Active ageing in the nursing home: Could participatory action research provide the answer?

Abstract

Within the Active Ageing context (WHO), enhancing older peoples’ quality of life by focusing on their participation is essential. Although Active Ageing is relevant in nursing homes, the nursing home residents’ autonomy and participation on organizational level are often restricted. New ways to structurally enhance their participation must be found. This article discusses possible contributions of participatory action research as structural method in a new Active Ageing-envisioned nursing home, enabling residents’ participation and focuses on the practicalities of its implementation process. During an implementation project in the nursing home, participatory action research was introduced in the nursing home as weekly activity where residents assembled to observe the nursing home operation, identify problems and make suggestions for improvement. Based on the researchers’ experiences, implementing participatory action research needs a preparation and adaptation period for the nursing home staff, the participatory action research moderators and the residents to cope with the experienced challenges. Nevertheless, participatory action research appeared feasible and can bring added value to residents’ living conditions. This article contributes to the development of the participatory action research theory and the Active Ageing implementation in nursing home, since it shows the possibilities, challenges and assets of participatory action research towards a more frail population in the nursing home environment. Participatory action research might in turn lead to the realization of Active Ageing nursing home who endeavours to optimize residents’ quality of life.

Keywords

Quality of life participation culture change residential care

Active Ageing in the nursing home (NH)

There is a worldwide silvering of society. In Europe, the share of people being 65 or older within the total population rose with 4% (Eurostat, 2012). The well-known population pyramids, based on age, have turned into population rectangles. In Flanders, the Dutch-speaking region of Belgium, 19% of the population, is 65-plus (Studiedienst Vlaamse Regering (Research Department Flemish Government), 2014). Seven per cent of them is living in long-term care facilities, and an exponential rise in the number of residents is expected in the following two decades (Huber, Rodrigues, Hoffmann, Gasior, & Marin, 2009). Due to physical and/or cognitive health problems, the NH population is often highly dependent, needing assistance on different basal activities of daily living (Saliba & Schnelle, 2002;Zimmerman et al., 2014).

Active Ageing (World Health Organization (WHO), 2002) is the leading concept within international policies for older people (Walker, 2015). Its aim is to enhance the quality of life of older citizens by optimizing their health, security and participation in different life domains (WHO, 2002).

Although Active Ageing research in general focuses on the active, community-dwelling older citizen (Bowling, 2008; Cloos et al., 2010; Green, George, Daniel, Frankish, & Herbert, 1995; Michael, Green, & Farquhar, 2006), it is also a right of more frail and dependent older people (Boudiny, 2013; Walker, 2002), including those living in NH. In Flanders, Belgium, where the study took place, a NH is defined as a facility where, in a home-replacing environment, shelter and care is provided to people of 65 years or older who are staying there permanently (Woonzorgdecreet (Decree on Living and Caring), 2009). People are only expected to move to a NH when, due to the severity of their long-term care needs, they can no longer stay at home (‘Vlaams Agentschap Zorg en Gezondheid’, Flemish Government). Based on a qualitative study with different NH stakeholders (including NH residents) in Flanders, the original Active Ageing framework (see Figure 1(a)) has been adapted to the setting of NH. Nine determinants were identified (see Figure 1(b)) in order to enhance residents’ quality of life (Van Malderen, Mets, De Vriendt, & Gorus, 2013). The variety of these determinants implies that optimizing the quality of life of NH residents requires a multidisciplinary approach. Active Ageing emphasizes older peoples’ competences, capabilities, wishes and desires. Central in the Active Ageing NH framework is, therefore, the participation of residents. Notwithstanding possible disabilities or dependencies, NH residents prefer to remain in control of their lives and want to be valuable for others. Still, this is often not yet the case (Persson & Wasterfors, 2009).

Figure 1.

(a) Active Ageing determinants identified by the WHO (2002) (adapted from the WHO). (b) Active Ageing determinants in the NH (Additional determinants relevant for NH (Van Malderen et al., 2013) are written in italic).

Participation in the NH

Participation in NH includes at least two levels: the individual and the organizational (Van Malderen et al., 2013).

