Annals of Long-Term Care: Clinical Care and Aging. 2014;22(3):28-33.
Affiliations: 1University of Arkansas for Medical Sciences Northwest Campus, Fayetteville, AR; 2Department of Human Development, School of Human Environmental Sciences, University of Arkansas, Fayetteville, AR
Abstract: Personhood, bestowed on others through social interactions, implies recognition, respect, and trust, making it an essential factor in maintaining identity in late life. Activity directors have a responsibility to provide opportunities to their residents for recreation, leisure, and social engagement in a way that is person-centered. One often overlooked aspect of identity and person-centeredness in nursing homes may be an individual’s sex. This article outlines a qualitative study that was conducted to gain insight into how being male or female plays a role in the development and provision of activities for nursing home residents. Suggestions for practice, education, and further research are also provided.
Key words: Activity directors, gender identities, long-term care, masculinity, patient-centered care, personhood.
Kitwood1 defined personhood as “a standing or status that is bestowed upon one human being, by others, in the context of relationship and social being. It implies recognition, respect, and trust.” The key to this definition is that personhood is bestowed on individuals through their interactions with others. Kitwood’s definition has been influential in geriatric care settings emphasizing person-centered care, particularly in dementia care because cognitive and communication deficits impair interactions between residents and nursing home staff. Buron2 noted how progressive cognitive deficits may lead to impaired communication and how increased misunderstandings between nursing home staff and residents may also be directly correlated with a progressive loss of personhood. Barriers to the maintenance of personhood are many and may include various differences between caregivers and residents, such as cultural and primary language discrepancies. In addition, 92% of direct caregivers in nursing home environments are women3; thus, misunderstanding or a lack of awareness of male identities may impair the ability of staff to recognize and respect male residents in ways that are essential to the maintenance of personhood.
Gender identities are developed over time and within a social context. Masculine identities refer to the particular dimension of identity associated with being a man. While masculine identities vary across and within cultures, a recurring theme in the scholarship of gender identities is that masculinities emphasize actions rather than expressions, are always in contention, are in need of maintenance, and have the possibility of being lost as a central component of men’s identities.4,5 In particular, the precariousness of masculinity may result in difficulties for aging men as they attempt to preserve the continuity of their masculine identities6,7—especially in the context of nursing home care,8,9 where goal-oriented activities may be limited.
Nursing home staff may emphasize a person’s dependence, disabilities, and frailty through their interactions with aging residents.10,11 A paternalistic approach challenges a man’s masculinity, as it strips away independence, self-reliance, and robustness.1,7 Indeed, an increased emphasis on abilities and autonomy may be key contributions to maintaining wellbeing for both men and women in nursing home care.
Activity directors are in a unique position to promote personhood in residents by providing them with individualized, gender-appropriate opportunities for recreation, leisure, and social engagement. Recognizing the centrality of masculinity to a man’s identity, however, is key to providing such opportunities in ways that emphasize recognition and respect. Guidelines from the Centers for Medicare & Medicaid Services emphasize the importance of “person appropriateness” in the planning and provision of activities, stating, “‘Person Appropriate’ refers to the idea that each resident has a personal identity and history that involves more than just their medical illnesses or functional impairments. Activities should be relevant to the specific needs, interests, culture, background, etc. of the individual for whom they are developed.”12
There has been little research, however, on how activity directors differentiate opportunities for recreation and leisure by sex. Therefore, we sought to examine whether these individuals provided residents with activities that were supportive of gender identities. The central question we sought to answer is “do activity directors offer opportunities for residents to demonstrate independence, reliance, and robustness?”
Study Design and Procedures
We attempted to contact the activity directors of all 229 Medicaid- and Medicare-funded nursing homes in Arkansas via telephone. The study was described to the activity directors with whom we made successful contact, and those individuals were invited to participate. The 100 activity directors who accepted the invitation over the phone were sent an email link to a Web-based survey. Of these individuals, 51 ultimately responded to the survey after multiple follow-up attempts, with 41 ultimately providing sufficient data to be included in the analysis.
The online survey consisted of three sections. The first section required activity directors to describe the five most common activities that had been provided for residents in their facility during the previous 2 weeks. They were also instructed to rank the order of these activities, from the most common activity to the fifth most common activity, as a means of identifying which activities were being provided and how often they were being provided. After describing and ranking each activity, they were asked to estimate the percentage of men and women who typically participated in that activity. Although activity directors were required to report only five activities, most chose to describe more than five while others described fewer than five. The second section of the survey asked participants to describe activities (labeled as “wish-list” activities) that they would provide residents with if they had unlimited resources. Participants were instructed to describe one wish-list activity for men and one for women, although several individuals described more activities than requested. The third section of the survey asked activity directors to respond to basic sociodemographic items, such as their age and sex; to indicate how long they had worked at their facility; and to estimate the number of male and female residents in their facility.
