Background
In the United Kingdom (UK), approximately 416,000 older people reside in care homes, making up 4 per cent of the over-65 population and 16 per cent of those over 85 (LaingBuisson, 2013). Most care home residents live with multiple morbidities, including dementia, stroke and Parkinson's disease, which are further compounded by physical frailty and declining functional independence (Gordon et al., Reference Gordon, Franklin, Bradshaw, Logan, Elliott and Gladman2013). On average, the length of stay in a care home is 15 months, with just under 30 per cent of people living longer than three years after admission into care (Forder and Fernandez, Reference Forder and Fernandez2011). Unlike other health-care institutions, care homes have a two-pronged responsibility that is encapsulated by the duality of the term ‘care home’ itself. Care homes must not only ensure that residents’ complex care needs are looked after but should also provide a homely and comfortable environment in which residents can continue to live full lives and experience optimal subjective wellbeing (Peace and Holland, Reference Peace and Holland2001). Care homes are also places of work and emerging models of care provision have been developed to support staff in providing person-centred care that views care home residents as rounded human beings rather than a collection of ailments and pathologies (McCormack, Reference McCormack2004). Given this multi-layered complexity, research that explores care home living from a broad social perspective – rather than a medical perspective – is critical to understanding how older people experience care home living.
The extent to which care homes meet their dual responsibility is variable. Even when residents’ physical care needs are met, many experience poor social and emotional wellbeing. In the institutionalised care home environment, residents can feel disconnected from their life-long identities as self-determining individuals (Andersson et al., Reference Andersson, Pettersson and Sidenvall2007). Anthropological studies of moving into a care home have described the ‘social death’ that can occur as residents become disconnected from the domestic and social environments that shape their sense of self (Hockey, Reference Hockey1990; Hazan, Reference Hazan1980). Identity is a social process, where the ‘self’ is created and sustained within the context of others (Jenkins, Reference Jenkins2014); however, there is considerable evidence that care home residents have scarce opportunity for social connection. In a study by the Alzheimer's Society (Sharp, Reference Sharp2007), care home residents were observed receiving only two minutes of meaningful social interaction within a six-hour window, with most staff–resident interaction focused on the direct provision of care – e.g. washing and dressing – rather than conversation. Elsewhere, residents have reported difficulties in developing new friendships or maintaining existing ones, as contact with friends and family declines by half after moving into a care home (Port et al., Reference Port, Gruber-Baldini, Burton, Baumgarten, Hebel, Zimmerman and Magaziner2001). Even when friends and family visit, the rigidity of the care home routine, lack of private space, and friends’ and relatives’ discomfort in the care home environment can limit the quality of these interactions (Timonen and O'Dwyer, Reference Timonen and O'Dwyer2009). There is convincing evidence that dwindling social interaction, inflexible care home routines and insufficient emotional connections with staff lead to increased depression (Drageset et al., Reference Drageset, Espehaug and Kirkevold2012), accelerated cognitive decline and decreased quality of life (Bradshaw et al., Reference Bradshaw, Playford and Riazi2012). Up to 42 per cent of the care home population experience loneliness, which is more than double the rates of loneliness reported amongst community-dwelling older people (Victor, Reference Victor2012).
Participation in structured group activities has been shown to have a positive impact on residents’ physical and emotional wellbeing (Hagan et al., Reference Hagan, Manktelow, Taylor and Mallett2014) and increases their feelings of social belonging (Lawrence et al., Reference Lawrence, Fossey, Ballard, Moniz-Cook and Murray2012). For instance, dance interventions (Guzmán-García et al., Reference Guzmán-García, Hughes, James and Rochester2013), reminiscence (Elias et al., Reference Elias, Neville and Scott2015) and gardening groups (Hernandez, Reference Hernandez2007) have been linked with greater social interaction, reduced boredom and improved mood. Although some of this research has shaped policy and guidelines around providing regular activity to mitigate the effects of loneliness and enable care home residents to continue living productive lives, there is resounding evidence that care home residents still spend most of the day unoccupied. A large study of 1,144 residents across 144 care homes found that two-thirds of residents experienced less than one hour of meaningful activity per day (Smit et al., Reference Smit, De Lange, Willemse and Pot2017). Moreover, far from offering opportunities for reciprocal relationships and social productivity, activities are often institutionalised, rigidly scheduled, controlled by staff and geared towards keeping residents superficially ‘busy’ (Knight and Mellor, Reference Knight and Mellor2007; Theurer et al., Reference Theurer, Mortenson, Stone, Suto, Timonen and Rozanova2015). This lack of meaningful participation can have serious implications, with research showing that residents who lack opportunity for engagement in pleasurable activities are more likely to die or report depression after nine months in the care home environment (Mozley, Reference Mozley2017). Moreover, for people with cognitive or communication impairment, difficulties interacting verbally and participating in activities independently may further compound their risk of loneliness and isolation (Victor, Reference Victor2012). As such, there is a strong imperative to explore, identify and understand how to optimise opportunities for participation in meaningful activity and to enrich social interaction within the institutional constraints of the care home.
In this paper, we describe a cross-disciplinary qualitative study exploring the potential of film screenings as a meaningful activity for care home residents. A small body of literature to date has examined the use of film-related materials in care homes, including: a book of photographs of classic stars to prompt reminiscence (Brenske et al., Reference Brenske, Rudrud, Schulze and Rapp2008); a touch-screen computer program called the Computer Interactive Reminiscence and Conversation Aid (CIRCA) that supports residents and their care-givers to watch and discuss selected film clips (Astell et al., Reference Astell, Ellis, Bernardi, Alm, Dye, Gowans and Campbell2010); and the development of specifically tailored films for people with dementia (Caserta and Lund, Reference Caserta and Lund2003; Bjørnskov et al., Reference Bjørnskov, Møller Jensen and Gregersen2018). However, the feasibility and impact of screening entire films for care home audiences has not yet been examined, and the social and emotional impact of shared spectatorship in this setting remains relatively under-explored. Indeed, film and television viewing has been excluded from many studies of activity in care homes because it is deemed too passive (Cowl and Gaugler, Reference Cowl and Gaugler2014; Young et al., Reference Young, Camic and Tischler2016). This is in contrast to Film Studies research which provides an evidence base for the therapeutic benefits of film (Izod and Dovalis, Reference Izod and Dovalis2015) and the emotional resonance of cinema (Plantinga, Reference Plantinga2009) in the general population. Developments in aesthetic science have led to film scholars tracing the ‘psycho-cinematic’ and cognitive elements of film spectatorship, demonstrating that film viewing is not passive but involves active sensory, cognitive, emotional and social engagement (Shimamura, Reference Shimamura2013).