The individual level concerns the autonomy of the NH residents, meaning that a person has the right and has to be enabled to make choices and decisions and to act according to her or his preferences (Anderberg & Berglund, 2010; Andresen, Runge, Hoff, & Puggaard, 2009; Barkay & Tabak, 2002; Custers, Westerhof, Kuin, Gerritsen, & Riksen-Walraven, 2012; Sherwin & Winsby, 2011). An increased autonomy leads to a higher quality of life and a higher participation in social activities (Barkay & Tabak, 2002). Since autonomy in NH residents is often limited due to frailty and disabilities, they need support in decision making and maintaining autonomy (Hwang, Lin, Tung, & Wu, 2006; Randers & Mattiasson, 2004) for which they depend on staff, and to a lesser extent on their relatives (Custers et al., 2012). Despite the fact that professionals do promote autonomy, it appears to be low in NH, based on different international studies (Barkay & Tabak, 2002; Harnett, 2010; Paterson, 2001). This is due to a variety of restraining factors (Barkay & Tabak, 2002; Harnett, 2010; Paterson, 2001). Routines and protocols are prominently present in organizations and are often used as a pretext to disregard the resident’s personal choices (Harnett, 2010; Persson & Wasterfors, 2009). The authority of the professional may also depreciate the contributions or questions of residents, which are often considered as trivial (Persson & Wasterfors, 2009). In the residents, feelings of powerlessness, abandonment and of losing ones identity can be the consequence (Anderberg & Berglund, 2010).

The participation on the individual level is strongly intertwined with the participation on the organizational level (Abbott, Fisk, & Forward, 2000). This democratic participation entails the ‘activation’ of the resident in the functioning of the NH. It refers to the active role of residents as equal partners in the general management and daily operation of the NH (Abbott et al., 2000; Baur & Abma, 2011; Paterson, 2001). The positive effects of democratic participation when properly installed are numerous. It activates the residents, strengthens their dignity and self-respect, initiates responsibility, enhances the social identity, leads to empowerment, improves communication, enhances quality assurance and ensures that the care given is responsive to the needs and wishes of the residents (Abbott et al., 2000; Baur & Abma, 2011; Devitt & Checkoway, 1982; Knight, Haslam, & Halsam, 2010). In general, the current, most frequently used medium for and, often, highest form of democratic participation is the resident council (Baur & Abma, 2011; Knight et al., 2010). In Flanders, the resident councils are supported by legislation since 2009 (Woonzorgdecreet, 2009). Each NH has to establish a resident council at least once per trimester, composed of at least 50% residents, next to staff and family members. This council can give advise regarding all aspects of the general operation of the NH. In practice, their primary goal is informing the residents on NH decisions and hearing possible complaints. They are more perceived as a formality by the NH and residents experience that their suggestions are not really heard and that the councils are, therefore, ineffective (Abbott et al., 2000; Baur & Abma, 2011). In general, several barriers for democratic participation can be identified (Abbott et al., 2000). On the organizational level, there are often inflexible routines and structural dependency (Baur & Abma, 2011). Managers and staff may not be convinced that residents are competent partners in policy making (Abbott et al., 2000; Baur & Abma, 2011). Also, residents may believe that they do not have any influence on the management of the NH and that one must comply with the existing traditions and practices. When residents experience that their suggestions are not dealt with, they may stop making efforts (Abbott et al., 2000).

This means that it remains a challenge to let the voice of the NH residents be heard in a structural manner. Nevertheless, enhancing individual and democratic participation of NH residents fits with the Active Ageing framework since it contributes to the realization of the Active Ageing determinants. Therefore, the question rises how residents can truly influence their life and the culture in the NH. Participatory action research (PAR) as a mean of structurally embedding the voice of the NH residents might be an answer.

