Associations Between Quality of Life and Outdoor Access in Nursing Homes: A Cross-Sectional Study

The benefits of being outdoors to improve the health and well-being of older people, including those living with dementia, is increasingly acknowledged.^1-4 However, upon admission to a nursing home (NH), the opportunity to venture outdoors is often limited for many residents.^5,6 Reduced access to outdoor areas may be particularly apparent in the current times as a response to COVID-19 restrictions or when isolation is necessary.^7,8 Residents with dementia, in particular, may be unable to venture outdoors unaccompanied, and doors to outdoor areas may be locked.^4,9,10 For people living with dementia, agitation, mood, and behavior may be improved by increased access to outdoor spaces, exposure to nature, and use of garden spaces.^2,3,11 It has been suggested that it may be enough to take in the light, smells, and view of a garden.^3,12,13

Newer models of NH care, such as the Green House model and the Eden Alternative, place increased emphasis on providing person-centered care, encouraging independence in residents, and emphasize principles of enablement.¹⁴ Thus, the provision of independent access to the outdoors within modern NHs is increasingly acknowledged as important in maximizing resident quality of life (QoL) and function.^1,3,15-17 However, the degree to which providing independent access to outdoor areas within NHs translates to practical increases in use of outdoor areas, or is associated with improvements in resident QoL, has received relatively little attention.^3,18

The aim of this analysis is to examine the association between provision of independent access to outdoor areas at the NH level and actual use of outdoor areas by the residents with health-related QoL (HR-QoL) in a population of residents of Australian NHs with a high prevalence of dementia. In addition, the association between living in a small-scale, homelike (normalized) model of care and frequency of going outdoors was examined. It was hypothesized that providing independent access to and use of outdoor areas would be associated with better HR-QoL and that there would be increased use of outdoor areas for residents living in a small-scale, homelike model of care. 

Methods

Ethics approval was obtained from the Flinders University Social and Behavioural Research Ethics Committee. Self-consent by residents to participate was obtained when possible; for residents with more severe cognitive impairment, proxy consent for participation was provided (usually by a close family member).

This analysis examines the HR-QoL of participants from the INSPIRED study, a cross-sectional study of 541 participants residing in 17 NHs in four Australian states. Homes with a high proportion of residents with dementia and/or offering an alternative model of care were purposefully approached for recruitment. The study methods have been described previously.¹⁹ Briefly, individuals living in the NH for 12 months or longer, having a proxy willing to participate on their behalf if required, and not being in immediate palliative care were included. Data was collected between January 2015 and February 2016. Consent for the study was obtained from the residents (24%) or their proxies (76%). 

The main outcome measure of HR-QoL was assessed with the EuroQol EQ-5D-5L instrument, the most commonly used HR-QoL measure in NH research.^20,21 The EQ-5D-5L is a widely used generic preference-based instrument for measuring and valuing HR-QoL. It is chosen in this study as it is among the mostly commonly used HR-QoL instrument for measuring and valuing the benefits of competing interventions within an economic evaluation framework. The EQ-5D-5L measures five dimensions influencing HR-QoL: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Health state utility values were generated using the preference-weighted scoring algorithm based on a United Kingdom general population sample.²² Utility scores are bounded from -0.281 to 1 where health states with a score of less than 0 are considered worse than death. HR-QoL questionnaires were completed by the residents where possible, and this was encouraged for those with a Psychogeriatric Assessment Scale Cognitive Impairment Scale (PAS-Cog) score of 11 or less, or a proxy family member completed the questionnaires where necessary. 

The main variables of interest were: (1) independent access to outdoor spaces (facility-level variable) and (2) frequency of use of outdoor spaces (resident-level variable). Independent access was defined as the residents having access to outdoor areas (eg, a garden, terrace, or balcony) and being able to use this without supervision. Lack of independent access was defined as residents having no access to an outdoor area from the living unit or only access under supervision. Data on access to and use of outdoor areas was obtained from resident and NH-level surveys adapted from Palm et al.²³ The resident questionnaire obtained information on frequency of venturing outdoors during the previous week. Frequency of going outdoors was analyzed as three categories: once or more per day (several times a day or daily), multiple times per week but not daily (1-3 times/week or 4-6 times/week), or not at all, as the frequency of responses to individual categories were prohibitively low.

Cognitive impairment was measured using the Psychogeriatric Assessment Scale Cognitive Impairment Scale (PAS-Cog), on a scale of 0 to 21. The PAS-Cog is routinely used in Australia during assessments of eligibility for admission to residential care.²⁴ Higher scores indicate greater impairment and a score of five or greater is considered indicative of cognitive impairment. Data on vitamin D prescription was obtained from pharmacy records. Frequency of social interactions was defined as weekly interaction with family or friends. NH-level variables were geographic location (major cities or regional) or size (total number of beds).

