A Literature review
Robert Pressley, Health Studies
at the Centre for Nurse Education, Hilary House, Prospect Hill
Douglas, Manchester Metropolitan University
Tutor Eileen O'Malley
If you wish to respond to the author,
you may contact Robert Pressley at 'The Beeches', 2 Sartfell
Road, Douglas, Isle of Man, United Kingdom IM2 3LZ or phone
44- 01624 629102
In this paper I have explored the
necessity of using nursing models in therapeutic recreation
to enable registered nurses to provide individualised plans
of care that are tailored to the individuals owns needs.
I have also suggested who is responsible
for implementing, planning, assessing and evaluating therapeutic
recreation in an elderly care environment. Along with clarifying
the role differences and similarities between nurses and other
health care professionals. Finally I have discussed some of
the limited research available in relation to recreational activities
1 - 2 Introduction
3 - 4 Nursing Models in Therapeutic
4 - 6 The Nurse and Therapeutic
6 - 7 Therapeutic Recreation
7 - 11 Research Discussion
12 - 13 Conclusion
14 - 15 References
Over the past six years I
have been working as a Social Therapeutic and Recreational Nurse
in an Elderly Persons Rehabilitation Unit. I have responsibility
for assessing, planning, implementing and evaluating activities
to aid in the rehabilitation process of the patients that are
referred to the unit. As the unit is designated primarily an
elderly care unit (65 years and over). I will limit the literature
review to the benefits of that age group only.
There has been much research done
in the field of therapeutic recreation on an international scale
mainly America, Canada, Australia, and the United Kingdom (Buettner,
L, L, Ferrario, J, (Date unknown). Barton, R. 1976. Goffman,
E. 1961). The literature I am using for the purpose of this
paper is from the United States of America and the United Kingdom.
The Recreational Therapist or Social
Therapeutic and Recreation Nurse came into being in the United
Kingdom in the early nineteen eighties through Theresa Brisco
who was one of the first recreational therapists in the United
Kingdom at this time. The concept of a social therapeutic and
recreational nurse / recreational therapist was to utilise/use
recreation as a way of promoting and maintaining an individuals
social, psychological needs and increasing self-esteem (Vise,
D. Murray, M. Scarth, M. Mills, S. and Forte, D. 1994). The
aims and objectives of therapeutic recreation, in the care of
the elderly setting, seen by Vise et al (1994), was in order
to preserve and maintain self-esteem, motivation, mobility,
challenge, social interaction and mental agility in elderly
This concept of therapeutic
recreation is supported by Lowry, L, Ryan, A. (1993), who state
that "Recreational therapy is a concept of meeting the
patients psychological and social needs through meaningful daily
activities". In this literature review I intend to discuss
the use and importance of nursing models, in therapeutic recreation
and the nurses role in relation to both the use of the model
and participation in recreational therapy.
Nursing Models in Therapeutic Recreation
The nursing profession has
used the nursing process for a number of years in order to base
care on an individual and holistic basis. The theory being that
nursing care and intervention is tailored to meet the individuals
needs. This approach to care is helped by using nursing models,
such as Roper Logan and Tierney (1985) systems approach "Activities
of Daily living" and Orem's (1991) developmental "Self
care defecit model". Models are useful frameworks from
which nurses can base their assessments of patients and decide
and agree appropriate interventions from. Powers, B. A. Knapp,
T. R. (1990) state:- "A model is a graphic and symbolic
representation of a phenomenon that serves to objectify and
present a certain perspective or point of view about its nature
and/or function. The major nursing models identify concepts
and describe their relationship to the phenomena of central
concern to the discipline: person / client, environment, health,
When using a model of nursing,
nurses are expected to provide individualised plans of care
aimed at identifying individual problems with the patient and
agreeing interventions that will, hopefully, achieve resolution.
All aspects, considered within the chosen model, need to be
carefully thought about, including recreational needs. Roper
et al. (1985) identifies twelve "Activities of Daily living"
(appendix one). This Nursing model specifically includes recreation
as one of the activities of daily living. Whereas Orem, D.(1991)
in her self care defecit model, does not focus on recreation
in such a direct manner. However the model does include time
spent with others and time spent alone (appendix two). With
using nursing documentation based on Orem's self care defecit
model, it provides an opportunity for health care professionals
to identify what self care abilities, and/or self care defecits,
the elderly individual has.
Whenever a nursing model is
used the nurse, by virtue of the model framework, is accepting
the responsibility of ensuring the individuals leisure/recreational
needs are identified and documented and where a problem has
been identified, an appropriate plan of care with realistic
and achievable goals should be developed in conjunction with
the individual. If the nurse fails to provide this they could
be considered to be in breach of his/hers professional responsibilities,
as stated in United Kingdom Central Council (1992) Code of Professional
Conduct section two which states: "Ensure that no action
or omission on your part, or within your sphere of responsibility,
is detrimental to the interests, conditions or safety of patients
and clients." and section five which states: "Work
in an open and co-operative manner with patients, clients and
their families, foster their independence and recognise and
respect their involvement in the planning and delivery of care."