We thus sought to combine cross-disciplinary perspectives from humanities, health and social science to explore the impact of film screenings in care home settings. As studies of the use of film have to date relied on survey data collected from care home staff and relatives, or through observation of residents (Caserta and Lund, Reference Caserta and Lund2003; de Medeiros et al., Reference de Medeiros, Beall, Vozzella and Brandt2009; Bjørnskov et al., Reference Bjørnskov, Møller Jensen and Gregersen2018), we wanted to engage with residents directly and elicit their opinions in our understanding of how they respond to and interact with film. Specifically, we explored the following interconnected research questions:
(1) How do care home residents experience film spectatorship in the care home environment?
(2) How do communal film screenings influence social connectivity in the care home?
Methods
We used multiple qualitative methods to generate data in two case study sites in Scotland, combining: participant observation of film screenings, audience group discussions after each film and individual interviews with staff. We used Shimamura's (Reference Shimamura2013) model of psycho-cinematics as our underpinning theoretical framework. Shimamura's (Reference Shimamura2013) I-SKE model comprises four concepts: the film maker's intention (I); the film's sensory and attentional features (S); how the film evokes knowledge, narratives and events (K); and how the film elicits emotions and empathy (E). This model provided a conceptual lens for our study of the aesthetic, affective and cognitive responses of viewers. To explore social interaction during the film, we added a new, fifth dimension to the framework: social connectivity (S). We refer to this adapted model as the ISKE-S framework throughout the rest of the paper.
Ethics
This study received ethical approval from the University of Dundee Research Ethics Committee (reference number UREC 16040).
Recruiting care homes
We identified potential care homes on the ENRICH database of research-ready care homes (https://enrich.nihr.ac.uk/). AS telephoned four care homes within pragmatic travelling distance and with Care Inspectorate ratings of ‘good’ or above. After speaking with care home managers, AS conducted preliminary visits to three of the homes to discuss the study further. Two homes agreed to take part with care home managers providing permission to undertake the project. Both were privately run care homes in Scotland offering a combination of residential and nursing care, each with an appointed ‘activities co-ordinator’. Both homes described having DVD libraries and had already attempted to create a cinematic experience for residents by using blackout curtains, serving refreshments and watching films on large-screen televisions. The homes were keen to work with researchers to capture the benefits and challenges of film viewing more systematically and to learn lessons about how to use film more effectively as a meaningful activity for residents. The characteristics of both homes are described in Table 1.
Care home characteristics
Recruitment and participants
We recruited residents, staff and relatives in each of the participating homes, as described next and detailed in Table 2.
Film screening schedule and participant involvement breakdown by week
Notes: 1. Director; year; Internet Movie Database URL. 2. In total, nine residents and four staff involved over three weeks. 3. In total, 17 residents, five relatives and five staff involved over 3 weeks.
Residents
Reflective of the broader care home population, many of the residents we recruited were living with dementia and our approach to recruitment and consent was guided by Dewing (Reference Dewing2008). The process method of consent (Dewing, Reference Dewing2008) is inclusionary and dementia-sensitive, rather than competency-based, and can be used alone or in combination with proxy consent. It is defined as:
the approach and methods taken both informally and formally to making consent a real and meaningful activity in research where the person with dementia is enabled to participate in meaningful ways to the level of their capacity and other abilities regardless of legal capacity. (Dewing, Reference Dewing2008: 60)
Taking a social – rather than medical – approach to exploring residents’ experiences of film we did not seek medical information regarding diagnoses and made no clinical assessment of capacity. Instead, we began by consulting activities co-ordinators in the homes who knew residents well and were best placed to establish a basis for capacity and ability to participate. Activities co-ordinators recruited residents in advance of the screenings by providing all prospective participants with a study information sheet, explaining this to them verbally and seeking their initial written consent.
Using the process method (Dewing, Reference Dewing2008), we recognised that residents’ ability to consent may fluctuate at different times and in different contexts. Activities co-ordinators therefore discussed the project with residents at different times in the week before each film screening, providing multiple opportunities for residents to understand the project, ask questions and reflect on whether they wanted to take part. Similarly, when the researchers arrived for the film screenings, we re-capped the purpose of the study, what it would involve and reminded residents that their participation was entirely voluntary. We then sought repeat consent verbally at each screening and before each discussion group. To ensure equity of opportunity, avoid disrupting usual practice and respect residents’ homes, the film screenings themselves were open to all residents, regardless of whether they were participants in the study. However, the data collected and reported relates only to those residents who consented to take part in the research. Participants were informed that they were free to leave the screenings at any time and the presence of staff who knew residents well meant they could monitor and respond to any signs that residents needed, or wanted, to withdraw from the study (Dewing, Reference Dewing2008). Residents were also given the opportunity to opt in or out of the audience discussion groups both before and during the discussion. In total, 26 residents took part in the film screenings, with the majority also opting to stay for the group discussion after the film (for a detailed breakdown, see Table 2).
Relatives
Relatives were conveniently sampled. Some residents had regular visitors at the time that the film screenings were scheduled in care home B and, rather than disrupt visiting, we invited relatives to stay. The researchers explained the purpose of the study to the relatives, provided them with an information sheet and asked them to sign a consent form to indicate their willingness to take part. A total of six relatives joined the film screenings and discussions over three weeks in care home B, with four relatives taking part in both Weeks 1 and 3. The opportunity to invite relatives did not arise in care home A.
