M.A. (Psychology) / Please refer to full text to view abstract

The general intention of recent Swedish legislation concerning adults with intellectual disabilities has been to provide care and support for this group in small settings in the community. It has been shown that adults with intellectual disabilities are better equipped to exert influence over their own care and support when living in group homes in the community and other forms of independent living as opposed to large institutional settings. Recent research on this group has to a great extent concerned the study of how life is in small group homes for this group and has highlighted obstacles preventing them from participating in society. Previous research has indicated that living in institutional settings makes it difficult for them to exert influence on their lives. A small number of large institutional care settings still exist, however, in Sweden and there is a dearth of research that focuses on how adults with intellectual disabilities experience everyday life in such settings. In addition, little research has been carried out on the role of the care workers who work in such settings. The aim of this research has thus been to describe the experiences of adults with intellectual disabilities and care workers of living and working in an institutional care setting in Sweden.   An ethnographic approach including participant observation and in-depth interviews was used to gain a deeper understanding of how adults with intellectual disabilities and staff experience their everyday life in an institutional care setting. The result showed that the residents experienced;  I) a sense of belonging, which was connected to having access to a private sphere and being part of social togetherness;  II) a feeling of insecurity in relation to other residents and care workers;  III) a longing for independence and a desire to get away. The study of the staff revealed three main themes that represent their approach; I) creating a family-like atmosphere; II) making the everyday life ordered and structured; III) being exposed to stress factors.   The results revealed the importance of paying close attention to what adults with intellectual disabilities and their care workers have to say about their everyday lives when living and working in an institutional care setting. It may be concluded that adults living in an institutional care setting experience their everyday lives in existential terms such as belonging, insecurity and longing. For caring science and in caring practices of people with intellectual disabilities, it is not satisfactory that residents experience such an insecure existence in a care setting. In order to provide individual care and support, staff need to be more open and vigilant as to the residents’ vulnerability and be able to guide them in matters  concerning emotional aspects. It was seen that care workers in their everyday work with residents in an institutional care setting used experiences from their personal lives in situations where they lacked formal care training. Such experiences may have helped to create meaningfulness but at the same time risked preserving inequality and gender stereotyping. In order to avoid these risks care workers should receive clear directives from the management about the care objectives, and guidelines about how best to care for adults with intellectual disabilities and offer them individualized care. Furthermore, it also became evident that care workers need additional support, training and opportunities for reflection to cope with their complex work situation. The results of this research can contribute to a greater insight and deeper knowledge of what adults with intellectual disabilities experience in an institutional care setting in the 2000’s , enabling the staff and management to further enhance the well-being for this group of individuals. The findings can provide feedback to staff, managers and researchers working in the intellectual disabilities field.   Keywords: adults with intellectual disabilities, care, care workers, ethnography, institutional care setting, Sweden

Os conhecimentos produzidos acerca das interações de bebês em contextos coletivos têm priorizado suas interações com os adultos. Em contextos de acolhimento institucional de crianças em situação de vulnerabilidade, isso se repete, o estudo de bebês nesse contexto estando imerso em invisibilidade. Entendendo que o ser humano é relação, tal característica estando presente mesmo no bebê, hipótese do trabalho é de que suas interações ali poderiam ser mais efetivadas com outras crianças acolhidas já que, nesse contexto, funcionárias são orientadas a não se apegar aos bebês e/ou dispensam pouca presença pela sobrecarga de trabalho. Assim, o objetivo foi investigar as ocorrências de práticas de cuidado na interação de crianças e bebês em situação de acolhimento institucional. A pesquisa teve fundamentação na perspectiva da Rede de Significações, de referencial histórico-cultural. O estudo foi realizado em instituição de acolhimento do interior do Mato Grosso do Sul, de onde se selecionou dois bebês focais Caio e Ana (de sete e dez meses) -, sem parentesco entre eles. Além deles, foram participantes as crianças também acolhidas naquele período e a própria pesquisadora. Foram realizadas 47 videogravações, de trinta minutos cada, por seis meses, sendo três meses com cada bebê focal. Também foram realizadas entrevistas semiestruturadas com funcionários da instituição e, ainda, construiu-se diário de campo. A noção de cuidado foi baseada nos conceitos de Heidegger - Cuidado por Ocupação (baseado em tarefas) e Cuidado por Preocupação (baseado no Ser Com). O cuidado por preocupação teve tonalidades diversas: Atenção, como ir em direção ao bebê, quando o percebia sozinho; Solicitude, como ir em direção ao bebê, em decorrência de expressividades diversas; e, Preocupação/tensão, ir em direção ao bebê, para protegê-lo/ socorrê-lo em situações de perigo. À análise, verificou-se muitas interações das crianças, a