Three separate coding schemes were required for the analysis (one for the actual activities provided, one for the men’s wish-list activities, and one for the women’s wish-list activities). The coding schemes for each list of activities were separately developed using an iterative process involving two graduate students and one of the lead researchers. The process consisted of the following steps: (1) the graduate students listed each activity description; (2) the graduate students worked independently to group similar activities together and to develop descriptive labels for each group of activities; and (3) the data were independently recoded by the graduate students using the coding scheme. After these tasks were executed, the graduate students and the lead researchers met to discuss and resolve discrepancies in the students’ activity codes.
What follows are the results of the three aforementioned components of the survey: (1) the five most common activities that residents had been provided with during the previous 2 weeks and the estimated percentage of male and female participants; (2) the activity directors’ wish-list activities; and (3) the sociodemographic information for the activity directors and their residents.
Most Common Resident Activities
As shown in Table 1, activity directors described 378 activities that their residents had been provided with during the previous 2 weeks. Of these, there were 131 descriptions of games, with Bingo being the most described activity from any category (n=45). Several participants indicated that Bingo was played as often as four times per week, and another suggested that the residents “really love this more than everything.”
Activity directors also described several active games (n=26), including bowling, ring toss, and pitching pennies. Other games that were listed included table and board games, dominos, card games, trivia games, Wii games, dice games, puzzles, and checkers. The remaining game descriptions were nonspecific and nonclassifiable; for example, some participants simply listed “games.”
The second largest category of descriptions was related to entertainment (n=49), which included watching movies or television shows (n=21) and music-related entertainment (n=28). Activity directors described different activities related to music, so separate categories were developed for “listening to music,” “participating in music,” and “nonspecific musical activities” (eg, when an activity director simply wrote “music”). Music was also described at other times, such as in conjunction with religious activities or exercise. When the focus of such activities was something other than music, those activities were coded to the other activity.
Exercise was the largest type of health and wellness activity (n=32). Some examples provided in the survey were “wheelchair exercise to video with lively oldies songs” and “senior Olympics.” One activity director listed shot put, discus throw, horseshoes, wheelchair races, and dance contests as events included in the senior Olympics. Other health and wellness activities included very specific forms of exercise (ie, yoga, tai chi; n=4), and a variety of therapies (n=6), including pet/animal therapy and music therapy. Music therapy was differentiated from other music activities because it was associated with physically therapeutic activities, such as dancing or exercise.
Overall, there were 30 descriptions of religious or spiritual-based activities, which included Bible studies and devotions. There were eight descriptions of music in conjunction with religious activities. Descriptions of religious activities were brief; one example provided was “church services such as devotional, Sunday school, or group sing-alongs.”
There were 29 mentions of arts and crafts. One activity director described morning crafts as consisting of making a different project each time. These projects included painting magnets and making dolls. Another participant described scrapbooking, and two individuals mentioned preparing holiday cards for military personnel.
There were 26 descriptions of social events, many of which were parties. Some specific examples included monthly birthday parties; food socials that served items like popcorn, punch, and ice cream; and coffee socials. In addition, 14 activities centered around food preparation. One activity director stated that they had a food preparation activity every Tuesday afternoon, whereas another described holding a cooking class, and several others included baking in their descriptions.
Educational activities were mentioned 24 times and included reading activities and cognitive training (eg, brain games, crossword puzzles, flash card, puzzles). There were also 15 descriptions of beauty activities. One activity director wrote, “the ladies get their nails painted in a group,” whereas another described “primp and polish” sessions where female residents received manicures, makeup, hand lotion application, massages, and simple hairstyles.
There were only 10 mentions of community outings. One activity director noted that they travel to a dollar store where residents are able to shop and “look around,” another described an “elders’ day out,” and yet another described community outings to restaurants and stores. The remainder of the survey responses focused on reminiscing activities (n=6), involvement in clubs or organizations (n=3), and gardening or household tasks (n=3).
Interest and participation in activities. After describing the five most common activities that were provided for residents, activity directors were asked to estimate the percentage of men and women in their facilities who participated in the activities. Because activity directors sometimes described several activities with varying degrees of commonality, it was not possible to link those responses with specific activities. The responses, therefore, were indexed into categories, such as “games.” Approximately 43.6% of female residents participated in the most common activity (ie, games, including Bingo) provided in the nursing homes, while the participation rate for men was only 36.8% (t=2.21; P<.05). Participation rates for women were also higher for all remaining activities, although the differences only reached statistical significance for arts and crafts (the fifth most common activity). For this activity, 35.8% of women participated compared with 30.3% of men (t=2.73; P<.05).