Staff
Prior to the study, care home mangers shared the study information with activities co-ordinators, who then invited all other care staff to join the film screenings and provided them with participant information sheets at least one week in advance. Staff did not have to commit to taking part in interviews and audience discussions, or attend the full film screenings, but were invited to come along if they wished and had time. This gave staff the opportunity to take part without imposing on their busy schedules. During the film screenings, AS approached staff who came into the room to take part in interviews. AS took staff members aside, reiterated the study information and gained written informed consent from staff willing to be interviewed. A total of nine staff (two activities co-ordinators and seven care assistants) took part in the film screenings, with four taking part in individual interviews (as broken down in Table 2). The activities co-ordinator in care home A took part in three interviews (one per week) to track her perspectives over time. Although this was the intention in care home B, this was not possible due to other competing demands on staff time.
Data collection
We ran three film screenings in each home, once a week for three weeks, to explore how residents responded to different films and generate sufficient data about the communal screening experience. At the start of each screening, we offered residents a choice of three films from different genres and featuring different stars. Based on prior consultation with care home managers and activities co-ordinators, these were around 80–90 minutes long. This sparked a group discussion amongst residents to agree upon a film, which was then screened in its duration. All film screenings took place in the care home day room, with comfortable seats, dimmed lighting and refreshments. At the end of each week, we asked residents to make suggestions for the types of films they would like us to bring to the following session.
Observations
AS and JPB acted as participant observers and each took detailed fieldnotes during the film screenings. We created a two-sided A4-page observation schedule using the headings from the ISKE-S framework with blank space for freehand fieldnotes underneath. The ISKE-S headings, with prompts, are shown in Table 3. JPB was present as an observer for the entire duration of the film, whereas AS left the film screenings for short periods in order to conduct individual interviews with staff (described later). Directly after each visit, we compared fieldnotes. Rather than focusing on inter-rater reliability (whether we had interpreted our observations in the same way), our primary focus was on comparing our different disciplinary perspectives and coming to a trans-disciplinary account of audience behaviour. AS is a film studies scholar and JPB is an occupational therapist and social science researcher, bringing different and complementary interpretations to the data.
ISKE-S1 observation schedule with prompts
Note: See the Methods section for details of the ISKE-S framework.
Audience discussion groups
Audience discussion groups lasted between 10 and 30 minutes and were facilitated by AS and JPB immediately following each film screening. The discussions were loosely structured using the ISKE-S framework (shown in Table 4). We allowed the audience to shape the discussion whilst also directly asking audience members about some of the behaviours we had observed during the screening. Discussions were audio-recorded and transcribed verbatim.
ISKE-S1 audience discussion group semi-structured guide
Note: See the Methods section for details of the ISKE-S framework.
Staff individual interviews
Interviews with staff explored their perspectives on the potential benefits and challenges of using film. Interviews lasted between 10 and 25 minutes and were semi-structured using the ISKE-S model (Table 5). All staff interviews were conducted by the same researcher (AS) in a private area of the care home. To fit with hectic caring schedules and ensure sufficient staff presence on the floor, AS conducted the staff interviews whilst the film was being screened and JPB continued with observation.
ISKE-S1 staff interviews semi-structured guide
Note: See the Methods section for details of the ISKE-S framework.
Data analysis
We analysed observational, discussion group and interview data using thematic framework analysis (Ritchie et al., Reference Ritchie, Lewis, Nicholls and Ormston2013). We generated a table in a Word document to create a ‘framework’ consisting of rows (representing participants and data sources) and columns (representing each component of the ISKE-S model). We also created an ‘other’ column to permit inductive coding of data that did not readily fit within the ISKE-S model. This helped to ensure that the theoretical framework was supportive but did not force the data into this perspective. Two researchers (JPB and AS) coded the data independently by pasting data directly from the transcripts under relevant headings in the framework. Observational, interview and discussion group data were all pasted into the same framework. The two researchers then met to compare and contrast their initial coding and generate key themes. We discussed each column in turn, identifying similarities and differences in our interpretations of the data. We inductively organised the data under each of the ISKE-S columns, making comparisons across the different data sources (observation, staff interviews, audience discussion groups). In so doing, we identified three higher-order themes that cut across the data, each of which was underpinned by data from each element of the ISKE-S model. The framework method was a useful approach because it facilitated systematic comparison across individual participants, the different care homes and the different data sources (i.e. comparing observational data with interview and discussion group data).
Findings
We identified three ways in which communal film viewing benefited residents and supported social connection within the care home community: supporting reminiscence; encouraging active contributions and communications in the present; and promoting a sense of shared future and connection between generations. The three concepts cross-cut the entire data-set and were equally evident in the data from both homes. These three concepts are now described in turn, illustrated by quotations from residents and staff. Quotations are labelled according to data source (audience discussion groups: ADG; staff interviews: SI), setting (care homes A and B: CHA and CHB) and timing (Weeks 1, 2 and 3: Wk1, Wk2 and Wk3).
Remembering the past
In our discussions with residents, both in choosing the film each week and offering a choice of film genres for the following week, they assured us – unilaterally – that what they craved were the films ‘from when we were young’. Although we had initially intended to offer a different genre or era of film each week, listening to residents’ preferences and requests resulted in a final screening list of exclusively ‘classic films’: You Were Never Lovelier (1942), Send Me No Flowers (1964), Down Argentine Way (1940) and Gentlemen Prefer Blondes (1953). In making the final decision about which film to watch, residents were primarily driven by a desire to watch their favourite stars. As opposed to preferences for style, plot or genre, this was consistently the over-riding factor influencing residents’ film choice:
Researcher: Are there any films you would like to request?
Resident: Elvis Presley!
