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The case study examined physical and social privacy for nine residents residing in personal care homes in Winnipeg, Manitoba, Canada. The study explored how residents’ well-being and quality of life was affected by the privacy afforded to them in various room accommodations. The case study explored residents’ social location, room preference, safety and security, communication with family, interaction with staff, and interaction with roommates. The study found that residents benefit from having access to locks for doors; specialized units for cognitively impaired residents; private health assessment rooms; phasing out multi-bed room; use of room barriers; privacy for intimacy; access to private lounges for visiting; and private room with a public telephone. The study assists health care providers and students in health fields in becoming aware of privacy issues. The study may be useful in assisting residents to prepare for adjustment to a personal care home.

The elderly are the fastest growing population in the United States. Nurses' attitudes toward caring for the elderly are a very real concern and may determine nurses' behaviors with the elderly. The purpose of this study was to examine the attitudes of nurses toward caring for the elderly residing in long term care institutions. A modified questionnaire, "Attitudes Toward Caring for the Elderly" was used. A combination of Jean Watson's theory of caring and the Ajzen & Fishbein's theory of reasoned action was the theoretical framework used for the study. Three research questions were asked. Data were collected from 32 registered nurses in four long term care institutions. Results showed that nurses attitudes toward caring for the elderly were positive. There were no significant relationships between demographic and personal data and nurses' attitudes toward caring for the elderly. Full time versus part time employment was a significant predictor of nurses attitudes toward caring for the elderly. The low reliability of the tool (Cronbach's alpha = 0.57) could have contributed to the lack of significant data. The study should be repeated after further development of validity and reliability of the tool. / School of Nursing

Background and Objectives: Antipsychotic medications (APMs) are used for the treatment of behavioural symptoms of dementia. The use of APMs among residents of long-term care facilities (LTCFs), who have a high probability of dementia, is correspondingly high, and has been linked to adverse patient outcomes. The study objectives were to: (a) describe facility variation in APM discontinuation rates, (b) test the association between time to APM discontinuation and patient and facility explanatory variables, and (c) conduct a sensitivity analysis about the effect of changes in the measurement of APM discontinuation on variable associations. Methods: The study used a population-based retrospective cohort design. Saskatchewan’s (SK) administrative health databases for the period from April 1, 2004 to March 31, 2011 were the data sources. The study cohort included all seniors (≥65 years of age) with a first admission to a SK LTCF and an APM dispensation on or after the admission date. Discontinuation was defined as a 70-day gap after the last APM dispensation. Patient-level explanatory variables included socio-demographics, comorbidity, prior medication exposure, behavioural and cognitive status, and health services utilization. Facility-level explanatory variables included size, location, licensing status, and type. Percentage discontinuation across facilities was descriptively analyzed. Cox proportional hazards regression models with adjustment for clustering of patients within LCTFs were used to test associations with time to discontinuation. A sensitivity analysis of APM discontinuation was conducted by shortening (35 days) and lengthening (105 days) the time from last dispensation. Results: Among all residents eligible to be cohort members 35.7% were dispensed an APM. A total of 19.5% of the 8358 cohort members discontinued APMs in the observation period. The Kaplan-Meier estimate of the median time to discontinuation was 6.5 years. Demographic, comorbidity, behavioural, and drug exposure variables were most strongly associated with APM discontinuation. Discontinuation was not associated with facility characteristics. Variable associations were insensitive to the definition of APM discontinuation, but changed over time. Conclusion: Discontinuation of APMs is low, despite high rates of utilization over long periods of time. Patient characteristics are associated with APM discontinuation, but not facility characteristics, suggesting that LCTFs are applying consistent approaches to patient management. However, low levels of discontinuation suggest that there may be a need for health care providers to regularly review the prescribing, dispensing, and administration of APMs to LTCF residents in order to ensure appropriate use of these pharmaceuticals.

