Benefits of a creative writing group for care home residents

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Nursing Practice

Innovation Dementia

Keywords Dementia/Creative writing/ Poetry/Nursing home

This article has been double-blind peer reviewed

In this article...

B enefits of a creative writing group for nursing home residents with dementia Framework of the Standards of Care for Dementia in Scotland How a nursing home achieved dementia care standards through a writing group

Benefits of a creative writing group for care home residents

Key points

1There are around 90,000 people living with dementia in Scotland alone

2Nursing homes are being encouraged to enable residents to exercise `voice, choice and control'

3With dementia, changes in the brain result in memory loss, cognitive decline and behavioural changes; some forms of dementia also provoke disinhibition, neglect of self-care or hallucinations

4Creative writing groups help people with dementia engage with others in a dialogue that creates meaning

5Creative writing groups in nursing homes are a channel for collaboration, communication and inclusion

Author Jeanette Laird-Measures is a retired nurse helping to deliver on the Standards for Care for Dementia in Scotland in residential care settings.

Abstract For nursing home residents, having a good life means being able to exercise voice, choice and control. However, many residents have dementia and so experience a cognitive and physical decline that is not only distressing for themselves and their families, but also requires staff to become creative in their approach to care. This article describes how a creative writing group was set up in a nursing home in Scotland, with benefits for residents, staff and families.

Citation Laird-Measures J (2017) Benefits of a creative writing group for care home residents. Nursing Times [online]; 113: 6, 45-47.

Nursing homes should enable residents to exercise `voice, choice and control'; this was one of the recommendations resulting from the My Home Life programme, commissioned by the Joseph Rowntree Foundation to promote quality of life in care homes (Owen et al, 2012). Towards the end of 2015, an exploration of the concept by staff at Victoria House nursing home in Blantyre, Scotland, led to creative writing initiatives that were empowering for residents and staff alike. This article discusses how the germ of an idea developed into a writing group led by residents who have dementia, with support from staff. It also explores the process and outcome, and gives examples of writing projects.

The impact of dementia It is estimated that 93,000 people are living with dementia in Scotland alone (Alzheimer Scotland, 2017). To help these people live fulfilling lives, increasing numbers of communities are becoming `dementia friendly' (Bit.ly/AScDementiaFriendly).

Dementia is a term covering a range of conditions with common features. There

is a change in the brain that is often gradual but can also have a rapid onset, and initially results in: l Memory loss; l D ifficulty in word retrieval; l G eneral cognitive decline.

As the condition progresses, behavioural changes occur, which can be particularly distressing for the individual concerned and for their family and friends. Typical behaviours are: l E xpressions of frustration about

feeling confused; l R eactions of distress including fear,

anxiety and verbal or even physical aggression. Ultimately, physical changes such as weight loss and incontinence occur and, in the later stages of the condition, there are often safety concerns, in particular because wandering ? more accurately described as purposeful walking ? may lead to the individual getting lost or falling (Alzheimer's Society, 2015). Some types of dementia have slightly different presentations. As an example, frontotemporal dementia does not usually manifest as memory problems in the early stages; instead, behavioural difficulties

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Box 1. Intended outcomes for residents with dementia

As a person with dementia I am involved in life, as follows: l I engage in activities that are

meaningful to me daily l I have the opportunity to participate

in the life of my community l I am able to communicate with

others to my highest capacity l I am able to do things independently

with safe supports l I enjoy the tastes, smells, sounds and

feelings of the real world l I have opportunities to enjoy the

outdoors/be outdoors

such as disinhibition and neglect of selfcare occur, and language difficulties sometimes develop (Bit.ly/ASFrontotemporal). Dementia with Lewy bodies shares symptoms of both Alzheimer's disease and Parkinson's disease, and often causes hallucinations (Bit.ly/SALewyBodies).

Launching the writing group When the proposal was put to the nursing home staff that a writing group might be a way to enable residents to exercise `voice, choice and control', some were understandably sceptical, but all were keen to hear more.

