Scandinavian Journal of Occupational Therapy

ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20

Altering the boundaries of everyday life in a

nursing home context

Margarita Mondaca, Staffan Josephsson, Lena Borell, Arlene Katz & Lena
Rosenberg

To cite this article: Margarita Mondaca, Staffan Josephsson, Lena Borell, Arlene Katz &
Lena Rosenberg (2018): Altering the boundaries of everyday life in a nursing home context,
Scandinavian Journal of Occupational Therapy, DOI: 10.1080/11038128.2018.1483426

To link to this article: https://doi.org/10.1080/11038128.2018.1483426

© 2018 The Author(s). Published by Informa

UK Limited, trading as Taylor & Francis
Group.

Published online: 25 Jun 2018.

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SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY
https://doi.org/10.1080/11038128.2018.1483426

ORIGINAL ARTICLE

Altering the boundaries of everyday life in a nursing home context

Margarita Mondacaa , Staffan Josephssona,b , Lena Borella , Arlene Katzc and Lena Rosenberga
a
Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Occupational therapy, SE-14183, Huddinge;
b
Norway University of Technology and Science, Department of Applied Social Sciences, NTNU, NO-7491, Trondheim, Norway;
c
Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, 02138, 02115, 256
Concord Avenue, Cambridge, MA, USA

ABSTRACT ARTICLE HISTORY

Background: Despite global and local policy frameworks that explicitly aim to privilege partici- Received 9 February 2018
pation and active engagement of older adults living in nursing homes, this group often has lim- Revised 13 April 2018
ited possibilities to engage in occupations and to have influence in their everyday lives. Accepted 28 May 2018
Aim: To explore how older adults’ engagement and influence in an occupation can emerge in
KEYWORDS
everyday life in a nursing home setting. participatory methods;
Material and methods: A participatory qualitative approach was applied. Older adults living in hermeneutic analysis; third
a nursing home participated in a Book Club that was created collaboratively between research- space; persons with
ers, residents, and the nursing home community. dementia; residential care
Findings: The analysis identified qualities of altering the boundaries of everyday life and address- facilities; older adults
ing the uncertain conditions for influence and engagement as processes actualized by the resi-
dents when engaging in the Book Club. Further analysis identified how these processes involved
ordinariness, familiarity, fellowship, and connectedness.
Conclusion and Significance: Engagement and influence in occupation in a nursing home is
possible when enabling partnerships and resourcefulness among the residents. However, such
enablement is not guaranteed and needs to be actively upheld by the nursing home community
in order to build practices aligned with policy frameworks of participation.

Introduction NHs often spend their time passively [16,30,31] by

Older adults’ engagement in occupations is an import-
ant issue in the development of quality standards and
the person-centred approach [1–3] within nursing
home (NH) and has been a clear focus in aging
research [4–8], occupational therapy research [9–16],
policy [17–19] and in clinical practices. It is well
known that older adults’ engagement in occupations
contributes positively to quality of life and meaning
making [13,20–25]. Although an occupational per-
spective [26] is often an important part of NH set-
tings, many programs fail to incorporate and
accommodate the residents’ views and resources
[2,11,14,24,27,28]. Occupations can take a more
instrumental form, as a tool that serves delimited pur-
poses, e.g. training the body or cognitive abilities
instead of focusing on accommodating and adapting
everyday life activities to create a meaningful everyday
life [29]. Research shows that older adults living in
sleeping, passing time, waiting for meals, having lim-
ited possibilities to engage in meaningful occupations
[30,32,33]. Research also shows that older adults are
often seen by NH staff as passive recipients [34] who
have limited possibilities to influence available occu-
pations. These constrained possibilities to influence
occupations [4,10,24,34–36] could, for example be due
a stereotyped view of older adults’ preferences and
interests [28]. However, there is limited knowledge
about how occupations could be embedded in every-
day life and aligned with older adults’ interests, pref-
erences, and values in the NH context.
When older adults are seen as resourceful, a shift
can occur towards enactment of their capabilities
[12,25,37] and fostering of engagement [11,25]. This
understanding of doing together [38,39] and to con-
nect with peers challenges an individualistic view of
engagement by proposing doing and co-creating in an
emergent dialog through occupations. An example of