PAR

PAR can be broadly defined as a ‘systematic inquiry, with the participation of those affected by the problem being studied, for the purposes of education and action or effecting social change’ (Green et al., 1995, p. 2). As part of the continuous quality improvement of an organization (Leykum, Pugh, Lanham, Harmon, & McDaniel, 2009), its members should collaborate to identify problems, and collect and analyse data regarding their situation in order to improve it (Garcia-Iriarte, Kramer, Kramer, & Hammel, 2009; Reason & Bradbury, 2008). PAR implies ‘learning from those who know’ (Shura, Siders, & Dannefer, 2010, pp. 213). The members of the organization or the participants are the true researchers and they should have the agency in all aspects of the process to achieve social change (Blair & Minkler, 2009). PAR aims to identify common fields of interest, to empower participants to develop a shared vision regarding possible improvements, and to communicate and implement these improvements (Blair & Minkler, 2009; Shura et al., 2010). By analysing current situations and working on improved practices, an individual and communal capacity is built (Blair & Minkler, 2009) and participants are empowered. They then become more critically aware of their situation (Conder, Milner, & Mirfin-Veitch, 2011). The process is reflective and cyclical (Day, Higgins, & Koch, 2009; Garcia-Iriarte et al., 2009), consisting of cycles of ‘looking, thinking, and acting’ (Day et al., 2009; Glasson et al., 2006), in which the action must be beneficial for all involved (McIntyre, Chatzopoulos, Politi, & Roz, 2007). Moreover, involving the participants enhances the responsiveness, effectiveness and quality of services, citizenship and social capital of the people, while decreasing expenses (Ottmann, Laragy, Allen, & Feldman, 2011).

It is obvious that PAR fits seamlessly with the Active Ageing concept. By activating NH residents and structurally monitoring and acknowledging their visions, ideas and proposed actions, the NH can improve its functioning and respond more accurately to the residents’ needs and wishes. Additionally, residents will experience being valued and are stimulated to think more critically about their own lives and how their quality of life can be enhanced.

Our objective is to show how PAR can be realized within the NH by focusing on the process of implementation and to delineate the challenges and the assets that go along with the implementation of PAR, based on our own experience.

A case of PAR in NH

The insights presented here are based on the experiences of our research team gained during a PAR implementation project in a NH. Weekly PAR sessions with a group of residents were started. During the first six months, this project was led and supported by the scientific university team. Afterwards, the NH continued on its own.

Setting the stage

The PAR study took place in a public NH of 180 residents in a Flemish city in Belgium, consisting of eight different wards, including four for persons without dementia. Daily debriefings of the residents’ status and staff meetings every fortnight were organized. The staff meetings were held to discuss the daily operation and make decisions on changes. They were attended by the administrator (manager); quality coordinators; the chiefs nursing; and delegates of the occupational therapists, animators, social workers and kitchen and maintenance personnel. As condition for a successful PAR, the administrator of the NH committed to systematically implement the changes proposed by the residents during PAR. The PAR sessions focused on residents without dementia. Next to an organizational commitment, and before starting, the staff on the work floor also had to be fully devoted and convinced of the value of PAR (Day, Higgins, & Koch, 2009). Different meetings were held to provide information and to allow open discussions on the expectations, wishes, concerns and doubts of each of the staff members.

Concerning the residents, a group of 8–10 participants was aimed for, since this is considered to be an optimal PAR size (Corey, Schneider Corey, & Callanan, 2004). A fixed group of nine residents, six women and three men, was enrolled, with an average age of 85 years (SD = 6.7) and an average length of stay of 27 months (SD = 28). The dependency level varied from having no problems in basal activities of daily living to being dependent on all those activities. The residents were recruited by information sessions during the resident council. Residents were informed in detail about the aim and the setup of the PAR sessions and were invited to participate when interested. In addition, one-on-one information was given to the residents who were not present during the council.

The PAR sessions were facilitated by two moderators: an external (the principal investigator of the university) and an internal moderator (the animator of the NH, which in the Flemish context is the professional responsible for the organization of meaningful leisure for residents). Moderating PAR requires extensive training and preparation, since it specifically focuses on facilitating the process without interfering on the content level (Hunter, Bailey, & Taylor, 1996). The moderator must provide structure, build trust, engage others in participation, model behaviour and thoughts, handle conflict, challenge the residents and enhance change (Corey et al., 2004; Hunter et al., 1996; Reason & Bradbury, 2008). The principal investigator was a gerontologist (MSc) working in the research team of the university for five years. She was specialized in the residential care for older people and had expertise in qualitative research methods (focus groups, interviews, etc.). Still, she had no previous hands-on experience in PAR. The animator was assigned for her experience of organizing activities for residents, but also because she was seen as the central person in the daily operation by the residents and was considered as the confidant of most residents and staff. As a preparation, the external moderator reviewed all the existing literature on PAR and made a summary and action book, which was handed over to the internal moderator. Also after each session systematic debriefings and monitoring of the used PAR methodology were provided. In addition, preceding the first sessions, the external moderator had an orientation period in the NH, during which, by means of conversations with staff and residents and participatory observation during one month on the different wards, the different stakeholders were met and daily operations were witnessed. Due to the orientation period, the external moderator had a better understanding of the issues mentioned by the participants during the sessions. Furthermore, it reduced the risk of being seen as threatening.

