Oral health has dramatically improved in most industrialized countries over the latter half of the 20th century. However, profound oral health disparities still exist especially for those most at risk of developing oral diseases and associated systemic consequences such as populations residing in long-term care facilities. Despite the growing body of literature that supports the link between oral microflora and the importance of oral hygiene in limiting the risk of pneumonia development, there are still gaps in our knowledge to effectively manage this risk. The research included in this dissertation sought to further our understanding of oral health and oral care in the context of pneumonia pathogenesis (chapter 3) and, by exploring the perspective of various stakeholders in oral health, we sought to further understand the factors that influence care provision (chapter 5). Additionally, a novel knowledge translation approach was tested to challenge traditional oral care interventions in order to promote improvements in front-line oral care practices (chapter 6). The relationship between oral microflora, oral care and pneumonia was found to be complex. It directs us to consider converging risk factors including a patient’s health status, health behaviours and access to oral care services. Different professional groups were found to possess different definitions of oral health, which influenced both their motivation to provide care as well as their focus of care. Definitions of oral health could also potentially influence the saliency of different types of oral care information to different targeted groups; therefore, this should be considered in developing education and training initiatives aimed at improving the provision of oral care. An appreciative knowledge translation approach was found to be effective in bridging the gap between oral care knowledge and the provision of care. Regardless of the type of intervention chosen, organizations were reported to play a crucial role in promoting oral health and supporting the successful implementation of oral care programs.

Antipsychotic use is an important issue in long-term care (LTC) homes due to their widespread use, the potential for serious adverse events and limited evidence about their efficacy in treating behavioural and psychological symptoms of dementia. Rates of antipsychotic use vary across LTC homes, but little is known about the contribution of physicians to this variation. This study documented the characteristics of physicians who regularly treated residents in Ontario LTC homes and examined variation in antipsychotic prescribing across physicians. In a population-based retrospective cohort of LTC residents, 637 (52.8%) of 1,207 LTC physicians cared for 46,365 (90.4%) of all residents. Overall, 27.3% of residents received antipsychotic therapy, but extremely high prescribers prescribed antipsychotics to 42.8% of their patients. Variation in physician antipsychotic prescribing persisted after controlling for clinical and behavioural resident characteristics. This variation was reduced by 47.1% when LTC homes were accounted for in multilevel cross-classification logistic regression models.

Objective: To assess the efficacy of personal support worker (PSW) mouth care education to improve the oral health of residents of long term care homes. Methodology: Experimental PSWs received mouth care education at baseline before taking the knowledge test. PSWs‟ mouth care knowledge was measured using a 20-item knowledge test at baseline, post-test (supervised); 6-months (un-supervised). Residents‟ oral health outcomes assessed at baseline and 6-months using the modified Plaque Index and modified Gingival Index. Results: Experimental PSWs‟ post-test knowledge (n=32;M=17.59;SD=1.43) significantly increased from pre-test (M=15.34;SD=2.10), F(2,72)=4.90;p<.05. 39 control residents and 41 experimental residents participated. Experimental residents‟ PI significantly decreased at 6-months compared to baseline, F(1,156)=5.52;p<.05, there was no significant difference in their GI between baseline and 6-months, F(1,156)=3.29;p=.07. Conclusion: PSWs‟ mouth care knowledge significantly increased after receiving mouth care education and was sustained over six months. Only experimental residents‟ PI significantly improved after 6 months.

This thesis aimed to test the relationship between resident satisfaction and staff satisfaction. Using a cross-sectional design, administrators, staff and residents from 24 LTC homes were surveyed. Logistic regression models predicting high resident satisfaction were developed with a primary focus on the relationship to direct care staff satisfaction, while controlling for facility, staff and resident characteristics (and facility-level clustering). Regression models were developed for overall staff satisfaction and three other domains of job satisfaction. The odds of high overall resident satisfaction decreased by 27% and 31% for each 1-unit increase in overall job satisfaction and satisfaction with workload, respectively. In contrast, the odds of high overall resident satisfaction increased by 5.56 times for each 1-unit increase in mean staff satisfaction with work content. LTC homes may be able to improve staff and resident experiences concurrently by encouraging direct care staff to enter into meaningful relationships with residents.