Older adults in residential care often lead sedentary lifestyles despite physical and cognitive activities being crucial for their well-being. Care facilities face the challenge of encouraging their residents to participate in leisure activities, but as the impact of age-related changes grows, few activities remain accessible. Video games in general – and motion-based games in particular – hold the promise of providing mental, physical and social stimulation for older adults. However, the accessibility of commercially available games for older adults is not considered during the development process. Therefore, many older adults are unable to obtain any of the benefits. In my dissertation, this issue is addressed through the development of motion-based game controls that specifically address the needs of older adults. The first part of this thesis lays the foundation by providing an overview of motion-based game interaction for older adults. The second part demonstrates the general feasibility of motion-based game controls for older adults, develops full-body motion-based and wheelchair-based game controls, and provides guidelines for accessible motion-based game interaction for institutionalized older adults. The third part of this thesis builds on these results and presents two case studies. Motion-based controls are applied and further evaluated in game design projects addressing the special needs of older adults in long-term care, with the first case study focusing on long-term player engagement and the role of volunteers in care homes, and the second case study focusing on connecting older adults and caregivers through play. The results of this dissertation show that motion-based game controls can be designed to be accessible to institutionalized older adults. My work also shows that older adults enjoy engaging with motion-based games, and that such games have the potential of positively influencing them by providing a physically and mentally stimulating leisure activity. Furthermore, results from the case studies reveal the benefits and limitations of computer games in long-term care. Fostering inclusive efforts in game design and ensuring that motion-based video games are accessible to broad audiences is an important step toward allowing all players to obtain the full benefits of games, thereby contributing to the quality of life of diverse audiences.

近年來，由於家庭型態急速變遷，受少子女化現象、公共衛生發展、疾病之有效控制，及科技醫療發達等影響，全球人口高齡化現象日益顯著。根據內政部統計統計，我國截至2012年止，老年人口所佔比率，已大幅攀升至11.15%，該現象顯示未來，老年生活之經濟安全保障，已成為國內重大社會課題之一，而政府為了加強老人福利服務、醫療照護與保健等，近幾年來更是積極規劃「長期照護」等相關政策。 在我國，「長期照護」主要係指針對缺乏自我照顧能力者，提供健康與社會照顧之服務，雖然各年齡層人口均有發生長期照顧需要之風險，惟老人係照護服務需求之主要族群；由於照護時間往往漫長且無法預期，其成本往往超出家庭成員可負擔之範圍，普遍認為需由政府積極介入；惟中央財政缺口日深，舉債額度業逼公債法之上限，如何籌措財源即成為首要之務，按政府目前規劃方向，係朝開辦單一制之社會保險因應。 然而，我國已開辦之社會保險種類繁多，根據立法院預算評估報告，勞保、退撫、國民年金保險三大退休保險基金財務缺口總額已逾台幣八兆元，且持續惡化中，如今再將全民強制納入長期照護之被保險對象，是否適當有待商榷，且長期照護保險未來開辦後，若仍維持「高給付、低費率」之設計，恐落入相同財政困境，使負債世代移轉問題日益嚴重，且影響基金永續經營。 況且，如何說服所有民眾願意繳納長達數十年之長照保險費，直至「有可能發生」身心功能障礙，且持續達六個月以上時，始得被列為長期照護服務之對象，獲取保險給付及相關補助等，亦是項艱難的任務；另外，開辦後對於國內經濟將產生之影響與衝擊，更須妥為評估。 本研究將以目前已開辦之社會保險經營現況、國家財政、經濟發展情況及各界觀點等為切入點，佐以他國實施之經驗為參考，並就各種財源籌措方式之優缺點，以及社會民眾之接受度等，討論我國長期照護財源籌措較可行之方式。 / Globally, population aging has become an increasing trend in recent years due to rapid changes in family patterns, low fertility rate, development of public health and effective control of diseases, and advanced medical technology. According to local statistics, as of 2012, Taiwan’s elderly population has substantially increased to 11.15%. This denotes the future economic security of old people which has become one of the major social issues in Taiwan. In recent years, the government has also actively implemented policies relating to “long-term care” in order to strengthen welfare services, nursing and medical care for the elderly. In Taiwan, “long-term care” means to provide health and social care for dependent-care patients. Old people are the primary focus of care services, although people of all ages are likewise at risk of requiring long-term care. Given the long-term and unexpected time involved in care giving as well as the high expense that families could incur, the government is actively considering a social insurance system. With the increasing gap between the national budget and the debt limit which affects the law governing government bonds, raising funds has become a priority. To establish a unitary social insurance system is the current direction that the government wants to take. However, Taiwan has already established various forms of social insurance. Based on reports from the legislatures’ budget and assessment, there is a financial gap in three major pension funds including labor protection, civil service pension and national annuity insurance, which has exceeded NTD 8 trillion and is constantly getting worse. Recently, there was an issue whether to require everyone to apply insurance with long-term care. By implementing a long-term care insurance in the future, there would be a constant need to maintain a “high pay, low rate” package that could possibly lead to a similar fiscal difficulty, which would increasingly aggravate the transfer of debt from generation to generation, affecting sustainable operation of the fund. It is also difficult to persuade people to pay insurance premium for decades until physical and mental problems occur and last for over 6 months. It is only during this period that people can avail long-term care services and receive compensation and subsidy. The effect and impact of introducing this form of insurance on the domestic economy needs to be further evaluated. With an established social insurance management status, the national budget, the economy and opinions from all members of society as well as experience of other countries should be considered as a starting point or reference in initiating such plans. This study discusses potential measures for long-term fund raising based on the advantages and disadvantages of various fund raising measures as well as social acceptance.