The home had already started to embed person-centredness into care plans and promote meaningful service user involvement ? for example, residents have the opportunity to meet potential new staff as part of the recruitment process, and also meet families of prospective new residents during their introductory visit. Care plans, operational policies and activity programmes incorporate a number of outcomes that the home intends to achieve for its residents with dementia. These outcomes are detailed in Box 1.

We explored with staff the research on using the arts with people with dementia and how a writing group might work. The team also discussed how such a group would fit in with the Scottish national standards for dementia care (Fig 1) and for care homes (Scottish Government, 2011; 2007).

The core team comprised a care assistant and the activities coordinator, who had volunteered to manage the writing group. I acted as facilitator. Approaching residents to ask if they were interested in joining the group was one of the most rewarding parts of the process, as all those

who were physically well enough to participate were eager to be involved. Bouchard Ryan et al (2009) suggested that:

"through writing it is possible for an individual with dementia to engage with others in a dialogue that creates meaning and forms identity".

Images spur discussions The first session took place in the lounge. I set up an area with photographs, posters, paintings and postcards loosely based on winter and/or nature. Residents who were mobile walked around looking at them, while those who were not mobile sat close by and the pictures were lifted up so they could see them.

Discussion was spurred by asking questions such as "what does this picture make you think of ?", which led to rich exchanges. John Anderson, looking at the image of a snowy mountain, talked about how, as a young man, he would walk in the hills; his daughter was present and they shared fond memories. Mr Anderson also revealed he was a keen bird watcher, which led the facilitator to ask people what sorts of birds reminded them of winter.

Unexpectedly, Marjorie Johnston, who was sitting at the back of the lounge, apparently not participating, called over: "Robins!". As the others began discussing colours associated with winter birds ("red for robin redbreast"), she explained that, as she was visually impaired, she could not see their colours but could hear their tweets ? and she started whistling. Then she recounted how, as a child, she would

get in trouble for feeding her lunch to the birds on the way to school.

A residents' rag After the first session, there was a noticeable energy around the home. Care assistants enthusiastically shared their thoughts about how residents had responded, and relatives were curious about the next steps.

In a meeting with a group of residents and staff, I suggested creating a newsletter. Mr Anderson's immediate reaction was: "No, no, no, that's for the bosses", and he left the group, walking towards the door. However, he stopped when another resident, Susan Munro, pointed out that it was wet outside ? at that point, I asked Mr Anderson what he would prefer to a newsletter for a residents' publication; he replied: "A rag. A residents' rag", so that became the title.

Over the next few weeks, a core group of residents and staff designed the first edition of Residents' Rag. They wanted it to be fun and, as it was December, they chose a Christmas theme. Staff kept a diary of some of the things residents said during those sessions ? "I climbed many a hill in my youth" or "Snow is wet and white" ? providing a rich record of observations gathered over the years and of memories that had surfaced in the here and now. The residents were accessing knowledge from `before' and articulating it with a newfound passion ? even if they forgot it seconds later. This led to the group's second initiative: a Christmas renga.

Fig 1. Framework for dementia care in Scotland

As a person with dementia...

I have the right to a diagnosis

I have the right to be regarded as a unique individual

and to be treated with dignity and respect

I have the right to access a range of treatment, care and supports

I have the right to be as independent as possible

and be included in my community

I have the right to have carers who are well supported and educated

about dementia

Source: Scottish Government (2011)

I have the right to end-of-life care that respects my wishes

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For more articles on older people's care, go to olderpeople

Box 2. What is renga?

Renga is Japanese genre of collaborative poetry that was a central literary art in pre-modern Japan. The oldest known rengas are found in a collection compiled at some point after 759AD.

A renga consists of at least two ku or stanzas. They are written by more than one person and have specific sound unit counts. The opening stanza of the renga, the hokku, became the basis for the modern haiku form of poetry.

Source: Higginson and Harter (2010)

Collaborative poetry We used renga ? a Japanese genre of collaborative poetry, described in more detail in Box 2 ? to help residents express and share what Christmas meant to them. We relaxed the strict rules of renga writing ? we did not count words or phrases ? as the point was to reminisce and engage. We asked residents: "What does Christmas mean to you?". Their words were written on paper and tied with ribbon to form a chain. Our Christmas renga flowed into a chain of humour and wit, a garland of meanings and memories. Family members and staff also contributed and their words became part of the renga.