maioria concentrada em brincadeiras. Com relação às práticas de cuidado, verificou-se grande ocorrência nas interações das crianças com os bebês e mesmo na interação de bebês, envolvendo as três tonalidades acima. Os cuidados eram, em grande parte, de interações recíprocas, diádicas e comumente viabilizadas por crianças mais velhas (multietárias). Os parceiros que ofertaram cuidados diferenciados eram os mais afetivos e buscados pelos bebês. Embora os cuidados fossem mais ofertados por meninas, este estudo demonstrou que meninos também cuidaram dos bebês. No caso de Ana, as interações não envolviam crianças com grau de parentesco, diferentemente do caso de Caio, que foi bastante cuidado pela irmã. Discute-se a importância do estabelecimento de relações naquele contexto, particularmente nos grupos de irmãos, de forma que possam preservar identidade familiar e manutenção dos vínculos afetivos. As interações permeadas por trocas afetivas foram vistas, como tendo indícios de empatia pelas crianças, mesmo as bem novas, sendo uma questão conceitual a ser explorada em futuros estudos. Pontua-se que tais interações e práticas de cuidados não devem substituir os cuidados dos adultos. A mediação pelo adulto é fundamental e deve ser implementada, inclusive considerando a questão da organização das crianças e sua localização dentro do ambiente de acolhimento / Interactions of babies with adults in collective contexts have been prioritized by most research literature. In institutional care of vulnerable babies, researches are immersed in invisibility. The relationship that features the human being is present even in the baby. Our work hypothesis is that babies interactions could be great effective when occur with children. In that context, employees are oriented not to attach to the babies and pay little attention due to work overload. The objective was to investigate the occurrences of care actions within the interaction of children and babies in an institutional host situation. The research was based on the Network of Meanings, historical, and cultural perspectives. The study was carried out in a care institution in the interior of Mato Grosso do Sul, from which two focal babies - Caio and Ana (seven and ten months old) - were selected, without any relationship between them. In addition, children who were also welcomed in the care institution and the researcher herself participated. For six months, thirty minutes of each 47 video were recorded, three months with each of two focal babies. Also, semi-structured interviews were conducted with employees of the institution, and a kind of logbook was also written to better understanding institutional dynamics. The notion of care was based on the Heidegger concepts - Care for Occupation (based on tasks) and Care for Concern (based on Being With). Care for worry had several tones: Attention, Solicitude, Worry, that is how heading towards the baby, when it was alone or crying, and protect or help it in dangerous situations. At the analysis, many interactions of the children were verified, most concentrated in jokes. With regard to the care practices, there was a great occurrence in the interactions of the children with the babies and even in the babies interaction involving the three shades above. Care was largely of reciprocal interactions, dyadic and commonly made feasible by older children (multistage). Partners who offered differentiated care were the most affectionate and sought after by baby. Although the care was more offered by girls, this study showed that boys also care. In Ana\'s case, interactions did not involve children with a degree of kinship, unlike the case of Caio, who was taken care of by her sister. It is discussed the importance of establishing relationships in that context, particularly in sibling groups, so that they can preserve family identity and maintain affective bonds. Interactions permeated by affective exchanges were seen as having signs of empathy for children, even the new ones, being a conceptual issue to be explored in future studies. It is pointed out that such interactions and caring practices should not replace the care of adults. Mediation by the adult is fundamental and should be implemented, including considering the issue of the organization of children and their location within the care environment

This study seeks the views of care workers working with older people about what impact social support resources has on the living conditions of older people. Social support was conceptualised in the study as support received from family members or close friends of the older people. Care workers were asked to share their views about social support for older people receiving care support in institutional setting or receiving home-based support services. This qualitative investigation involved eight care workers working with older people in Sweden. It has been argued in the study that care workers proving support for older people could have useful information about the social support of older people because they would have witnessed interactions between older people and their immediate network members. Qualitative interviews were conducted with eight care workers providing care support in institutions and home-based to explore their perspectives on the impact of social support on older people. Data from the interviews were analysed using thematic analysis. It was revealed from the views of care workers that both family and friends were engaged in different ways to provide support for older people, although not at all times. Managing loneliness, satisfaction with life and feeling better about themselves emerged as the ways social support impacted on the living conditions of older people. The care workers highlighted certain activities or areas that could ensure continuity of social support for older people. These included family members having regular contact with older people, older people acknowledging the need for support. Implications of the study for the practice of care for older people were highlighted.

