Safety of residents has gained increased popularity in recent years following a report from the Institute of Medicine attributing 98,000 hospital deaths each year to errors by staff. As a result, regulatory agencies, advocates, and health care providers have shifted their focus to understanding patient safety and developing a culture that promotes safety. However, nursing homes lag behind other health care providers in their adoption of a patient safety culture and understanding what factors affect safety in resident care. These insights are needed to ensure that nursing home residents receive the safe care. The purpose of this dissertation is to explore factors that influence the safety of residents in nursing homes by conducting three separate studies and using Donabedian's Structure Process Outcome (SPO) framework. The first study examines facility characteristics that predict higher patient safety culture scores given by top managers among a nationally representative sample of nursing homes. Using the same sample, the second study examines the relationships among the three components of Donabedian's SPO model as they relate to patient safety: structure (patient safety culture), processes of care (restraint use) and a common patient safety outcome, resident falls. The final study uses a sample of Florida nursing homes and the SPO model to examine the relationships between nursing staff turnover, processes of care, and patient safety outcomes in nursing homes. Findings from this dissertation can contribute to a greater understanding of what predicts higher levels of patient safety in nursing homes. In the first analysis, facility characteristics that are traditionally related to quality of care in nursing homes are predictive of higher patient safety culture scores. In the second analysis, higher ratings of patient safety culture are related to better processes of care and a decreased likelihood of resident falls. In the final analysis, results indicate that Certified Nursing Assistant (CNA) turnover had an independent effect on two patient safety outcomes, falls and UTIs, and that this effect is mediated by processes of care within the nursing home. Collectively, the findings from this dissertation may have important implications for policy makers, providers, and consumers of nursing home services.

<p><em>Background & Rationale</em>: Early mobilization (EM) can minimize intensive care unit aquired weakness (ICUAW) among survivors of critical illness. Clinician awareness of ICUAW, perceived barriers to EM, and acute rehabilitation in Canadian ICUs have not been well described.</p> <p><em>Objective:</em> To assess (1) awareness of ICUAW and EM, (2) perceived institutional, clinician, patient level barriers to EM, (3) stated practice of acute rehabilitation in Canadian ICUs.</p> <p><em>Design</em><strong>:</strong> A cross-sectional, self administered postal survey</p> <p><em>Setting:</em> Academic Intensive Care Units (ICUs) in Canada</p> <p>Subjects: 134 physiotherapists and 302 critical care physicians</p> <p><em>Interventions & Measurements:</em> Item generation followed a review of relevant literature and discussion with 26 content experts. We reduced the survey to 10 domains and 29 specific questions. The survey intrument was piloted and evaluated for clinical sensibility and intra-rater reliability. Up to 3 surveys were mailed to potential respondents. Descriptive statistics were reported as proportions, means (+/- SD) or mode, as appropriate. We used the chi-squared test to compare proportions and multi-variate logisitc regressions to test for association between independent and dependent variables. <em></em></p> <p><em>Main Results:</em> The survey instrument had excellent clinical sensibility and good intra-rater reliability (Cohen’s kappa > 0.4). The overall response rate was 71.3% (311/436) including 87.3% (117/134) of physiotherapists and 64.2% (194/302) of physicians. The incidence of ICUAW in the general medical-surgical population was under-recognized by 68.8% of clinicians and 59.8% of clinicians stated they were either insufficiently trained or informed to mobilize mechanically ventilated patients. Excessive sedation and medical instability were perceived as the most important patient barriers. Limited staffing, safety concerns (by nurses) and delayed clinician recognition to initiate EM were key provider barriers to EM. Important institutional barriers to EM included insufficient guidelines and equipment. Only 19.9% of clinicians stated that patients with suspected ICUAW were referred to an out-patient clinic after ICU discharge for long term rehabilitation.</p> <p><em>Conclusions</em>: Over 60% of respondents to this national survey underestimated the incidence of ICUAW and do not feel adequately trained to mobilize mechanically ventilated patients. Multiple patient, provider and institutional barriers may also contribute. Clinical leaders and administrators should consider these modifiable factors when designing EM programs in the ICU.</p> / Master of Science (MSc)

