Self-regulation capacity allows individuals to manage their thoughts, feelings, and actions to attain personal goals (e.g., well-being and performance), as well as adjust to their changing social and physical environment (Zimmerman, 2000). Self-regulation as a positive adaptive skill and process has not been examined in relation to well-being in the context of medicine. The purpose of the current study was to examine self-regulation with 37 medical students and 25 supervising physicians to determine whether or not it may enhance well-being and performance, and reduce stress and burnout. A mixed-methods design was used to collect and analyze the data, and findings from the quantitative and qualitative phases were presented in two separate articles. Self-regulation capacity appears to be an important skill that may help both physicians and medical students to meet the demands of the medical profession and maintain an adequate level of well-being and performance in their work and daily life.

This dissertation combines three contributions to the literature on the determinants of well-being and the social nature of preferences. Departures from self-centred, consumption-oriented decision making are increasingly common in economic theory and are empirically well motivated by a wide range of behavioural data from experiments, surveys, and econometric inference. The first two contributions are focused on the idea that reference levels set by others’ consumption may figure prominently in both experienced well-being and in decision making. In the first paper, the well-being question is addressed empirically through the use of self-reported life satisfaction and high-resolution census and survey data in Canada. Strong income externalities are found at multiple spatial scales after controlling for various confounding factors. The second paper explores the general equilibrium consequences of a utility function having an explicit comparison with neighbours’ consumption. The question is investigated in a model in which decision makers knowingly choose their neighbours — and hence their consumption reference level — as well as their own consumption expenditure, thereby helping to set the reference level for nearby others. For both discrete and continuous distributions of types in an economy with a heterogeneous population undergoing such endogenous formation of consumption reference groups, there exist general equilibria in which differentiation of neighbourhoods occurs endogenously. The novel welfare implications of growth in such economies are described. The final paper addresses econometric reservations about the use of subjective reports as dependent variables. The date and location of survey interviews are combined with weather and climate records to construct the random component of weather conditions experienced by respondents on the day of their interview. Standard inferences about the determinants of life satisfaction remain robust after taking into account this significant source of affective bias.

Suicide in later life is a growing public health concern that is expected to increase as the baby boom generation reach late adulthood. In the general population, older adults have rates of suicide that are higher than any other age group. The rate of suicide is particularly higher for older men. In Canada, older men between 80 and 84 years have rates of suicide approximately six times greater than older women the same age. Older adults living in the community are a sub-set of the population that are at high risk for suicide yet are not typically a focus of suicide research. As a result they remain hidden from the view of mental health promotion and suicide prevention programs until a decline in mental status brings them to the attention of formal mental health care services. Improving our understanding of suicide in later life particularly among community-residing older men can inform suicide prevention strategies. To improve this understanding, the goals of this research were three-fold: to comprehensively describe the sociodemographic and clinical characteristics of community residing older adults who have experienced suicide-related behaviour; to describe the rates, risk and protective factors, and predictors of suicide-related behaviour among this population; and to compare these findings to a subpopulation of community-residing older adults with neurological conditions. To achieve these aims, this research utilized a secondary data analysis approach using health information from multiple linked datasets. The Canadian Institute of Health Information (CIHI) performed record linkages between Ontario hospital administrative data (Discharge Abstract Database, National Ambulatory Care Reporting System, and Ontario Mental Health Reporting System) and Ontario home care data (Home Care Reporting System). Home care data are sourced from the Resident Assessment Instrument–Home Care (RAI-HC) Assessment Instrument, the provincially mandated assessment tool used to identify the strengths, preferences and needs of all long-stay home care clients. The RAI-HC contains over 350 items across a wide range of domains including health, functional status and resource use. Linkages of these data records between home care and hospital sectors enabled the prospective examination of community-residing older adults with recent suicide-related behaviour. This is one of the first national and international studies to use the RAI-HC to examine older home care clients with experiences of suicide-related behaviour. The study samples consisted of Ontario home care clients aged 60 years or older assessed with the RAI-HC between April 2007 and September 2010. Clients’ initial RAI-HC assessment was examined followed by corresponding hospital records for suicide-related behaviour (N = 222,149). The prevalence of suicide-related behaviour for the sample was 1.01% (n=2,077) with higher rates for older men than women. Rates were examined across geographic regions of Ontario. Descriptive analyses demonstrated that older adults with suicide-related behaviour had more indicators of psychiatric distress (including cognitive impairment) and psychosocial dysfunction than the general home care population. Multivariate analyses showed significant effects for age and gender in the prediction of suicide-related behaviour after adjusting for risk and protective covariates. Tangible areas for intervention were revealed that may reduce future suicide risk such as managing alcohol use and dependence, managing pain, increasing positive social relationships, and reducing social isolation. Time-to-event analysis supported the multivariate regression findings. Analyses of two subpopulations of older adults with neurological conditions (dementia and Parkinson’s disease) demonstrated marked differences in suicide risk and protective factors compared to the general home care population. Findings suggest that a one-size-fits-all approach to suicide prevention and intervention is not appropriate for persons with these conditions, as their specific risk and protective factors need to be taken into consideration. This study based on provincial data covering the home care sector in Ontario defined high risk groups of older adults and provided evidence for risk and protective factors associated with suicide-related behaviour. Findings point to several areas that should be assessed by home care professionals to reduce risk in the older home care client population. This multi-dimensional profile of high risk older adults will assist in initiating a policy dialogue regarding the need for targeted suicide prevention strategies in Ontario’s home care sector.