PAR sessions

Every week, the PAR group met (and still meets) for 1 h on Friday morning to discuss their lives in and the functioning of the NH. The sessions were all audiotaped (with residents’ consent) and written out verbatim, immediately after each session. For validation, the PAR participants received a weekly report based on the transcripts. Feedback on the reports could be given if they felt the content of the report did not reflect the content of what was said in the session.

The first meetings were mainly intended to acquaint with each other and with the PAR method (Brown, 2005; Corey et al., 2004; Smith, Bratini, Chambers, Jensen, & Romero, 2010). During these first session, the residents were not sufficiently familiar with bringing up new topics on their own. Therefore, the first session was started by the moderator prompting the broad question ‘What entails a good life for you in the NH?’, immediately revealing various topics which were close to the heart. Later sessions only needed the question ‘Does someone want to say something?’ As the PAR sessions progressed, residents analysed their current situation and the organization. Based on the observations they made about their lives, issues relevant for them emerged (Glasson et al., 2006), followed by reflecting on the actual and the desired situation. Specific to PAR, the residents themselves consider possible modifications and plans of actions to improve their life situations on these issues. Every two weeks, the moderators presented the proposed actions to the management and staff during the staff meetings, where the steps in implementation were further elaborated. The moderators could be seen as advocates of the PAR participants and PAR issues. This format was chosen to ensure confidentiality towards the residents. As has been observed in resident councils, residents are often afraid of giving their opinion openly, since they don’t want to be considered as complainers and they fear repercussions (Boelsma, Baur, Woelders & Abma, 2015). To avoid experienced limitations in freedom of speech, the two moderators were go-betweens between staff and residents, ensuring confidentiality and anonymity towards the participants. After each staff meeting, feedback was given to the PAR group. In later sessions, the agreed implementation was further monitored and evaluated, as advised (Glasson et al., 2006).

PAR examples

Based on a content analysis of the transcripts of the sessions, different themes could be identified. By means of illustrations, we will further present a few of them to give insight in the issues that arose during the sessions and how they evolved to actions. During the half year that PAR was co-moderated by the principal investigator, the residents came up with many topics regarding a broad spectrum of life domains, including social aspects, psychological support, safety issues, food, meal gatherings and communication issues. Four examples of these topics are discussed below to show the diversity in needs but foremost to illustrate the process level. We do not want to focus too strong on the content of the PAR sessions, since at the end the topics discussed were specific for that group of residents in that NH. Therefore, we found it more important to make professionals acquainted with the process of PAR, rather than the content of our project.

Missing contacts and the contact corner

The first case is an example of the potential of PAR letting residents speak up and rapidly revealing emergent burning topics, encountered shortcomings in the NH and the encountered context factors influencing them. Furthermore, it makes clear that putting action plans into practice may ask time, also for residents.

‘What does a good life mean to you in a NH?’. The opening question of our first PAR session revealed a distinctive need in the group, which was the lack of social contacts with other residents. A year before PAR started, the NH and the residents moved to a new and larger building elsewhere in the city, because the old building had become too small and unpractical, obliging all residents to share rooms. The move was experienced as having serious implications on the contacts between residents. ‘I used to see and talk to everyone, now I don’t see a living soul’ – ‘The groups and residents are all dispersed. The visits, the ambiance and atmosphere of before in the communal space was great, now this happens rarely’.

