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Benefits of a gardening project for people with dementia in nursing homes

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Two nursing homes in Scotland are involving their residents and staff members in gardening activities, raising physical activity levels and providing opportunities for meaningful interaction

Abstract

Gardening and garden-related activities can be a fun way of getting nursing home residents more physically active and engaged. For residents with dementia, they can provide opportunities to be involved, express themselves and interact with others. Gardening can also be a way of getting all members of the nursing home community involved in a common project. This article describes a gardening project undertaken at two nursing homes in Scotland, where it was found to have numerous benefits for all involved.

Citation: McClellan J (2018) Benefits of a gardening project for people with dementia in nursing homes. Nursing Times [online]; 114: 2, 38-40.

Author: Jeanette McClellan is a retired nurse helping to deliver on the Standards of Care for Dementia in Scotland in residential care settings.

Introduction

In 2016, staff at two nursing homes in Scotland set up a gardening project with the aim of improving outcomes for residents, with benefits for the whole nursing home community. The idea was to use gardening to improve activity levels of residents in a creative and fun way, and to get nurses in the position of active participants and facilitators. This article describes the project, now embedded in the care plans of all residents, and how it helps enhance residents’ quality of life.

Setting the project in motion

In 2016, the World Health Organization launched a strategy for its European region aimed at improving physical activity levels in people of all ages to reduce the burden of disease caused by sedentary lifestyles (WHO, 2016). One of the priorities was to get older people to be more active, as it is recognised that physical activity in that age group helps slow down physical and mental health deterioration.

Many nursing homes recognise the benefits of activities for their older residents and often employ coordinators to plan and deliver them. Residents value activities programmes (Barbera, 2010), but nurses rarely have time to get involved, notably because of the burden of administrative tasks (Costello and Haggart, 2008).

Residents of Victoria House and Ballantine Court – two nursing homes in Lanarkshire – have a variety of health issues and conditions, such as the consequences of stroke, Parkinson’s disease and dementia. Gardening was seen as a way of increasing their levels of physical activity in a fun and creative way that would also benefit the wider community.

Enthusiastic response

When the project was first suggested, it was met with enthusiasm from staff and residents in both homes. To check whether there would be enough interest, volunteers contacted residents, families and staff. The feedback they received was very encouraging, so it was decided to go ahead.

Staff members started discussing the project with residents, seeking their input, and asked who would volunteer to join gardening steering groups. Some were very keen, particularly those who had a garden area adjacent to their rooms. The initial steering groups comprised two to five residents and two staff members.

A 90-year-old, wheelchair-using resident, Mary, responded with enthusiasm and showed staff her own ‘garden’, created by her family for her birthday on the decking outside her room with bright planters, wind chimes, paper windmills and a gnome. Alec and Jane, a couple living together at one of the homes, were also excited by the project, as they used to have a garden that they looked after together. Another resident, Ken, was enthusiastic but concerned that he would not be able to take part because he had had an arm amputated.

Safe and accessible gardens

Staff used a factsheet from Trellis, a Scottish therapeutic gardening network, to get ideas and safety tips (Trellis, 2010). Box 1 outlines advice from Trellis on how to make a garden safe and accessible for older people and people with dementia.

Box 1. Providing a safe, accessible garden

Safety and access issues must be considered when designing gardens for older people and people with dementia. People with sight problems can find it difficult to handle too much light reflection or too many dark areas, as degenerative eye conditions such as diabetic retinopathy or cataracts can cause problems with visual perception (for example, a dark manhole cover can be perceived as a hole in the ground). People who have difficulty walking, poor mobility and/or balance problems are at risk of falls. You may also want the garden to be accessible to wheelchair users.

Features of a safe and accessible garden are:

  • Smooth paths
  • No steep gradients or steps
  • Easily identifiable handrails along the paths
  • No materials that reflect too much glare
  • Not too many dark areas or objects
  • Paths and patios wide enough for wheelchair users
  • Concrete walkways with upward bevel edges to keep wheelchairs from rolling into lawns or plant beds

Source: adapted from Trellis (2010)

Victoria House had a suitable outside area: a sheltered and sunny spot with level ground, a terraced area for a rockery, easy access to water, and a fence separating it from the car park and exit.

Ballantine Court had a lot of gardening equipment stored in different places: the maintenance team agreed to make an inventory and flag up what was missing. At Victoria House, relatives and visitors were asked to contribute any unwanted tools and pots.

What does a garden do?

At Ballantine Court, the activities team had originally decided to focus on residents with dementia, however there had been reservations about the residents’ ability to participate given their dementia diagnosis. Also, several of the residents were new to the home and were still being assessed, so there were concerns about stress/distress due to unfamiliarity of their new environment. However, the majority of the residents were mobile and could access the patio and during a planned crafts session, the idea of a gardening project was brought up.

One resident, 71-year-old Ellen, started talking in an animated fashion and said: “My mother gardens, she gardens, oh but my mother is dead, she is dead, she grew flowers, I look out of the window is it rain or is it pain? What does a garden do?” She also wrote a short poem about cherry blossom and illustrated it with a drawing.

Ellen’s poem and drawing were discussed by the steering group: they felt her words showed her talent, grief and love of nature, as well as an ability to communicate through a medium so far untapped. The steering group therefore decided that all residents and visitors as well, would be asked “What does a garden do?”. Another resident, John, suggested writing in large letters “what does a garden do?” on a flip chart and leaving sticky notes and pens so that people could write a short answer.

