Exploring the facilitation of meaningful leisure activities in designated centres for older persons (nursing homes) in Ireland: A protocol for content documentary analysis of HIQA inspection reports.

Introduction

In Ireland there are 567 registered nursing homes (HIQA, 2020a) with over 30,000 residents. These registered nursing homes are operated by private (for-profit) providers, voluntary (not-for-profit) providers and the Health Service Executive (HSE). The majority (80%) of nursing homes (NHs) are private, operated by individual providers/provider entities and the remainder are public NHs, owned and operated by the HSE (Pierce, 2020). The Health Act 2007 (as amended), and its associated regulations and mandated standards provide the legal underpinning for the regulation of designated centres for older persons (nursing homes) in Ireland.

A designated centre for older people is defined in the Health Act (1990) as an institution at which the HSE, or a service provider on behalf of the HSE, provides residential services for two or more dependent people (Government of Ireland, 1990 - S.I. No. 23/1990). These residential services are provided to dependent persons in relation to their dependencies. For the purpose of this study, designated centres for older persons will be referred to as nursing homes. The purpose of regulation is to safeguard all individuals receiving residential care services. Regulation provides assurance to the public that people living in residential settings are receiving a safe, high-quality service that meets the requirements of the regulations (HIQA, 2018). Regulation is overseen by the Health Information and Quality Authority (HIQA) and consists of three components: registration of centres, compliance monitoring and enforcement. Registration of new NHs is conducted through the Office of the Chief Inspector of Social Services (HIQA) and existing NHs are required to renew their registration every three years thereafter. Compliance monitoring is a dynamic and continual process. Through the use of an enhanced authority monitoring approach (HIQA, 2018), compliance with regulations is assessed through gathering information and evidence, with information then reviewed and risk-rating applied to inform regulatory judgment.

The information gathered can be either solicited or unsolicited. Solicited information comprises documents submitted to HIQA during the registration process, notifications submitted to HIQA on a quarterly or three working day basis (dependent on the type of notification) and information provided by NHs during inspections (which can be announced, short-notice announced or unannounced) (see Table 1). Unsolicited information can comprise submissions of complaints and/or concerns regarding the operation of a NH to HIQA. Under the Health Act (2007), HIQA does not have the power to investigate complaints related to the care of individual residents.

The information gathered is comprised from inspection of the following areas: premises, compliance plans, compliance with conditions of registration, and receipt of unsolicited and solicited information (HIQA, 2018). A substantial component of compliance monitoring is conducted through inspection of NHs. Inspections assist in the ongoing regulatory decision-making process, with the function of providing updates to centres on the status of regulation compliance, while also giving a voice to residents within the centres in order to keep the public informed of the quality of services provided (HIQA, 2018). All members of HIQA's Older People's inspection team are legally responsible (under the Health Act (2007), as amended) for the monitoring, inspection and registration of nursing homes in Ireland (HIQA, 2021).

These statutory functions that may be performed by inspectors are set out in the “Scheme of Determination”. In order to be able to perform these functions, inspectors must have a degree qualification (level 8 on the National Framework of Qualifications) or equivalent in social care or nursing or other healthcare or social care or regulatory professions deemed relevant by HIQA. In addition, all inspectors must engage in two levels of standardised training within HIQA. Following completion of the first level of training, an inspector will receive the first part of the scheme of determination and can accompany inspectors of social services on inspection and use the evidence that they gather to inform judgements. Following completion of the second level, an inspector can then lead inspections of social services. Providers of nursing homes must meet regulations in order to remain registered and continue operation. Regulations for nursing homes under the Health Act (2007) as outlined in Table 2 below.