The model of care provided in the NHs was examined as an exposure variable. Homes defined as providing a home-like (normalized) model of care were those that met at least five of the six following criteria: (1) independent access to outdoors, (2) 15 or fewer residents per living unit, (3) allocation of staff to the units, (4) residents having the opportunity to participate in meal preparation, (5) self-service of meals, (6) or meals cooked within the units.¹⁹ 

The associations between going outdoors and QoL were examined using multilevel regression models. Analyses were adjusted for individual and NH-level characteristics including age, gender, function (modified Barthel Index), cognition (PAS-Cog score), marital status, number of comorbidities, vitamin D (cholecalciferol) administration, social interactions, geographic location, and NH size. Associations between the main variables and the main outcome of QoL were also adjusted for the model of care. There were no missing data on access to outdoors from the NH-level surveys. At the individual level, there were few missing values for the ED-5D-5L (n=3) or frequency of outdoor access (n=6), no special treatments were performed on these missing values, therefore, results were based on complete cases. Adjusted means with confidence intervals and model-generated P values are presented. The odds of going outdoors between the different models of care was determined using multinomial logistic regression, adjusted for the factors listed above. Study size was determined based on 80% power required to detect a difference in HR-QoL between the models of care with an effect size of 0.3 (Cohen’s d). Statistical significance was considered at P <.025 as hypotheses were directional.

Results

Participants had a mean age of 85 (SD 8.5) years: 75% were female, 84% had cognitive impairment, and 63% had a formal diagnosis of dementia (Table 1). Approximately three quarters of the population (72%) lived in a NH with independent access to the outdoors, and one fifth of the population did not go outdoors in the week before data collection. 

Article continues after Table 1

After adjustment for potential confounders, including the model of care, living in a NH with independent access to the outdoors was not associated with a better HR-QoL (EQ-5D-5L β=-0.01; 95% CI, -0.09-0.07; P=.80; Table 2). Going outdoors daily in comparison to not at all was significantly associated with a better HR-QoL (β=0.13; 95% CI, 0.06-0.21; P<.001). However, going outdoors multiple times (1-6 times) per week but not daily was not significantly associated with a better QoL in comparison to not going out at all (β=0.03; 95%CI, -0.03-0.09; P=.305). 

Unadjusted analyses were consistent with adjusted results. There was no association of provision of independent access to outdoors with HR-QoL, but significantly better HR-QoL was observed for individuals venturing outdoors daily or multiple times per week (Table 2).

The odds of people going outdoors daily for residents living in a homelike model of care, in comparison to a standard model of care, were significantly greater, after adjustments (odds ratio 15.1, 95% CI, 6.3-36.2; P<.0001; Table 3). 

Discussion

This analysis aimed to examine the associations between independent access to the outdoors, use of outdoor areas, and QoL of residents of NHs, as well as comparisons of these factors between different models of care, in the pre-COVID era. The findings suggest that simply providing independent access to outdoor areas is insufficient to achieve HR-QoL benefits for residents in NHs; there is a need to enable and support regular use of outdoor spaces. Going outdoors daily was associated with better HR-QoL of residents; however, living in a NH with independent access to outdoor was not. To the authors’ knowledge, this is the first study to examine associations of HR-QoL with both the resident’s frequency of going outdoors and provision of independent access at a facility/design level.

Frequently going outdoors may increase the HR-QoL of residents through interaction with nature, the activities undertaken while outside, such as walking or other physical activities, or possibly by elevating vitamin D.^2,25-28 For people living with dementia in NHs in the UK, restricted access to outdoor areas has been associated with depressive symptoms,⁹ but only a relatively short duration of outdoor exposure may be needed to show an association with improved mood.¹¹ Residents of NHs frequently have low serum vitamin D, which has been associated with depression, so increased time spent outdoors may improve mood by increasing vitamin D.^25,29 In this study, 31% of participants were receiving vitamin D supplementation, so adjustments were made in analyses for vitamin D prescription.³⁰ Given existing recommendations for prescription of vitamin D in adults residing in NHs, this rate appears low.^31,32 Increasing time outdoors could further increase vitamin D levels for residents, which may have benefits in fall prevention.³² Increased time outdoors has also been demonstrated to improve sleep in this population.^33,34

