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Journal article review: Dying of Boredom

Stephen WeyDying of Boredom: An exploratory case study of time use, apparent affect, and routine activity situations on two Alzheimer’s special care units. American Journal of Occupational Therapy reviewed by Stephen Wey, Senior Lecturer at York St John University.

Stephen is currently engaged in doctoral studies related to ‘the dynamic assessment of zones of proximal development in the context of dementia rehabilitation and enablement’

This powerful and challenging new paper by Wendy Wood, Jenifer Womack and Barbara Hooper, discusses selected findings from a larger study conducted by Wendy Wood into opportunities for meaningful occupation and use of time by people with dementia resident in two “Special care units” in the United States. From this standpoint it can be read as an empathic and insightful study of the occupational needs, and striving for occupation, of people with dementia in care settings. As such it will be of particular interest to those of us who work with people who have dementia. However, it would be a mistake to see it as limited to any one field of practice. Anyone who is familiar with Wendy Wood’s work will know that she has carried out many studies that explore the origins, supports for, and limits of occupation and occupational behaviour; in particular, the relationship between ecological setting, occupational behaviour and quality of life. So this study is also of importance to anyone interested in exploring some of the central and foundational questions of occupational science.

“I’m dying of boredom”: Wood describes in her field notes from the study how she was greeting with this statement by Joseph, one of the residents, and that it haunted her throughout the study. The two Special Care Units (SCUs), where the study was conducted, were each purpose built with the needs of people with dementia in mind. For methodological reasons Wood chose two units that had good reputations for quality of care but that represented divergent social and physical environments. One was described as more “homelike” with seven residents, the other as a more “traditional” nursing home environment with 27 residents.

The  methodology involved a process of structured observations using observers trained to use a tool developed by Wood. The tool used was the Activity in Context and Time (ACT) tool, which enabled recording of residents’ use of time, the immediate socio-physical environmental context, and the resident’s affective state at the time. Affect was used to inform hypotheses regarding the person’s well-being, in a manner that appears broadly similar to the approach used in the Bradford Dementia Group’s Well-Being Profiling and Dementia Care Mapping tools. The study discusses the findings of these observations in relation to several case examples, which not only helps place the findings in a human context but also brings home some of the emotional depth of the residents’ experience.

The study focused on meaningful use of time and emotional well-being – both issues that previous research has shown strongly correlates with the socio-cultural and physical environment for people with dementia. In particular it discusses the concept of excess disability (i.e. disability beyond what is attributable to disease process alone); such as that which results from care practices that do not support or sustain existing skills or provide activity opportunities that tap into the person’s full range of skills and capacities. In each unit it was found that individuals were spending inordinately large periods of time dozing or unengaged and that only a small percentage (5-6%) of time was spent engaging in meaningful direct interactions with staff members. The study did not identify significant differences between the two settings, despite the lower numbers of residents and more “homelike” environment in one setting.

One important finding was that many everyday occupations that people with dementia themselves were attempting (not always successfully) to engage in were often seen but not noticed. Additionally, in some instances attempts at meaningful occupations were pathologised; for example a person seeking to walk outside at night and expressing anger at a locked door was construed merely as symptomatic of “sundowning” rather than any attempt being made to explore the unmet occupational and emotional needs being expressed. On the other hand, people spending many hours disengaged, withdrawn or asleep was seen as normal. 

The authors draw attention to the fact that, like many care settings here in the UK, there is a notable absence of any support for occupations of people with dementia by occupational therapists and end with a plea for greater involvement and suggestions for future research.

This study is highly recommended reading. It demonstrates with great power how actively observing, noticing and building on the striving for meaningful and relevant occupation, and contact of people with dementia themselves, is an essential requirement for creating opportunities for enhancing quality of life and overcoming excess disability for this client group.

If you would like to read this research article the reference is:

Wood W, Womack J, Hooper B (2009) Dying of Boredom: An exploratory case study of time use, apparent affect, and routine activity situations on two Alzheimer’s special care units. American Journal of Occupational Therapy, 63(3) 337-350