Using a realist approach to explain outdoor activities and mobility in care homes: the ROAM Study

King, A.L. (2018) Using a realist approach to explain outdoor activities and mobility in care homes: the ROAM Study. PhD thesis, University of Nottingham.

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Background: Whilst outdoor activities and mobility are believed to be beneficial for older care home residents, UK best practice guidance is based on occupational therapy-led expert consensus. This thesis reports research which aimed to provide theory-driven explanations about residents’ occupational engagement in the gardens and outdoor spaces of UK care homes.

Method: A systematic mapping review was used to identified gaps in the evidence base, which informed the research to be undertaken. A multi-phase, realist theory development cycle incorporated: identification of initial context, mechanism and outcome (CMO) components guided by the review literature and expert stakeholder consultation; CMO configuration (CMOc) using data from non-participant observations, Dementia Care Mapping (DCM) values, plus characteristics questionnaires; theory refinement which involved using a retroductive approach to triangulate and synthesise observational and staff focus group data and finally, theory articulation, in which the overall findings were interpreted in the context of the broader literature and substantive theories to produce a middle-range theory for further testing.

Results: Contextual barriers to residents’ outdoor use were reported frequently in the mapping review articles, but explanations about why or how these operated as such were largely absent. A realist approach was selected to address this. Observational data provided by 50 residents and 35 care staff from three care homes, plus questionnaire data indicated that residents’ outdoor use was influenced primarily by the practice context rather than by intrinsic resident mechanisms. Data from three focus groups (14 staff) confirmed that staff reasoning about supporting outdoor use was characterised by risk aversion, which was partly a consequence of organisational and building design constraints. A middle-range theory posited that cognitive dissonance about outdoor use was experienced by a particular staff reference group – those who shared person-centred values and an outdoor ethos but felt that they lacked time to enact these. This dissonance was mediated by widespread attitudes about the influence and impact of weather on residents which resulted in outdoor opportunities being restricted to periods of sunshine and warm temperatures.

Conclusion: As an unintended consequence of the prevailing social structures in the care home context, it is possible that many UK residents are being denied year-round opportunities to use care home gardens and outdoor spaces. To support practice change in this area, population-level, practice environment and resident-focused recommendations were produced. This study is the first to explore how and why residents’ use of care home gardens and outdoor spaces came about using a realist approach. Occupational therapy practitioners and researchers are well-placed to contribute to the evidence-base in this area.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Logan, P.
Gladman, J.
Gordon, A.
Chadborn, N.
Keywords: Care homes; Outdoor spaces; Outdoor activities; Older people
Subjects: W Medicine and related subjects (NLM Classification) > WT Geriatrics. Chronic disease
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 55473
Depositing User: King, Amanda
Date Deposited: 13 Mar 2019 13:09
Last Modified: 07 May 2020 14:32

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