Religious coping and spiritual well-being were found to be culturally important resilience factors for African American women suffering from abuse and depressive symptoms. This investigation aimed to investigate whether: (1) spiritual well-being and its two components of existential and religious well-being mediate the Intimate Partner Violence (IPV)-Depressive Symptoms (DS) link; (2) positive and negative religious coping moderate the IPV-DS association; and (3) the mediating effect of spiritual well-being in the IPV-DS link is moderated by level of religious coping (i.e., moderated mediation). The study utilized data from 208 low income, suicidal and abused African American women, ages 18-55. Only the existential component of spiritual well-being was found to fully mediate the IPV-DS link. This indirect effect weakened at higher levels of negative religious coping. As predicted, higher levels of negative religious coping were associated with higher levels of depressive symptoms. Surprisingly, higher levels of negative religious coping were also associated with increases in existential well-being which, in turn, led to decrease in depressive symptoms. The findings underscore the importance of addressing existential well-being and religious coping in clinical interventions and in training for mental health professionals. Clinical and research implications of these findings are discussed and future directions recommended.

Lately, alarming reports have appeared regarding the work environment and work situation of social workers. Research focusing on the promotion of health and well-being in the workplace among other professionals show that factors such as social relationships, ability to influence their work situation and leadership are important. A quantitative study was conducted focusing on the work climate for social workers employed by some of the district administrations in the City of Malmö. A questionnaire with questions and statements on various factors in the work environment was sent to 34 social workers. They were asked how important these factors were for their well-being, as well as to what extent they felt that these factors were present at work. A total of 17 social workers filled out the questionnaire. The study results showed that communication and leadership were the two themes that had the greatest impact on the well-being at work for the social workers. The results also showed a discrepancy regarding the relationship between how the importance of the statements in the questionnaire was considered, and the degree to which they were present at work. However, the results could not demonstrate any difference between how younger and older social workers assessed the importance of the work environment factors' importance for their well-being at work. Further studies with different approaches of how communication and leadership affects social workers well-being at work could help identifying appropriate actions for improved working conditions for social workers. / Socialsekreterare är en utsatt yrkesgrupp som det kommit negativa signaler från på senare tid vad gäller deras arbetsmiljö och arbetssituation. En stor andel sjukfrånvaro, hög personalomsättning och svårigheter till nyrekrytering kan få allvarliga konsekvenser för yrkesgruppen. Det finns en hel del forskning som visar på att arbetsmiljön har betydelse för människors hälsa och välbefinnande. Strategier för hälsoarbete i Sverige kopplat till arbetsplatsen har i allt större utsträckning antagit en hälsofrämjande utgångspunkt i stället för att enbart vara riskorienterade. Forskning med fokus på främjande av hälsa och välbefinnande på arbetsplatsen visar att faktorer som sociala relationer, möjlighet att påverka sin arbetssituation och ledarskap har betydelse i många olika typer av verksamheter. Om arbetsgivaren har kännedom om vilka arbetsmiljöfaktorer som socialsekreterare bedömer som viktigast för sitt välbefinnande i arbetet, där det även tas hänsyn till om det skiljer sig något i bedömningen mellan yngre och äldre personer, skulle riktade arbetsmiljöinsatser som främjar en hälsosammare arbetssituation för socialsekreterarna kunna identifieras och initieras från arbetsgivarens sida. En kvantitativ studie genomfördes som riktade sig till socialsekreterare anställda vid några av stadsdelsförvaltningarna inom Malmö Stad. En enkät skickades ut till 34 socialsekreterare med frågor och påståenden om olika arbetsmiljöfaktorers betydelse för deras välbefinnande och i vilken grad de ansåg att dessa förekom på arbetsplatsen. Enkäten besvarades av 17 personer. Resultaten från studien visade att kommunikation och ledarskap var de två teman som hade störst betydelse för socialsekreterarnas välbefinnande i arbetet. Resultaten visade också på en diskrepans avseende förhållandet mellan hur viktigt påståendena i enkäten ansågs vara och i vilken grad de förekom på arbetsplatsen vilket pekar på utvecklingsmöjligheter. Däremot kunde det inte påvisas någon skillnad mellan hur yngre och äldre bedömde vikten av de olika arbetsmiljöfaktorernas betydelse för deras välbefinnande i arbetet. Fler studier med olika infallsvinklar av hur kommunikation och ledarskap påverkar socialsekreterares välbefinnande i arbetet skulle kunna bidra till att identifiera lämpliga arbetsmiljöinsatser för en förbättrad arbetssituation för socialsekreterare.