Even if NHs offer independent access to outdoor spaces, there may be barriers to the residents using these areas, explaining the lack of benefit on QoL. While dependencies due to physical health and mobility issues are possible barriers,^5,9 this analysis has adjusted for differences in function and cognition between the residents. A recent systematic review has found that key barriers and enablers relate to the design of outdoor areas and the main building in providing doors that are easy to open and close, access points,
weather (which can be addressed in part by providing adequate and appropriate shade, shelter, and clothing), staffing factors, and provision of social activities outdoors.³⁵
Perceptions of the safety of residents accessing outdoor areas independently can also pose a significant barrier. Decline in cognitive function for people with dementia means they may be less likely to initiate going outdoors themselves. Staff need to provide incentives and support for residents to utilize outdoor areas; planning and providing structured and scheduled activities outdoors is recommended.^5,10,35 

In an Australian discrete choice experiment, residents valued having outdoor access whenever they wanted as more important than did their proxies (family members) answering on behalf of residents.³⁶ This discrepancy may be due to safety concerns of family members, so strategies to increase resident use of outdoor areas must also consider potential family as well as staff concerns regarding safety. Culture change within the organization and regular conversations about the benefits and potential harms of residents going outside should take place among staff, residents, and family members.³⁵

In the current study, the odds of going outdoors daily in the previous week were greater for those living in a home-like (normalized) model of care, after adjustments for potential confounding factors. As well as having design differences, including housing for smaller groups of residents and independent access to outdoors, the homelike model of care incorporates a different staffing structure, with higher direct care hours and investment in staff training.³⁷ Dutch studies have also indicated that small-scale living environments have the potential to benefit residents and that factors other than just the physical design, in particular staffing factors, have a role in optimal use of outdoor areas.¹⁸ These studies however did not directly measure resident QoL. Fewer residents living together has also been shown to be associated with increased activity involvement for residents living with dementia in Dutch NHs.³⁸ 

This observational study has a number of limitations. The use of outdoor areas was analyzed as either daily, one to six times per week, or not at all. The number of categories considered are not enough to accurately inform the “dose” or frequency of outdoor use required to achieve a HR-QoL benefit, and it is also limited by being based on activity over a single week. Thus, they do not capture variations in use of outdoor areas over time for the residents, information on the activities undertaken while outdoors, or the duration of time spent outside. Nevertheless, these findings emphasize the value of residents getting outdoors for QoL rather than just being provided access to outdoor spaces at a design level. 

A strength of this study is that it includes a large proportion of participants with cognitive impairment (84% had a dementia diagnosis or PAS-Cog of five or more), from a range of homes across four Australian states who self-rated their HR-QoL whenever possible (28% self-rated, 72% proxy). Although concerns with proxy ratings of HR-QoL have been raised, including proxy ratings is an important approach to capture the HR-QoL of participants with moderate to severe cognitive impairment who are unable to answer questionnaires on their own behalf.^39,40 In general, proxy responses tend to give poorer rating of HR-QoL than the person with dementia does if self-completing, although some studies have found good agreement between using the EQ-5D in people with vascular cognitive impairment and family member proxies.^39,41,42 Excluding proxy ratings in this study would result in the findings no longer being applicable to a population of people living with dementia in NHs. 

In addition, there are limitations inherent to the study design. The cross-sectional design means that only association and not causation can be determined. That is, those with a better QoL may go outdoors more frequently, or those that prefer venturing outdoors may choose a more homelike model of care. However, in Australia the choice of NH is generally driven by immediate availability of places within the locality, often precipitated by a crisis, and free choice across types of NHs is generally limited.⁴³ Also, while analyses have been conducted using multilevel regression models adjusting for many potential confounding factors at both the resident and facility level, the possibility of residual confounding remains. The current analysis used the EQ-5D-5L scoring algorithm based on a UK general population sample as there is no algorithm based on an Australian general population sample. There may be some differences in how the UK and Australian general population value the dimensions of the EQ-5D-5L, and therefore future studies conducted in Australia should consider using a scoring algorithm developed from the Australian general population sample as it becomes publicly available. 

Some existing studies have demonstrated associations of higher QoL with going outdoors in residents of NHs, although the evidence is both contradictory and sparse.^3,18 However, to the authors’ knowledge this is the first study to examine associations with both residents’ going outdoors and the provision of access to outdoor areas at the organizational level within the same population, plus a comparison of resident outdoor use between different models of residential care.

Conclusion

Provision of independent access to outdoor areas in NHs may be insufficient to achieve HR-QoL benefits in residents, including those with dementia. Living in a small-scale, homelike model of care may enable greater access to outdoor areas for residents. However, designs, staffing structures, and attitudes as well as the organization of suitable activities that enable and encourage residents to venture outdoors frequently are required to maximize use of outdoor areas and achieve the greatest impact on resident well-being. Consideration of how to maintain use of outdoor areas for NH residents while adhering to any COVID-19 related restrictions is an important consideration to maintain resident QoL. 

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