CONTACT Margarita Mondaca margarita.mondaca@ki.se Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of
Occupational therapy, SE-14183, Huddinge
ß 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-
nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed,
or built upon in any way.
2 M. MONDACA ET AL.
this is how simple household chores such as helping
to fold clean laundry or setting the table can be expe-
rienced as meaningful [21,23,40,41] or connecting
with peers [12,23,42–45] when performed in accord-
ance with older adults’ capabilities, desires, and inter-
ests. However, there is still limited knowledge about
how this dialog through doing is played out in real
situations. Although NHs might strive in practice
towards the ideal of a meaningful everyday life, these
efforts can easily be overshadowed by institutional
routines [4]. This tendency carries the risk of institu-
tions affecting the experience of occupations [46,47]
and thus being detrimental to peoples’ engagement in
occupations and everyday life. Importantly, occupa-
tions valued by older adults living in NHs can differ
significantly from the institutions’ routine activities.
This study proposes to focus on the qualities that
occupations can bring into older adults’ living in a
NH everyday life. The aim of the study is to explore
how older adults’ engagement and influence in an
occupation can emerge in a nursing home setting.
Material and methods
Project context
This project was conducted in a NH in an urban area
of Sweden with a total capacity for about 200 resi-
dents divided into smaller units. Three occupational
therapists were employed in this facility, and their
main focus was on the prescription of assistive devi-
ces, adaptations in the residents’ flats, and organiza-
tion of entertainment activities that took place once a
month. A total of 20 nurses and three physiotherapists
were also part of the professional team. Nurse assis-
tants assisted the majority of the residents in daily life
activities, such as toileting, dressing, getting in and
out of bed, and during mealtime.
The unit involved in this project had a capacity for
54 residents and was divided into groups of nine resi-
dents each. The building had three floors, one of which
was profiled for people diagnosed with a dementia dis-
ease. The two other floors were open for old adults
diagnosed with a variety of chronic conditions. The res-
idents’ flats were about 20 m2, distributed in one room
and a bathroom and were rented by the residents.
There was a weekly group activity scheduled in the
unit in which this project was conducted. The resi-
dents gathered together for two hours in order to par-
ticipate in singing and playing bingo or memory
games. Besides this group activity, the setting was
generally lacking in other activities the older adults
could engage in. Other activities were less frequently
carried out by the nurse assistants, such as gymnas-
tics, reading the newspaper together or watching a TV
show, but these were also lacking the active influence
of the older adults living at the NH.
Project design: the creation of a third space
A participatory approach was applied in this study
[48–50]. This participatory approach gears towards
planning and conducting the research process with
people whose life-world and meaningful actions are
under study [50] as a way to bridge the gap between
research and practices, the researcher and participants
[51]. In order to create a space where older adults in
the NH could enact influence over occupations, this
study makes use of the concept of third space [52].
This concept, originally emerged in the post colonial-
ist research, is defined as a a site for collaboration,
contestation and negotiation [52]. The third space is a
place, both symbolic and concrete, where new identi-
ties are tried out, and reformulated, as it aims to
bring new contributions and fill gaps within the cur-
rent context [53], opening an arena for possibilities
and struggle. The third space in this study is defined
as a co-created practice that was not part of the regu-
lar culture of the NH at the moment, and at the same
time could meet some expressed needs and wishes of
the participants living there. The third space granted
access to situations where the participants’ views and
values could have a place within the institutional cul-
ture. In this study, the third space took the form of a
Book Club that served as a source to answer the
research inquiry and at the same time as a feasible
occupation that could be part of the everyday life
practices at the NH. The concept of third space,
became a theoretical resource that served to inquiry
about how dialog through doing together may be
played out- in real life- in an institutional setting.
In a previous study conducted in the same setting
[24] occupational interests among older adults living
at a NH and the facilitating conditions to enact those
interests were explored. The main findings revealed
that older adults wanted to feel connected with the
world outside the NH, to put their capabilities in
action, to have something to look forward to, to have
a chance of meeting new people and to feel active in
their own capacity. Through the previous study, we
also found that older adults were interested in discus-
sing literature. Therefore, the present study took the
form of an adapted Book Club at the NH. It was
adapted in the sense of being accommodated to the
participants’ capacities and interests [29]. The first
author, in collaboration with a nurse assistant,