Objective: To assess the efficacy of personal support worker (PSW) mouth care education to improve the oral health of residents of long term care homes. Methodology: Experimental PSWs received mouth care education at baseline before taking the knowledge test. PSWs‟ mouth care knowledge was measured using a 20-item knowledge test at baseline, post-test (supervised); 6-months (un-supervised). Residents‟ oral health outcomes assessed at baseline and 6-months using the modified Plaque Index and modified Gingival Index. Results: Experimental PSWs‟ post-test knowledge (n=32;M=17.59;SD=1.43) significantly increased from pre-test (M=15.34;SD=2.10), F(2,72)=4.90;p<.05. 39 control residents and 41 experimental residents participated. Experimental residents‟ PI significantly decreased at 6-months compared to baseline, F(1,156)=5.52;p<.05, there was no significant difference in their GI between baseline and 6-months, F(1,156)=3.29;p=.07. Conclusion: PSWs‟ mouth care knowledge significantly increased after receiving mouth care education and was sustained over six months. Only experimental residents‟ PI significantly improved after 6 months.

This thesis aimed to test the relationship between resident satisfaction and staff satisfaction. Using a cross-sectional design, administrators, staff and residents from 24 LTC homes were surveyed. Logistic regression models predicting high resident satisfaction were developed with a primary focus on the relationship to direct care staff satisfaction, while controlling for facility, staff and resident characteristics (and facility-level clustering). Regression models were developed for overall staff satisfaction and three other domains of job satisfaction. The odds of high overall resident satisfaction decreased by 27% and 31% for each 1-unit increase in overall job satisfaction and satisfaction with workload, respectively. In contrast, the odds of high overall resident satisfaction increased by 5.56 times for each 1-unit increase in mean staff satisfaction with work content. LTC homes may be able to improve staff and resident experiences concurrently by encouraging direct care staff to enter into meaningful relationships with residents.

This study uses a grounded theory approach (Charmaz, 2006) in a small case study to examine if drama as praxis influences long-term care residents when presented as a recreational activity. When used as “praxis” (Taylor, 2000), drama focuses solely on the learning and personal growth of the participants. The growth of long-term care underscores the value of recreational programming for quality of life in these institutions; drama as praxis has not been widely used in this context. Elements of the literature review were used to identify areas where dramatic activities have demonstrated influence in educational contexts: • Engagement / Participation • Self-Confidence / Sense of Efficacy • Social Skills / Empathy • Creativity / Imagination • Cognitive Skill Development / Understanding These became sensitizing concepts for the creation of “drama as praxis” activities, presented in six sessions to a small group of residents at a long-term care residence in the Toronto area. Data collection was based on the researcher’s observations and participant interviews. Drama was found to have a recreational benefit impacting quality of life, with Engagement, Social Skills,, and Self-Confidence, the predominant benefits observed. Creativity and Cognitive Skill Development were less frequent. A Theory of the Recreational Benefit of Drama as Praxis was then developed to help the researcher understand why these benefits might be caused by drama. Based on theoretical sampling from recent research in gerontology and brain science, the theory highlights four beneficial components of drama as praxis: 1. Kinesthetics – Fosters engagement and memory retrieval 2. Play and Endorphinal Release – Triggers cognitive work without fear or fatigue 3. Imagination and Perspective-taking – Helps individuals retrieve emotional memories, develop different perspectives, and joyfully create 4. Narrative - Helps participants access and process events in their lives, past and present The study ends with a discussion of possible implications for the use of drama in long-term care but emphasizes that, due to the size of the sample, the results of the research cannot necessarily be assumed to apply in other contexts. Suggestions for further research are made that might address this and help to clarify the findings of the study.