Orientador: Carlos Magno Castelo Branco Fortaleza / Banca: Antônio Carlos Campos Pignatari / Banca: Rosely Moralez de Figueiredo / Resumo: O aumento recente da incidência e gravidade de Staphylococcus aureus tem suscitado diversos estudos abordando sua epidemiologia em instituições fechadas. Isolados de S. aureus resistentes à meticilina (methicillin resistant S. aureus, MRSA) são agentes comuns de infecção em hospitais. Nos últimos anos, a atenção dos epidemiologistas e clínicos tem se voltado aos MRSA de origem comunitária, associados a infecções graves de pele e trato respiratório. Nesse contexto, as Casas de repouso representam espaços de especial interesse, já que são instituições intermediárias entre a comunidade e os serviços de saúde. Não há dados sobre prevalência de S. aureus e MRSA em Casas de repouso no Brasil, um país onde somente 0,8% da população idosa são institucionalizadas. O presente estudo teve delineamento transversal e objetivou identificar a prevalência e fatores de risco para colonização por S. aureus como um todo e MRSA em particular. Foram incluídos 300 idosos vivendo em Casas de repouso no município de Bauru (SP). A colonização foi analisada através de coleta de swabs nasais dos sujeitos da pesquisa. Estes foram cultivados, e nos casos de isolamento de S. aureus, foi realizada a caracterização molecular da resistência à meticilina. Adicionalmente, os isolados de MRSA foram submetidos à genotipagem por Pulsed-Field Gel Electrophoresis (PFGE). Para análises de fatores de risco, foram levantados os prontuários dos sujeitos de pesquisa. Dados demográficos, internações, procedimentos e uso de antimicrobianos foram identificados. Análises univariadas e multivariadas (regressão logística) foram aplicadas. As prevalências identificadas para S. aureus e MRSA foram 17,7% e 3,7%, respectivamente. A idade avançada e a internação recente em hospitais foram preditores independentes para colonização por S. aureus como um todo. Os fatores associados à colonização por MRSA foram à residência em instituições de ... / Abstract: The recent increase in the incidence and severity of Staphylococcus aureus gave rise to many studies on its epidemiology in closed institutions. Isolates of methicillin-resistant Staphylococcus aureus (MRSA) are usual agents of infection in hospitals. In recent years, the attention of epidemiologists and clinicians has turned to MRSA of community origin, associated with severe infections of skin and respiratory tract. In this context, nursing homes represent areas of special interest, since they are intermediary institutions between the community and health services. No data on the prevalence of S. aureus and MRSA in nursing homes in Brazil, a country where only 0.8% of the elderly population is institutionalized. This cross-sectional study aimed to identify the prevalence and risk factors for colonization by S. aureus as a whole and MRSA in particular. We enrolled 300 elderly living in nursing homes in the city of Bauru, São Paulo State, Brazil. Colonization was analyzed by collecting nasal swabs of research subjects. Whenever S. aureus was isolated, we performed molecular characterization of methicillin resistance. Additionally, MRSA isolates underwent genotyping by pulsed-field gel electrophoresis (PFGE). For analysis of risk factors, we reviewed the charts of research subjects. Demographics, hospitalizations, procedures and uses of antimicrobials were identified. Univariate and multivariate (logistic regression) were applied. The prevalence identified for S. aureus and MRSA were 17.7% and 3.7%, respectively. Old age and recent hospitalization in hospitals were independent predictors of colonization with S. aureus as a whole, while small or medium-sized facilities and recent hospital admission were associated with carriage of MRSA. In the molecular analysis of 11 MRSA isolates, six were identified as carriers of chromosome cassette SCCmec type II (typically hospital), and two as carriers of SCCmec IV (associated with the community). ... / Mestre

Orientador: Regina Célia Popim / Banca: Silvia Cristina Mangini Bocchi / Banca: Stael Silvana Bano Eleutério da Silva / Resumo: O envelhecimento da população tem se tornando um dos maiores desafios das últimas décadas, principalmente no que diz respeito à saúde pública, em países em desenvolvimento, como o Brasil. Objetivou se avaliar a qualidade de vida, saúde mental, autonomia funcional, risco de quedas de idosos que frequentam as Unidades Saúde da Família na cidade de Nova Campina. Trata-se de um estudo transversal descritivo, no qual foram aplicados instrumentos de avaliação geriátrica, validados para a população idosa, em 250 indivíduos cadastrados nos serviços de saúde do município. A análise revelou que as mulheres foram a maioria e com maior fragilidade. Mesmo os idosos referindo uma ou mais doenças consideram seu estado de saúde bom. O impedimento físico não alterou suas atividades básicas da vida diária, mas houve interferência significativa nas atividades instrumentais. A saúde mental apresentou-se preservada, o escore diminuído deveu-se ao fato da baixa escolaridade, não caracterizando distúrbio. Sentem-se felizes com a vida que vivem. Sinalizo que foi fator protetor para saúde mental, morar com algum familiar e viver em sua própria casa. Em relação marcha e equilíbrio observou-se que os idosos conseguem se movimentar livremente, chamando atenção para as mulheres que apresentaram maior lentidão na execução dos testes, em especial Time Up and Go, não apresentando riscos acentuados para quedas. A maioria referiu ter sofrido queda no ultimo ano e 14,94% sofreu fratura, em especial as mulheres. Os dados analisados possibilitaram identificar a condição real de saúde desses indivíduos inseridos na comunidade. Chama atenção para a importância de se implantar políticas municipais que garanta o acesso aos serviços de saúde, bem como ações de cuidados integrais, de acordo com as demandas de cada indivíduo, nas suas necessidades comprometidas. Atenção especial deve se dar ... / Abstract: The aging of the population is becoming one of the biggest challenges in decades, particularly with regard to public health in developing countries like Brazil. Aimed to evaluate the quality of life, mental health, functional autonomy , risk of falls in patients attending Family Health Units