Residents missed the contacts they had before. They felt that no efforts were made by the NH in enabling them to meet each other on informal occasions and, since the corridors were so long, less mobile residents did not go further than the own ward. Since everyone suddenly had a private room, they didn’t dare to intrude each other’s privacy by paying a visit, which resulted in more lonely moments, without a social atmosphere, and a continual wondering of how it would be with their former friends/neighbours. To assist the participants in analysing how this could be improved, they were asked how they met in the past with friends and relatives, in the former NH as well as at home. Out of these stories, the residents realized there was often a central place where people met, a pub, the former club or the communal space of the old building. Once this was revealed, the residents wondered if a central space in the NH could be a possible solution. Although these were the first PAR gatherings and it was the first time they had to think and rethink possible solutions, all participants were eager to find the right spot where residents could join. ‘It has to be a place where everyone feels comfortable and feels a bit at home.’– ‘A place that is big enough’– ‘A location that is separate enough, but at the same time sufficiently accessible and open for everyone’. Some residents noticed that many of the communal spaces presented were often occupied by activities or by staff. At the end, they came to the conclusion that one specific corner with a lot of sofas and chairs was the ideal location. ‘Wow, that corner there, yes, what a cozy corner!’ – ‘It is the perfect spot’. Afterwards, further reflections were made on how to spread the word towards the other residents. They advised the moderator to announce it in the next resident council and the weeks after they arranged specific actions to make the corner work, for example by planning a specific hour when they would sit there. Despite all good intentions, after a few weeks it became clear that most of the participants did not go to the corner, or at most a few times; due to the absence of other people they were not motivated to keep on sitting there. At the end, they concluded that the corner was too distant from the actual wards. Therefore, they decided to make the sofa corner next to the physiotherapy room. The new location was mentioned in the newsletter of the NH. Still, the participants were aware that this would be a process of maturation which would need time.

Morning routine: Hello’s and washcloths

The second example shows the possibility of easy implementation of suggestions made by residents and is a nice illustration of the devotion of staff to work on some of these action plans. In the PAR group, people with different levels of dependency were participating. A few of them did not need any support in their basic activities of daily living, such as washing or clothing. One of these residents noticed that during the morning routine, she did not get a ‘good morning’ visit from the staff nor did she get any washcloth or towel for her morning toilet. They wanted more equity in morning routine between residents. ‘In all the rooms next to me, they (the staff) come and stay a long time; my room they just pass, without any concern of how I would be and how I feel. I do mind, you can lie there on the floor without being seen’. – ‘A “Good morning, are you awake? Here are your washcloth and towel for today”, that is what I would like. Now I have to find their cart every morning and steal a washcloth in order to be able to wash myself that day’.

As simple solution, they suggested to ask the staff to complete their morning round, by quickly entering each room for a ‘good morning’ and the provision of a towel and washcloth if necessary. This experienced problem was immediately taken seriously and the staff started to fulfil the needs of the independent residents as well. ‘(at the beginning of a session) you know what, such a pile of washcloths now in my room! I got seven this week! (smiling)’.

A piece of bread, butter and jam please!

This is an example showing that PAR and the implementation of change might sometimes be a tough struggle. Traditions in working operation sometimes do prevail, preventing true quality of care, and are hard to adapt on a bottom-up resident basis. This requires an intense commitment from staff.

During breakfast, food was not put on the table and residents always had to ask the care providers for bread or for jam, butter or other fillings. Sometimes, the staff did a round to ask who wanted bread, but most of the fillings were on the staff’s table and given when someone asked, not provided automatically. This led to long waiting times, frustration and feeling dependent. In addition, choices were limited, since residents did not have an overview of the available options for the day. For example, when residents wanted jam, they did not know which different kinds of jam were available that day. ‘They (the staff) get pleasure and feel honored that we have to ask them for food and that they are in control to give it to us, for which we have to say thank you’ – ‘They always forget butter, and then you have to repeat it and wait even longer until they give it to you’.

