Original Research

To What Extent are Alberta Nursing Homes and Supportive Living Facilities Integrated with Their Community? A Sequential Quantitative-Qualitative Study

Michelle C. Gao, BHSc1,2, Saima Rajabali, MBBS1, Adrian Wagg, MBBS1
1Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB
2McMaster University, Hamilton, ON

DOI: https://doi.org/10.5770/cgj.28.783

ABSTRACT

Background

Nursing homes and supportive living facilities (continuing care homes [CCH]) are often regarded as separate from their communities. Although occasional studies highlight volunteering or intergenerational activities, there is little systematic evaluation of the existence of activities in CCH that may promote community integration.

Methods

Study Design: The study utilized a sequential quantitative-qualitative approach: cross-sectional survey followed by semi-structured interviews. Setting: All registered long-term care (nursing home) and supportive living facilities (Levels 3, 4, and 4 Dementia) within Alberta. Subjects: The survey and interviews were conducted with directors of care. The survey was distributed to 334 facilities. Data saturation in the interviews was reached with seven participants.

Results

140 responses were received; 116 were analyzable (34.7% response rate). The range of activities varied widely. Prior to Covid-19, the most common were spiritual activities entering CCH (96.5%) and volunteers entering CCH (93.0%); CCH rarely had activities such as child daycare (5.2%). 12.9% of spiritual activities entering CCH had not been restarted following the pandemic, but homes were planning to restart this activity (16) or start it as a new activity (1). There was no statistically significant relationship between any activity and facility owner-operator model, size, type, or geography (urban/rural) at any survey time category. Four themes emerged from the interviews: resident quality of life and well-being, home’s capacity and openness, sources of support, and planning and programming for implementation.

Conclusions

This study addresses a knowledge gap regarding community integration in CCH and provides insight on the types of community-integrated activities occurring in Alberta’s CCH.

Key words: continuing care, long-term care, Covid-19, recreation activities, community engagement, older adult

INTRODUCTION

Long-term care (LTC) and supportive living (SL) facilities (continuing care homes [CCH]) have historically been regarded as black boxes, operating separately from the communities in which they are situated.(1–3) Despite calls to improve the quality of care for older adults in CCH, there have been limited advances;(4) CCH continue to be criticized for concentrating on the provision of physical care, while neglecting residents’ social or cultural needs.(5–7) Older adults may equate living in CCH to “being in jail” or feeling like “mice in our cages” due to an overwhelming sense of institutionalization.(8[p.328]) Isolation of CCH is fueled by negative societal perspectives that may stem from common ways to describe life in CCH (e.g. using “end up” when referring to entering continuing care) and their largely negative portrayal in the media.(9,10) Although meaningful relationships are the most frequently cited contributor to feeling at home in a CCH,(8) loneliness is common, with higher rates in CCH residents than in community-dwelling older adults.(11,12) Similarly, social isolation disproportionately affects the psychological and cognitive health of older adults in CCH.(13) Therefore, efforts to increase CCH residents’ quality of life, the “degree to which a person is healthy, comfortable, and able to participate in or enjoy special occasions and activities,”(14) may involve strengthening the connection between CCH and their communities.(15)

Previous research suggests close relationships between CCH residents and community members are critical to improving residents’ quality of life and increasing social integration.(15) Community integration refers to individuals’ physical, psychological, and social presence within their community(16) and may occur through two broad approaches. “Going out” entails residents leaving the CCH and entering the community for purposes such as visiting loved ones, entertainment, or pursuing individual interests.(17) “Bringing the outside in” involves community members or organizations entering the home, either directly or indirectly (e.g., through virtual means).(18) Common examples include volunteers and visits from local schools.(19,20)

Increasing community integration appears to be one way of improving the quality of care for older adults in CCH. However, there is little research on the degree to which CCH are integrated into their surrounding community. Studies highlighting one activity, often time limited, are more common, such as the Friendly Companion Program involving adult and youth volunteers within a nursing home.(21) The coverage of novel or unique activities is sparse; however, endeavours—such as an intergenerational ballet program—have demonstrated the benefits of unconventional approaches.(22) A more comprehensive understanding of community integration in CCH may aid planning and highlight opportunities and barriers. Given this study’s timing (2022), the additional impact of Covid-19 on community integration must be considered; this study aimed to examine the extent of community-integrated activities occurring in Alberta CCH.

Research Questions

  1. To what extent are Alberta LTC and SL facilities integrated with their community?
    In Alberta, SL refers to licensed settings where older adults can be as independent as possible with 24-hour safety and security services and accommodation assistance, while LTC/CCH homes include additional 24-hour health and personal care services.(23,24) SL3 includes 24-hour personal care and support services from Health Care Aides.(25) SL4 includes additional 24-hour professional health services from Licensed Practical Nurses and Registered Nurses, while SL4D provides a home-like design for residents with dementia in a secured therapeutic environment.(25)
  2. What are the potential benefits, risks, harms, and barriers to implementation of community-integrated activities to the CCH and the residents?

