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The joy of bringing Outside In

During this period of COVID-19 social distancing restrictions, members of the Outside In Collective have been working with Australian aged care providers to connect with, stimulate and bring happiness to residents with cognitive impairment through window visits, courtyard sing-a-longs and video chats. Lee-Fay Low, Maurie Voisey-Barlin and Andy McDonell report

The COVID-19 respiratory virus spreads rapidly, and older people with health conditions are at high risk of mortality. It is challenging to contain outbreaks of COVID-19 in residential aged care and the fatality rate for aged care residents is estimated at 25% (Hsu et al 2020).

While social distancing and non-essential visitor restrictions were introduced in Australian residential aged care facilities, many providers went beyond these measures and also stopped family members from visiting residents (Low 2020). While some of these restrictions have now been eased to allow small numbers of family and friends to visit, at the time of going to press, volunteers, school groups and entertainers are still not able to enter facilities.

During this period of COVID-19 social distancing restrictions, members of the Outside In Collective (including co-authors Maurie and Andy) have been working with innovative Australian aged care providers to connect with, stimulate and bring happiness to residents via interactions through windows in their rooms or common areas, in courtyards, and with video chat.

Outside In Collective members are trained engagement specialists with backgrounds in the performing and creative arts. Members have been working in-person with aged care residents for between two and 10 years. This in-person engagement approach was evaluated in a randomised controlled trial and shown to reduce agitation and antipsychotic use and increase happiness (Low et al 2013; Low et al 2014). The collective was established during the COVID-19 pandemic to share learnings around how to engage through these media, and to promote the approach. Lee-Fay provides dementia and evaluative expertise.

Creating connections: Maurie Voisey-Barlin, from the Outside In Collective, uses neon chalk markers to trace the hand of a resident at Amaroo aged care facility (above) and encourages interaction with cheeky banter and play (below). Photos courtesy Kate Austen (top) and SummitCare Wallsend (below) 

In adapting this approach for delivery via windows, the glass between resident and performer is not a barrier; it’s a prop to be used during the interaction. These window connection sessions have been referred to as ‘window therapy’. While the approach isn’t intended as therapy, sessions have had positive therapeutic effects on residents’ mood and self-esteem.

Meaghan Feringa, a Care Supervisor at Merton Living, Denman, in NSW, where Outside In Collective has been running sessions, explains: “In such uncertain times, window therapy has provided consistency, a familiar face, an emotional connection of a friend and something to look forward to for our consumers, many of whom are craving the outside world. This approach is a creative way of bringing it as close to home as safely as possible. This approach evokes playfulness and creativity, both of which are not easy to find when isolated from the people they care about. On an individual level, it provides the sense of validation [that] ‘we see you’ and ‘you are important, you are not alone’.”

Creating connections

In the following section, Maurie and Andy explain how the sessions work:

Our role as engagement specialists is to ensure that we get maximum engagement with each resident in order to improve wellbeing and quality of life (Aged Care Quality Standard 4). Engagement means two-way communication between the specialist and each person, produced through conversation, provocative banter, physical play (eg, asking the resident to throw a soft ball at a target on the glass), singing and percussion, games (eg, Tic-Tac-Toe on the windows), eye contact and body language.

We don’t put on a musical performance or comedy show. Our job is to provoke a response. If no connection arises or interest wanes, we change our approach. The older person’s engagement is the sole determinant of what we do.

In preparing for the session, staff brief us with the names of the residents and some background about them. This helps make the connection. For example, we might be told that Heidi is living with moderate dementia, doesn’t talk much, and is from Germany. With Heidi we might sing Brahms’ Lullaby in German, draw objects and try to name them in German and get her feedback on correct pronunciation, show pictures of German food and ask her advice on how to cook favourite dishes, or tell a funny story about our holiday in Germany.

On our next visit, what we have learnt about Heidi (eg, that she responded strongly to music, was from Bavaria) will be incorporated into the interactions (eg, with pictures of Bavaria, more German songs). Even if she doesn’t verbally respond, we are directed by Heidi’s physical and emotional reactions to offers of interaction.

It requires the emotional intelligence to understand the vulnerability that people may experience living in aged care and, as engagement specialists, we are instinctively good at ‘reading a room’. We are experts in communicating (including non-verbally) and in building positive relationships, and over time identifying the strengths of older people (Aged Care Standard 7). We have lots of love and energy to share and believe in open-hearted play, where everyone is welcome to join in, family and staff included. We empower older people so they feel seen and heard. They are able to share of themselves, when sometimes they may not have much opportunity to give. We reinforce self-identity and confidence through our interactions.