Other residents: (talking over one another) Oh no! … Oh yes! (ADG, CHB, Wk 1)
Famous names like Elvis Presley, Marilyn Monroe, Rita Hayworth and Carmen Miranda united and divided residents, resulting in a dynamic discussion each week about which film to select. The discussions always culminated in a consensus, in the knowledge that there would be an opportunity to watch another star the following week. One staff member supposed that there was something comfortable about familiar faces and their power to evoke memories of a bygone era:
when they heard it was Doris Day, it makes them feel safe like it's a comfortable time in their life where they can memorise [reminisce]. (SI – activities co-ordinator, CHA, Wk 2)
Moreover, and particularly for those residents with dementia, watching older films with recognisable stars created less pressure to recall recent memories:
It is things that recall, that brings back memories from back then as opposed to up-to-date memories, yes. (ADG – resident, CHA, Wk 1)
As one of the staff members noted, watching older films with which residents were familiar also served a functional purpose in helping them to attend to the film and follow the story:
Unless they're familiar [with the film] … they can't concentrate to follow the story … you know like Fred Astaire and Rita Hayworth, they relate that back, they used to watch these movies, so the stories are there, and I would imagine these are movies that they've already seen before, so it's easier for them to follow because their concentration's not very good … Something new to them, I personally think it's difficult for them to concentrate on. I think they wouldn't really follow the story. (SI – care assistant, CHA, Wk 1)
In our interviews with care home staff, we ascertained that reminiscence was a popular activity in both care homes and was considered unanimously by all staff as the primary reason to watch films. Our observations corroborate staff's perceptions, and collective film viewing was undoubtedly a route into reminiscence. In the group discussion after each film screening, residents shared lots of positive memories sparked either by the film itself, or its content, styling and themes. Residents recounted, for example, memories about dating, dancing, going to the cinema and getting married, and enjoyed the opportunity to revisit personal landmarks from the past.
As one of the residents pointed out, film created the opportunity for embodied reminiscence that not only sparked verbal discussion of past events but a virtual re-enactment of scenes from residents’ own lives. Residents were able to (re)live moments from the past vicariously through the characters on screen:
Resident: When you see some films like that, do you make any comparison to your own life?
Researcher: That's a good question.
Resident: Have you had as good a time as you see some of these people having or sad days just the same as them? (pause) Life's a mix-up, isn't it? You have your good and not so good times, and your fabulous times.
Resident: It's lovely. (ADG, CHA, Wk 2)
For residents whose cognitive or communication impairments made it difficult for them to engage conversationally in reminiscence, film encouraged them to express memories of their past selves non-verbally. During the dance numbers in You Were Never Lovelier and Down Argentine Way, one resident mimicked elegantly the artistic placement of the dancers’ hands on screen. Her innate musicality and dance ability were evident, telling us something of her personality and enabling us to glimpse a vision of a different time in her life. Her engagement was not only indicative of familiarity with the film itself (its genre, stars, songs) but in its likeness to her own lived experience (the movement, the clothes, the dancehall, the courtship). In her non-verbal interactions, she was expressing knowledge of the place, time and wider social context of the film setting, and was able to communicate this in a way that may not otherwise have been enabled by talk-based reminiscence.
As the earlier quotation demonstrates, the act of reminiscence was not simply about relaying memories but recasting them in a reflective light. It is interesting to note that staff, in their interviews, focused only on the joys of reminiscing and none talked about the emotional, reflective aspect of summing up a long life. Indeed, in our observations and group discussions, it was evident that the act of remembering the past was not always comforting for the residents. As one resident's reaction to You Were Never Lovelier demonstrates, even happy memories could be emotionally difficult, particularly in the juxtaposition between a bygone era and the stark reality of the present day:
When I saw it first, I was a very young child and my grandpa and my aunt took me to the pictures down from the house, and I watched this and I thought this was the most wonderful thing I could see … [When we watched the film today] I just had my grandpa and my aunt beside me (gestures to the space beside her on the settee) … so that was (pause). It's all these kind of things that suddenly brings it back, and everybody is dead (crying). (ADG – resident, CHA, Wk 1)
Film itself is a visual record of the past; places, objects and even people who have long since died are resurrected in physical form each time a film is screened (Bazin and Gray, Reference Bazin and Gray1960; Kracauer, Reference Kracauer1997; Mulvey, Reference Mulvey2006). In this way, film stars become immortal and frozen in time. In this resident's film viewing experience, however, it is the figures within her memories that take on a corporeal presence as she describes the physical sensation of invisible bodies beside her, where they once were. Remembering the past through film appears, therefore, to be far more complex than staff's perceptions. Reminiscence is a physical, as well as a verbal, activity with the potential to recall, re-cast and create new emotions with each screening.
Enhancing the present
As an embodied phenomenon (Sobchack, Reference Sobchack2004), we observed how film could heighten residents’ experience of the present through active, sensory engagement. In response to music and dance numbers, residents clapped their hands, swayed to the music, tapped their feet, sang along and some even got up to dance:
It takes all your willpower to stay in the armchair and not jump up! (ADG – resident, CHA, Wk 3)
It was not only musical numbers that generated an embodied response, but also broad physical comedy. This was particularly evident in the scene in Send Me No Flowers where Doris Day loses control of a golf cart. The audience (care home staff and researchers included) leaned back-and-forth and side-to-side involuntarily as if slaloming downhill with Doris Day and living out the on-screen action in the care home day-room. Rather than inciting memories of the past, in this moment we were all collectively caught up in the immediacy and the thrill of the present. These autonomic responses to visual stimuli on the screen were free from premeditation or agenda, but enabled residents – and us – to ‘be’ and to derive spontaneous pleasure from the moment. Moreover, physical responses – laughter, gestures, facial expressions and body positions – communicated residents’ engagement in the films non-verbally, offering a window into their present selves (revealing something of their current preferences and sense of humour), not just the past stories of their lives.