It is therefore every nurses responsibility to consider activity
along with all other aspects of the patients care.
The Nurse and Therapeutic Recreation
Lowry. et al (1993) state that
the Social, Therapeutic and Recreational Nurse/ Recreational
Therapist offers individuals opportunities to pursue their own
choice of activities. Yet we should question who's responsibility
this is, is it solely the responsibility of the Social, Therapeutic
and Recreational Nurse/Recreational Therapist. to provide such
therapy?. Roper et al (1985), in their "Activities of Daily
living" model, identify recreation as one of the activities
of daily living, while Orem's (1991) model includes time spent
with others and time spent alone. This then, places the responsibility
on the registered nurse to consider this within the nursing
process to identify and develop plans to overcome any problems
in this area with patients.
Vise, D. et al.(1994) suggests
that it is the responsibility of the Social Therapeutic and
Recreational Nurse/ Recreational Therapist to educate others
in the nursing profession on the use and benefits of therapeutic
recreation. This is supported by Crump, A. (1991) who suggests
that the concept of nurses becoming more actively involved in
patient activities is receiving increased professional attention.
Even though there is evidence to
suggest an increase in professional awareness regarding therapeutic
recreation, Crump, A. (1991) goes on to argue that many nurses
working with Elderly Patients still fail to provide purposeful
activities for Elderly people and see the role of providing
recreational therapies as the remit of other health care professionals
such as Occupational Therapists. This argument is also supported
by Armstrong-Esther, C. A. Browne, K. D. McAfee, J. G. (1994)
who, through non-experimental research, observed that nurses
only tended to have meaningful communications with patients
when involved only in direct nursing care.
Crump, A. (1991) states that nurses
place therapeutic recreation low on the priorities of nursing
intervention and see the remit of providing therapeutic recreation
as the role of other health care professionals such as Occupation
Therapists and Physiotherapists. It is true that the Physiotherapist
and the Occupational Therapist may both also have a part to
play in helping individuals to develop a positive self image
and adjust to disabilities. The College of Occupational Therapists
(1990) defines Occupational therapy as: "The treatment
of people with physical and psychiatric illness or disability
through specific selected occupation for the purpose of enabling
individuals to reach their maximum level of function and independence
in all aspects of life."
Through searching the World
Wide Web on the Internet for information on the subject of therapeutic
recreation I located 136,589 sites pertaining to this topic.
Although I do not know the origin or amount of information in
all the sites on the Internet, the magnitude of sites found
certainly indicates an increased interest and awareness of this
subject on an international scale.
Recreation, play or work, no matter
what word is used to describe activity, activities are an essential
part of an individuals life. From an early age children play.
This early stage of play has no structure, but it is vital for
the child's social and intellectual development. Sulva, K. Lunt,
In adult life meaningful activities
are just as vital as this early type of play to prevent boredom,
isolation and aggression. Roper et al (1988). Throughout adult
life we spend most of our time working to provide ourselves
and family with shelter, warmth and food. Groenman, N. H. D'A
Slevin, O. Buckenham, M. A. (1992). But alongside work we also
need to relax.
This is achieved in many different
forms which may be in isolation, or in groups of various sizes
depending on the individual needs and activity involved. In
the well adult this can be easily achieved by the individual
themselves. Though in the sick this need for leisure activities
can cause concern for individuals and may well prevent the individuals
from having a meaningful life style which may ultimately affect
In latter years, the needs pertaining
to leisure requirements in the elderly have been addressed by
many businesses such as banks, by encouraging the individual
to plan for retirement and providing courses to deal with the
prospect of retirement.
Many centres of adult learning
now run courses for people who are planning to retire. One such
place is the Isle of Man College of Further Education. Throughout
adult life the individual is able to meet people, have a large
circle of friends and choose their own activity, within their
own interests and limitations. In retirement the individual
has a much greater amount of time to fill, and without any meaningful
activity, the individual may become increasingly bored and could
well suffer from feelings of grief and increased boredom as
a result of his/her retirement. This may cause the individual
to sever all forms of activities in which they have been involved.
This separation from the activities and friends they used to
have is known as disengagement theory (Groenham et al 1992).