METHODS

Setting

All registered LTC and SL facilities (Levels 3, 4, and 4 Dementia) within Alberta.

Participants

Emails were distributed to directors of care, who could pass it on to a delegate within the CCH to participate in the survey, interview, or both.

Survey Design, Data Collection Methods, & Data Analysis

A cross-sectional survey (Appendix A) was emailed to all Albertan directors of care by M.G. Directors of care were free to delegate completion of the surveys as they wished. Each email contained a secure link to REDCap ( https://project-redcap.org), a data management system at the University of Alberta that housed all survey data.(26,27) Email addresses were acquired by telephoning facilities or through publicly available information.(25) The survey was open for responses from June to September 2022 and distributed to 334 homes. Demographic information was collected (Table 1). Respondents were asked about community-integrating activities that occurred in their home prior to the Covid-19 pandemic restrictions, at the time of the survey (2022), and any planned over the next two years.

TABLE 1 Demographic characteristics of survey respondents and interview participants

All responses were anonymized upon completion. Frequencies and percentages of yes/no responses were assessed for each question. Comparative analyses were conducted with chi-squared testing to determine any relationships between the extent of community-integrated activities and facility type, size, owner-operator model, and geography at any of the survey time categories.

Interview Design, Data Collection Methods, & Data Analysis

In the survey, respondents could indicate an interest in semi-structured qualitative interviews about the potential benefits, risks, harms, and/or barriers to implementation associated with community-integrating activities. M.G. then emailed interested individuals. Interviews were conducted in English, at a time convenient to participants, over Zoom software, and following a semi-structured interview guide (M.G.).

Interviews were analyzed using a conventional content analysis approach(28) with iterative coding. Each interview was audio recorded, de-identified, and transcribed verbatim (M.G.). M.G. and S.R. independently coded two transcripts, creating codes aligning with the secondary, interview-specific research question. From their codes, the researchers developed an initial coding framework together that was used by M.G. to code the remaining transcripts, including reassessment of the first two. Together, M.G. and S.R. determined which codes could be combined, collapsed codes into categories, and further collapsed categories into themes.

Ethics

Ethics approval from the University of Alberta Health Research Ethics board (Pro00119622) was received before the start of any procedures. Voluntary response to the survey was viewed as consent. Written and verbal informed consent was obtained for all interview participants.

RESULTS

Survey

Respondent Characteristics and Response Rate

Of 203 SL facilities, 17 did not respond and five declined to participate; of 169 LTC homes, 14 did not respond and two declined. The survey was distributed to 181 SL facilities and 153 nursing homes, and 140 responses were received. Twenty were incomplete and removed; four responses were excluded as the site was not SL3, SL4, SL4D, nor LTC. The remaining 116 records were analyzed, for a response rate of 34.7%. The demographic characteristics were diverse (Table 1).

Main Findings

The range of community-integrated activities varied widely (Figure 1), including arrangements where the CCH offered residency to populations other than older adults (Figure 2A) and/or offered services on site (Figure 2B). Before Covid-19 restrictions, the most common activities were spiritual activities entering CCH (96.5%) and community volunteers entering CCH (93.0%, Figure 1). CCH rarely had activities such as offering residence to young families (7.8%) or child daycare (5.2%, Figures 2A and 2B). At the time of the survey (2022), spiritual activities entering CCH continued to be the most common (83.6%). However, this had not been restarted by 12.9% of respondents; CCH were planning to restart the ceased activity in the future (n=16) or start it up as a new activity (n=1). All community-integrated activities were reduced at the time of the survey, compared to before Covid-19 (Figures 1 & 2). This decrease was more drastic for some activities than others; for example, dining facilities open to the community fell by 36.5%, whereas daycare for older adults fell by 2.6%. For activities planned over the next two years, many CCH wanted to re-implement ceased activities. Some CCH intended to begin new activities that were not present before Covid-19; the percentage of “Yes” responses to residents volunteering in the community was 31.9%, compared to 23.5% before Covid-19. There was no statistically significant (p < .05) relationship between any activity and facility type, size, owner-operator model, or geography at any survey time category (Table 2).

 


 

FIGURE 1 Percentage of “Yes” respondents for community-integrated activities

 


 

FIGURE 2 Percentage of “Yes” respondents for other resident populations

TABLE 2 P values of chi-squared tests between community integration and demographic conditions

Qualitative Interviews

Respondent Characteristics

Data saturation was reached following seven interviews, each lasting less than 45 minutes. All participants were female; demographic characteristics are shown in Table 1.