As already noted, it is interesting that interviews with staff focused primarily on reminiscence. Except for one activities co-ordinator, staff typically overlooked or did not identify film's potential for enhancing the present, particularly when they perceived residents’ up-to-date memories and attention spans to be prohibitively fleeting. As a result, staff described how they would turn off films part way through or opt for shorter media forms. They appeared to have a variable definition of ‘film’, using it to signify any sequence of moving imagery (e.g. YouTube clips of animals and musical concerts, or episodes from television sitcoms) rather than a feature-length narrative production.
What we usually do is half an hour then we'll stop and do something else. And then the ones that want to watch the end of the film will stay and the ones that say no they don't want to watch it then they'll go. (SI – activities co-ordinator, CHB, Wk 1)
Although typically reluctant to show full-length feature films, one film seemed to break the mould. Commenting on Down Argentine Way, a staff member noted:
I really feel it's the best, there's more interaction with the ladies, they're really enjoying it, even the ladies who usually kind of nap off, are actually watching. So I think it's obvious, something is clicking and saying that I remember this and Carmen Miranda, even one of our more difficult clients was actually enjoying it. She was sitting there watching it and enjoying it … I will be very truthful; the last two films were, I felt like oh gosh this is not working, but I am totally on fence today, I can really see that there's just the right film for the right time. It's again, just being lucky and getting everybody at the right time, in the right place and the right film. (SI – activities co-ordinator, CHA, Wk 3)
Down Argentine Way, a golden age musical starring Betty Grable, follows the archetypal structure of the genre. With a music or dance number interspersed at 10–15-minute intervals to break up the dialogue, its structure appeared to be perfectly suited to wavering attention spans. Whenever dialogue-driven scenes went on for a bit long, and viewers’ attention waned, the next musical number recaptured interest – allowing for a renewal of focus that would cycle through to the next musical number.
That the structure was effective in making this classic musical ‘the right film’ was reflected by another staff member at the end of the three weeks:
I think the length of a movie is sometimes, whatever movie it is would be too long. However, they can, I think go in and out of concentration with the movie, so maybe midway through the movie they kind of lose it. But then they pick it up again when music comes on. Or when the humour comes back in. I don't actually think they concentrate throughout the whole movie. I think they go in and out of concentration. Depending on the movie you'll find either they'll stay, or they'll just get up and go. (SI – care assistant, CHA, Wk 2)
This also suggests that apparent lapses in concentration (such as falling asleep, leaving the room or ‘off-topic’ chatting) cannot simply be assumed to be a sign of passive disengagement, disinterest or a by-product of the film's length, but as an active assertion of agency. Different forms of spectatorship may be a way for residents to exercise preferences; not those rooted in their past identities and the films they used to like but based on their present-day mood, feelings and opinions. All three quotations from different residents below demonstrate how residents negotiated their spectatorship, choosing how they might engage, or disengage, with the movie depending on their preferences:
Resident: If I was hauled in to see something that you had to watch because [you were made to] you know your head would be that way and your eyes would be the other way.
Resident: I didn't know what I was going to watch at all, knew nothing about it and then settled down and when it started, ah I like this one.
Resident: I thought well I am tired, if I am not enjoying it I can just sit and go to sleep … as we did in the pictures. (ADG, CHA, Wk 1)
In addition to physical ‘in the moment’ experiences, and the potential to use the body to enact agentive choice (choosing to look away, or to fall asleep), the embodied nature of film viewing also stimulated self-awareness in the present:
This week they seemed to be talking about things through the film. One of the ladies was speaking about Doris Day's hair and saying it was like hers, things like that. (SI – care assistant, CHA, Wk 2)
This quotation shows how residents’ response to the star is not simply about remembering the past, but that film also stimulates conversations about their present selves. The film awakened residents’ sense and awareness of their bodies. After watching You Were Never Lovelier, a staff member introduced us to one of the residents in the discussion group as a ‘good singer’, to which the resident tearfully replied, ‘I used to be before I lost [my voice]’. Intending the comment as a compliment, by likening the resident to Rita Hayworth's character, the staff member had inadvertently positioned the film as a reflection of the resident's past self in a way that highlighted the painful decline of age. When it was later revealed in the discussion group, however, that Rita Hayworth's singing voice was always dubbed, the resident's note of surprise and her markedly changed body language hinted at a sense of pride, as if recasting her self-assessment in the realisation that she had once been a better singer than the film star. In this way, the interface between past and present contributed to a reshaping of present identity and the collective recognition of the resident's musical accomplishments re-established her identity as the ‘musical person’ within the care home community.
Sharing the future
The shared experience of watching the films appeared to last beyond the film screening itself, and staff reported that some of the residents had talked spontaneously about the film screenings after the event:
They'll come out with ‘oh remember we did that yesterday’. (SI – activities co-ordinator, CHA, Wk 2)
Staff described residents recalling particular highlights on- and off-screen, whether it was a conversation about Carmen Miranda or Fred Astaire, or recalling stand-out reactions ‘like [resident's name] getting up to dance, that will have been spoken about’. As another staff member pointed out, one of the benefits of watching familiar films from the past was that it enabled those residents with dementia to join in with these conversations without the pressure of having to recall short-term memories:
if you then talk about it tomorrow, they won't remember what it was today, yesterday, but you could still recall the film. (SI – care assistant, CHB, Wk 1)
The weekly pattern of the film screenings evoked an awareness of the future, and staff described residents looking forward in anticipation of our visits, saying ‘I wonder what film we'll have today’. The care home staff made each visit a special occasion, attempting to create an authentic cinema-going experience:
This is meant to be the movies and what do you do when you go to the movies? You have popcorn and hot dogs … So I asked them would they like popcorn and hotdogs and they were all ‘Yeah, yeah’ … It was to make them more of outside at the movies. (SI – activities co-ordinator, CHB, Wk 1)
This not only enhanced the present experience of the film screening but built anticipation and excitement: it created an opportunity to look forward. One staff member suggested that the opportunity for choice was especially important and, in an institutional environment where their remaining choices are limited, the residents looked forward to having that opportunity again:
The ladies have been looking forward to what film they were watching. It's nice to give them that opportunity to make them feel that they are getting the choice. (SI – activities co-ordinator, CHA, Wk 3)
Although we initially planned the discussion groups after each screening as a way to collect data, it was undeniably part of the activity itself. The opportunity to chat with the researchers was eagerly embraced by many of the residents. Residents were surprised to hear of the researchers’ (both women in our thirties) appreciation of classic films. In response to a question about residents’ favourite film stars, one woman in care home B gave her answer with a dismissive caveat, ‘Clark Gable, but you'll never have heard of Clark Gable!’ This raises a potentially important observation that residents may hold back from discussing the things that are of interest to them because they do not believe the younger person listening will have the desire, interest or knowledge to respond.