La adicción al trabajo es un concepto que con el tiempo ha generado cada vez mayor interés e investigación. A través de la realización de 5 estudios empíricos, en esta tesis se profundiza todavía más en su estudio. Concretamente se estudia cualitativamente la adicción al trabajo, proponiendo un modelo heurístico en el que constan diversos antecedentes y consecuentes de la misma. Así mismo se determina que la adicción al trabajo y el engagement (vinculación con el trabajo en español), son dos estados mentales diferentes relacionados con el ámbito laboral (el primero meramente negativo, el segundo totalmente positivo). Además, se presenta el perfil de personalidad que caracteriza a los trabajadores adictos al trabajo y a los trabajadores "engaged", y se expone la relación que este daño psicosocial tiene con el bienestar (i.e., felicidad y salud percibida), la aufoeficacia laboral (relación sorprendentemente positiva) y con otras variables como la satisfacción laboral (negativa), la sobrecarga de trabajo (positiva) y el conflicto trabajo-familia (positiva). Además al final de la tesis se plantean diversas preguntas de investigación que todavía quedan por responder para que investigación futura pueda continuar con el estudio del concepto. En su conjunto con esta tesis se ha avanzado en la comprensión de algunos de los factores clave para la aparición y desarrollo de la adicción al trabajo.

In recent years, research related to older adults and long-term care has been growing. Although much research in the past was focused on biomedical issues, more recent research has examined psychosocial issues faced by older adults within the long-term care setting. Despite the increase in literature and research on aging, long-term care, and dementia, there are still many gaps in our understanding of these phenomena. The concepts of body, self-identity, and place have received some attention over the last decade or so, but little systematic attempt has linked these concepts together, especially with relation to older adults and long-term care. In addition, the adjustment process of older adults into the long-term care facility has been examined, but the socialization processes have not been systematically examined. The purpose of this phenomenological study was to examine the process of socialization for new residents into the long-term care culture and environment, specifically focussing on how identities, bodies, and place are constructed and reconstructed by residents. Three residents were recruited for this study from a home for the aged in northwestern Ontario. Participant observation and three interviews over a six-month period with these residents focussed on concepts of place, self, and the body, as well as adjustment. Fifteen staff were also interviewed initially to gain an understanding of the long-term care environment and culture. Thirteen staff and two family members were interviewed at the end of the six-month period to gain an understanding of their perceptions of the resident’s transition into the long-term care facility. The findings indicate that a dismantling of the self occurs prior to coming into long-term care. Life in long-term care was described as living an altered life. Once admitted to the home for the aged, two types of socialization processes occurred—institutional and (inter)personal. Institutional socialization processes consisted of placing the body, defining the body, focussing on the body, managing the body, and relating to the body. Placing the body refers to the placement within the physical and social environment, residents’ adjustment to a new place, and how space within the facility was used. Defining the body refers to the assessments that were used just after admission which were focussed on the body as dysfunctional and limited. Focussing on the body occurred through the institution’s focus on body care, as well as the residents’ focus on their aging and unpredictable bodies, with a greater awareness of mortality and the immanence of death. Managing the body occurred through routines, risk management, and waiting. Finally, relating to the body referred to the boundaries of relationships that were defined, both resident relationships and staff relationships. The (inter)personal socialization processes capture the ways that residents internalized the institutional socialization processes. Internalizing the body refers to being a number and being a burden. Accommodating the body suggests ways in which residents complied to the institutional socialization processes. Accepting-resisting the body refers to the struggle residents had in accepting and fighting becoming a body, body limitations, and life in the institution. Re-creating the body illustrates ways in which residents reclaimed the body and alternative identities. All of these processes came together to create institutional bodies. These findings lead to a greater understanding of the ways in which body, self and identity, and place are intertwined. The institution served as a container for life, defining each of the lifeworld existentials. Lived space became institutional space, as personal space was redefined by the institution. Lived time also became structured by the institution, as temporal dimensions were defined by institutional time. The lived other became the institutional other, as staff became institutional brokers, attempting to balance the needs of the residents while adhering to the rules and regulations of the institution. The lived body also became the institutional body. The care encounter brought these dimensions together, and was the site for the production of institutional bodies. The findings of this study invite a rethinking of conceptions of the body and old age, particularly within the context of institutionalization, with bodies viewed as repositories of memories and containing both youth and age, rather than age as a ‘mask’. Residents exist within paradoxical rhythms of life, and thus, old age and institutionalization are not easily defined or theorized, but rather, reflect the complexity of lived experience.

