 8* E ~  t~ fe  s.  E  CD  3  es  CD  o M  § 2 2 cn _ CD to  »  h3  CD  |-1 cn O  3  SL  2CD*  3  00  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0090791/manifest

Comment

Related Items