Despite the benefits of physical activity for older adults, many residents living in long-term care homes (LTC) are relatively inactive. Previous research has revealed barriers to physical activity at the resident-level, organizational, and environmental level. However, little attention has been paid to other factors influencing physical activity within the broader institutional complex. The goal of this study was to uncover how the work of personal support workers (PSWs) related to the promotion of physical activity was socially organized. Institutional Ethnography (IE), developed by Dorothy Smith, guided this study. Smith proposed that peoples’ everyday experiences in local settings are organized, often unknowingly, by the actions of people located outside of the local setting and that this organization is textually-mediated. Two LTC homes in Ontario participated in this study. I began data collection by observing PSWs as they went about their work. Next, I interviewed PSWs and other people located inside (e.g. nurses, managers) and outside the LTC homes (e.g. representatives from the Ministry of Health and Long-Term Care (MOHLTC). Lastly, I collected texts that organized the PSWs’ work, such as Ministry standards. The findings revealed that although the MOHLTC standards were viewed as producing something “good” for the residents, some of the standards disrupted the PSWs’ work, which made it challenging for them to support daily physical activity. The promotion of physical activity was seen as an additional program that happened a few times per week and it was parceled out as a professional activity that was socially organized “out” of the PSW role. The findings suggest that local solutions are needed. A good starting point would be to go and talk to PSWs and residents to determine what type of assignments would permit the incorporation of physical activity into daily care. To embed the promotion of physical activity into daily care, a major rethink and reorganization of PSWs work will be needed, including a greater investment in human and material supports for PSWs.

Objective: This research explores the critical need for individualized care planning to ensure maximum cost savings by providing a balance between individuals’ care needs and care wishes. The primary objective of this research is to identify common goals of care (GoC) expressed by long-term care residents (using the interRAI LTCF) and clients receiving community supportive services (using the interRAI CHA) or community mental health services (using the interRAI CMH). Methods: Three interRAI datasets were used to perform data analyses. The responses to the open-ended GoC item were quantified and grouped into common goal categories, which were then examined against the interRAI outcome measures and Clinical Assessment Protocols (CAPs). Demographic and clinical characterisitics were compared across the sample populations using the chi-square test. Logistic regression models were created to reveal variables that are predictive of not having a GoC recorded within each care setting. Results: Twenty-five GoC categories were created. Although the GoC responses were very diverse, many persons had no goal recorded. Nearly 70% of long-term care (LTC) residents and community support service (CSS) clients were unable to state a GoC. Different populations in different service settings had distinct GoC but had some commonalities as well such as goals that focused on general physical or mental health issues. GoC varied with the CAPs- the triggering of a CAP did not necessarily mean a corresponding GoC was noted. Each care sector had different predictor variables that were strongly associated with not having a GoC. Conclusions: There is not a “one size fits all” solution to care planning. The same goals and outcome measures are not appropriate or realistic for all persons. It is critical to incorporate self-reported goals into the development of effective and individualized care plans to ultimately improve one’s quality of life, satisfaction with care, and success in achieving desired outcomes of care.