Gardening activities

The gardening activities on both sites run along a similar model. The activities team along with other staff who are available use opportune moments when the weather is suitable to take small groups of residents outside and carry out seasonal tasks – for instance, in spring they could be weeding raised beds ready for spring planting, in summer they may well spend some time watering plants. In Victoria House the focus has been on herbs for the kitchen, with the chef guiding choice, but there are also a wide variety of perennials. Those residents who do not want to go outside at such times are still able to contribute: for instance, Ella painted some planters for the patio in the craft group. All these activities are simple, engaging, inclusive and cheap to run.

Integrating gardening in care plans

Today the gardening projects are no longer separate, formal programmes. Instead, gardening activities are woven into residents’ care plans at a level acceptable for each person; for example, someone who is a wheelchair user will have trips to the garden planned every day. Activities around gardening that require more planning – such as trips to community gardens, gardening centres, car boot sales and art exhibitions – are incorporated into the general activities timetables.

The activities fully incorporate the standards of care for dementia laid out by the Scottish Government (Scottish Government, 2011a). Box 2 shows some of the desired outcomes for people with dementia that gardening activities can help produce.

Box 2. Dementia outcomes supported by gardening activities

  • As a person with dementia I have the best possible physical wellbeing:
    • I am physically active
  • As a person with dementia I am involved in life:
    • I engage in activities that are meaningful to me daily
    • I enjoy the tastes, smells, sounds and feelings of the real world
    • I have opportunities to enjoy the outdoors and/or be outdoors

Source: adapted from Scottish Government (2011a and 2011b)

Benefits for residents

Jansen et al (2014) suggest that physical activity enhances cognitive and social functioning in older people. Detweiler et al (2012) found that horticultural therapy can reduce pain, improve attention, lower stress and reduce agitation. Similar benefits are evident in the two homes:

  • Ken found that he was able to use a trowel to re-pot marigolds brought by a nurse; he goes out every day to water the plants without being prompted;
  • Discussing the project prompted Ellen to share her grief and her love of nature;
  • Mary is spending more time outside, not just on the decking in her own garden but also in the communal garden;
  • Flora appears less distressed when she walks in the garden while activities are going on; she is not actively participating but is interacting more with other residents;
  • Michael, a young adult with physical disabilities and early dementia, is supporting residents with more advanced dementia with activities mixing gardening and art.

Benefits for staff

Each person in the team has brought a unique slant on what might be enjoyable for the residents. In a reflective piece of writing, one nurse recorded that the garden had helped her understand the Standards of Care for Dementia in Scotland as a ‘living document’ – for instance, one standard says “I have a right to be as independent as possible and be included in my community” (Scottish Government 2011a). She articulated in her writing that helping Betty pick chives for the chef to use in a salad made her realise that not only did this help Betty feel included but also acknowledged the chef’s role in the project. Interestingly, early concerns about having time to be involved due to the pressure of work were settled when those involved realised it would involve opportunistic moments – such as mid-afternoon when plenty of staff and visitors are around.

Webster suggests that the “key to the therapeutic relationship is working in partnership with the older person and their supporters” (Webster, 2004). Several partnerships are at work in the gardening project: between care staff and relatives, between residents and their families and friends, and between residents of different abilities.

Quinn et al (2016) found that enabling people with dementia to take control and manage their condition fosters independence and promotes social support. Involving the residents in planning and delivering the project gave them some control. Residents in the earlier stages of dementia appeared to find this empowering.

Kitwood has outlined a fundamental denial of personhood in many care settings for people with dementia (Kitwood, 1997). In 2008, Dunham and Cannon found that some care staff thought people with dementia had somehow lost their very essence. “That body is not who the person is. The person is gone.” This caused a stir among practitioners in the field and the concept of personhood was revisited.

Recognising the personhood of people with dementia has become a driver of policy and practice (National Institute for Health and Care Excellence, 2006). Personhood can be defined as simply being a human being, and is at the heart of our residents’ care plans.

Anderson, quoted in Thomason (2012) suggests that “for professional carers, there is a message to develop a culture of stimulation for people with dementia … and keep people’s brains active”. That ethos is central to this project. For example, when John suggested the flip chart, pens and sticky notes for people to answer the question “what does a garden do?”, he was being creative and using deeply embedded skills that staff helped him access again.

Gardens and gardening provide prompts for interaction and reminiscence for residents (Trellis, 2010). For example, flowers in one of the gardens prompted Alan to talk about his mother’s chrysanthemums.

Conclusion

The gardening project has been popular with staff and residents. People are getting outside more, with numerous benefits. The project has not been formally evaluated due to its transient nature. Audit or research would allow staff to evaluate the impact of the gardening activities, measuring it against the desired outcomes included in each resident’s individual care plan. Anecdotal evidence in the form of residents’ and staff’s responses certainly shows that a gardening project brings fun to all involved. 

Key points

  • Physical activity reduces physical and mental health decline in older people
  • Gardening activities can improve the quality of life of nursing home residents
  • Gardens in nursing homes need to be safe and accessible for residents with mobility issues and residents with dementia
  • A gardening project is a good way of involving the whole nursing home community
  • By facilitating gardening activities, nurses can use their specialist knowledge in creative ways
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