Thesis (Ph. D.)--School of Nursing. University of Missouri--Kansas City, 2007. / "A dissertation in nursing." Advisor: Katharine Smith. Typescript. Vita. Title from "catalog record" of the print edition Description based on contents viewed Jan. 2, 2008. Includes bibliographical references (leaves 155-168). Online version of the print edition.

Thesis (Ph.D.)--Wayne State University, 2007. / Adviser: Gail A. Jensen. Includes bibliographical references.

Thesis (Ph.D.)--Memorial University of Newfoundland (Canada), 2007. / Includes bibliographical references.

Thesis (Ph. D.)--University of Louisville, 2009. / Department of Leadership, Foundations, and Human Resource Education. Thesis (Ph. D.)--Western Kentucky University, 2009. College of Education and Behavioral Sciences. Vita. "May 2009." Includes bibliographical references (leaves 118-124).

The purpose of this study was, first, to further our understanding of the experience of dying in a long-term care (LTC) facility from the perspective of family members and second, to identify the relationships between the various factors which may influence satisfaction with end-of-life care. Using a sequential mixed methods design, a convenience sample of 87 family members completed a survey interview using a modified version of the Toolkit of Instruments to Measure End-of-life Care (TIME) Nursing Home Version in the first phase of the study. Findings from the parametric and non-parametric analyses indicated that family satisfaction with end-of-life care was best predicted by contact and communication with nursing staff, feeling that care provided at the end of life met expectations, staff providing consistent care, feeling that the health care aide listened to their concerns about care and that respondents felt they had received enough emotional support. Being transferred to hospital in the last month of life, dying in a place other than the LTC facility, and respondent age and employment status were all associated with significant mean differences in satisfaction scores. In the second phase, three focus groups were conducted to further explore areas of satisfaction and dissatisfaction with end-of-life care. Focus groups provided confirmation of the findings of the first phase of the study and were instrumental in developing a list of ten recommendations for improvements in end-of-life care delivery. Recommendations for future research are made based on the study results. / October 2007

Long-term residential care (LTRC) is a complex sociopolitical milieu where people from diverse backgrounds come to live and work together. In recent years health care restructuring has resulted in the closure of facilities; health care policy has narrowed the population that accesses LTRC so that only those who are the most medically and socially complex are admitted; and there has been a transformation of the work force, a workforce that is mainly comprised of Women of Colour and is among the lowest paid in health care. The purpose of this study was to critically examine the organization of care in LTRC within this context. The theoretical perspective guiding the study was informed by postcolonialism, postcolonial feminism, intersectionalities, and Foucaudian epistemology. The method of inquiry for the study was critical ethnography, which allowed for critical analysis of `taken for granted' assumptions in the organization of care. Over a period of ten months, I was immersed in two LTRC facilities in the Lower Mainland of British Columbia. Field work consisted of approximately 218 hours of participant observation. I conducted 51 interviews with administrators, family members, residents, and staff. I reviewed relevant provincial policies and facility-based policies and procedures. I also collected quantitative data related to resident transitions in the health care system (for example, admissions, discharges, and hospital admissions), and staffing levels. Findings from this study were discussed in three key themes. First, a systematic decommissioning of citizenship occurred for residents and staff in this setting. Second, the impact of health care restructuring over the past decade had important consequences for relationships between residents, family, and staff. Third, relational care took place in `stolen' moments that occurred despite heavy workloads. All of these themes were underscored by intra-gender oppression, relations of power, and influenced by discourses of ageism and corporatism, which ultimately played out in day to day interactions between those who live and work there. Recommendations from this study included: addressing the entrenched hierarchies in nursing, further examination of the public-private funding model in LTRC, and the introduction of an independent ombudsperson to ensure consistent, high quality care across the LTRC sector. / Applied Science, Faculty of / Nursing, School of / Graduate

Americans over age 65 constitute a larger percentage of the population each year: from 14% in 2010 (40 million elderly) to possibly 20% in 2030 (70 million elderly). In 2015, an estimated 66 million people provided care to the ill, disabled, and elderly in the United States. In 2000, according to the Centers for Disease Control and Prevention (CDC), 15 million Americans used some form of long-term care: adult day care, home health, nursing home, or hospice. In all, 13% of people over 85 years old, compared with 1% of those ages 65 to 74, live in nursing homes in the United States. Transitions of care, among these various levels of care, are common: Nursing home to hospital transfer, one of the best-studied transitions, occurs in more than 25% of nursing home residents per year. This article follows one patient through several levels of care.

