This analysis suggests that simply providing independent access to outdoor areas is insufficient to achieve QoL benefits for residents in residential aged care; there is a need to enable and support regular use of outdoor spaces. Going outdoors daily was associated with better QoL of residents; however, living in a nursing home with independent access to outdoors was not. To the authors’ knowledge this is the first study to examine associations of 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 QoL of residents through interaction with nature, the activities undertaken whilst outside, such as walking or other physical activities, or possibly by elevating vitamin D [2, 23-26]. For people living with dementia in residential aged care in the UK, restricted access to outdoor areas has been associated with depressive symptoms [7], but only a relatively short duration of outdoor exposure may be needed to show an association with improved mood [9]. Residents of care facilities frequently have low serum vitamin D which has been associated with depression, so increased time spent outdoors may improve mood by increasing vitamin D [23, 27]. In this study 31% of participants were receiving vitamin D supplementation so adjustments were made in analyses for vitamin D prescription [28]. Given existing recommendations for prescription of vitamin D in adults residing in aged care homes, this rate appears low [29, 30]. Increasing time outdoors could further increase vitamin D levels for residents which may have benefits in terms of falls prevention [30]. Increased time outdoors has also been demonstrated to improve sleep in this population [31, 32].
Even if facilities offer independent access to outdoor spaces there may be barriers to the residents using these areas, explaining the lack of benefit on quality of life. Whilst dependencies due to physical health and mobility issues are possible barriers [5, 7], 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 terms of 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 [33]. 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 utilise outdoor areas; planning and providing structured and scheduled activities outdoors is recommended [5, 8, 33].
In an Australian discrete choice experiment, residents valued having outdoor access whenever they wanted as more important than did proxies (family members) answering on behalf of residents [34]. 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 as well as potential harms of residents going outside should take place between staff, residents and family members [33].
In the current study, the odds of going outdoors daily in the previous week were greater for those living in a home-like (normalised) 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 home-like model of care incorporates a different staffing structure, with higher direct care hours and investment in staff training [35]. 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 [16]. These studies however did not directly measure resident quality of life. Fewer residents living together has also been shown to be associated with increased activity involvement for residents living with dementia in Dutch residential aged care homes [36].
This observational study has a number of limitations. The use of outdoor areas was analysed 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 quality of life benefit and it is also limited by being based on activity over a single week. Nevertheless, these findings emphasise the value of residents getting outdoors on quality of life, rather than just being provided access to outdoor spaces at a design level.
A strength of this study is that it includes a large number 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 QoL whenever possible (28% self-rated, 72% proxy). Although concerns with proxy ratings of QoL have been raised, including proxy ratings is an important approach to capture the QoL of participants with moderate to severe cognitive impairment who are unable to answer questionnaires on their own behalf [37, 38]. In general, proxy responses tend to give poorer rating of QoL than the person with dementia does themselves 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 [37, 39, 40]. Excluding proxy ratings in this study would result in the findings no longer being applicable to a population of people living with dementia in residential aged care.
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 quality of life may go outdoors more frequently, or those that prefer venturing outdoors may choose a more home-like model of care. However, in Australia the choice of nursing home is generally driven by immediate availability of places within the locality, often precipitated by a crisis and free choice across types of residential aged care homes is generally limited [41]. Also, whilst analyses have been conducted using multi-level regression models adjusting for many potential confounding factors at both the resident and facility level, the possibility of residual confounding remains.
Some existing studies have demonstrated associations of higher quality of life with going outdoors in residents of aged care homes, although the evidence is both contradictory and sparse [3, 16]. 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 organisational level within the same population, plus a comparison of resident outdoor use between different models of residential care.