Frequently within the dynamic of the group discussions, roles reversed, and interviewees probed and explored aspects of the researchers’ lives. Reminiscence was not simply a route to the past but fostered intrigue about contemporary social norms and etiquettes. The themes within the films, as well as the talents and physical characteristics of the actors, prompted residents to reflect on wider cross-generational issues. They sought to compare and contrast their own life experiences – from dance styles and fashions, to dating, marriage and the decision to have children – with those of the researchers. This created opportunities for residents to impart knowledge:
Researcher: I'm not a good dancer…
Resident: I can teach you a lesson! (ADG, CHA, Wk 3)
More often than not, the intergenerational dialogue served to highlight shared, rather than different, experiences and concerns. In addition to learning about researchers’ lives, and reflecting on their own, residents sought to guide and support the researchers as younger women. Their reflective memory extended beyond simply summing up their own lives, but helping to develop and mentor others:
Resident: You also obviously get a great feeling when you're all dressed up to go somewhere … Any photographs of you all dressed up?
Researcher: No … I've got lots of nice dresses in the cupboard … and I must've tried on about ten, and only one fitted me.
Resident: Oh my goodness.
Researcher: So yes, at the moment I don't enjoy dressing up.
Resident: You will be back to where you were.
Resident: We've all put on weight and lost weight. I've never gone back to what I was anyway. (ADG, CHA, Wk 2)
In this exchange, the shared bond around issues with body image not only provided an opportunity for residents to relate to one another, but to combine their collective wisdom for the benefit of others. Their conversation set the researcher's concern in a lifecourse context and provided reassurance by highlighting its universal commonality. Older people, particularly those with dementia, are frequently underestimated in their role as teachers and mentors, and yet these exchanges show that care home residents are keen, willing and able to contribute positively to reciprocal intergenerational learning and support. Although these intergenerational exchanges could have conceivably arisen in other contexts, we specifically highlight the universal nature of broad cinematic themes to stimulate shared conversations across generations.
Discussion
Our findings demonstrate that film screenings for care home residents serve a threefold purpose: remembering the past, enhancing the present and sharing the future. In the small body of literature on the use of film and television with care home residents, ours is the first to explore film viewing from a complex psycho-cinematic perspective. Existing studies have taken a reductionist perspective, focusing exclusively on residents’ cognitive ability to comprehend film material and using quantitative measures of behaviours (such as dozing or yelling) to measure residents’ attention to the screen (Caserta and Lund, Reference Caserta and Lund2003; de Medeiros et al., Reference de Medeiros, Beall, Vozzella and Brandt2009). For existing research – and certainly, for the care home staff taking part in our study – residents’ sustained attention to the film is highly desirable, hence the preferred use of short film clips (Caserta and Lund, Reference Caserta and Lund2003; Bjørnskov et al., Reference Bjørnskov, Møller Jensen and Gregersen2018). In the ISKE-S model, however, sustained attention to the detail of a film is not a prerequisite for enjoyment, which is equally derived from sensory and emotional engagement with the on-screen action (Shimamura, Reference Shimamura2013). Our findings are a powerful illustration of this, whereby residents reacted physically and emotionally to moments on screen even when the dialogue was beyond their comprehension. Moreover, our findings show that the behaviours traditionally associated with diminished attention span (e.g. sleeping, chatting or leaving the room) need not necessarily be problematised as an undesirable cognitive failure. As the first study to explore residents’ experiences and opinions qualitatively, we have shown that these behaviours may be active choices that permit personal agency in an otherwise systems-driven institutional environment. This is affirmed by Downs (Reference Downs2013), who has cautioned against pathologising the behaviours through which people with dementia communicate their selfhood.
Our findings also challenge prevailing misconceptions within the care home literature that film is a passive activity (Cowl and Gaugler, Reference Cowl and Gaugler2014; Young et al., Reference Young, Camic and Tischler2016). Instead, from a psycho-cinematic perspective (Shimamura, Reference Shimamura2013), we have demonstrated that spectatorship is an active endeavour. Music and movement on screen prompted residents to sway, clap their hands and tap their feet; realising many of the same benefits documented in the growing evidence base for the use of music interventions in care homes (Costa et al., Reference Costa, Ockelford and Hargreaves2018). Moreover, in addition to prompting actual physical activity, film also sparked conversations around movement, activity and body image. Seeing different physical forms on screen – the actors’ body shapes, hairstyles and athleticism, whether in slapstick comedy or elegant dance – prompted residents to talk about their own bodies, both past and present. Thus, our findings suggest that, far from being passive, film enables care home residents to connect with their physical bodies. Misconceiving film as a passive activity risks neglecting the embodied nature of spectatorship (Sobchack, Reference Sobchack2004) and therefore missing opportunities to use film as a conduit for important physical activity promotion amongst care home residents. Indeed, physical activity promotion is a key policy and practice concern for the care home population (Macintosh and Laventure, Reference Macintosh and Laventure2014; Hawkins et al., Reference Hawkins, Prashar, Lusambili, Ellard and Godfrey2018). Our findings show that film could provide a useful vehicle for encouraging physical activity in care home residents and creating a window for providing health and wellbeing advice around movement and nutrition, for example.