As shown in the Figure, approximately 50% of activity directors thought that the most common activities reported (ie, games) were gender neutral in interest or equally interesting to both sexes; 46.2% thought that they were more interesting to women than men; and only 2.6% judged the activity to be more interesting to men than women. After excluding the “equally interesting to both” response, all five of the most common activities (ie, games, entertainment, health and wellness, religious, arts and crafts) were similarly judged to be more interesting to women than to men.
Activity directors’ “wish-list” activities were used to gain insight into their perceptions of the activities that might engage male and female residents. We compared their wish-list activities with the actual activities to examine the consistency between what activity directors imagined would be engaging and what activities were actually shown to be engaging.
Wish-list activities for women. The three dominant themes of the wish-list activities for female residents were arts and crafts, beauty-based activities, and shopping outings. One director wrote “spa day, massage, and facials” as wish-list activities while another wrote “facials at least two times weekly.” With regard to arts and crafts, one activity director stated, “More elaborate crafts and decorations like silk floral arrangements.”
Most directors said that they would use increased resources to enhance the activities that were already available to female residents. It was their perception that current activities were engaging female residents, but they could be enhanced with more resources. One participant, however, noted, “We have no problem with the female residents attending,” suggesting that the activities he or she was already providing were sufficiently engaging female residents.
Wish-list activities for men. Wish-list activities for men included outdoor activities, arts and crafts, and games. The most commonly described activities for men were outdoor activities, with fishing being the most frequently cited of these. One participant said that if resources were unlimited, “I think the men would like to get a boat and go fishing on the lake,” whereas another suggested “going to a pond where the men could fish.” Golf trips were also included in several descriptions of aspirational activities. One participant wrote, “I would provide the men with a small golf course and possibly a small fishing pond.” Nearly all of the activities mentioned for men required a trip outside of the nursing home, with additional suggestions for trips to a sports bar for a meal, more trips to a casino, and attending sporting events (eg, a professional football game, horse races).
Arts and crafts were another theme in wish-list activities for men, although the way in which men were imagined to engage in arts and crafts was quite different from what was envisioned for women. Activity directors saw crafts as fulfilling an occupational role for men. For example, one participant suggested that men could be provided with a “fix-it shop” where they could, with supervision, “work on things that would help other residents make their lives easier.” Other responses included “a woodworking shop” and “model kits and woodworking/leather projects.” While activity directors in this study imagined arts and crafts activities to engage both women and men, the arts and crafts that they actually provided and those they aspired to provide were more in line with female interests (eg, doll-making was an actual activity provided).
Playing games was also a theme in wish-list activities for men. Again, however, there was a relatively larger disconnect between the aspirational and actual games provided for men than those for women. One activity director suggested a “poker night,” while another suggested “a game room with a pool table, ping pong table, and air hockey.” It was also mentioned that men could be engaged in playing pool or darts. Finally, appearance-based activities were also thought to be important to men, such as outings to barber shops. A complete list of wish-list activities is provided in Table 2.
Nearly all activity directors were women (98%) and they ranged in age from 20 to 64 years (mean, 41.6 years). They had worked in their current job between 0 and 18 years (mean, 3.5 years) and were employed by facilities ranging in size from 25 to 200 residents. The percentage of male residents in each facility ranged from 7.8% to 84.0% (mean, 30.0%).
This study was descriptive and had several limitations. First, the data came from a relatively small number of participants, all concentrated in just one state. Second, because the data were collected using a Web-based survey, there was no opportunity for follow-up to pursue topics of interest that arose in participants’ responses. A future study using a more flexible-guided interview approach may be needed for some of the issues raised in this study. A third limitation is that data were collected from activity directors rather than residents, making it impossible to know for sure what residents might say about preferred activities. Despite these limitations, this study highlights the importance of gender awareness in developing activities for nursing home residents.
Activity directors in nursing homes have a unique opportunity to promote personhood among residents in their care. Unlike other healthcare providers, activity directors focus on providing opportunities for recreation, leisure, and social engagement—components of care essential to fostering personhood.2 The findings from this study suggest that male nursing home residents may not have ample opportunities for participation in activities designed to support their masculine identities. As Kitwood1 and Buron2 have suggested, this lack of social support for masculine identities may lead to impairments in personhood status, depression, and overall poor quality of life.