facilitated 27 sessions of the Book Club, and the
fourth author also participated as a facilitator in the
Book Club meetings on several occasions. The Book
Club meetings lasted one and a half hour and took
place once a week over a period of seven months.
The location of these meetings was considered a
key element in the design of the project, and meetings
at one of the participant’s flats was part of the dialogs
and decisions made with the participants. The idea
behind this was to have an authentic meeting where
the participants could communicate easier with each
other without interference from staff and other resi-
dents and thus have the chance to be themselves and
to listen to each other in a comfortable atmosphere.
At the end of each meeting, the group decided on the
themes they wanted to discuss the next week, and the
first author could bring several relevant illustrated
books on the topic to the next Book Club meeting. At
the meetings, some paragraphs of the books were read
out loud, pictures were discussed, and an open dialog
emerged. All of these activities, decisions, and negotia-
tions were co-created with the participants, docu-
mented, and considered part of the data-gathering
process [50]. These Book Club meetings became a key
activity for the research inquiry by co-creating a new
practice – a third space – with the participants where
they could interact and have a say regarding the occu-
pation [49]. The research project was approved by the
Regional Ethical Committee in Stockholm.
Participants in the book club
The time spent in the NH by the first author in a pre-
vious study [24] served to build trust and engagement
with the participants and to get an informed sense of
their aspirations and interests related to occupations.
Older adults who showed interest to participate in the
Book Club were invited. An additional inclusion crite-
ria was being able and comfortable with interacting in
the Book Club’s meetings. The group of participants
consisted of seven persons who participated regularly
and five persons who participated less frequently.
Three of them were men, and nine were women. The
participants’ age ranged between 74 and 90 years, and
their lengths of stay at the NH varied from two weeks
to five years. The majority of the participants had
multiple chronic conditions and diverse degrees of
cognitive impairments, including being diagnosed
with a dementia disease. The participants’ attendance
in the Book Club meetings was dependent on multiple
factors such as health status, energy, motivation, and
logistics at the NH. The same nurse assistant partici-
pated throughout the entire project by facilitating the
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 3
group dynamics, reading, and helping to set up the
meetings. Prior to each meeting, the participants were
visited by the first author and consulted about
whether they felt they had the energy and motivation
to participate that day. The participants came from
three different floors of the unit of the NH, and they
verbally agreed on each occasion to participate.
Data generation and analysis
The first author took the role of group facilitator with
a reflective stance, as is traditional within the partici-
patory traditions [53]. Data were generated through
fieldwork that included Book Club participants and
staff [54]. Focus was given to the Book Club meetings
and the immediate moments before and after the
meetings. As is characteristic for doing participant
observations [55,56], the first author also posed ques-
tions to the participants during these moments to
facilitate a better understanding of the unfolding sit-
uations. Situations of interest were those where the
participants reacted, interacted, or encountered each
other in new ways. Thick descriptions [57] of the
observations were written as field notes after each
meeting. Along with the project, the nurse assistant’s
overall impressions of facilitating the Book Club were
gathered through short conversations and an inter-
view at the end of the project. The collaborative
emphasis was put in the design, content and emergent
character of the Book Club meetings. The first author
actively placed her understanding of the emergent
knowledge in dialog with the participants in order to
assure the accuracy of this understanding [58,59].
The data were analyzed following Gustavsson’s her-
meneutic interpretative approach [58]. This approach
was chosen because it has a special focus on human
action and its contextualization and can therefore con-
tribute to a better understanding of occupations [60,61].
Gustavsson [58] recommends following an iterative
approach in analyzing data between the whole, particu-
lar pieces of the generated data and theoretical resources
during the interpretation. This interpretative framework
explores the possible meanings that some accounts
might have for the participants, and it emphasizes the
contextualization of the process of interpretation.
Following Gustavsson’s approach, the data were
interpreted in three main steps. The first step was to
capture the most striking situations of each session
related to the focus of the study. From each session,
initial interpretations that could explain these situa-