Oral health has dramatically improved in most industrialized countries over the latter half of the 20th century. However, profound oral health disparities still exist especially for those most at risk of developing oral diseases and associated systemic consequences such as populations residing in long-term care facilities. Despite the growing body of literature that supports the link between oral microflora and the importance of oral hygiene in limiting the risk of pneumonia development, there are still gaps in our knowledge to effectively manage this risk. The research included in this dissertation sought to further our understanding of oral health and oral care in the context of pneumonia pathogenesis (chapter 3) and, by exploring the perspective of various stakeholders in oral health, we sought to further understand the factors that influence care provision (chapter 5). Additionally, a novel knowledge translation approach was tested to challenge traditional oral care interventions in order to promote improvements in front-line oral care practices (chapter 6). The relationship between oral microflora, oral care and pneumonia was found to be complex. It directs us to consider converging risk factors including a patient’s health status, health behaviours and access to oral care services. Different professional groups were found to possess different definitions of oral health, which influenced both their motivation to provide care as well as their focus of care. Definitions of oral health could also potentially influence the saliency of different types of oral care information to different targeted groups; therefore, this should be considered in developing education and training initiatives aimed at improving the provision of oral care. An appreciative knowledge translation approach was found to be effective in bridging the gap between oral care knowledge and the provision of care. Regardless of the type of intervention chosen, organizations were reported to play a crucial role in promoting oral health and supporting the successful implementation of oral care programs.

Antipsychotic use is an important issue in long-term care (LTC) homes due to their widespread use, the potential for serious adverse events and limited evidence about their efficacy in treating behavioural and psychological symptoms of dementia. Rates of antipsychotic use vary across LTC homes, but little is known about the contribution of physicians to this variation. This study documented the characteristics of physicians who regularly treated residents in Ontario LTC homes and examined variation in antipsychotic prescribing across physicians. In a population-based retrospective cohort of LTC residents, 637 (52.8%) of 1,207 LTC physicians cared for 46,365 (90.4%) of all residents. Overall, 27.3% of residents received antipsychotic therapy, but extremely high prescribers prescribed antipsychotics to 42.8% of their patients. Variation in physician antipsychotic prescribing persisted after controlling for clinical and behavioural resident characteristics. This variation was reduced by 47.1% when LTC homes were accounted for in multilevel cross-classification logistic regression models.

This study uses a grounded theory approach (Charmaz, 2006) in a small case study to examine if drama as praxis influences long-term care residents when presented as a recreational activity. When used as “praxis” (Taylor, 2000), drama focuses solely on the learning and personal growth of the participants. The growth of long-term care underscores the value of recreational programming for quality of life in these institutions; drama as praxis has not been widely used in this context. Elements of the literature review were used to identify areas where dramatic activities have demonstrated influence in educational contexts: • Engagement / Participation • Self-Confidence / Sense of Efficacy • Social Skills / Empathy • Creativity / Imagination • Cognitive Skill Development / Understanding These became sensitizing concepts for the creation of “drama as praxis” activities, presented in six sessions to a small group of residents at a long-term care residence in the Toronto area. Data collection was based on the researcher’s observations and participant interviews. Drama was found to have a recreational benefit impacting quality of life, with Engagement, Social Skills,, and Self-Confidence, the predominant benefits observed. Creativity and Cognitive Skill Development were less frequent. A Theory of the Recreational Benefit of Drama as Praxis was then developed to help the researcher understand why these benefits might be caused by drama. Based on theoretical sampling from recent research in gerontology and brain science, the theory highlights four beneficial components of drama as praxis: 1. Kinesthetics – Fosters engagement and memory retrieval 2. Play and Endorphinal Release – Triggers cognitive work without fear or fatigue 3. Imagination and Perspective-taking – Helps individuals retrieve emotional memories, develop different perspectives, and joyfully create 4. Narrative - Helps participants access and process events in their lives, past and present The study ends with a discussion of possible implications for the use of drama in long-term care but emphasizes that, due to the size of the sample, the results of the research cannot necessarily be assumed to apply in other contexts. Suggestions for further research are made that might address this and help to clarify the findings of the study.