Response Facilitation in Dementia Care: Exploring Engagement Through Social Contexts: A Qualitative Study in Dutch Nursing Homes

Background/Objectives: Dementia-related cognitive impairments and staffing shortages in nursing homes challenge the possibilities for individually tailored recreational activities, raising the question of how the physical and social environment might be leveraged to stimulate engagement through response facilitation, a form of vicarious incentive motivation grounded in Social Cognitive Theory. This study examines in which social contexts observing others’ recreational activities can effectively engage residents with moderate to advanced dementia. Methods: A qualitative, scenario-based multiple case study was conducted in four nursing homes (n = 21), using fly-on-the-wall observations, narratives, and three experimentally embedded social contexts (individual, dyadic, group) around familiar leisure activities. Behavioural engagement, mood, and agitation were assessed with validated observational scales (e.g., OERS and MEDLO), complemented by wearable sensor data (HR/PR, HRV/PRV, SCL, and temperature) and video for contextualised interpretation. Results: Across scenarios, non-participating residents showed limited behavioural responses in individual and dyadic settings, while group activities more frequently elicited both observable engagement and physiological markers consistent with attention or cognitive engagement. Observational and physiological data frequently diverged, which may indicate cognitive or emotional engagement even when overt participation or affect remained minimal or appeared negative. Conclusions: Response facilitation appears most likely in structured group activities if supported by explicit social scaffolding, rather than in individual or dyadic constellations alone. Reliance on behavioural observation or environmental design in isolation risks underestimating engagement; multimodal, context-sensitive approaches are recommended to better harness social mechanisms for meaningful participation in dementia care. Future research should integrate contextual factors with physiological measurements and observations as well as further explore patterns of inactivity to distinguish disengagement from subtle forms of cognitive engagement.