in the City of New Campina. This is a descriptive cross-sectional study in which geriatric assessment instruments validated for the elderly population , in 250 enrolled in health services in the municipality individuals were applied. The analysis revealed that women were the majority and more fragile. Even the elderly referring to one or more diseases consider their health good. The physical impairment did not alter their basic activities of daily life, but there was significant interference in instrumental activities. Mental health was preserved, the score decreased was due to the fact of low education level, featuring disorder. Are happy with the life you live. I signal that was a protective factor for mental health, living with a family and live in your own home. In relation gait and balance it was observed that the elderly can move freely, calling attention to the women who had greater slowdown in the execution of tests, in particular Time Up and Go, showing no pronounced risks for falls. The majority reported having been dropped in the past year and 14.94 % suffered fractures, particularly women. The data analyzed possible to identify the actual health status of these individuals within the community. Calls attention to the importance of implementing municipal policies that ensure access to health services as well as comprehensive care actions, according to the demands of each individual in their needs compromised. Special attention should be given to professional training, on the topic aging and quality of life of persons assisted, especially the elderly. Also draws attention to the trainers of health bodies to this issue of elder ... / Mestre

As práticas de assistência às crianças e aos adolescentes alijados do convívio familiar de origem, resultantes de diferentes processos históricos e sociais, culminaram nos atuais programas sociais de proteção integral, dentre eles, os serviços de acolhimento institucional (abrigos). Partindo de perspectiva que entende o desenvolvimento humano como se dando nas inerentes relações estabelecidas com o outro e ambiente, aquelas sendo mediadas pela linguagem e engendradas num determinado contexto histórico-cultural, questionamos: como o bebê se relaciona com e nesse ambiente? Há especificidades no acolhimento e na construção de relações dessa faixa etária? Assim, a presente pesquisa propôs-se investigar como se dão as relações entre bebês, adultos e outras crianças. A meta é apreender a existência (ou não) do (re)conhecimento de pessoas e parceiros preferenciais; e, se ocorrem interações que envolvam trocas afetivas, com indícios de vínculos afetivos. O estudo foi realizado em cidade de médio porte do interior de São Paulo. Foram realizadas videogravações, por três meses, tendo como foco dois bebês, cujos nomes (fictícios) são Lucas (3 meses) e Luis/Guilherme (10 meses). Para apreensão das relações, foram utilizados dois métodos: uma observação sistemática, de caráter quantitativo, buscando avaliar, por meio do uso de recursos comunicativos e emocionais específicos, a ocorrência de \"orientação da atenção\", \"busca/manutenção de proximidade\" e \"trocas sociais\" com os diferentes interlocutores deste contexto; e, utilizando método de cunho qualitativo, também foram realizadas seleções e descrições de oito episódios interativos envolvendo trocas afetivas. A Rede de Significações, enquanto perspectiva teóricometodólogico, amparou o olhar para a complexidade e apreensão dos entrelaçados e múltiplos sentidos que se apresentam nas situações. A análise das relações bebê-adulto e bebê-bebê evidenciaram trocas afetivas, com carícias, brincadeiras, vocalizações e um padrão diferencial de interação. Os indícios de preferência (seletividade) e de compartilhamento sugeriram a manifestação de vínculos afetivos nesse contexto. Por outro lado, os dados também mostraram que são diversos os modos de relações estabelecidos no contexto de acolhimento institucional, dependendo tanto do perfil dos funcionários quanto das características de cada criança. Ainda que os bebês tenham demonstrado preferências e busca de proximidade, predominantemente, com funcionários, na maioria das vezes, esses não eram muito responsivos. Além dos funcionários, os próprios bebês/crianças foram outros importantes parceiros de interação e de trocas sociais, sendo, inclusive, mais responsivos aos comportamentos direcionados a eles. No entanto, no geral, devido à organização do ambiente e às conceções/normas, tais relações eram dificultadas, fragmentadas ou com ausência de objetos que mediassem suas atividades. Concluindo, os dados revelaram a ocorrência das relações envolvendo trocas afetivas, com indícios de vínculo, apesar dessas interações não serem freqüentes. Novos estudos devem aprofundar a questão, de modo a se considerar intervenções junto a essas instituições, que potencializem a qualidade das interações e a construção de vínculos, mesmo que a criança ali permaneça de forma temporária. / The assistance practices aimed to children and adolescents jettisoned from their biological family, resulted from different historical and social processes and culminated in the current diverse social programs of custody, one of which is the institutional care service. Based on a perspective that understands human development as unfolding from the inherent relationships established both with the other and the environment, the process being mediated by language and engendered in a particular historical and cultural context, we argued: how does the baby relates him/herself to and in that environment? Are there specificities of greeting, care and relationships construction regarding this age group? Considering this questions, this research aimed to investigate the forms of relationship construction between babies, adults and other children, seeking to apprehend the presence (or the absence) of the babies\' recognition of people around as well as presence (or the absence) of preferred partners, in the institutional care context. Specifically, the goal is to investigate if affective bonds are established in that context; and, in an affirmative case, investigate how they are established. The study has been carried out in a city of São Paulo. Video records were made during three months, focusing on two babies with the following ages and fictional names: Lucas (3 