Existing studies of film-based activities with care home residents have focused predominantly on their potential to support reminiscence (Caserta and Lund, Reference Caserta and Lund2003; Brenske et al., Reference Brenske, Rudrud, Schulze and Rapp2008; Astell et al., Reference Astell, Ellis, Bernardi, Alm, Dye, Gowans and Campbell2010; Bjørnskov et al., Reference Bjørnskov, Møller Jensen and Gregersen2018). According to Bjørnskov et al. (Reference Bjørnskov, Møller Jensen and Gregersen2018), care-givers found film to be a participatory, feasible, affordable and easy-to-use reminiscence activity. Film was perceived to be less time-consuming than object-based reminiscence, enabling all residents to engage with objects ‘in use’ at the same time; all residents can perceive the objects being used on-screen, rather than waiting for physical objects to be passed around individually. Both Bjørnskov et al. (Reference Bjørnskov, Møller Jensen and Gregersen2018) and Astell et al. (Reference Astell, Ellis, Bernardi, Alm, Dye, Gowans and Campbell2010) concluded that film-based reminiscence activities placed less burden on staff to generate and facilitate conversation topics. The presence of dementia-friendly cinema screenings (e.g. https://www.alzheimers.org.uk/get-involved/dementia-friendly-communities/organisations/dementia-friendly-screenings-cinemas) demonstrates that interest in the benefits of film for older people and people with dementia is growing. However, our conversations with care home managers and staff suggest that travelling to cinemas can be prohibitively expensive and is only suitable for the ablest and least frail care home residents. As such, even with dementia-friendly provisions in place, the opportunity to experience meaningful film viewing may only be available to a very small proportion of residents from the most affluent of care homes. Creating a cinematic experience within the care home itself – as demonstrated in our study – therefore potentially offers a more inclusive, feasible and affordable option for enabling all residents to benefit from film.
Reminiscence is often the primary focus of organised care home activities; however, it is important to recognise that there is still limited evidence about its effectiveness (Woods et al., Reference Woods, O'Philbin, Farrell, Spector and Orrell2018). Moreover, the unintended negative consequences of reminiscence have been little explored (Woods et al., Reference Woods, O'Philbin, Farrell, Spector and Orrell2018). As our findings attest, remembering the past can be useful and reflective for older people, but it can also be distressing. According to Grøndahl et al. (Reference Grøndahl, Persenius, Bååth and Helgesen2017), care-givers can find it challenging to respond to older peoples’ painful memories, particularly when these arise unintentionally. As our findings show, even films with happy themes can elicit negative emotions. Because film stimulates memories not only through its content but by reawakening memories of past cinema going and key milestones in residents’ lives, it can be hard to predict whether negative memories will surface. We agree with Bjørnskov et al. (Reference Bjørnskov, Møller Jensen and Gregersen2018) that good knowledge of an older person's life story could inform film choice, but it is no guarantee for how residents will respond to a film in the present. The key, however, is perhaps not in avoiding painful pasts but in ensuring that care-givers are adequately prepared to support residents emotionally should the need arise. Moreover, conversations and emotional reactions sparked by film can continue after the film has ended and care home staff may find themselves talking with residents about the film, or issues it has raised, throughout the night, during personal care provision or at any other time outside the temporal and physical boundaries of activity programmes. As such, engagement with film and its impact on residents is not simply the domain of social activities co-ordinators, but all care home staff.
Selecting films solely for their potential to evoke the past risks missing out on the other benefits we have identified in this paper. At a base level, one of the important aesthetic benefits of film is its capacity for instant, immersive escapism. From a psycho-cinematic perspective (Shimamura, Reference Shimamura2013), by permitting residents to live vicariously in the on-screen action, film can suspend painful memories or transport residents far away from their present realities of physical decline and institutional care home routines. Our study adds to and challenges the privileging of reminiscence in the existing literature by providing a more complex, socio-temporal exploration of film. We have shown that film operates at multiple temporal levels, simultaneously evoking residents’ past, present and future selves. This epitomises the Heideggerian concept of Dasein, in which exploring the past, understanding how it has shaped the present and reflecting on a finite future are an important part in creating and sustaining selfhood (Dreyfus, Reference Dreyfus1991). As other qualitative studies suggest, care home residents’ self-esteem comes not only from their past lives but from their ability to still be useful to others in the present (Dröes et al., Reference Dröes, Boelens-Van Der Knoop, Bos, Meihuizen, Ettema, Gerritsen, Hoogeveen, De Lange and SchöLzel-Dorenbos2006). Our findings demonstrate that residents frequently reflected on the past with the aim of reconceptualising the future; even if it was not their own. Older peoples’ sense of selfhood is often eroded when their identity is recast as ‘care home resident’, where they are no longer positioned as active contributors to family and society (Jenkins, Reference Jenkins2014). In our study, the intergenerational dialogue after each film screening enabled residents to gain satisfaction from imparting wisdom to younger generations.
For the threefold benefits of film screenings to be fully realised – remembering the past, enhancing the present and sharing the future – it is important that frontline care staff understand the concealed complexity of film and its as-yet-unrealised potential as a meaningful activity. We observed, in care home B particularly, that staff tended to view the film screenings as an intervention for residents, not as a mutual community activity; staff busied about and, other than occasionally checking if residents were okay, did not really invest in the film. Given residents’ demanding care needs and the tightly structured institutional routine, it is perhaps understandable that staff are predominantly task focused. Moreover, staff's perception that film is too ‘passive’ may have deterred them from sitting down to watch for fear of being considered lazy or not doing their jobs. However, on the occasions where staff sat with residents to share the film experience (more common in care home A), this was more effective in stimulating conversation and social connection between staff and residents that may not have otherwise happened. Staff participation in the film screenings and discussions was crucial in achieving the core components of a ‘flourishing’ care home environment as defined by Dewing and McCormack (Reference Dewing, McCormack, McCormack and McCance2017): positive emotion, engagement, relationships, meaning and accomplishment. Therefore, to use film most effectively in supporting care home residents to express their selfhood and to connect socially within the care home environment, it must be used proactively and in a way that permits residents to reflect, to escape and to contribute to the social world around them.