The participants wanted more choice, freedom and autonomy when it concerned their own breakfast. After some reflection in group, they concretized their wishes into the practical suggestion of putting baskets on the table with bread, butter and different kinds of sweet spreads. They suggested not to put meat or cheese on the tables for hygienic reasons, but it was perfectly feasible to put individually packed jams, chocolate paste and butter on the table. This action plan was presented during the staff meeting and afterwards spread during daily team gatherings to ensure its realization. However, over the course of months of PAR sessions, the problem remained. ‘There is nothing anymore on the table. They just give the jam when you ask for it’. Only occasionally, baskets were put on the table, but most of the times they weren’t. When hearing these encountered problems in implementation, the internal moderator further discussed this issue with the responsible care provider and gave feedback on it during PAR. One problem appeared to be the communication to the many internships who did not know what to do and did not follow the arrangements made. Another reason, however, appeared to be motivational. Without putting it to the test, some professionals assumed it would lead to additional workload, which they wanted to avoid by just leaving it the old way. They also believed that the residents would start to hoard. Fortunately, after many reminders from residents during PAR, after many repetitions from management staff towards the care provider and due to the growing boldness of the PAR participants asking themselves for the baskets at breakfast, there was a slight positive evolution over time, but still systematic provision of table baskets remained absent. ‘The best solution, when the baskets are still not on the table, is for us to say “Put in on the table”’.

Fire, then what?

Not all PAR actions have to be big or require permanent changes. PAR can also concern more practical problems encountered. A last short example along this line, regards the need of NH residents for practical information, leading to a simple process of implementation which is more practical of nature, that is the organization of a single information session.

At the start of one of the sessions, a resident asked: ‘Recently, we talked about personal alarms, but what with fire alarms? What do we have to do when there is a fire?’ It appeared that nobody was informed or aware of the actions they had to take in case of a fire. They had no idea of the evacuation plan nor of the most secure places to go to. The participants themselves proposed to arrange an information session for the whole building, so everyone would be up to date. As a reaction, the management arranged a special fire meeting, inviting a fireman responsible for the NHs of the city, who explained in detail what would happen in the building when a fire occurred and where the residents had to go to, depending on the location of the fire. This led to residents feeling safer on this topic.

A new Active Ageing paradigm for NHs embracing PAR

This article does not concern a systematic qualitative content analysis of all themes brought up during the PAR sessions in our project, but exemplifies, outlines the feasibilities, added values, practicalities and challenges that go along with the process of PAR. Given examples illustrate how the process of implementation of PAR in NH has the potential to give residents a voice, engaging the NH to a more bottom-up operation. The examples show the feasibility of residents to give their opinions and thoughts about what they experience and what they want. Still the process of PAR and of PAR implementations is one of successes and of challenges, in need of structural monitoring and combating the traditional way of working and thinking about residents.

Active Ageing is a competency based framework changing the way of envisioning and treating older people. Slowly but surely, this model finds its way within residential care (Van Malderen et al., 2013). It is unthinkable to only approach residents as frail, passive, dependent people. The NH vision should be one of building on residents’ capabilities, desires, aspirations and wishes. This entails a holistic model focusing on all life domains, or Active Ageing determinants, and therefore on their quality of life (Van Malderen et al., 2013). As mentioned in the introduction, resident councils have been proven not to fit in this new model due to its ineffectiveness. As shown in Figure 2, PAR fits better in the Active Ageing scope, since it does allow residents to actually experience changes in the NH, decided by them during the group gatherings.

Figure 2.

The relationship between participatory action research and the new Active Ageing-minded nursing home.

This project was one of the first putting PAR central as a structural method in a global new NH vision, this in contrast to earlier PAR studies towards NH populations (Baur & Abma, 2012; Boelsma et al., 2015). It showed that PAR is of value in NH, according to the Active Ageing model, since by introducing this one, relatively simple intervention, issues are brought up by residents on the different Active Ageing determinants and a multidimensional quality improvement can be assured. This article is additionally the first focusing on the actual implementation process to serve as aid to start PAR within this specific context.

This project and the examples described above showed that residents are able and motivated to talk about and critically reflect on their life situation and suggest themselves improvements to implement.

It is often said that in PAR trust building, certainly with older people can be a long process (Blair & Minkler, 2009; Corey et al., 2004). Feelings of discomfort, distance and power relation problems have to be dealt with (Smith et al., 2010). Still, our project demonstrated that NH residents adjust rapidly to new people as well as to each other. Therefore, the PAR introduction/adaptation period in this project was relatively short, since personal experiences, expectations, thoughts and emotions were rapidly expressed.