Although there have been numerous investigations of laryngeal muscle activity during phonation in the chest and falsetto/head registers in trained and untrained classical singers and non-singers, no research has been conducted examining laryngeal muscle activity during phonation in the chestmix register, a register used extensively by many female commercial singers, particularly for the production of higher frequencies. The purpose of this study was to test the hypothesis that commercial singers produce chestmix by maintaining or increasing adduction of the vocal processes and by engaging the thyroarytenoid muscle to a greater degree than they would to produce a head register sound. Simultaneous recordings of thyroarytenoid and cricothyroid muscle activity, videonasendosopy, and audio were obtained from seven female commercial singers (5 trained, 2 untrained) during sustained phonation and song phrases produced in chest, chestmix, headmix, and head registers. Thryoarytenoid and cricothyroid muscle activity was normalized to a percent of mean maximum activity and compared across registers and frequencies both within subjects and across subjects. Video stills of vocal processes adduction patterns were rated for degree of vocal processes adduction and also compared across register and frequency within and across subjects. All audio samples were rated for register by two singing teachers and audio samples of sustained phonation were analyzed via Fast Fourier Transform to measure the number and energy of the harmonics present in each sample. Interjudge and intrajudge reliability tests were performed for both the vocal processes adduction rating and audio sample rating tasks. Results from the study confirmed the hypothesis and showed that thyroarytenoid activity and adduction of the vocal processes was greater for chestmix than headmix or head, particularly during production of higher frequencies, but less than for chest productions. Cricothyroid activity was similar for chestmix, headmix and head during production of lower frequencies, but greater for chestmix during production of higher frequencies.

Over the next thirty years, Alzheimer’s disease rates will increase alongside global aging. To handle the anticipated increase in demand, knowledgeable and skilled dementia caregivers are in need throughout the long-term care spectrum. Online training programs have emerged as a viable and convenient platform to educate both formal and informal caregivers. The first and second study systematically reviewed online dementia training programs and evaluated the CARES® Dementia Basics Training Program among formal and informal caregivers. The first study is a systematic review of online dementia-based training programs for both formal and informal caregivers conducted using the Preferred Reporting Items for Systematic Reviews (PRISMA) method. Methodological quality of the final sample (N=15) was assessed by the Cochrane Collaboration Back Review Group criteria. Results of the systematic review suggests that online interventions improve the condition and preparedness of caregivers, but future evaluations should consider study designs with multiple time points, control groups, and content that is personalized and interactive. In the second study, an evaluation of the online CARES® Dementia Basics Program among formal and informal caregivers was performed. The sample (N=233) included respondents from the states of OR, WA, CA and IL over three time points. Results indicate baseline differences in education, race, and caregiver type and a modest improvement in knowledge among both formal and informal caregivers. Recommendations are provided for future development and evaluation of online interventions.

The purpose of this dissertation was to investigate the influences of auditory information provided by the cochlear implant (CI) on the readings skills of children born with profound deafness. I investigated the relationship of access to the sound signal provided by the CI on a constellation of skills related to word-reading. In a preliminary study, I examined the relationship between the early speech production and perception skills of 72 CI users on later reading skills. Using regression analysis, I found I could explain 59% of the variance of later reading skills by early speech perception and production performance. Secondly, I examined the phonological processing skills of 29 children with prelingual, profound hearing loss with at least 4 years of CI experience. I compared this performance with 29 children with normal hearing, matched with regard to word-reading ability and Socio-Economic-Status. I also compared speech production and perception skills with phonological processing and reading skills. Results revealed that children with CIs were able to complete tasks measuring phonological processing, but there were performance differences between the two groups. Although the children with CIs had mean standard reading achievement standard scores that were about 12 points lower than the children with normal hearing, the mean standard scores for both groups was within the normal range. Finally, a regression analysis revealed that the Phonological Processing skills accounted for 50%, and 75% of the variance in word and paragraph reading scores for all the children. In conclusion early speech perception and production skills of children with profound hearing loss who receive CIs predict future reading achievement skills. Better early speech perception and production skills result in higher reading achievement. Furthermore, the early access to sound helps to build better phonological processing skills, which is one of the likely contributors to eventual reading success. Thus, it is reasonable, possible and important to assess the early speech production perception and subsequent phonological processing in children with profound hearing loss who receive CIs.