Since Christmas 2015, our renga has been redesigned and has become a collaborative memory tree. Every month we ask a themed question; residents, relatives and visitors write their thoughts on luggage labels, and these are hung on the tree (Fig 2). The writing group has become a channel for collaboration and has inspired interest and inclusion.

How does our experience relate to the literature? Walker (2015) suggested that poetry and other forms of cultural expression offer myriad benefits for older people, such as improving interpersonal and intergenerational relationships. Mr Anderson certainly enjoyed interviewing young care assistant Mandy for the Residents' Rag (Box 3). He needed help to stay focused, as drifting attention is in the nature of dementia, but he was more involved in life ? which is one of the care home's intended resident outcomes.

Mandy began to see her role in a different light; she described feeling "humbled" by the authoritative manner in which Mr Anderson conducted the interview. In supervision, she disclosed that, when

someone questioned the value of the group, she replied:

"Does it matter if Alan walks away then wanders back? No. What matters is that in the group he feels valued, engaged and has an opportunity to share his lifetime of experience."

Phillips et al (2010) suggested that this type of group activity builds social confidence, which is fundamental to good dementia care. Reflecting on the experience of Ms Johnston, who shared with the group her memories of feeding her lunch to the birds, it appears that, in the group, she displayed confidence that had not always been apparent before.

Killick (2012) found that arts-related group activities promote the expression of emotions in settings where this is often viewed as disruptive and therefore discouraged. In our group, inclusion and participation was encouraged.

Conclusion Using a creative writing group to help nursing homes deliver on quality standards has benefits for residents and staff. This was demonstrated by the joy on Mary Carter's face when she saw the renga on the Christmas tree and was told she had contributed to it; by the interest generated among our partners in care ? even the pharmacy delivery driver contributed; by the involvement of relatives helping their loved ones turn their memories into verses

Fig 2. Memory tree

Box 3. Residents' Rag interview

Issue 1 of Residents' Rag featured Mr Anderson, a resident, interviewing care assistant, Mandy.

Mr Anderson: What's your favourite part of Christmas, Mandy? Mandy: Well John, I have to say it's Christmas dinner! Mr Anderson: What's your `Bah Humbug' about Christmas? Mandy: I don't get presents any more like I used to as a kid! Mr Anderson: What do you like eating on Christmas Day? Mandy: My lovely turkey dinner. Mr Anderson: What message would you like to give everyone here at Christmas to wish them well? Mandy: Merry Xmas and a Happy New Year ? all the best from Mandy!

of a renga; and by the insight gained by staff into how being creative in their approach to care can help residents exercise `voice, choice and control'. NT

All residents' names have been changed; residents and carers consented to the use of photographs and examples of their input

References Alzheimer Scotland (2017) Statistics: Estimated Number of People with Dementia in Scotland 2017. Bit.ly/AScStatistics2017 Azheimer's Society (2015) Walking About. Bit.ly/ AScWalking Bouchard Ryan E et al (2009) The dementia narrative: writing to reclaim social identity. Journal of Aging Studies; 23: 3, 145-157. Higginson WJ, Harter P (2010) The Haiku Handbook: How to Write, Teach, and Appreciate Haiku. New York, NY: Kodansha. Killick J (2012) Working as an Artist with People with Dementia. Bit.ly/NAWEArtistDementia Owen T et al (2012) My Home Life: Promoting Quality of Life in Care Homes. York: Joseph Rowntree Foundation. Bit.ly/JRowntreeHomeLife Phillips LJ et al (2010) Effects of a creative expression intervention on emotions, communication, and quality of life in persons with dementia. Nursing Research; 59: 6, 417-425. Scottish Government (2011) Standards of Care for Dementia in Scotland. Bit.ly/ScotGovStandards Dementia Scottish Government (2007) National Care Standards: Care Homes for Older People. Bit.ly/ScotGovStandardsCareHomes Walker A (2015) HPU LifeLines Handbook. Bit.ly/HPUHandbook

For more on this topic go online...

l Improving communication in dementia care Bit.ly/NTCommunicationDementia

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