months); Luis/Guilherme (10 months). To grasp the relationships, we used two methods: a systematic observation (quantitative) seeking to evaluate, through the infant\'s use of specific emotional and communicative means, the occurrence of \"orientation of attention\", \"search/maintenance of proximity\" and \"social exchanges\" with different interlocutors in this context; and, by using a qualitative method, it was also performed selections and descriptions of eight interactive episodes involving emotional exchanges. The Network of meanings was the theoreticalmethodological support, which helped at analyzing the interwoven multiple meanings and at their complexity on the situation. Analysis of the infant-adult and infant-infant/children relations revealed the presence of emotional exchanges, constituted by caresses, games, vocalizations and a differential pattern of interaction. Evidence of preference (selectivity) and of sharing activities made unmistakable the manifestations of affective ties in this context. Moreover, data also showed that there are several modes of relationships established within the institutional care context, depending on the profile of both employees and the characteristics of each child. Although babies have shown preferences and proximity search, predominantly with employees, in most cases, adults were not highly responsive. In addition to employees, the other babies / toddlers were other important partners of interaction and social exchange, even being the most responsive to behaviors directed at them. However, in general, due to the organization\'s environment and conceptions, such relationships were hindered, fragmented or unfolding with the absence of objects that could mediate their activities. Finally, the data revealed the occurrence of relations involving emotional exchanges with evidence of linkage, although these interactions did not happen frequently. Further studies should examine the issue in order to consider interventions with these institutions to leverage the quality of interactions and bond constructions, even if the child stays there temporarily.

The primary focus of this organizational study of thirty two homes for the aged was to explore the degree of difference between administrator (expert) and resident (consumer) judgments of the psycho-social environment of their homes and to detect organizational variables which might account for these differences. It was hypothesized that adequate communication linkages to the homes would be negatively correlated with resident-administrator differences in viewpoints of the psychosocial environment. Adequate communication linkages were defined as those which approximated a model of linkage adequacy derived from the ''balance theory of coordination" postulated by Eugene Litwak. Based on a multimodel theory of organizational structure it calls for mechanisms of coordination between antithetical organizational substructures to insure sufficient closeness for communication but sufficient distance to prevent conflict. A secondary focus of this study was the substantive findings regarding resident viewpoints of the psychosocial environment irrespective of their differences from administrators. The concept of "psychosocial environment" was defined and operationalized by Allen Pincus who developed an instrument (HDQ) for measuring the degree of privacy, freedom, social resources, and integration into the larger community provided by the psychosocial environment of homes for the aged. The study hypothesis was not supported by correlational findings; however, linkage adequacy ratings did account for seven percent of the variation in administrator-resident differences when entered into a regression analysis with variables measuring contacts between administrator and residents and residential participation in group activities. Of significance at the .05 level was the age of the administrators with the younger ones tending to have fewer differences from the residents; administrators' ranking of professional staff meetings and communications with the housekeeping staff as useful sources of information about their residents; and higher mean resident HDQ Dimension II (freedom) scores. A multiple regression analysis of these variables plus the mean home ratings of resident friendliness to staff accounted for 55% of the variation in resident-administrator differences. These findings support the balance theory of coordination in that they reflect both distancing mechanisms (indirect linkages; i.e., administrator-staff contacts) and conditions which promote closeness (resident friendliness to staff). The age of the administrator, positively correlated with resident-administrator differences, reflected greater reliance by the younger administrators on their staffs and less control by their boards. Neither resident age, health, size of home, socio-cultural similarity between resident and administrator, nor the degree of informal administrator contact with residents were associated with resident-administrator differences. Resident scores on the HDQ suggest the psychosocial environments of the homes providing a great deal more privacy than a lack of privacy, more integration into the larger community than isolation, slightly more social resources rather than a lack of social resources, and as much freedom as structure. Those variables negatively associated with the dimension scores on a home by home basis included poorer ratings on resident mental health, mobility, and physical isolation. Homes with a greater degree of board control less participating activities and where residents tended to take their complaints to the administrator tended to have less freedom. Homes located in the country, with a resident council and social worker and with frequent administrator-resident contacts tended to score higher on the resource dimension. Implications for social planning include greater confidence in the older consumer as a source of informational feedback and increased scrutiny of administrator viewpoints especially as they relate to utilization of staff. The study suggests that planning must be geared to providing for the needs for the immobile, mentally impaired, isolated resident as well as stimulating administrative and structural changes which allow for a greater degree of freedom and social resources.