tions were articulated. This initial analysis could be
exemplified with an interpretation initially called
‘Vacillating while facing a new occupation’ to express
4 M. MONDACA ET AL.
the ambivalent attitude of the participants when the
Book Club meetings were about to start or the hesita-
tion towards initiating new commitments. Another
interpretation found in the initial analysis was
‘Growing and being more together’ to express the
actions taken by the participants of the group when
encountering someone together or when positioning
themselves in the discussions as a new form of
response. The second step was to contextualize the
data in a variety of everyday situations of the partici-
pants at the NH. Previously framed situations were
put in dialog with analytical questions such as: Does
this happen in other particular situations? Is this situ-
ation unique in its quality? Is this situation limited to
the Book Club? This analytical step sought to discover
more about the meaning embedded in the partic-
ipants’ everyday life. Regular analytical meetings
between the authors served to interpret particular sit-
uations in the particular context and to look for
nuances and at the same time to sharpen the focus of
what was novel and emerging in the Book Club.
Based on this work, an iterative analysis of the mater-
ial started to form more solid interpretations. For
instance, the above-mentioned ‘Vacillating while
facing a new occupation’ was interpreted as
‘Reconnecting timidly with former roles’, thus giving a
more specific focus to the situated and local experien-
ces of the participants at the NH in the context of the
Book Club meetings. The third step focused on con-
textualizing the emerging findings from the analysis
and explored them in light of existing knowledge
about occupations at nursing homes, nursing home cul-
ture, and occupational engagement. The conceptual
areas explored were corresponding with the theoret-
ical grounding of the authors and consequently with
the interpretations presented in the findings section.
The initial tentative interpretation ‘Growing and being
more together’, for example, was interpreted in light of
the literature as ‘Trying out different modes of
engagement’, which later led to a final interpretation
of the findings. Together these findings propose situ-
ated qualities of engagement and influence in relation
to occupation of older adults living in a NH setting.
The findings are presented with citations that stand
out from the field work, followed by information of
the situation to contextualize them, and finally fol-
lowed by interpretations to invite the reader into pos-
sible understandings.
Trustworthiness was assured [54], by the extensive
period spent in the setting, thick descriptions of the
fieldwork and consequently a comprehensive data
generation. Also, trustworthiness was enhanced by the
positioning of the researchers understanding in con-
stant dialog with the participants and regular peer
debriefing through the analysis process. Of particular
importance was to apply reflexivity [48], as the collab-
orative approach situated the researchers in multiple
roles at the same time.
Findings
In the findings, the identified situated qualities of
engagement and influence in occupation of older adults
living in a NH setting are framed under headings to
visualize various facets of these phenomena and how
they are embedded in the everyday of the participants.
Altering the boundaries of everyday life
These findings illustrate how engagement and influ-
ence could take different expressions, sometimes
through hesitation about what rules everyday life and
other times fostered through reconnecting with
‘natural and refreshing’ social situations.
What rules everyday life?
The Book Club meetings seemed to be something
relatively simple to start at the NH. One of the first
surprising elements while setting up the Book Club
was the insecurity about who was entitled to decide
upon using the participants’ rented flats. When some
of the participants involved in the project and the
researchers were planning where to gather for the
Book Club, one of the participants suddenly reflected:
‘But are you sure we can invite people to our flats?’
Yes, I am sure, replied the first author. ‘Well I think
you need to check with the staff if it is possible
anyway, I am not sure we can!’ was her reaction.
Another resident participating in this conversation
added: ‘It will be better if you ask if it is possible’,
agreeing with this hesitation.
Somehow the idea of meeting at one of the partic-
ipant’s flats was new not just to the participants, but
also for the NH. This small change of the habitual
routines at the NH turned out to be more controver-
sial than anticipated. The day the Book Club was sup-
posed to start, the first author went around reminding
staff and participants about the time and place of the
meeting. The nurse in charge held a meeting with the
nurse assistants and expressed her concern about
some residents having a cold and said:
‘About the Book Club, I am not sure if it is a good
idea. One of the residents has a cold. I will be very
upset if this cold is spread in the house! I really don’t