Each of us has a different mixture of artistic skills, including improvisation, physical comedy, dance, visual art, puppetry, singing and music. We also have an understanding of ageing and dementia and how it affects perception and processing of the environment, and adapt our interactions accordingly. Most of us have a big box of visual props, eg wigs, costumes, hats, photo albums, recipe books, puppets, dolls, old-style cameras, phones etc, that help us hold attention.

Here are some examples of running jokes and conversation that we might use during a session, interspersed with questions and banter, songs, games and physical play:

“Let me in please I need to use the toilet,” we say, while staff (aka the ‘Insiders’) and residents try to keep the engagement specialist out.

“After weeks of quarantine my family are sick of my stories, my jokes and constant singing, so they sent me here to annoy you.”

“During tough times we often sing and share stories to keep up morale, let’s do this together!”

Learnings

The following points illustrate the key learnings from the window and video chat sessions. The information has come from observation and staff and resident feedback.

  • For older people with moderate dementia, the same level of engagement and emotional connection can be obtained through glass or a video screen as face-to-face.
  • The approach is successful one-on-one or with small spatially distanced groups.
  • Many older people are craving company and connection, even those with family visitors.
  • Older people enjoy the feelings of belonging and bonding through sharing the same experience in a group, as they are missing group activities.
  • Sessions were sometimes the first time the resident had smiled, laughed or responded verbally in weeks.
  • Sessions provide an opportunity to share the emotions and feelings of living during the time of COVID-19. Older residents can give advice on how to cope, having lived through crises before, such as wars and the Great Depression.
  • Engagement specialists can build new relationships with older people that they hadn’t previously met.
  • Residents with dementia remember the connection with the engagement specialist from visit to visit.
  • Staff are excited and happy to be stimulating residents who they’ve observed as disconnecting during this time.
  • We’ve learnt that we have to allow extra time for each group of residents to transition in and out of the activity.
  • If there’s no undercover area outside, the engagement specialist must figure out how to work in the rain and cold with an umbrella/raincoat and multiple layers under their ‘costume’.
  • The engagement specialists have found that collective meetings help them share ideas and continue to develop different ways of engaging with residents.

Partnership with providers

Staff at each facility choose who attends the window and video chat sessions and select residents according to their psychosocial needs. The engagement specialists engage with those who are lonely, anxious, don’t have other visitors cannot communicate easily with those around them, who don’t respond readily to others, self-isolate and need stimulus and companionship. Staff set up a safe space for each session (in terms of spatial distancing, access for the performer and environmental ambiance), and clean the area between each session as required.

The Outside In engagement program being used during the time of COVID-19 requires the following:

For window sessions

  • Safe access to big windows without bright sunlight producing glare.
  • To allow residents to hear the performer, either the window has to be thin enough to allow sound to penetrate; a microphone connected to an amplifier is set up inside the facility; or, if safe to do so, the window is opened slightly (eg at the top).


For courtyard sessions

  • Ability to set up at an appropriate distance in front of an open door or window, with a barrier to stop residents from coming too close.

Photos are used to draw elders close to share humorous moments 

The glasses, drawn on the window with neon chalk marker, are used to start each of Mauries sessions with residentsPhoto: Maurie Voisey-Barlin 

For video chat sessions

  • iPads are sufficient for one-on-one sessions which ideally happen in the resident’s room. Some might need headphones with a microphone to help with communication.
  • For group sessions, a large television-size screen with good speakers, and a camera and microphone that can pick up the group are needed. Standard laptop cameras and microphones are not adequate for group sessions.
  • Glare should be minimised for both the residents and the camera.
  • All technology should be tested before the session, including the Wi-Fi in every space. Lag is a challenge for singing, but the residents singing as a group don’t seem to notice.

For all sessions

An ‘Insider’ or staff buddy is essential to a successful session. Insiders are often the lifestyle or activities officer or any other staff who know the residents well. The ‘Insider’ helps with the logistics on the inside (eg, bringing residents to the space, cleaning between sessions, setting up the technology), as well as supporting the interactions from inside, adding security and safety when the residents are new to this way of interacting, making it fun and even cheeky and helping those with physical or cognitive difficulties.

Briefings before and after each session with the ‘Insider’ give the engagement specialist up-to-date information about the aged care facility or residents (eg, someone who has been particularly agitated or withdrawn, or someone who is having a birthday), to share ideas, to talk about what engagement activities could be tried, and what worked well. This ensures that the program is constantly evolving and tailored to the residents’ individual needs.

Robyn Blackwell, General Manager at SummitCare Wallsend, explains: “The work that Maurie does is about improving the wellbeing of the resident he works with. He connects in a way that allows residents with dementia to connect, laugh, play and story-tell…After each session Maurie carefully documents his observations and this is used by our staff to provide insight and care

Engagement specialist Rob Feldman shows that the window glass is a prop, not a barrier to interaction 

Creative Engagement Specialist Andy McDonell 

Conclusion

At the time of writing, it’s not certain when services deemed ‘non-essential’ (even though we consider our service essential) will be allowed inside Australian aged care facilities. We hope that aged care providers will consider this approach using either performers who were previously visiting their facilities or Outside In Collective members.