Three experiments examined normal-hearing and cochlear-implant listeners' abilities to perceive and use talker-specific information in the speech signal. In Experiment 1 voice similarity judgments were gathered from normal-hearing listeners to maximize variability across talkers used in Experiment 2. These judgments were submitted to a multidimensional scaling (MDS) analysis; this solution was used to select the talkers of Experiment 2. Experiment 2 was an approximate replication of Nygaard and Pisoni's (1998) work. In this study cochlear-implant and normal-hearing listeners were trained to recognize 6 different voices. The cochlear-implant users recognized the voices with 59.31% accuracy and the normal-hearing listeners achieved 92.64% accuracy. After training the listeners completed a sentence recognition task in noise. In the task 6 familiar talkers spoken half of the sentences and 6 novel talkers spoke the other half. It was predicted that sentences spoken by the familiar talkers would be more accurately perceived than those spoken by the novel talkers. However, there was no difference in accuracy, nor was there a difference in performance across the groups of listeners. The factors contributing to these null results were discussed at length. Experiment 3 gathered voice similarity judgments from the normal-hearing and cochlear-implant listeners of Experiment 2. These data were submitted to both classical and weighted MDS analyses. The voice maps showed notable differences in the perceptual spaces of the two groups of listeners. The participant space yielded from the weighted MDS showed great variation across all of the participants' judgments, but no clear trend supporting the listeners' group membership. In conclusion, despite listening via a constrained, electric signal, the cochlear-implant users were trained to recognize voices with notable accuracy (as were the normal-hearing listeners). Nevertheless, Experiment 2 failed to provide insight into talker familiarity's effect on the sentence recognition skills of cochlear-implant and normal-hearing listeners. These results are contrary to research with normal-hearing listeners that suggests talker familiarity facilitates speech processing in noise. The present studies did show, though, that cochlear-implant users appear to perceive and use talker-specific information differently than normal-hearing listeners.

The National Quality Award Program, sponsored by the American Healthcare Association National Center for Assisted Living, was implemented to cultivate continuous quality improvement in nursing homes and assisted living facilities. Based upon the Baldridge Criteria for Performance Excellence, the program utilizes a systems-based or Big “Q” approach to quality and requires applicants to examine seven categories of their organizational environment including: 1) leadership, 2) strategy, 3) customers, 4) measurement, analysis, and knowledge management, 5) workforce, 6) operations, and 7) results. The subsequent dissertation examines whether award status is associated with better performance on publicly reported quality measures and financial performance within the nursing home setting. Findings suggest implementation of Baldridge principles may promote improved quality; however, further research is warranted to fully understand the relationship.

Rationale and study aims: Persons with mild cognitive impairment (MCI) experience declines in everyday functioning and cognitive performance greater than what is experienced in normal aging but less than that of dementia. Daily stress and daily memory complaints associated with cognitive deficits may contribute to greater psychological distress in the day-to-day experiences of persons with MCI. However, research examining the occurrence of daily stressors, daily memory complaints and psychological distress in MCI is limited, and it is not clear how the daily processes of stress and affect in persons with MCI compare to cognitively healthy older adults. This dissertation examined the occurrence of daily stressors, daily memory complaints, retrospective and daily well-being in persons with MCI compared to cognitively healthy controls. Main analyses examined whether daily stressors and daily memory complaints were associated with worse daily affect in MCI participants compared to controls, and whether increased daily stress was associated with a greater number of memory complaints. Methods: The study used a short-term repeated measures design, and included MCI and control participants recruited from a university-based memory clinic. The interviews consisted of a baseline interview and up to eight consecutive days of brief daily phone interviews. The interviews included both retrospective and daily measures of psychological well-being, daily stressors, daily memory complaints, and open-ended questions about daily experiences. Results: Persons with MCI reported a greater number of daily memory complaints and worse psychological distress, as measured by both retrospective and daily reports. There were no significant differences between MCI and control participants, however, in the frequency of daily stressors. In both unadjusted and adjusted analyses, on days when a participant reported more daily stressors, they had higher negative affect. The stress-negative affect relationship was stronger for MCI participants compared to controls. MCI and control participants who reported more memory complaints, on average, had higher negative affect. Discussion: Daily stressors were disproportionally associated with greater psychological distress in MCI participants as compared to cognitively healthy controls. Interventions targeting the potential distress associated with daily life may be beneficial for psychological well-being in persons with MCI. Future research should examine other potential mechanisms of distress in daily lives of persons with MCI in order to inform relatives and caregivers of persons with MCI, clinicians who give diagnoses to their patients, and individuals providing community support for individuals living with MCI.