think it is a good idea to be moving people, and going
into each other’s flats!’
This was initially interpreted as opposition, and
sounded at first very surprising to the research group,
but was considered reasonable because many residents
had frail health conditions and thereby the concern
about spreading a cold was well grounded. On the
other hand, it is possible to argue that there is a con-
stant risk of contagion when residents and staff meet
in the dining area and other common spaces and the
staff walk in and out between the residents’ flats on a
daily basis. Another possible interpretation of the
nurses’ unwillingness towards this new activity was
that it challenged the institutional order and that the
proposed Book Club meetings lacked references and
were not part of the ordinary everyday life within the
institutional routines. The hesitation in the residents
about being authorized to gather in their own flats
could be interpreted as an embodied institutionaliza-
tion that serves in adaptation at the NH but risks the
resident’s integrity.
When engagement and influence become ‘natural
and refreshing’
As the meetings continued to be held at one of the
participants’ flats every week, one of the participants,
Ann, acquired the role of hostess. Ann felt comfort-
able the first time she hosted the Book Club members
and she wanted to continue doing so. Each time, she
was thrilled to use her finest coffee cups and welcome
the Book Club members into her flat. Ann was in
need of using a cane or a walker, but despite this she
welcomed each participant standing, and she waited
to sit until everybody else was seated, making an obvi-
ous physical effort. She enjoyed telling stories about
the family pictures and paintings on the walls, and
she created a friendly and familiar atmosphere. She
also offered coffee and some cake to each one of the
participants; even if her hands were not steady
enough to serve her guests the coffee, she attempted
to. When the participants went back to their flats after
one of the first Book Club meetings, Ann reflected:
‘It felt so natural to have these friends here.’ Ann was
obviously touched when saying this, but also a bit
surprised by her natural way of handling the situation
and the experienced familiarity during the meeting.
Ann continued to hold the hostess role, and even if
some days her dementia symptoms could be very dis-
rupting, these meetings did not cease to trigger her
natural sense of being a remarkable hostess. One pos-
sible interpretation of her engagement could be that
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 5
her role in the Book Club gave her a chance to prac-
tice being a hostess and connected her with experien-
ces she had mastered in her earlier life. Embodying
this role again could then be seen as allowing her to
temporarily cease being a resident at the NH, and in
contrast connecting her with a well-known, natural,
familiar, and comfortable embodied way of being in
this situation, putting her in contact with the ordin-
ariness and familiarity of the everyday life she lived
before moving to the NH. The members of the Book
Club expressed the same comfort and familiarity by
the way they appropriated the room and the conversa-
tions and the relaxed way they started to connect to
each other. When gathering some impressions after
one of these meetings, one of the participants said:
‘We laughed so much today, it just felt so refreshing,
so life-giving!’ pointing towards a clear distinction
with other qualities in the occupations experienced at
the NH.
The qualities of a refreshing familiarity, fellowship,
and connectedness brought by the Book Club could
be interpreted as altering the boundaries of the insti-
tutional routines and other occupations available at
the NH.
Addressing the uncertain conditions for influence
and engagement
These findings give new nuances to how engagement
and influence can take different expressions.
Engagement and influence could sometimes be threat-
ened, limited, contained, created or nurtured through
fellowship in this setting.
Influence and engagement as fragile
and contingent
Some of the most popular and appreciated occupa-
tions for the participants at the NH, were those that
allowed them to feel connected with the context out-
side the institution, both in a real and a symbolic
sense. The Book Club group started to plan other
activities together such as go walking in the neighbor-
hood, museum visits, visits to small shopping centers.
While preparing for one those outdoor activities, the
nurse assistant asked one of the members, Karin, if
she wanted to join the others:
‘Of course, I want to!’
‘Well, then it is good if you put your jacket on and
some comfortable shoes to walk,’ the nurse assistant
replied, and added: ‘don
t forget to bring your
walker too!’
6 M. MONDACA ET AL.
Karin reacted to this last part of the comment with
energy: ‘I would rather take my cane. I have walked
with it [the cane] for many years now, and I am sure
I can use it today too if I want to.’
‘But you will get tired easily,’ the nurse assistant
argued, trying to persuade Karin to use the walker.
‘Well, I will try this way anyway,’ was Karin’s
final answer.
When the first author turned to see the reaction of
the other women who were ready to go out, she saw
that one of them was smiling with some kind of
pride about what she just witnessed and that another
woman was showing her approval by giving her a
‘thumbs up’. With this, the nurse assistant could not
come up with anything more to say.
The situation described above shows how the Book
Club group allowed the participants to enact resource-
ful dimensions of themselves in turns, even if this
wasn’t in a constant flow. However, Karin’s and the
other participants’ engagement could be seen as a
response to the situation they were in, and their
engagement could be described as being fragile and
contingent in the sense that it was dependent on the
conditions of the very moment and on others to be
actualized. This engagement had the potential to arise,
to disappear, to be encouraged, disregarded, or neu-
tralized by others. This was also observed at the Book
Club meetings on several occasions, sometimes in
subtle ways and at other times more explicitly:
One of the women, Greta, was thanking the hostess
for the coffee and for an enjoyable afternoon at the
Book Club meeting. Greta asked out loud if she could
be the hostess next time, at her flat. The other group
members were approving this idea. She continued
by assuring:
‘Then, I will call you all next week some days before
the meeting to remind you.’ No one made notice that
the use of a telephone between residents was not a
possibility at the NH. Then, another woman in the
group asked back, just getting along with
the dialogue:
‘Do you need us to bring anything?’
Greta answered with joy: ‘Oh no, don’t worry, I am
planning to do some baking myself, so just come as
you are!’
The nurse assistant interrupted the dialogue, this time
in an effort to mark the boundaries of this
emergent initiative:
‘But you can’t bake here, Greta!’ she said.
Then the whole group reacted and mumbled as a sign
of complaining and opposition about this statement,
until one of the participants stated: ‘But for sure it is
possible to bake here, isn’t it?’ Thus, appealing to the
rest of the group members and challenging the nurse
assistants’ view.
This could also be seen as an example of contingent
engagement, and we can question whether the Book
Club’s response would have been the same without
the group’s history together. The quality of engage-
ment could in this example be seen as telling about
the necessary conditions to start up such a response,
in this case the fellowship and connection experienced
at the Book Club. On the other hand, as exemplified
here, the contingent quality of engagement can
emerge in ordinary and unpredictable situations.
When engagement turns into
dangerous enthusiasm
The enthusiasm of being part of the Book Club
expressed by the participants could evolve and endure
for some days; however, according to the nurse assis-
tants this could turn problematic. One day when the
Book Club gathered, one participant of the group was
missing and another member of the group, Astrid,
asked for her and wondered why she wasn’t there.
Astrid got the following response from a
nurse assistant:
‘You know it is difficult with her because after these
meetings she gets very excited and she starts asking all
the time and every day when the next meeting is going
to be. Some nurse assistants consider this too difficult
to manage’.
Then Astrid reflected and asked back: ‘So she is not
invited anymore?’
The nurse assistant answered with a lower tone in
her voice: ‘At least not today’, as if she was realizing
how her explanation did not match the Book Club
participants’ expectations.
This remarkable and unexpected finding about pre-
venting and endangering participation at the Book
Club meeting to the missing lady, could be under-
stood as presenting the fragile nature of engagement
in this context and the need to uphold it not just by
the participants, but also by the institutional practices
imbedded in the NH culture. Another possible inter-
pretation is that the lady’s enthusiasm is somehow
labeled as endangering the institutional order by the
staff in this case. This makes visible that in an institu-
tionalized setting engagement in an occupation is at
risk of being pathologized and therefore in need of