When COVID-19 is over, we’ll return to engaging inside. However, during future facility lockdowns, such as for gastroenteritis outbreaks, this approach can be used again. We can also bring the arts to residents in remote areas through video chat.

For more information about the Outside In Collective and the engagement program described in this article, contact Maurie Voisey-Barlin at mauriebarlin@gmail.com

Acknowledgment

The authors would like to thank their aged care partners on this project: The Whiddon Group, Merton Living, Hunter Valley Care, SummitCare, IBIS Care and Calvary Aged Care.

Associate Professor Lee-Fay Low, (pictured left) Maurie Voisey-Barlin and Andy McDonell are members of the Outside In Collective. Lee-Fay is Associate Professor in Ageing and Health and NHMRC Boosting Dementia Leadership Fellow, The University of Sydney; Maurie Voisey-Barlin is a Creative Engagement Specialist in aged care and is the founder of Window Therapy; Andy McDonell is a Creative Engagement Specialist who has been undertaking window and video chat visits

View from the inside

Karn Nelson, Executive General Manager, Strategy and Innovation, at Whiddon, provides an ‘insider’s’ perspective on the window therapy program

When the COVID-19 crisis began to unfold, like many aged care providers, Whiddon made the decision to implement tight visitor restrictions to our care homes, to help prevent the spread of the virus. This was a difficult decision as we know how important supporting our residents to maintain their meaningful relationships is to their wellbeing. The health and safety of our residents, clients, employees and visitors is our highest priority and we had to juggle this with our holistic model of care and strong focus on wellbeing and tackling loneliness and isolation.

As part of our response, we developed a range of innovative and creative ways to help keep our residents connected, supported, stimulated and entertained during this time. One of these was working with creative engagement specialist Maurie Voisey-Barlin to bring ‘window therapy’ to life at our care home in Largs, NSW. This aligns well with our creative ageing programs and provides much-needed stress relief and engagement through play and humour to our residents at a difficult time.

Under normal circumstances, Maurie visits Whiddon Largs every week and provides a much-loved creative engagement and play program for residents. This was put on hold due to the Covid-19 restrictions. It is an important part of our residents’ week, and Maurie’s idea to continue it “through the window” was a stroke of genius that we all welcomed. It was important though, that our leisure officers provided good support to Maurie ‘on the inside’. Our leisure officers have become the play partners and encourage the residents to interact, respond to Maurie’s antics and everyone laughs together.

It would be difficult to run the program without effective support from an experienced leisure officer. The use of creativity and humour is important in keeping not only the residents’ but also our employees’ spirits up during this challenging time. The program’s success has led to it being offered at a number of our other care homes, and it is currently being trialled at the dementia specific unit at our Easton Park campus in Glenfield, NSW. Maurie has worked with some of our other engagement partners – Benhur Helwend at Whiddon Hornsby and Rob Feldman at Whiddon Glenfield – so that they too can deliver the program using their own engagement skills.

The window therapy program also aligns with Whiddon’s ‘risk-free’ visits, which we have been offering across our homes in regional, rural and remote NSW and Queensland during the COVID-19 restrictions. These visits allow families to enjoy spending time together through a window or other barrier and to celebrate special occasions in a safe way during this time.

The window therapy program will continue to run until Maurie is allowed inside the facility again to deliver the program in person. The medium will change but the principles of engagement will remain the same.

References

Hsu AT, Lane N, Sinha SK, Dunning J, Dhuper M, Kahiel Z, Sveistrup H (2020) Impact of COVID-19 On Residents Of Canada’s Long-Term Care Homes – Ongoing Challenges And Policy Responses. Available at: https://bit.ly/2XYgCfM.

Low L-F (2020) Easing Lockdowns In Care Homes During COVID-19: Risks And Risk Reduction. Available at: https://bit.ly/2As4BqO.

Low LF, Brodaty H, Goodenough B, Spitzer P, Bell JP, Fleming R, Casey A-N, Liu Z, Chenoweth L (2013) The Sydney Multisite Intervention of LaughterBosses and ElderClowns (SMILE) Study: Cluster Randomised Trial Of Humour Therapy In Nursing Homes. BMJ Open 3(1) doi: 10.1136/bmjopen-2012-002072.

Low LF, Goodenough B, Fletcher J, Xu K, Casey AN, Chenoweth L, Brodaty H (2014) The Effects of Humor Therapy on Nursing Home Residents Measured Using Observational Methods: The SMILE Cluster Randomized Trial. Journal of the American Medical Directors Association 15(8) 564-569.

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