With the Elderly in a care environment,
they may not be able to control their own recreational needs
due to the routine of the institution, or the cushioning effect
of the Nurses. This lack of control may cause the elderly individual
to adopt a submissive outlook on his/her own needs. It is this
which Goffman (1961) describes as institutionalisation. In this
situation either the social therapeutic and recreational nurse
/recreational therapist or registered nurse should enable elderly
individuals to regain a feeling of self worth by assessing individual
abilities and assisting individuals to participate in therapeutic
Even though there has been a lot
of research in the field of therapeutic recreation it was difficult
to locate any research on the beneficial effects of therapeutic
recreation in the elderly. The four studies that I was able
to locate were from the United Kingdom, the United States of
America and Canada.
Three of these studies were
set in continuing care nursing homes (Beuttner, L.L. Ferrario,
J. (date unknown), Dawe, D. Moore-Orr, R. 1995, Quattrochi-Tubin,
S. Jason, L.A. 1979).
Armstrong-Esther, et al (1994)
based their research in a hospital environment. All the studies
were relatively small using between 20 and 99 subjects. Beuttner,
L, L.., Ferrario, J. 1996 researched the effect of therapeutic
intervention on nursing home residents with demetia. As the
patients used in this study were mentally impaired I have decided
not to use the study in this review.
Dawe, D. Moore-Orr, R. (1995) looked
at the effect of single sessions of mild exercise in a group
of cognitively unimpaired institutionalised elderly patients.
The sample size of patients was 20, all of which were white
and aged over 70 years, it is not known whether they were all
male,female or mixed sex. In order to be eligible they had to
fulfil the following criteria:
B) Did not suffer any cognitive
C) Had resided in the home for
more than 6 months.
D) Had a sedentary life style.
The residents were randomly assigned
to an experimental group (exercise) or control group (video
of exercise). There were 10 in each group.
Both the experimental and control
group were given the same battery of questions and tasks both
pre and post and 30 minutes after exercise to determine if cognitive
performance increased in the experimental group.
The outcome from the research
did confirm that acute exercise benefits aspects of neuropsychological
performance. This, the authors suggest, could prove a very beneficial
and cheap intervention that could aid the promotion of independence,
memory, self-esteem and quality of care of institutionalised
One of the main problems with this
study is the selection criteria for inclusion in the study.
Two of the four factors required were open to individual interpretation.
These being 'alert' - there was no definition of the word and
how it was to be applied and also sedentary lifestyle - there
was no explanation of what this encompassed either.
Qualttrochi-Tubin, S. Jason, L.
(1978) investigated the effectiveness of a stimulus controlled
procedure (access to free coffee and biscuits) and its effect
on attendance by residents at therapeutic recreation sessions
in a nursing home. This study used a collection of data taken
from behaviour observed during two minute time periods, pre
and post stimulus, three days a week, by two independent observers,
for a period of sixteen days, excluding the initial pilot experimental
stage of four days. The recreational therapist was also asked
to record their opinion of the performance of the residents
during recreation sessions.
The study demonstrated that by
offering elderly patients free coffee and biscuits in the lounge,
only for a defined time period, the attendance at activity sessions
and interaction of the elderly patients, with each other, increased.
During the observation periods of this study it was noted that
with the increase in activities and social interaction the elderly
patients appeared to become less interested in the refreshments
and more interested in what they were doing and whom they were
The free refreshments were
an incentive to help increase attendance at the activity sessions
within the elderly care setting, providing a catalyst for improving
a psychological sense of community in the elderly care setting.
With the increase of community interaction it may be possible
to assume the elderly patients felt more confident and may have
an increased self-esteem.
Throughout this study the elderly
patients were able to make the choice of attending activities
for free refreshments or staying in their rooms. While this
was also a means of allowing the elderly to take control over
their own decisions, it could be said that they were given no
choice but to join in as refreshments were not available elsewhere.
The research has several methodological
flaws these including using the same residents for both the
control and experimental conditions. The study would also have
benefited by clearly identifying what was meant by social interaction,
as the term is open to interpretation from each of the two independent
observers. The short time period of the experimental phases
of the study did not exclude the possible effect the novelty
value of the stimuli may have had on the results. This study
did not appear to be statistically analysed and so it cannot
be known if the results are significant or not.
Because of the relatively small
sample sizes within the above three research studies and the
fact that they are limited to residents in a nursing home, it
would not be possible to generalise the results from any of
these studies to other areas. However it would be interesting
to repeat the studies in a variety of other settings including
my own, elderly rehabilitation.
A slightly different view
of patient activity was undertaken by Armstrong-Esther, et al
(1994) whose research investigated the activities and interactions
of elderly patients in an acute medical geriatric unit and a
psychiatric unit. Twenty four patients were studied and divided
into three groups of eight. The Clifton Assessment Procedures
for the elderly were used to measure cognitive and behavioural
functioning. The three groups were categorised as Lucid, Confused
and Demented, information was gained by time sampling by non
participant direct observation.