研究背景: 居住於安老院舍的長者通常患有多種不可逆轉的慢性疾病或未期病症。相對其他組群，他們將更快面對臨終與死亡的問題。因此，了解他們對「臨終問題」的態度、臨終地方的選擇意向及其預測因素是非常重要的。研究所得資將有助提供優質的“善終“服務予這群弱勢的長者。 / 研究目的: 本研究旨在探討有關居於香港安老院舍的長者對「臨終問題」的態度、臨終地方的選擇意向、是否視安老院舍如同自己的家及其預測因素。 / 研究方法: 本研究採用橫斷面量性研究的方法，以便利抽樣方式在香港不同地區的安老院舍進行研究。研究對象為年齡65歲或以上，及簡短智能測試達6分或以上，並能以廣東話溝通的安老院舍長者。研究採用結構性問卷以面對面訪談形式進行，作者把「對臨終問題的態度調查問卷」翻譯成中文版本用作調查長者對臨終問題的態度。並採用EQ-5D和Barthel Index (20) 以評估長者的自我健康評估及日常生活自我照顧能的狀況。調查問卷亦包括探討長者對安老院視為自己的家的看法和死亡地點的選擇。收集之數據採用了二分類邏輯回歸進行各因素與結果變量之間的單因關聯分析，那些p值<0.25的因素被選定為候選自變量，然後利用逐步多因素邏輯回歸分析來劃定結果變量的獨立相關因素。 / 研究結果: 合共317名來自20間安老院舍的長者參與了此項研究，包括248名女性(78.2%)和69名男性(21.8%)，年齡介乎65至99歲，平均年齡為84歲(標準差6.6)。多因素分析顯示多種預測因素與「臨終問題」的態度有著相關性；對於有家庭財政支持的長者來說，他們較傾向不同意由醫生作出所有有關照顧上的決定；有接受教育和患有較多慢性病的長者較傾向同意訂立預前指示；那些在安老院舍居住時間較長的長者較傾向不同意使用藥物讓他們可以隨時選擇結束生命；但患有糖尿病者較傾向同意安樂死；有宗教信仰者較傾向同意靈性或宗教的支持對他們是重要的。此外，310名安老院舍長者(97.8%)認為安老院舍如同自己的家。有261名長者 (68.1%) 表示希望在目前的安老院去世。那些認為安老院舍如同自己的家、有獨立經濟支持、及同意安樂死的院舍長者，較傾向希望在目前的安老院去世。 / 研究結論: 本研究譂述了居於香港安老院舍的長者對「臨終問題」的態度及其相關因素的實證結果。研究發現幾乎所有安老院舍的長者視安老院舍如同自己的家，明顯地相當多的長者表示如果條件允許下，希望在目前的安老院舍去世。這種強烈的聲音指出我們需要發展院舍的臨終照顧以滿足院舍長者的需要及期望。而從獲悉長者對「臨終問題」的態度及臨終地方的選擇意向，可讓醫護專業人員在安老院舍裡更有效地規劃臨終照顧服務，並能讓長者善終與好死。 / Background: Older people living in residential care homes for the elderly (RCHEs) have high incidences of irreversible chronic illnesses and terminal diseases. They are the most significant group facing impending death and dying. It is vital to understand their attitudes toward end of life (EOL) issues and their preference for EOL care in order to promote their quality of life. / Objective: This study aims to examine the attitudes toward EOL issues, the preference for place of death, the perception of RCHE as a resident’s own home and their predictors amongst older RCHE residents in Hong Kong. / Method: A cross-sectional quantitative study with convenience sampling was conducted in RCHE in different regions of Hong Kong. RCHE residents aged ≥65 achieving abbreviated mental test score ≥6 and who were able to communicate in Cantonese were recruited. Face-to-face interviews were conducted with the aid of a structured questionnaire. Demographic and clinical characteristics were collected. Health and functional status were measured by Euroqol-5D and Barthel Index (20). The “Attitudes of older people to end of life issues questionnaire“ was translated from the English version into a Chinese version and employed to examine the attitudes toward EOL issues. The perception of RCHE as own home and the preference for place of death were examined. Univariate analysis on the association between the outcome variables was performed. Factors with a p value <0.25 in univariate analyses were selected for multivariable logistic regression to delineate factors independently associated with the outcome. / Results: A total of 317 participants including 248 (78.2%) women and 69 (21.8%) men from 20 RCHE participated in the study. Their mean age was 84 ± 6.6 (mean ± SD). As showed in multivariate analysis, respondents financially supported by their family were less likely to allow doctors to make all the decisions about their care. Those respondents with higher number of morbidities and had higher education were more likely to agree with making a living will. Those who lived longer in RCHE were less likely to agree to having a drug at their disposal to end their life. Respondents with diabetic mellitus were more likely to agree with euthanasia. Respondents who followed a religion were more likely to agree on the importance of spiritual or religious support. Furthermore, 310 (97.8%) respondents perceived RCHE as their own home. Two hundred and sixteen (68.1%) residents wished to die in their present RCHE. Residents with the means to support themselves financially, agreed with euthanasia and who perceived RCHE as their own home were more likely to wish to die in RCHEs. / Conclusion: Nearly all residents perceived RCHEs as their own home and a significant proportion wished to die there if conditions allowed. This asserts that EOL care in RCHE should be developed to meet the wishes of the older residents. This study delineated significant factors associated with the attitudes of older people toward EOL issues. Knowing those factors allows health care professionals to plan for quality EOL care services in RCHEs more effectively and foster good death for this vulnerable population. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Law, Po Ka. / Thesis (D.Nurs.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 160-173). / Abstracts also in Chinese; appendixes includes Chinese. / Chapter 1. --- CHAPTER ONE: INTRODUCTION AND BACKGROUND / Chapter 1.1 --- Introduction --- p.1 / Chapter 1.2 --- Epidemiology data of ageing in Hong Kong --- p.3 / Chapter 1.3 --- Impact of ageing population --- p.4 / Chapter 1.4 --- Residential care services in Hong Kong --- p.5 / Chapter 1.5 --- Quality of residential care homes for the elderly (RCHEs) in Hong Kong --- p.7 / Chapter 1.6 --- Definition of end of life care, palliative care and hospice care --- p.9 / Chapter 1.7 --- End of life care in residential care homes in Hong Kong --- p.11 / Chapter 1.8 --- Dying in place --- p.14 / Chapter 1.9 --- Perception of RCHEs as own home --- p.15 / Chapter 1.10 --- Factors influencing attitudes to end of life issues --- p.15 / Chapter 1.11 --- The proposed framework --- p.18 / Chapter 1.12 --- Aim of the study --- p.20 / Chapter 1.13 --- Operational definitions of key terms --- p.20 / Chapter 1.14 --- Significance of the study and its impact on the society and future service development --- p.22 / Chapter 1.15 --- Overview of each chapter of the thesis --- p.24 / Chapter 2. --- CHAPTER TWO: LITERATURE REVIEW / Chapter 2.1 --- Introduction --- p.25 / Chapter 2.2 --- Literature search --- p.26 / Chapter 2.3 --- Search results --- p.27 / Chapter 2.4 --- Unmet need for end of life care in RCHEs in Hong Kong --- p.28 / Chapter 2.5 --- EOL care in RCHEs of other Western and Asian countries --- p.33 / Chapter 2.6 --- Preference for place of death --- p.34 / Chapter 2.7 --- Attitudes toward end of life issues --- p.38 / Chapter 2.8 --- Factors affecting older residents when choosing to die in RCHEs --- p.41 / Chapter 2.9 --- Barriers to EOL care in RCHEs --- p.43 / Chapter 2.10 --- Conclusion --- p.45 / Chapter 3. --- CHAPTER THREE: RESEARCH DESIGN AND METHOD / Chapter 3.1 --- Introduction --- p.47 / Chapter 3.2 --- Aim of the study --- p.47 / Chapter 3.3 --- Objectives of the study --- p.47 / Chapter 3.4 --- Research questions --- p.48 / Chapter 3.5 --- Research design --- p.50 / Chapter 3.6 --- Sample size --- p.51 / Chapter 3.7 --- Study setting --- p.52 / Chapter 3.8 --- Sampling method --- p.52 / Chapter 3.9 --- Data collection --- p.54 / Chapter 3.10 --- Study instruments --- p.55 / Chapter 3.11 --- Translation process for the AEOLI questionnaire --- p.60 / Chapter 3.11.1 --- Establishing the semantic equivalence --- p.64 / Chapter 3.11.2 --- Establishing the content and face validity --- p.66 / Chapter 3.12 --- Pilot study --- p.67 / Chapter 3.12.1 --- Testing the feasibility --- p.67 / Chapter 3.12.2 --- Test-retest --- p.68 / Chapter 3.13 --- Data cleaning --- p.70 / Chapter 3.14 --- Data analysis --- p.70 / Chapter 3.15 --- issues and consent Ethical --- p.72 / Chapter 4. --- CHPATER FOUR: RESULTS / Chapter 4.1 --- Introduction --- p.74 / Chapter 4.2 --- Recruitment of participants --- p.74 / Chapter 4.3 --- Characteristics of the study sample / Chapter 4.3.1 --- Socio-demographic characteristics --- p.76 / Chapter 4.3.2 --- Clinical characteristics --- p.79 / Chapter 4.3.3 --- Functional and health status --- p.81 / Chapter 4.4 --- Descriptive statistics of AEOLI-C, preference for place of death and perception of RCHEs as residents’ own home / Chapter 4.4.1 --- Descriptive statistics of AEOLI-C --- p.83 / Chapter 4.4.1.1 --- Decision making (Attitude 1) --- p.83 / Chapter 4.4.1.2 --- Pain (Attitude 5, 9, 20) --- p.83 / Chapter 4.4.1.3 --- Care environment (Attitude 3, 6, 10, 15, 27) --- p.84 / Chapter 4.4.1.4 --- Living wills (Attitude 8, 14, 19, 24) --- p.84 / Chapter 4.4.1.5 --- Euthanasia / Physician assisted suicide (Attitude 4, 