Main Themes

Analysis resulted in 99 codes, collapsed into 16 categories, and from which four themes emerged: 1) Resident quality of life and well-being; 2) Home’s capacity and openness; 3) Sources of support; and 4) Planning and programming for implementation (Appendix B).

  1. Resident quality of life and well-being. Participation in community-integrated activities had multiple benefits for residents, providing opportunities to interact with people outside of those seen daily and to retain a sense of normality. Following an activity, staff observed that responsive behaviours amongst residents decreased and some continued to talk about the activity days after its occurrence. Residents appeared happier and activities helped ease the transition into a CCH (Quotes 1 and 2, Table 3). However, Covid-19 restrictions halted many activities, and the effects were detrimental to residents’ well-being (Quote 3, Table 3). Despite attempts to work around the restrictions (e.g., virtual programming), staff noted lower levels of resident engagement and satisfaction with the altered activities.
  2. Home’s capacity and openness. The home’s ability to offer any community-integrated activity was dependent on openness to the idea of the activity and physical capacity to offer the activity (including the space, design, and internal resources, such as staffing). Many staff were open to a broad range of activities, including those that opened the home to the community and those that involved the community coming into the facility (Quote 4, Table 3). However, the home’s physical limitations often prevented the activity from being implemented (Quotes 5 and 6, Table 3). Community integration was dependent on the presence, knowledge, and experience of the recreation therapist within the CCH. All participants cited the recreation therapist as responsible for planning and implementing community-integrated activities; the types of activities were influenced by factors such as the recreation therapist’s lack of awareness of opportunities, unfamiliarity with the community, or strong networking and creative planning abilities. This discrepancy in the ability of CCH recreation therapists was emphasized by one participant, who suggested that variation could be alleviated through the creation of a standardized resource for recreation therapists in Alberta (Quote 7, Table 3).
  3. Sources of support. CCH experienced a bidirectional relationship of support with the community. The home could receive, or was receiving, support from a variety of sources in the community, including individual members and organizations, residents’ families, and volunteers (Quote 8, Table 3). This support included financial (e.g., donations, funding), manpower (e.g., volunteers), and personal/emotional (e.g., families, volunteers). In some instances, an activity was completely dependent on external support and could not run without it; outings were not possible without volunteers, and a program integrating CCH with local high schools ended when government funding stopped. The CCH supported the community through many ways, such as organizing events for community members. One home acted as a hub for community activities, hosting activities that did not directly involve their residents but still allowed residents to connect with community members (Quote 9, Table 3). Another home echoed the same sentiment for an increase of community integration through indirect interactions between residents and community, such as a play structure on-site that would increase the CCH’s appeal to younger generations. Additionally, CCH supported their communities by acting as a source for information, even for levels of care that weren’t offered by the homes themselves (Quote 10, Table 3). As this reciprocal relationship benefited both CCH and the community, staff were keen to improve and maintain it (Quote 11, Table 3).
  4. Planning and programming for implementation. After an activity was deemed feasible, many factors had to be considered in subsequent planning and implementation. Covid-19 had a massive impact on recreational programming, essentially halting all community-integrated activities. Homes attempted to work around Covid-19 restrictions with some activities continuing in an altered form, through virtual means or creative adaptations (e.g., students on the outside playing Tic-tac-toe on the windows with residents inside). However, due to continued outbreaks, many of these activities had not been able to return to their original forms or frequency, with some that have not been restarted at all (Quote 12, Table 3). When restarting activities, there was an additional level of planning that was required in advance and after to monitor symptoms.

TABLE 3 Qualitative data from semi-structured interviews


Many factors affecting community integration existed before Covid-19 and continue to exist. Diversity amongst residents meant that a community-integrated activity could be appropriate for one group, while inappropriate for another. Residents’ participation levels were largely dependent on their health. For example, one home did not offer any programs involving children as their resident population largely comprised those with mental health issues that did not allow them to be around children. Physical health limitations were especially prominent in LTC homes, limiting the scope of appropriate activities, with lesser effects in SL facilities (Quotes 13 and 14, Table 3). Additionally, residents had differing faiths, interests, backgrounds, and ages that resulted in varying levels of engagement. One home had admitted younger adults into their SL side and found it difficult to cater programs to different generations (Quote 15, Table 3). For most participants, transportation was a barrier, as homes had to coordinate how residents would get to and from locations, who would go with them, who would receive them, and this often required family involvement. Some activities came with additional regulations or policies that the CCH had to consider, such as regulations surrounding food sale or Covid-19 policies (Quote 16, Table 3). Maintaining the physical, emotional, and mental safety of residents was consistently mentioned.

DISCUSSION

Overall, the type and range of community-integrated activities varied widely across surveyed CCH. Interviews revealed that, while community integration had significant benefits for the home and residents, there were various barriers and risks to be considered with each activity.