being contained. In addition, this finding raises the
question about what types of values the NH strives
for. This understanding could be seen as endangering
the chances of older adults living at the NH to hope
for and pursue a meaningful everyday life and engage-
ment in an occupation on their own terms.
Setting engagement, influence, and fellowship
in motion
The resourceful dimensions of the participants, as
described in this study, can easily pass unseen in the
every day. This resourcefulness was observed, for
example, when the participants, depending on the
topic of the day, could flourish and show previously
unseen expertise about a specific period of time, a
part of the city or a particular topic. The reading of
well-known persons’ biographies and the use of books
with pictures opened up for engagement in diverse
dialogs. These dialogs were about the group members’
personal lives, world visions, and experiences contex-
tualized in their current situation. In contrast to flour-
ishing, some participants also dared to share their
current struggling. In one of the Book Club meetings,
one of the participants triggered by a dialog about a
picture in a book said:
‘I can’t remember how to cook anymore. Imagine! I
was a professional cook once and now I can
t even
follow a recipe!’
One of the ladies comforted him by saying: ‘Don
t
worry about that, nowadays there is all kind of ready-
to-eat food, you just have to heat it! You don
t need to
know how to cook anymore!’
The man then said: ‘Well, maybe I have to start
thinking like that’. The man remained mostly in
silence, but apparently less anxious and able to
engage with the group during the rest of the meeting
by looking at the illustrations of cars in some books.
It was interesting to notice how the dialog pre-
sented above was not about practicalities but about
existential reflections about changes in life. This dia-
log could be seen as exemplifying the expertise of liv-
ing an everyday life, the losing of control, and, despite
their frailty, being able to console, support, and
encourage each other. This could also be understood
as a shift in the traditional NH roles, of not just being
a passive recipient of care, but also having the possi-
bility to care about others, a seldom highlighted
aspect of older adults in this context. This interpret-
ation was strengthened by the nurse assistant who
actively participated along with the Book Club, and
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 7
when reflecting back she noticed this resourcefulness
and fellowship:
‘For me the most surprising of all was to see that they
are more together, that they light up together, the way
they grow together. I didn
t expect to see this kind of
support for each other here [at the NH]’.
The surprise of the nurse assistant could be under-
stood as the rarity of paying attention to older adults
taking care of each other and fostering fellowships in
contexts such as NHs.
In summary, both Altering the boundaries and
Addressing the uncertain conditions for influence and
engagement inform about how older adults’ engage-
ment and influence in an occupation emerged in
everyday life through doing together in a NH setting.
Altering the boundaries refers to the creation of a
third space, the Book Club, and the entering into a
new territory of action that brings about distinctive
qualities to everyday life. Distinctive qualities such as
enjoyment, fellowship, and a sense of familiarity and
normality refer to a way of being seen, met, sensed,
understood, and cared for at the NH. In other words,
to be seen and encountered by others as persons, and
not just as residents at the NH, by being enabled to
enact influence and by doing so to alter institutional
boundaries. The finding Addressing the uncertain con-
ditions for influence and engagement in an occupation
refers to the actions performed by the participants in
everyday practices as a response to the institutional
order. These actions were facilitated by a new situat-
edness, a new social context, given by the Book Club
meetings. These actions could be seen as challenging
the traditional view of engagement in this context.
Discussion
As identified in this study, qualities such as enjoy-
ment, fellowship, a sense of familiarity and normality
were regained when the occupation was aligned with
mundane aspects of everyday life. Qualities such as
ordinariness, familiarity, fellowship, and connected-
ness were actualized by the residents by engaging in
the Book Club. In contrast, if occupations are seen
instrumentally, as fulfilling specific but limited pur-
poses such as training memory or activating certain
body functions, everyday life could be seen as being at
risk of losing its vital function of giving sense and
meaning to life [26,62]. This understanding of every-
day life is in line with previous research showing that
older adults engage in occupations that promote a
sense of familiarity and that are ingrained in their
identities [2,14,21,43,63]. These qualities present a
8 M. MONDACA ET AL.
clear contrast with restricted possibilities to enact
influence at the NH whose culture is still rooted in a
medical model. It is possible to argue that the under-