In this study, 98% of activity directors were female. While few activities were male-focused, it is unclear whether that was appropriate given the demographic makeup of residents in their respective facilities. Regardless, activity directors should consider gender when designing and implementing nursing home activities. While many of the male wish-list activities were similar across nursing homes, there was a disconnect between these wish-list activities and the activities that were actually provided for male residents. Possible barriers to providing male wish-list activities may be that these activities require more financial and staff resources to implement. Many male-focused activities that were mentioned, for example, would require trips outside the nursing home to go fishing or attend a sporting event, and were resource-intensive in other ways. Developing simulated activities through innovation and technology may be one way to meet the needs of men residing in nursing home settings, where resources are often limited.
For example, Wii may be used to simulate golf, fishing, and bowling in nursing home activity rooms. Because the personhood of male residents is associated with their constructions of masculinity, it is important to emphasize gender-specific activities for the maintenance of identity and personhood in late life.6 Although more research is needed, it is reasonable to expect that increased emphasis on gender-specific activities may be key in maintaining late-life identities, supporting personhood, and improving quality of life for nursing home residents.
Another barrier to incorporating gender-specific activities into person-centered care is a lack of standardization of education for activity directors, as practice requirements vary from state to state. Some states, for instance, do not require any specialized education, whereas others have very specific education and licensing requirements. Furthermore, many nursing home facilities that are seeking activity directors through job postings do not require formal training, although many prefer experience in nursing home care. If activity directors do not receive formal education or training about the importance of person-centered care and identity development, they may not recognize the need for gender-specific social support. As educational standards for activity directors increase, the concept of gender-specific social support should be incorporated into person-centered care in activity director curricula. Specifically, greater emphasis on gender-specific activities may lead to greater independence, self-reliance, robustness, and overall improved self-esteem among residents. More research is needed, however, to understand how gender-specific activities may be related to quality of life for male nursing home residents.
In response to increased emphasis on person-appropriate, person-centered care, activity directors will be continually challenged to promote personhood by providing activities that help residents maintain their identity. Ignoring an individual’s sex as an integral component of his or her identity may impair the process of identity maintenance and personhood in late life. This may be particularly detrimental to male residents, for whom masculinity becomes precarious as dependency increases. This study points to the need for an expansion of the meaning of person-centered care to incorporate gender identities in future practice and research.
1. Kitwood T. Dementia Reconsidered: The Person Comes First. New York, NY: Open University Press; 1997:8.
2. Buron B. Levels of personhood and dementia: a model for nursing home care. Geriatr Nurs. 2008;29(5):324-332.
3. Centers for Disease Control and Prevention. Table 1. Number and percent distribution of all nursing home certified nursing assistants and those currently working in nursing homes, by selected nursing assistant characteristics: United States, 2004-2005. www.cdc.gov/nchs/data/nnhsd/Estimates/nnas/Estimates_DemoCareer_Tables.pdf#01. Accessed November 18, 2013.
4. Gilmore DD. Manhood in the Making: Cultural Concepts of Masculinity. New Haven, CT: Yale University Press; 1991.
5. Vandello J, Bosson J, Cohen D, Burnaford RM, Weaver JR. Precarious manhood. J Pers Soc Psychol. 2008;96(6):1325-1329.
6. Calasanti T. Feminist gerontology and old men. J Gerontol B Psychol Sci Soc Sci. 2004;59(6):S305-S314.
7. Courtenay WH. Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Soc Sci Med. 2000;50:1385-1401.
8. Moss S, Moss M. Being a man in long term care. J Aging Studies. 2007;21(1):43-54.
9. Smith J, Braunack-Mayer A, Wittert G, Warin M. “I’ve been independent for so damn long!”: independence, masculinity, and aging in a help seeking context. J Aging Studies. 2007;21(4):325-335.
10. Baltes M, Honn S, Barton E, Orzech M, Lago D. On the social ecology of dependence and independence in elderly nursing home residents: a replication and extension. J Gerontol. 1983;38(5):556-564.
11. Miner Salari S. Infantilization as elder mistreatment: evidence from five adult day centers. J Elder Abuse Negl. 2006;17(4):53-91.
12. Centers for Medicare & Medicaid Services. State Operations Manual Appendix PP, Guidance to Surveyors for Long Term Care Facilities. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Published January 7, 2011. Accessed November 18, 2013.
Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Bill Buron, PhD, APRN, GNP-BC, FNP-BC, University of Arkansas for Medical Sciences Northwest Campus, 1125 North College Avenue, Fayetteville, AR 72703; firstname.lastname@example.org