In the PAR sessions, there was no lack of ideas and topics. The examples mentioned above were only four of the many raised. The participants took pride in their actions and their contributions to a better quality of life for all. They became bolder to defend their suggestions outside PAR, as also seen in other studies (Baur & Abma, 2012).

Challenges

Still, there are challenges in introducing PAR within this specific NH setting.

Moderating PAR asks for critical reflexivity from the facilitator. As external moderator, it was important at the start to get acquainted with the daily operation and policy in the NH (Smith et al., 2010). The one-month orientation period scheduled for this purpose did, however, also lead to preliminary personal opinions on the quality of the NH functioning from the perspective of a gerontological researcher. It did ask a very self-critical attitude during the first PAR sessions to leave these opinions behind and to remain neutral as a facilitator. For this reason a weekly journal on self-reflections was kept. On her turn, the internal moderator in our project had to learn to behave as facilitator and not as a care provider. Inherent to the job as animator, she had been used to help residents when they were in need of something. In PAR, she had to avoid getting involved on the content level. In relation to this, guaranteeing discretion and confidentiality is an absolute must as moderator. The moderator, therefore, had to learn not to brief personal remarks given by the residents to other members of the staff. This learning process took some time. It was a main advantage in this project that there were two moderators, two persons with different backgrounds, who remained alert and critical towards each other’s moderating process. It can, therefore, be advised, in order to obtain an optimal PAR context, to start with two trained moderators who remain critical towards each other’s facilitating skills.

Another challenge for this specific NH setting regards the composition of the PAR session. As we experienced, it is important not to use too many inclusion and exclusion criteria to assure that the final group of participants encompasses a variety of residents. It is tempting and easy only to recruit the ‘loudest’ and most active residents. Still, the group should encompass a variety of people with different backgrounds, experiences and abilities. For PAR, and more specific for this project, a requirement was being cognitively able to participate. People with dementia require a specific approach, in order to allow them to express thoughts, opinions and feelings. Therefore, PAR with people with dementia is not part of the scope of the present paper. Including people with different physical dependency levels is, however, vital and tend to give added value. Constituting a representative PAR group remains a concern. Nevertheless, even if representative, it remains a challenge how to extrapolate the effects of PAR to the whole NH population. In our project for example, the experience grew that one PAR group for four (nondementia) wards might not be enough. Both the moderator and the NH, therefore, have to bear in mind that other residents might not be heard and might have diverging opinions. Additionally, it might be difficult at start to recruit residents. Especially with the experiences of residents councils in mind (Abbott et al., 2000; Baur & Abma, 2011), the enthusiasm of residents to participate in PAR can be low. It was in our project therefore hard to find participants before the start, but the interest did grow by word of mouth once started. In general, the current NH population often regards people who were never used to be bold or critical (Boelsma et al., 2015). In addition, the experienced power relations do often prohibit true freedom of speech to avoid any repercussions (Boelsma et al., 2015). Notwithstanding this might be seen as a violation of true PAR research, it was, for this reason a deliberate choice to work with the moderators as go-betweens between staff and participants, to guarantee confidentiality, which led to residents feeling safe to openly express their thoughts. This was, therefore, well appreciated by the participants.

Residents are not used to be heard, to give their opinions and to listen to each other’s propositions. Therefore, when starting PAR, a certain amount of rigidity and rumination can be present. At start of our project, the participants frequently mentioned their ideas separately, but in a rigid manner, without listening to the others or building on each other’s contributions. We therefore changed seating arrangements and worked with visual aids (e.g. during the first meetings we used name cards for seating arrangements and a ball or other small object to put on the table in front of who is talking so participants not only hear but also see who is talking) to enable their listening skills. This enabling context is also advised by Corey et al. (2004). These solutions might seem obvious or trivial, but due to the experienced effectiveness, it is important to mention them.

A last specificity of doing PAR in NH is that it is hard to implement a bottom-up approach in a context that is primarily organized top-down, as is also stated by Jacobs. In a NH, long-standing schedules and structures are present and are used as guidelines for staff members (Harnett, 2010). For this reason, there might be a certain fear among the staff to change these routine approaches, which was also put forward by some staff in our project. We experienced that there can be some reluctance. Often, the organization and the staff members first must experience that the encountered problems or the proposed changes by the residents are not necessarily invasive. It often regards relatively small things that make life better. Still, also in our project some employees remained negative or neglected the agreements made on the implementation of some of the proposed changes, as is shown in the example on the breakfast baskets. A good structural communication and monitoring between management and staff is therefore crucial.