standing of everyday life in an institutional culture
frames the types of activities that are emphasized and
enabled. This framing of activities imprints its con-
tents, qualities, and forms [25,35,64].
The findings presented in Altering the boundaries
of everyday life might be useful knowledge for under-
standing the actual possibilities of transforming trad-
itional care practices into more inclusive and
meaningful ones. When the participants were enabled
to engage in the Book Club meetings, they could
enact alternative practices that were grounded in their
values and capabilities. This has been addressed as a
key issue for good care quality at NHs [2,65] but has
also been framed as a challenge in clinical and
research practices [11,25,63]. In order to enable this
type of engagement in this occupation, it was a neces-
sary precondition to address power positions and to
redefine the role of the participants as experts in their
own everyday life at the NH [27,59,66]. This under-
standing facilitated interactions where the participants
could enact resourceful and insightful dimensions of
themselves together in the Book Club meetings. As
expressed by the nurse assistant involved with the
project, this resourceful side of the participants is sel-
dom seen in action and is not sufficiently highlighted
in research regarding older adults [27,66]. Connecting
with other older adults through doing and co-creating
could be seen as promising for the enactment of influ-
ence over their everyday life and occupation.
The resourcefulness triggered by doing together
[39] tells us about the emergent nature of engagement
and could, for example, be identified in the hostess
role adopted by one of the participants. Her familiar-
ity with the role could be seen as reconnecting with
embodied dimensions in a social context. This way of
understanding could be related to habits [67] referring
to how the social is both incorporated and constitu-
tive of our identity and subjectivity [15]. Habits have
been referred as having a practical sense, as a know-
how sense of enacting in familiar social situations. In
other words, this familiarity of being the hostess could
be understood as an internalized and embodied his-
tory, that is actualized through engagement in a new
occupation at the NH. The fellowship that was built
into the Book Club could be interpreted as an engag-
ing occupation that enabled the participants to experi-
ence other qualities in everyday life, such as a sense of
reconnection with the social dimensions of being a
person and not just a resident at the NH. This
reconnection with well-known social forms could be
seen as helping older adults to reclaim a sense of
ordinariness in everyday life.
The findings of this study suggest that when col-
laborating with older adults in a NH on co-creating
an occupation that is grounded in their interests and
desires, everyday life might shift from a medicalized
tone towards a mundane, ordinary, and familiar tone
for older adults. However, the understanding of
everyday life focuses almost exclusively on the provi-
sion of care activities that set an institutional tone
and dynamic in everyday life [10,35]. In line with
this logic, the dominant view in research about occu-
pations in this field has been limited to symptomatic
management and other health outcomes [2], and not
as a fundamental dimension of life and meaning
making [13,24,26,43,45]. The dominant view of occu-
pations in this field could then be seen as endanger-
ing social aspects of identity and subjectivity, aspects
that are at stake for older adults living in a NH.
Returning to the story of the lady missing the Book
Club meeting because of her excitement, this could
be showing the collision between the institutional
culture logic and influence enacted as enthusiasm for
the Book Club meetings. In this case, this enthusi-
asm in the institutional logic was labeled as dysfunc-
tional behavior and pathologized and therefore seen
as in need of being managed. This perspective on
this particular occupation could be seen as privileg-
ing the institutional order but failing to acknowledge
the value that older adults assign to other qualities
brought by a meaningful occupation into everyday
life [26].
The findings presented in Addressing the uncertain
conditions for influence and engagement supports the
claim that everyday life has a dynamic nature [26],
however they also point to the adaptation and align-
ment in practice [44] which does not happen by itself
but emerges through openings created by engagement
in occupation. The findings of this study suggest that,
engagement of older adults will require practices that
notice and acknowledge significant events and that
put them in dialog with others to actively facilitate
influence in a given occupation [11,59]. This was the
case of the Book Club that served as an arena to enact
engagement in occupation and to gain influence in
everyday life.
Finally, the findings of this study urge us to critic-
ally reflect on how everyday life in NHs might mirror
policies of participation, influence, and empowerment
of older adults as guiding frameworks both locally
[19] and worldwide [68]. Furthermore, these findings