The effectiveness of the A Matter of Balance (MOB) program, a multifactorial falls prevention intervention, is uncertain. Although targeting multiple risk factors of falling at the same time seems reasonable and desirable, in that falls are often caused by several risk factors, results from previous studies investigating the effects of multifactorial falls prevention interventions are inconsistent. In addition, research shows that single factor interventions (e.g., exercise) can produce the same effects. The cost-effectiveness of multifactorial falls prevention interventions has varied across studies (e.g., Jenkyn, Hoch, & Speechley, 2012; Tinetti, Baker, et al., 1994). Despite the fact that the American Geriatrics Society and British Geriatrics Society (2001) have incorporated multifactorial falls prevention interventions into geriatric practice guidelines, more studies are needed to better understand the effects of the MOB program on falls and risk factors for falling among older adults. The MOB program aims to reduce fear of falling by increasing self-efficacy and perceived control (Tennstedt et al., 1998). This program provides exercises to enhance older adults' physical capacities, lessons to teach seniors fall-related risk factors, and methods to enhance self-efficacy. Previous studies mainly focused on the effects of the MOB program on fear of falling and falls efficacy. However, falls, fear of falling, and physical frailty (e.g., poor balance) are all correlated. Little is known about the effects of the MOB program on falls and related physical risk factors. Meanwhile, fear of falling and falls efficacy are two constructs often used to delineate psychological consequences of falling, but there has been confusion about these two constructs. As a result, researchers have been using measures developed for falls efficacy to assess fear of falling in error. Previous study also shows that both fear of falling and falls efficacy need to be examined after intervention with separate appropriate measures(e.g., Valentine, Simpson, Worsfold, & Fisher, 2011). Nevertheless, in the research of the MOB program, studies often examined either fear of falling or falls efficacy, but not both (e.g., Tennstedt et al., 1998; Zijlstra et al., 2009). Therefore, whether the MOB program could improve both fear of falling and falls efficacy is uncertain. This dissertation includes three studies to examine the effects of the MOB program. The first study explores whether the program could effectively prevent falls and improve physical risk factors (i.e., mobility, walking speed, and postural control) among older adults. The second study examines the psychometric properties of a modified fear of falling measure and the effects of the program on fear of falling and falls-efficacy. The third study investigates whether the effects of the MOB program on falls, mobility, walking speed, and postural control can be maintained across five months. Three studies using a comparison group design were conducted to examine each objective. Data were collected at baseline (Time 1), the conclusion of the program (Time 2), and at a 3-month follow-up (Time 3). Overall, the studies in this dissertation show that older adults can improve their mobility, walking speed, postural control, fear of falling, and falls efficacy by participating in the MOB program but the program did not affect the total number of falls. The results also showed that older adults who received the MOB program reached their highest performance on mobility and walking speed immediately at the end of the program. However, their performance on postural control continued to improve and was the best at the 3-month follow-up.

Exercise has many physical, cognitive, and social benefits, but the majority of older adults do not meet the recommended level of physical activity (Centers for Disease Control and Prevention, 2014). TAGteach, which combines elements of both behavioral coaching and acoustical feedback, has been demonstrated as an effective way to teach athletic skills (Fogel, Weil, & Burris, 2010; Quinn, Miltenberger, & Fogel, 2015; Stokes, Luiselli, Reed, & Fleming 2010). However, none of the current research on teaching athletic skills targeted an older population. This study evaluated TAGteach in a multiple baseline across behaviors design as a method of teaching 4 basic baton twirling skills to 3 women aged 62-73. Performance accuracy was low in baseline but improved substantially following the implementation of TAGteach. Participants also rated the intervention positively on a social validity survey. Implications and suggestions for future research are discussed.