You are caring for Mrs. R, a 75-year-old woman admitted to your hospital with pneumonia. After a few days, Mrs. R starts frequently ringing the call bell. She says that her breathing is better, but she complains about everything else. Mrs. R tells you that her hospital bed is uncomfortable, her doctor hasn’t gotten back to her about when she can go home, and her family hasn’t visited. Finally, Mrs. R bursts into tears when she tells you that no one has helped her wash her hair in a week. You help Mrs. R reposition herself in bed and ask the nursing assistant to wash her hair. But you recognize that you have little control over Mrs. R’s other complaints, and you’re sure that she will continue to use the call bell excessively. You don’t want staff to brush her off as “difficult,” and you wish your unit had a resource that could better meet Mrs. R’s psychosocial needs.
Older adults spend a considerable amount of time trying to acclimate to the unfamiliar hospital environment. While waiting for the next test or treatment, they struggle to cope with fears and maintain control of their lives. As a nurse, you recognize that Mrs. R’s behavior reflects her profound loss of control. Being in the hospital prohibits her from performing her normal routine. She is isolated from her family and the creature comforts of home. Mrs. R’s complaints and repetitive use of the call bell could be signs of boredom, which is a key issue for many hospitalized older adults.
A nursing concern
At first glance, you might think your patient’s boredom is not a nursing concern. But consider that boredom heaps frustration and powerlessness on top of the pain, anxiety, and uncertainty of illness. This situation may worsen as your patient heals because as she begins to feel better, her attention shifts away from focus on her disease. Uninteresting and unenjoyable activities, including time spent in a hospital bed, makes the time spent in the hospital feel like “forever” to patients.
At New Jersey City University, professors and accelerated BSN students observed the detrimental effects of boredom on older adult patients. In response, we created the Activity Menu, a kit of diversional, downtime activities for hospitalized older adults. The Activity Menu kit includes seven evidence-based activities (art making, craft making, The Reminiscence Journal, puzzles, listening to music, The Stretching Book, and the Activities of Daily Living Book). Each of these activities can be performed at the bedside with or without assistance. Our accelerated BSN students produced the Activity Menu kit and then donated it to a partner hospital in the same region.
The Activity Menu kit is designed to increase patient choice and control while minimizing boredom. The activities within the kit promote positive thinking, encourage expression of emotions, and decrease isolation. Although the Activity Menu is a simple intervention, the effect of its positive outcomes could motivate patients to better participate in their care. We believe that the Activity Menu kit also can act as a template for other in-patient organizations to improve older adult patient outcomes.
The heart of the Activity Menu kit is its menu—a list of the activities available to the patient.
Once the nurse identifies a patient is a candidate for the Activity Menu kit, he or she gives the patient a laminated menu card from which to order. Nurses confirm that the selection is appropriate for the patient’s abilities.
The nurse then brings supplies and directions corresponding with the activity to the patient. Some of the advantages of the menu format include:
- Promotion of patient choice and control. Use of the Activity Menu allows the patient the choice of downtime activity, giving him or her control over something, however small, within the hospital environment.
- Convenient implementation. Nurses only need to carry the supplies for the request activity, not the entire storage box, which is kept in the nurse’s station.
- Potential for delegation to a volunteer. Hospital volunteers can help your patients with the selected activity if supervision or assistance is needed.
Here is a closer look at a few of the activities and how you, as the nurse, would use them.
Activity: Art making
Our team designed each intervention in the Activity Menu kit to be easy to use, low cost, reproducible, and carry a low risk of disease transmission. The art making intervention is a great example of these caveats. When your patient selects the art making activity, he receives a pre-drawn, but empty, paper silhouette of a human head, a pencil, and a box of crayons. The instructions encourage him to fill the silhouette with words and/or pictures that represent what is “inside his head.” There are multiple benefits to this type of intervention. The art making activity:
- Temporarily alleviates boredom. Participation in art making provides distraction from boredom and thoughts of illness, as your patient passes time in a pleasant way.
- Encourages self-expression. Your patient may not verbalize his thoughts and feelings to the healthcare team. He may find a shift from “voicelessness” to empowerment while creating art. In a qualitative study, Sagan found that narratives of mental health patients who utilized art therapy contain reoccurring themes of self-expression through art when the participants previously could not express feelings.
- Fosters connection. Viewing and participating in art reminds your patient of his humanity, which increases his feelings of connectedness and decreases his sense of isolation. Narratives within Sagan’s qualitative study revealed participants’ felt that their artistic creations provided internal and external connections. Your patient will feel connection to his work, while his art may provide you with an opportunity to interact with him.
- Facilitates self-worth and sense of accomplishment. Sagan also found that art therapy users expressed that the act of creating art increased their feelings of positivity and productivity. Display the finished artwork in your patient’s room; it will provide color and interest to the environment. Even more importantly, it will remind your patient of his individuality and accomplishment.
Activity: Reminiscence journal
Reminiscence therapy is the reflection, expression, and documentation of a person’s life memories. Selection of The Reminiscence Journal (TRJ) comes with a notebook, writing tools, and instructions with suggested topics. TRJ:
- Promotes reminiscence. TRJ uses simple reminiscence technique, or the detailed retelling of life stories to remember, inform, teach, and communicate.
- Encourages your patient to remember affirming life events and positive coping mechanisms. In a meta-analysis of 128 reminiscence studies, Pinquart and Forstmeier found that older adult patients who used reminiscence therapy had statistically significant improvements in ego-integrity and positive well-being. After using TRJ, your patient can apply her positive emotions and remembered coping mechanisms to her current situation.
- Acts as an icebreaker and encourages interaction. Decrease your patient’s boredom and loneliness by combining the effect of this activity with the company of a volunteer.
Activity: Listening to music
Our university’s nursing department donated five iPod Touch MP3 players to the Activity Menu kit. The students downloaded free music apps, with a range of preset music stations, onto each iPod Touch. We believe the MP3 player is ideal for this intervention; however, music can be delivered by other means. Listening to music:
- Normalizes the hospital environment. Your patient chooses the type of music that he enjoys playing in his room. Listening to favored music can encourage positive associations between songs and familiar situations.
- Provides distraction from illness and promotes relaxation. Lin and colleagues found that providing 30 minutes of music to chemotherapy patients before therapy significantly decreased anxiety for this population. Listening to music may make the hospital environment less stressful for your patient.
Transform the environment
Keep in mind that your patients may not admit to feelings of boredom or loneliness because they don’t want to “bother” you, and they may believe the common misperception that hospitals are strictly for physical healing. As nurses, we recognize the importance of treating patients’ physical AND psychosocial needs. Including the risk for boredom in your care plan is no less important than any other psychosocial risk.
Diversional activities can transform the hospital environment as well as change your patient’s state of mind. Make a difference by implementing an Activity Menu kit, or something similar, at your facility.
Mrs. R chooses the art making and listening to music from the Activity Menu. She soon seems more positive and hopeful about her situation. She does not ring the call bell as frequently and participates more actively in her care.
Jennifer Racine Ricker is a critical care staff nurse at St. Josephs Regional Medical Center in Paterson, New Jersey. Kevin O’Neill and Kimberly Dudas are faculty members at New Jersey City University in Jersey City. O’Neill is associate professor and nursing department chairperson; Dudas is associate professor and associate dean of Nursing and Health Science.
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