17, 18, 26) --- p.85 / Chapter 4.4.1.6 --- Ageism (Attitude 13, 16, 23) --- p.85 / Chapter 4.4.1.7 --- Psychological needs including religious/spiritual (Attitude 11, 25) --- p.85 / Chapter 4.4.1.8 --- Quality versus quantity of life (Attitude 2, 7, 21, 22) --- p.85 / Chapter 4.4.1.9 --- Societal awareness (Attitude 12) --- p.86 / Chapter 4.4.2 --- Descriptive statistics of the perception of RCHEs as residents’ own home --- p.86 / Chapter 4.4.3 --- Descriptive statistics of the preference for place of death --- p.86 / Chapter 4.5 --- Correlational and logistic regression results / Chapter 4.5.1 --- Correlational and regression results of the predictive factors associated with AEOLI-C --- p.89 / Chapter 4.5.1.1 --- Decision making (Attitude 1) --- p.89 / Chapter 4.5.1.2 --- Pain (Attitude 5, 9, 20) --- p.90 / Chapter 4.5.1.3 --- Care environment (Attitude 3, 6, 10, 15, 27) --- p.91 / Chapter 4.5.1.4 --- Living wills (Attitude 8, 14, 19, 24) --- p.93 / Chapter 4.5.1.5 --- Euthanasia / Physician assisted suicide (Attitude 4, 17, 18, 26) --- p.95 / Chapter 4.5.1.6 --- Ageism (Attitude 13, 16, 23) --- p.97 / Chapter 4.5.1.7 --- Psychological needs including religious/spiritual (Attitude 11, 25) --- p.99 / Chapter 4.5.1.8 --- Quality versus quantity of life (Attitude 2, 7, 21, 22) --- p.100 / Chapter 4.5.1.9 --- Societal awareness (Attitude 12) --- p.101 / Chapter 4.5.2 --- Correlational and regression results of the predictive factors associated with the perception of RCHEs as residents’ own home --- p.104 / Chapter 4.5.2.1 --- Relationship with socio-demographic characteristics, clinical characteristics, health and functional status --- p.104 / Chapter 4.5.2.2 --- Relationship with AEOLI-C --- p.108 / Chapter 4.5.3 --- Correlational and regression results of the predictive factors associated with preference for place of death --- p.110 / Chapter 4.5.3.1 --- Relationship with socio-demographic characteristics, clinical characteristics, functional and health status --- p.110 / Chapter 4.5.3.2 --- Relationship with AEOLI-C --- p.114 / Chapter 4.6. --- Summary of the results --- p.116 / Chapter 5. --- CHAPTER FIVE: DISCUSSION / Chapter 5.1 --- Introduction --- p.117 / Chapter 5.2 --- Characteristic of the participants --- p.118 / Chapter 5.3 --- The attitudes toward end of life issues --- p.120 / Chapter 5.3.1 --- Decision making (Attitude 1) --- p.121 / Chapter 5.3.2 --- Pain (Attitude 5, 9, 20) --- p.123 / Chapter 5.3.3 --- Care environment (Attitude 3, 6, 10, 15, 27) --- p.125 / Chapter 5.3.4 --- Living wills (Attitude 8, 14, 19, 24) --- p.128 / Chapter 5.3.5 --- Euthanasia / Physician assisted suicide (Attitude 4, 17, 18, 26) --- p.131 / Chapter 5.3.6 --- Ageism (Attitude 13, 16, 23) --- p.133 / Chapter 5.3.7 --- Psychological needs including religious/spiritual (Attitude 11, 25) --- p.135 / Chapter 5.3.8 --- Quality versus quantity of life (Attitude 2, 7, 21, 22) --- p.136 / Chapter 5.3.9 --- Societal awareness (Attitude 12) --- p.137 / Chapter 5.4 --- The perception of RCHEs as residents’ own home --- p.138 / Chapter 5.5 --- The preference for place of death --- p.140 / Chapter 5.6 --- Summary --- p.143 / Chapter 6. --- CHAPTER SIX: CONCLUSION / Chapter 6.1. --- Introduction --- p.145 / Chapter 6.2 --- Limitations of the study --- p.145 / Chapter 6.2.1 --- Generalization of the results --- p.145 / Chapter 6.2.2 --- Lack of theoretical construct of the translated questionnaire --- p.147 / Chapter 6.2.3 --- Limitations of quantitative study and cross-sectional design --- p.149 / Chapter 6.3 --- Contributions of the study --- p.150 / Chapter 6.4 --- Recommendations and implications to nursing practice --- p.152 / Chapter 6.5 --- Implications to the EOL Care Practice in Residential Care Setting --- p.154 / Chapter 6.6 --- Implications to residential care policy --- p.155 / Chapter 6.7 --- Recommendations for further studies --- p.156 / Chapter 6.8 --- Conclusion --- p.158 / Chapter 7. --- REFERENCES --- p.160 / Chapter 8. --- APPENDICES --- p.174

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