Background: Quality of life (QoL) of long term care facility (LTC) residents is being recognized as an important outcome of care by LTC providers, researchers, and policy makers. For residents, measurement of QoL is a valued opportunity to express their perception of the quality of their daily life in the LTC facility. For clinicians, self-reported QoL provides useful information in planning and implementing resident-centred care. Purpose: The purposes of this study were: (1) to examine the distributional and psychometric properties of the interRAI Self-Report Nursing Home Quality of Life Survey (interRAI_QoL Survey); and (2) to explore the relationship of selected socio-demographic and clinical characteristics of residents and LTC facility attributes with residents’ self-reported QoL. Methodology: This was a cross-sectional observational study. A convenience sample of 48 volunteer LTC facilities from six Canadian provinces was involved in this study. Nine hundred and twenty eight (928) residents agreed to participate in this study. Resident inclusion required an interRAI Cognitive Performance Scale score of 0 (intact) to 3 (moderate impairment). Residents’ self-reported QoL was measured by trained surveyors using the interRAI_QoL Survey instrument. Residents’ socio-demographic and clinical characteristics were obtained from the most recentResident Assessment Instrument –Minimum Data Set 2.0 prior to the QoL interviews. LTC facility attributes were measured by a survey form specifically designed for this purpose. Descriptive statistics were used to describe the participating LTC facilities, the sample of residents, and residents’ self-reported QoL. Psychometric tests for reliability (test-retest and internal consistency) and validity (content and convergent) were conducted. Bivariate analyses were conducted to examine the relatioships between QoL and resident and facility charateristics. Multivariate linear and logistic regression analyses were conducted to identify predictors of residents’ QoL. Results: The study confirmed the feasibility of assessing LTC facility residents’ self-reported QoL. The findings showed positive ratings of some aspects of residents’ daily lives while negative ratings in other aspects. Psychometric tests showed that the interRAI_QoL Survey instrument had test-retest reliability, internal consistency, content validity and construct (convergent) validity. Several resident and facility characteristics were associated with self-reported QoL. Religiosity and highest education level attained were significantly and positively associated with QoL. Other resident characteristics such as age, gender and marital status were not. Mild cognitive impairment, depression, aggressive behaviour, hearing impairment, bowel and bladder incontinence, and extensive assistance in activities of daily living were significantly but negatively associated with QoL. LTC facility ownership showed significant association with QoL. Residents in municipal LTC facilities followed by private LTC facilities reported higer QoL in contrast to charitable LTC facilities. Profit status, accreditation and leadership stability were not associated with QoL. Residents in rural settings reported significantly higher QoL than those in urban settings. Facility size (measured in number of beds), registered nurse hours of care, nursing staff turnover, and ratios of registered to non-registered nursing staff did not have a significant association with QoL. However, higher management hours and total hours of care had significant and positive associations with residents’ overall QoL. Multiple linear regression showed that residents’ religiosity, degree of social engagement, post secondary education, dependence in activities of daily living, and positive global disposition, and LTC facilities situated in rural settings and ownership type together accounted for 24% (adjusted R2=0.24) of the variance in overall QoL (the dependent variable). In logistic regression, low QoL was used as the binary dependent variable. Residents who were religious, were socially engaged and had a positive global disposition were less likely to report low QoL. In contrast, residents with dependence in activities of daily living and post secondary education were more likely to report low QoL. Residents in LTC facilities located in rural settings and operated by municipal or private operators were less likely to report low QoL compared to charitable facilities. Strengths and Limitations: This study had several strengths, including a sample of 928 residents who self-reported on their QoL and the use of RAI-MDS 2.0 for objective, external indicators of QoL. This study had several limitations, including response bias due to method of sample selection, inability to draw causal inferences due to study design; limited generalizability due to use of a convenience sample, lack of monitoring of surveyors for the integrity of resident interviews, and exclusion of residents with cognitive performance scale scores of more than three or inability to communicate in English. Future research should address these limitations. As well, future research should conduct more stringent psychometric analyses such as factor analysis and use multi-level modeling procedures. Implications: The findings of this study have implications for improving residents’ QoL, LTC facility programming, future research, and social policy development. Conclusion: QoL can be measured from resident self-reports in LTC facilities. Self-reports from residents may be used by clinicians to plan and implement resident-centred care. There are significant associations of residents’ QoL with select resident socio-demographic and clinical characteristics and facility attributes. Some of these resident characteristics and facility attributes may serve as predictors of QoL.