The study found that all patients,
irrespective of their cognitive state, spent 95% of their time
sitting during the observational periods. Lucid patients spent
the majority of their time interacting with others and only
7% of the time interacting with the staff.
All the nurses involved in the
survey saw talking to patients as the most rewarding and enjoyable
aspect of their job. However as can be seen above a very small
proportion of their time was spent interacting with the patients.
The author of this study suggests that nurses are either missing
or ignoring the opportunity to engage and involve elderly patients
in activities that could maintain their independence and social
skills. They also conclude that it is the needs of the institution
that are given greater importance that those of the patients
It is essential that nurses use
a nursing model to guide their assessment of the patient. Using
the information gained from the assessment to develop meaningful
and realistic plans of care. The ultimate aim being to improve
the quality of nursing interventions and subsequent outcomes
In terms of therapeutic recreation
I have shown the importance of this aspect of patient care within
this literature review. The benefits of therapeutic recreation
have been discussed and this remains important whether or not
a social therapeutic and recreation nurse/recreational therapist
is available or not. Physiotherapists, Occupational therapists
and Registered Nurses all have a responsibility, to a greater
or lesser extent, in considering and providing patient activity
Armstrong-Esther et al (1994) state
that:- "An objective for nursing care is to ensure that
their level of function (Lucid Patients) is at least maintained
and does not deteriorate. Hence engaging them in conversation
or structuring activities with other patients that will stimulate
psychosocial activities and skills must be seen as an important
and worthwhile nursing activity, enjoying the same status as
the administration of medicines. In fact it is not unreasonable
to suggest that with more therapeutic and recreational activities,
nurses could extend their range of skills from the present model
of custodial care for elderly patients to one that has a restorative
They further conclude that :- "Nurses
need to acquire a repertoire of skills that embraces psychosocial
and physical rehabilitation, to ensure that the focus of care
of the elderly moves from custodial to the restorative. The
elderly must regain, wherever possible, some of their independence
by being encouraged and assisted to acquire or retain the skill
Within my own practice this
is what I have aimed towards within my role as social therapeutic
and recreational nurse. The challenge to me now is to persuade
other Registered Nurses that they too need to acquire a repertoire
of skills to assist not only with physical rehabilitation but
also psychosocial rehabilitation.
Armstrong-Esther, C. A. Browne,
K. D. McAfee, J. G. (1994) Elderly Patients: Still Clean and
Sitting Quietly. Journal of Advanced Nursing, 19: 264-271
Barton, R. (1976) Institutional
Neurosis, (3rd edition) Wright and Son, Bristol
Buettner, L. L. Ferrario, J. (date
unknown) Therapeutic Recreation-Nursing Team: A Therapeutic
Intervention for Nursing Home Residents with Dementia. Alzheimer's
Disease Assistance centre, Decker School of Nursing, Binghamton
University, Binghamton, N Y 13902-6000. Internet address: http://www.recreationtherapy.com/re-dem.htm
College of Occupational Therapists
(1990) Standards, Policies and Proceedings: Statement on Occupational
Therapy Definition, College of Occupational Therapists Ltd:
6/8 Marshalsea Road, London SE1 1HL
Crump, A. (1991) Promoting Self-esteem;
Nursing the Elderly 3, 19-21.
Dawe, D. Moore-Orr, R. (1995) Low-Intensity,
Range-of-Motion Exercise: Invaluable Nursing Care for Elderly
Patients, Journal of Advanced Nursing 21,675 - 681
Goffman, E. (1961) Asylums. Penguin,
Groenman, N. H. D'A Slevin, O.
Buckenham, M. A. (1992) Social and Behavioural Sciences for
Nurses: P 147-149: Campion Press Ltd, Edinburgh.
Lowry, L. Ryan, A. (1993) Recreation
is not a Luxury; Elderly Care 5, 6, 24-26
Orem, D. (1991) Nursing Concepts
of Practice (4th edition) Mosby.
Powers, B. A. Knapp, T. R. (1990)
A Dictionary of Nursing Theory and Research, Sage Publication
Quattrochi-Tubin, S. Jason, L.A.
(1979) Enhancing Social Interactions and Activities Among the
Elderly Through Stimulus Control, Journal of Applied Behaviour,
1, 13, 159 - 163.
Roper, N. Logan, W. W. Tierney
A. J. (1985) The Elements of Nursing, Churchill Livingstone,
Sulva, K. Lunt, I. (1982) Child
Development: A First Course. P157-172 Grant McIntyre, London
United Kingdom Central Council
for Nursing, Midwifery and Health Visiting (1992) Code of Professional
Vise, D. Murray, M. Scarth, M.
Mills, S. and Forte, D. (1994) Social Therapeutic and Recreational
Nursing Fact Pack., R.C.N. Publication