Unlike the limited focus of the existing body of research on the use of film with older people, our study has taken a holistic, psycho-cinematic approach to understand how care home residents engage with film. Further research in this vein is required if we are to ultimately develop a recommended approach to the most effective use of films with this population. It is important to develop an understanding of what constitutes the ‘right film’ at the ‘right time’. The seemingly serendipitous nature of selecting the right film demonstrated within our findings suggests that it is insufficient to base film choice solely on the length and style of the film or on the broad diagnostic cognitive and attentional ability of care home residents. Similarly, care home staff told us in their interviews that they felt men were less interested in films generally and would only want to watch action or war movies; it is not possible to say whether the relatively low number of men taking part in our study was because they did not want to take part, or a consequence of staff's recruitment practices. Further investigation is therefore merited into the variable social, affective and life-history factors which shape how individual residents approach a film on a given day. Like Bjørnskov et al. (Reference Bjørnskov, Møller Jensen and Gregersen2018), we found that care home staff often believed that certain films would, or would not, engage residents only to find the opposite to be true. For this reason, Bjørnskov et al. (Reference Bjørnskov, Møller Jensen and Gregersen2018) have highlighted the importance of sometimes trying something new or unexpected. Further research is therefore needed to explore and identify the principles and processes behind selecting the ‘right film’, in recognition that this choice should go beyond consideration of cognition and attention, but taking into account the individual, cultural and social factors within each person's past, person and future. Film undoubtedly has the potential to create physical, social and temporal opportunities for residents to express agentive selfhood and to participate more fully in their care home communities, but only if we commit to moving beyond the general hypercognitive bias in the field that dismisses relationships and emotions as secondary to memory and cognitive function.
Limitations
Both participating homes were privately funded with good Care Inspectorate quality ratings, limiting the extent to which the findings from our study transfer into other settings. Thus, further research is needed to explore the benefits and challenges of film screenings in a more diverse range of care homes and care home populations. Shimamura's model of psycho-cinematics provided a framework balanced between film studies and health and social science, bringing together issues of aesthetics and cognition in its consideration of the audience's engagement with a given film. Addressing every element in the framework, including our own social component, may have limited more in-depth exploration of specific, promising areas. For example, sustained analysis of the residents’ sensory experience may have yielded more data about how the film screenings offered physical benefits comparable to other activities such as dance or gardening. Future research could situate Shimamura's model alongside related theories of spectatorship, such as embodied visuality (Sobchack, Reference Sobchack2004), allowing for more versatility in the areas of focus.
There are some further methodological limitations in our study. Ideally, it would have been more rigorous to have two observers present for the entire film screening; but we made the pragmatic decision to conduct staff interviews during this time in order to be least disruptive to the care home schedule. We also experienced some contextual challenges in collecting data in care home B (fewer staff available and competing with other scheduled activities), therefore, our findings may predominantly reflect the experience of care home A. Moreover, our data generation strategy in both homes meant that only initial reactions to the film were captured, that is, whilst watching and in the discussions that followed immediately afterwards. To capture more effectively the impact of film viewing on the care home community, an unstructured ethnographic approach with researchers embedded in the care home environment over long periods could have yielded important insights into the long-term or delayed impacts of the film-viewing experience on both residents and staff. Such embedded ethnographic work is particularly effective in care home settings (Hockey, Reference Hockey1990). Moreover, our presence in the home and the facilitation of the discussion groups could be considered a part of the ‘intervention’ itself, meaning that residents may have gleaned much of the social connectivity benefits from the discussion, rather than directly from the film itself. This is not necessarily a limitation but is an important point to note in future development of this work to understand if and how film screenings could/should be supported and facilitated in future to maximise benefits. Finally, care home residents’ experiences of ageing and their perceptions of time and meaning may be qualitatively different from the position of the – much younger – authors. While we have endeavoured to approach this paper with reflexivity and an ethnographic stance that values observation and interaction as a means of insight into social worlds, we must also acknowledge that this paper is situated within our own ways of being in and viewing the world and must be interpreted as such.
Conclusion
Care home residents experience a loss of autonomy compounded by loneliness and social isolation, leading to a loss of sense of self and connection with others. This study is the first to explore the opportunities and challenges of facilitating collective film screenings in care homes from a holistic psycho-cinematic perspective and offers useful insights into the rich potential for film to enhance the care home community, facilitate social connectivity and promote resident wellbeing. Our findings demonstrate that film viewing is far from passive and that, by dismissing it as such, care homes are missing out on its therapeutic, community-building potential. Our paper highlights how watching films in care homes does not simply enable residents to reminisce but can enhance residents’ present and enable them to look towards the future. To maximise the full potential of film to enhance care home residents’ sense of self and social connection, it is important to capitalise on these three benefits. Future research is needed to develop an evidence base for film as a practical resource in care homes to promote social connectivity, selfhood and social wellbeing. This research should adopt a psycho-cinematic perspective, in which cognitive ability and attention are only one part of a complex socio-temporal understanding of spectatorship.
Acknowledgements
We would like to thank staff, residents and relatives from both participating care homes for welcoming us into their communities and sharing their experiences and opinions with us.
Author contributions
JPB contributed to study design, led and conducted data collection and analysis, and drafted the manuscript. AS conceived the study, contributed to study design, recruited care homes, collected data, and contributed to data analysis and drafting of the manuscript. TK and GW contributed to study design and commented on the manuscript. All authors reviewed the manuscript prior to submission.
Financial support
This work was supported by the Carnegie Trust Research Incentive Grant. The funder played no role in the design, execution, analysis and interpretation of data, or writing of the study.
Conflict of interest
The authors declare no conflicts of interest.
Ethical standards
This study was granted favourable ethical approval by the University of Dundee Research Ethics Committee on 4 April 2016 (reference number UREC 16040).