Negative interpersonal workplace behaviours are an important but relatively infrequently studied occupational-stressor. The present research investigated the connection between these behaviours and employee well-being. This work had two main goals. The first goal was to provide greater insight into when and why social interactions at work can be harmful to employee well-being. Consistent with this goal, theory and research were reviewed, and results from two field studies were presented suggesting that (1) disrespect is an important characteristic of interpersonal workplace events that can explain detriments to employee well-being, and (2) both individual and contextual moderators are relevant in this process. In a first study, disrespectful leader behaviours were shown to negatively relate to employee well-being independent of demanding, production-focused leader behaviours. In a second study, perceived disrespectfulness mediated the relationship between exposure to negative interpersonal behaviour and well-being; workplace norms, social support, control-related self-beliefs, and negative affectivity moderated associations within the mediation sequence. Given the importance placed on objective measurement methods in the occupational stress literature, the inherent difficulties in measuring social stressors objectively, and the widespread use of self-report instruments in the literature, the second main goal of this work was to approach greater objectivity in the measurements of self-reported negative interpersonal workplace interactions. A number of approaches were used toward this end, including the development of a more objective self-report measure of interpersonal workplace behaviours, as well as the use of aggregate variables and the investigation of moderated relations within multilevel frameworks. Implications of this work and directions for further research are discussed.

Research exploring identity in the dementia context reveals that some aspects of personal and social identity persist in dementia while others evolve as persons living with dementia find ways to live with the changes in their lives. Leisure can be a space for developing and expressing identity and a space to resist stereotypical images and social expectations. Leisure may also play an important role in providing meaningful activity and engagement in life. Nonetheless, the meaning and experience of leisure in the context of dementia have received very little attention in the literature. Guided by the personhood movement, this phenomenological study aims to understand the subjective experience of dementia and the meaning and experience of leisure in the lives of persons living with early stage dementia. It explores leisure’s role in identity maintenance and/or development and leisure as a space for slowing down the process of dementia and resisting stigma associated with dementia and identity loss that could occur in dementia. Four persons living with early stage memory loss were recruited through local agencies to participate in this study. Each participant engaged in four conversational interviews following McCracken’s (1988) long interview format. Interviews were recorded and transcribed verbatim. Data were also collected through participant observation. The participants and I engaged in at least one of their favourite leisure activities together. Detailed field notes were recorded following each participant observation session. Using the method of photovoice, participants were given disposable cameras and asked to take photos of objects, places, and subjects that were meaningful for their leisure. These photos were discussed in Interview 2. Data were analysed in a manner consistent with phenomenology. Findings revealed that the participants experienced their journeys of memory loss within a paradox of challenge and hope. Participants juxtaposed the negative aspects of living with memory loss with the positive aspects of their lives. Essences of the experience include struggling with change, in which participants experience a wide variety of challenges as a result of being diagnosed with memory loss, including muddled thinking, fluctuating abilities, draining energy, frightening awareness, and disquieting emotions. However, participants counter these changes with the variety of ways in which they tackle life with dementia, including reconciling life as it is, battling through the changes by being proactive, living through relationships, being optimistic, and prolonging engagement in meaningful activity. Participants also experience threatening assaults on identities. Identity is threatened in terms of disappearing roles, losing independence, struggling with demeaning images and expectations, and losing confidence. However, participants juxtapose these threatening assaults by upholding identities. They do this by emphasizing abilities through leisure, changing perspectives, and engaging in life through leisure. This study deepens our current understandings of the subjective experience of dementia and leisure’s role within that experience. It helps us to understand the experience of leisure within the context of memory loss in terms of four lifeworld existentials: lived time, lived space, lived body, and lived other. The findings also contribute to our understandings of how persons living with dementia use leisure to resist a master status of dementia. Participants in this study used leisure as a space for resisting both the stigma of memory loss and the progression of memory loss. They overcome challenges in their leisure to demonstrate to themselves and others that they have many remaining abilities and are able to maintain valued aspects of their identities. The findings suggest that service providers, family members, and persons living with dementia should carefully consider the meaning of leisure and find ways to facilitate involvement in leisure that is meaningful for persons living with memory loss. In terms of future research, leisure in the context of relationships, including the importance of advocacy work for persons with dementia, should be examined. Although this study provides insight into the possibilities of alternative methods for understanding the experience of memory loss, further exploration is needed in this area.