Similar as for Active Ageing as a framework, it is also a reality for PAR that it is a very new approach of organizing a daily operation, which requires a fundamental shift in mindset. The different stakeholders are not necessarily used to it or open-minded for it. Still, it is often only a question of time and this project and others (e.g. Baur et al., 2013; Shura et al., 2010) show the feasibility of structurally implementing PAR within this setting. We are aware that within the action research community, PAR just as weekly activity is not necessarily seen as true PAR, but due to the deeply established top-down operations present in NH, weekly PAR sessions are the first step in introducing residents as co-creators of NH and evolving to a true Active Ageing, bottom-up way of working. A summary of the guidelines we propose can be found in Table 1.

Table 1.

A summary of the key points of introducing participatory action research (PAR) as method in an Active Ageing-minded nursing home.

When considering PAR in a nursing home, keep in mind that:

• Fruitful participatory action research as structural method in nursing homes is feasible

• There has to be an organizational commitment

• The moderator has to be trained and need to remain self-critical through each session

• Residents nor staff are acquainted with this activity at the start and have to be enthused

• A varied group of residents should be aimed for

• Sessions must be organized in a private enabling environment to enhance good communications

• The implementation period of the proposed actions do at start need a continuous monitoring and engaging of staff, since it is a new approach of working, invading existing traditions

• Once PAR is installed, this activity requires less extra efforts and rewards can be reached

Conclusions

Within an Active Ageing-based NH, residents are systematically heard and can participate as full agents by structurally using PAR. PAR has the potential to empower residents to be part of the community and to be in control over their life and living conditions. New, refreshing ideas and initiatives to improve the NH emerge, which might lead to a better quality of life of the residents (Shura et al., 2010).

Participation of older residents is the key factor of Active Ageing. PAR has the key features to enhance this participatory process, which further stimulates the self-value of residents who are often suffering from stigmatized identities (McKeown et al., 2012).

Although at the start PAR is an effortful technique, once it becomes an established activity, all parties realize the richness of information and how small and feasible adaptations can change lives.

Footnotes

Acknowledgements

We thank the PAR-NH and all the residents and staff-members participating in this research for their cooperation and interesting contributions.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is part of a PhD project funded by the Research Foundation-Flanders.

Author biographies

Lien Van Malderen (Educational Scientist (Disability Studies) (MSc), Gerontologist (MSc)) is a PhD Fellow at the Research Foundation Flanders and at the Vrije Universiteit Brussel. Within the University, she is embedded in the Gerontology () and Frailty in Ageing (FRIA) research Departments. Her areas of interest concern amongst others the topics of active ageing, residential care and empowerment/participation.

Patricia De Vriendt (Occupational Therapist (BSc), Gerontologist (MSc, PhD)) worked as an occupational therapist at different settings for older people, among others at the geriatric department of University Hospitals and at nursing homes. She is since long time lecturer at the Artevelde University College and she is since 2012 part-time professor at the Vrije Universiteit Brussel (Faculty of Medicine and Pharmacy). She is embedded in the Gerontology () and Frailty in Ageing (FRIA) research Department. Her areas of interest concern amongst others the topics active ageing in nursing homes and in particular enabling meaningful activities, cognitive disorders and the evaluation of activities of daily living, and frailty.

Tony Mets is Medical Doctor, specialized in Internal Medicine and Geriatrics, and Ph.D. in Medical Sciences, with special interest in the frailty of aging and in biogerontological studies. He is professor at the Vrije Universiteit Brussel.

Ellen Gorus (Clinical Psychologist (MSc), Gerontologist (MSc, PhD)) works as a Clinical Psychologist at the Geriatric Department of the Universitair Ziekenhuis Brussel and is since 2010 part-time Professor at the Vrije Universiteit Brussel (Faculty of Medicine and Pharmacy). She is embedded in the Gerontology () and Frailty in Ageing (FRIA) research Departments. Her areas of interest concern amongst others the topics active ageing, cognitive frailty and motivators and barriers for physical activity in older persons.

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