also urge occupational therapist to reposition the rele-
vance of occupation, everyday life and the role of the
profession in this field.
Methodological discussion
A strength of this study is the active effort to include
older adults in research despite their frailty [65,68].
The methodology used, framed as a third space, served
to get nuanced and situated knowledge about one
occupation, engagement and everyday life for older
adults living in a NH and at the same time had a func-
tion in the participants’ setting. However, more
research is needed in order to get a broader under-
standing of occupations in this kind of settings. The
participants of this project were only a small group of
the total population of older adults living in NHs in
Sweden, and the authors are aware that occupations
might vary in other NHs. Nevertheless, this is an
important group exemplifying the challenges of people
in this vulnerable age living in an institutional setting.
The chosen approach situated the researchers within
multiple roles in the setting, which could create both
challenges and possibilities [48]. This required a con-
stant attention to ethical issues applying a reflective
attitude in order to involve the participants as much as
possible in all stages of the research project. Special
consideration was needed when finalizing the research
project, in particular regarding dialog with the partici-
pants about the withdrawal of the researchers. The
length of the Book club was not established in advance.
Initially the focus was on how the Book Club was
received by the participants and the NH community.
Once this was clarified, the duration was determined in
collaboration with the participants based on sustain-
ability criteria as is characteristic in collaborative
approaches [48]. A detailed presentation of both the
setting and the analysis was given, striving for trust-
worthiness by inviting the reader to engage in the con-
text and logic of the analysis and findings [58]. The
collaborative nature of the approach served to formu-
late the multiple steps in dialog with the participants,
and other initiatives were formulated as a result of this
approach. This collaboration also helped to inform
future research questions, for example, for a coming
study that focuses on the NH staffs’ understanding of
occupations grounded on the older adults’ interests
and capabilities.
Conclusions
This study shows that older adults’ engagement and
influence in an everyday life occupation in a NH
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 9
setting is possible when enabling partnerships and
resourcefulness among the residents. These findings
suggest that engagement and influence on occupation
is fragile and contingent, and therefore in need to be
consciously enabled by the NH community. This
study also indicates that if a given occupation is
grounded in older adults’ values and interests, the
institutional order can be challenged. An important
consequence of this approach, is that it can provide a
positive impact on older adults’ identities and integ-
rity. Taking these findings together, we can conclude
that engagement in an occupation, can challenge ster-
eotyped views of older adults living in NHs, and could
make practices more representative of the policy
framework regarding participation.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by the Swedish Research Council
for Health, FORTE (2014-04980) and Vårdalstiftelsen (id
e-
provning 2012).
ORCID
Margarita Mondaca http://orcid.org/0000-0003-
1575-2582
Staffan Josephsson http://orcid.org/0000-0002-3428-561X
Lena Borell http://orcid.org/0000-0001-6899-1013
Arlene Katz http://orcid.org/0000-0001-9157-3012
Lena Rosenberg http://orcid.org/0000-0003-1727-369X
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