Each year, hospitalizations from long-term care (LTC) settings occur, in part, due to underdeveloped nursing assessment skills, ineffective communication with primary care providers (PCPs), and delayed intervention. Through staff development nursing education, the quality and timeliness of care can be improved. The practice question that guided this doctoral project focused on whether evidence-based research information would assist in decreasing LTC-to-hospital admission rates through improved nursing assessment skills and better communication with PCPs. Using the logic model, the effectiveness of a program was evaluated and the impact of interventions on a predicted outcome was determined. Sources of evidence included obtaining best practice research information from scholarly nursing journals and official nursing websites. Analytical strategies included a review of the literature to examine data from nursing journals, websites, and other publication sources in addition to the use of a synthesis matrix that classified different ideas rated by the Cochrane Consumer Network. The findings of this project might contribute to positive social change by fostering improved patient assessments, enhanced communication with PCPs, early intervention, and decreased LTC-to-hospital admission rates through the improvement of nursing practice policy.

The Palliative and Therapeutic Harmonization (PATH) program was designed to help frail older adults and their family members prepare for and make medical decisions, in the context of frailty and dementia. This sandwich thesis includes three manuscripts that present the findings from a mixed methods study exploring the implementation and outcomes of the PATH program, in three long-term care (LTC) home settings. The purpose of the first sub study was to describe both the perceived need for the PATH program, and initial reactions following its training and implementation. Quantitative surveys and qualitative interviews with bereaved family members showed that prior to implementation, they were mostly satisfied with their relatives’ end-of-life care. Through qualitative interviews, clinical leaders shared a positive impression of the training and PATH principles. They also explained how the PATH program could help them improve palliative and end-of-life care planning and communication with residents and families. In the second sub study, qualitative interviews were conducted with family members to learn about their experiences with and perceived outcomes from the PATH program. All family members had a positive experience. They shared perceived outcomes such as, opportunities to share and learn about their relative’s health status and trajectory, creating a mutual understanding of directions for care, and receiving support and reassurance for health care decision making. Finally, the purpose of the third sub study was to describe both the perceived outcomes of the staff who implemented the PATH program, and differences in documenting residents’ advance care plans and discussions. Staff described both personal and practice related outcomes. In addition, documentation around advance care planning changed with the program’s implementation. Overall, the PATH program offered frail older adults, their family members and their professional caregivers an opportunity to communicate about and prepare to make decisions for palliative and end-of-life care. / Dissertation / Doctor of Philosophy (PhD)

The long-term care (LTC) sector in Canada has experienced high numbers of COVID-19 deaths. However, there is a paucity of data on the impact of COVID-19 in LTC by different socio- demographic variables and in LTC homes within different regions. Additionally, the question remains as to how exactly and by how much the pandemic has impacted mortality in LTC in comparison to previous years’ mortality. Ranges for expected mortality by sex, province, and age, for the 2020-21 fiscal year were determined by creating forecasts and confidence intervals based on mortality trends in the preceding four fiscal years. These ranges were then compared to the actual mortality data in 2020-21. Comparisons between expected ranges and actual data were also conducted for the number of active residents, admissions, and discharges in LTC by sex, province, and age. Further, mortality ratios were created and studied by sex, province, age, and health region/authority/local health integration network. Overall, the number of deaths in LTC in Canada increased beyond the expected ranges in quarter one and three of 2020-21, and the patterns in death ratios were similar. Increases were exceptional in comparison to the peaks in deaths in previous years for specific variables, but not all variables. Most commonly, the number of active residents and admissions decreased in 2020-21 and the number of discharges from LTC did not change in quarter one and three and decreased in quarter two and four. However, importantly, these trends also varied across variables. This was the first study to comprehensively examine mortality due to COVID-19 in LTC overall, and by multiple socio- demographic variables while elucidating the complexity in the study of mortality in LTC. Further research is required to concretely understand mortality in LTC by different variables and regions. / Thesis / Master of Arts (MA) / This study examined mortality due to COVID-19 from April 2020 to March 2021 in Canadian long-term care (LTC) homes by sex, age, province, and health region. Ranges of predicted values for mortality were created from mortality data from previous years and then compared with actual mortality. The number of active residents, admissions, and discharges were also examined by sex, age, and province to factor for changes in the population at risk. Overall, mortality increased in some quarters (April-June 2020 and October-December 2020) but was not always exceptional, as similar mortality rates had been observed in the four years prior to the pandemic. Also, the increase in mortality was seen mostly among younger residents (65 to 85); mortality remaining stable for the 85+. Further research is still required to better understand mortality in LTC by regional characteristics.