In Ireland, the regulation of Resident’s Rights (9.2) under the Health Act 2007 (as amended) for NHs states that the registered provider must provide the following for residents: a) facilities for occupation and recreation, and b) opportunities to participate in activities in accordance with their interests and capacities (Government of Ireland, 2013). In an overview of the regulation of nursing homes in 2019, HIQA highlighted that there were relatively high levels of non-compliance in the area of residents’ rights, mainly concerning a lack of privacy and dignity provided to residents (HIQA, 2020b). However, this level had reduced from 27% in 2018 to 20% in 2019. Similar findings have been reported from studies with residents of nursing homes whereby opportunities for meaningful activities can enhance quality of life (Burack et al., 2012; Hall et al., 2011; Schenk et al., 2013). Despite the proven benefits of engagement in activities when an older person enters a NH, residents often lose autonomy in decision‐making, occupational roles, and engagement in meaningful activities (Causey-Upton, 2015) and are deprived of accomplishment, value and personal meaningfulness and participation in activities that they would have engaged in within community settings (Morgan-Brown et al., 2019). Participation in activities and recreation in accordance with their interests and capacities is central to the health and well-being of older adults.

Leisure activities and meaningful activities are associated with enhanced physical and mental health, cognitive abilities and maintenance of identity through occupational roles for older adults (Causey-Upton, 2015; Palacios–Cena et al., 2016). Leisure activities are non-obligatory activities that are intrinsically motivated and engaged in during discretionary time that is not committed to obligatory occupations such as work, self-care, or sleep (AOTA, 2020; Chen & Chippendale, 2018). The National Standards for Residential Care Settings for Older People in Ireland (2016) describe meaningful activities as activities that promote physical health, mental health and wellbeing, and opportunities for residents to socialise. Meaningful activities should be based on each resident’s preferences, interests, past activities, and are informed by and recorded in individual care plans. Activity programmes must take account of the age, gender, and different levels of functioning and ability of each resident, and provides for highly dependent residents and those with cognitive and or sensory impairments (HIQA, 2016).

From an international perspective, insufficient meaningful leisure activity and occupational deprivation among NH residents was a concern before the COVID-19 pandemic (Mansbach et al., 2017; Palacios–Cena et al., 2016; Pirhonen et al., 2017). However, infection control and prevention measures introduced within residential settings in response to COVID-19 has further heightened this pre-existing challenge for NH residents and their families (Kehusmaa et al., 2021; Paananen et al., 2021). Research has highlighted the importance of meaningful activities within NH settings throughout this pandemic in order to offset some of the effects of restrictions on visitations and social distancing measures (Fuller & Huseth-Zosel, 2021; Whitehead & Torossian, 2021).

A report by HIQA in 2020 highlighted that the experiences of NH residents in Ireland throughout the COVID-19 pandemic mirrored that of wider society. However, NH residents experienced additional stressors related to isolation experienced due to lack of visitation and a constant fear of an outbreak (HIQA, 2020a). In addition, infection prevention and control measures meant that residents were largely confined to their own bedrooms, with external activities cancelled due to infection prevention and control measures (HIQA, 2020a). The need for measures to address the individual wellbeing of residents were identified in light of the social isolation likely to be experienced (HIQA, 2020a).

Given the central role of leisure activities to older adults’ health and well-being, this study aims to understand how NH residents were afforded opportunities for meaningful engagement in activities prior to and throughout the COVID-19 pandemic (2019 – 2021). This study seeks to explore:

Methods

Discussion and conclusions

The current study will explore how residents’ rights were upheld over a three-year period in nursing homes in Ireland during the COVID-19 pandemic, specifically how they were afforded facilities and opportunities to participate in activities in accordance with their interests and capacities. Kuruvilla et al.’s Research Impact Framework (2006) outlines four core categories of impact: research-related, policy, health and societal impacts. This study will contribute to research evidence exploring meaningful leisure activities in NHs from an Irish perspective. It may also be beneficial to policymakers and on a national level by offering insights into how meaningful activities were facilitated both before and during COVID-19, and what measures can be taken to ensure that these activities continue to be facilitated. As previously stated, leisure and meaningful activities are associated with enhanced physical and mental health (Causey-Upton, 2015; Palacios–Cena et al., 2016). This research could re-enforce the importance of maintaining and facilitating opportunities for meaningful activities in order to contribute to the positive and healthy aging of older adults in nursing homes. In terms of societal impact, a recognition of the importance of meaningful activity and its facilitation may improve the health status of for population.