In the survey, “bringing the outside in” (e.g., community volunteer programs) was more common than “going out” (e.g., residents volunteering in the community). While CCH were open to implementing “going out” activities, staffing limitations posed a significant challenge as outings were difficult to plan with adequate staff numbers or impossible without the presence of volunteers. Understaffing has been a persistent issue within CCH. Care staff are often heavily occupied with numerous essential duties centred around physical care, leaving minimal time to focus on social and cultural needs.(5) The introduction of human service professionals and social workers to CCH to focus on meaningful activities for residents has been suggested.(1,9,29) A multidisciplinary approach engaging other professions to focus on residents’ social needs may help alleviate the burden on current health-care staff, and increase the types of activities that may be offered by CCH.

All activities were decreased at the time of the survey due to Covid-19 restrictions that imposed new challenges to their continuation. While Covid-19 was a limitation, the implications remain relevant as infection prevention is a priority in CCH, with protocols and responses that similarly affect community integration.(30) The decline in these activities had major detriments to residents, highlighting the importance of maintaining community connections for older adults in CCH. While restrictions limited the types and amounts of activities that CCH could offer, they also prompted CCH to undertake different approaches to community integration. As CCH prepare to bring activities back, it may be beneficial to incorporate some of these innovative ways to open CCH up to their communities. Existing technology (e.g., Zoom) used to support virtual programming during Covid-19 may be maintained or expanded upon to give residents a way to remain connected to their communities in the event of illness.

The physical design of CCH was identified as a barrier in interviews to implementing activities, as echoed by others.(5,20) CCH struggled with finding additional space to accommodate visitors, impacting the types of community-integrated activities that could be offered. To overcome this barrier, there has been success in repurposing existing space by opening common areas for external usage (e.g., as locations for meetings and events); this may help convert CCH into places where communities grow together, rather than existing as isolated spaces.(6,9,31) In the future, designing new facilities with community integration as a core consideration would be of considerable benefit (e.g., on-site café, placing CCH near other living facilities to allow intermingling between different populations).(5,32)

To counteract the prevailing view that CCH are separate from their communities, existing research has focused on bringing community members into CCH with activities such as intergenerational programs.(19,20,22) However, this study demonstrates that there are many ways that CCH can also support their community. Some homes were acting as hubs to host community meetings and programs, as well as provide information on all levels of care. The concept of bidirectional support has emerged in previous research, although evidence is sparse.(9,31) Recognizing the support that CCH can provide for their communities can be vital in overcoming the enduring perspective of CCH as “total institutions” with an impassable barrier between residents and the outside world.(31,33) When people start to associate CCH with uses that incorporate leisure and result in connections, CCH may be “re-imagined as spaces that are vital for promoting community cohesion and increasing social acceptance.”(31[p.31])

Interviews revealed a knowledge gap; the specific role of the recreation therapist in creating and maintaining community connections remains unknown. The background, personal interests, and age of a recreational therapist may affect the extent, range, and types of community-integrated activities offered in CCH, warranting further investigation. Resources may be created to assist recreation therapists in connecting the home with appropriate community groups and allow sharing of opportunities with each other. A shared space (e.g., online discussion board and resource page) can increase the communication between individual CCH, their communities, and other facilities, making community integration more accessible and achievable.

Limitations

This study was limited to CCH in Alberta, which may affect the generalizability of findings to other locations. The perspectives of residents and community members, which may have differed from the opinions of CCH staff, were not captured. The timing of the project, during the Covid-19 pandemic, led to limitation of activities of interest and may have led to inaccurate reporting.

CONCLUSION

This study addresses a gap in the current literature by demonstrating the importance of community-integrated activities in CCH, and providing insight on the level and types of activities occurring in Alberta’s CCH. Findings will prove valuable to researchers, policymakers, and directors of care alike, who aim to make CCH feel more like home.

ACKNOWLEDGEMENTS

We gratefully acknowledge the participants of the survey and the interviews for their valuable time and opinions.

CONFLICT OF INTEREST DISCLOSURES

We have read and understood the Canadian Geriatrics Journal’s policy on disclosing conflicts of interest and declare that we have none.

FUNDING

This study was funded by The Muhlenfeld Family Fund. The funder played no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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APPENDIX A. Physical copy of survey



APPENDIX B. Codes, categories, and themes from semi-structured interviews


Correspondence to: Adrian Wagg, MBBS, Division of Geriatric Medicine, 1-198 Clinical Sciences Building, 11350—83 Ave. NW, Edmonton, AB T6G 2P4, E-mail: adrian.wagg@ualberta.ca

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COPYRIGHT

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.

Canadian Geriatrics Journal, Vol. 28, No. 1, MARCH 2025