Purpose: The purpose of this dissertation was to examine the determinants of unplanned emergency department (ED) use by home care clients, the profile of older ED patients, their transitions from the ED, as well as the determinants of post discharge outcomes among older ED patients. The goal of this dissertation was to create theoretically driven, evidence-based, and practical risk identification methods for home care and the ED. Methods: First, a multi-year, census-level cohort study was conducted on home care clients in two Canadian provinces (N=617,035). Census-level data from RAI-HC assessments were linked to census-level ED records. A needs-based decision tree model – the ED Model – informed by the Andersen Behavioural Model, was created using decision tree analyses. The final model was validated on a separate data partition and compared to the ERA Index and the CARS. Multilevel analyses were conducted to test regional variation in model performance. Disease stratified analyses were also conducted to test model generalizability across common disease classes. Regression analyses determined the effect of predisposing and enabling factors within ED Model strata. Second, a multi-site, multi-province prospective cohort study was conducted, termed the Management of Older Persons in Emergency Departments (MOPED) Study, using a clinically representative sample of 2,101 older ED patients. The interRAI ED-CA was used to assess older ED patients, and a 90-day disposition was collected. The profile of older ED patents was examined. Best-subset regression analyses identified person-level determinants of acute inpatient admission. Two needs-based decision tree models – the ALC/LTC and ED Revisit Models – were created using decision tree analyses to determine the risk of ALC designation or LTC placement, and unplanned repeat ED visits, respectively. Both models were validated on separate data partitions. Multilevel analyses were conducted to test site-level variation in the models’ performance. Results: Overall, 41.2% of home care clients had at least one unplanned emergency department visit within 6 months of an assessment. Previous ED use, cardio-respiratory symptoms, cardiac conditions, and mood symptoms featured heavily in the ED Model. The ED Model provided moderate risk differentiation and clinical utility. It achieved an area under the curve of 0.62 (95% CI: 0.61-0.62) and showed clear differentiation in Kaplan-Meier plots using validation data. Multi-level analyses showed no regional variation. The ED Model significantly outperformed the similar tools specific to primary care with respect to overall accuracy and perceived clinical utility. Predisposing and enabling characteristics provided little added differentiation beyond evaluated need. The majority of older ED patients were dependent on others for basic tasks of daily living, and many had fragile informal care or lived alone. Triage acuity generally did not differentiate chronic geriatric disabilities and conditions. Previous ED or hospital use was associated with chronic geriatric disabilities and conditions as well as informal caregiver distress. The Admission Model found that multiple factors were associated with admission to inpatient acute care, including: acuity, instability, changes in ADL function, cognition, nutrition, and anhedonia. Overall, 20.7% of older ED patients admitted to acute care were designated ALC or discharged to LTC; whereas 39.5% of older ED patients discharged home had one or more repeat ED visits within 90 days. Cognitive, functional, and informal care indicators were predictive of ALC/LTC; whereas functional status and symptoms were predictive of repeat ED use. The ALC/LTC and ED Revisit Models provided good risk differentiation, achieving AUC’s of 0.74 (95% CI: 0.69-0.79) and 0.69 (95% CI: 0.63-0.74), respectively. The ALC/LTC and ED Revisit Models showed clear differentiation in Kaplan-Meier plots. Multi-level analyses showed no site-level variation in each models’ performance. Conclusions: This dissertation produced tangible and empirically-based risk assessment models for clinical practice in home care and the ED. The models developed in this dissertation can support the targeting of preventative services as well as better communication strategies between the ED and community supportive care, primary care, and inpatient acute care. Key questions related to the prevention of the risk pathways identified in each risk assessment model remain unanswered, and should be a focus of future research.