UNDERSTANDING QUALITY OF LIFE
IN ASSISTED LIVING:
INFLUENCE OF THE BUILT AND ORGANIZATIONAL
ENVIRONMENT
CHÉOS Work in Progress seminar | Oct 23, 2013
Dr. Sharon Koehn, Dr. Atiya Mahmood and Sarah Stott
Assisted Living in BC
Assisted Living (AL):
housing, hospitality and
personal-care services
for people in a noninstitutional environment
who do not need 24/7
nursing care
Focus on quality of life
(QoL)
Since 2002 in BC:
194 registered ALs
6,832 units
64% publicly
subsidized
Tenants pay 70% of
income
Diversity of Canada’s Older Adults
Visible
Minority 65+
Canada
BC
Vancouver
CMA
7.3 %
16.1 %
31.2 %
% Chinese
35.1
51.8
55.6
% South Asian
24.5
26.1
23.5
7.1
5.6
5.7
66.7
83.5
84.9
% Filipino
Total
Our research questions
How do ethnically diverse older adult residents of
Assisted Living (AL) facilities in British Columbia
experience QoL?
What role, if any, do organizational, physical, and
social environmental features play in influencing
how QoL is experienced?
Understanding Quality of Life
QoL is a broad concept
that incorporates “in a
complex way, a person’s
physical health,
psychological state,
level of independence,
social relationships,
personal beliefs and
relationship to salient
features in the
environment” (WHO 2002).
QoL of seniors
Negative influences
Declining health
Retirement ($ and role
loss)
Breakdown of
extended families
Loss of spouse et al
Positive influences
Religious faith
Positive comparison
with contemporaries
Adaptation to
hardship
…
Building blocks of QoL measure
based in theory
grounded and
validated in the
realities of research
participants
permit comparisons
between groups
distinguish clearly
between determinants
(influences on QoL)
and the attributes of
QoL
Grewal et al’s approach to QoL
QoL is
contingent on
older adults’
capability to
pursue five
conceptual
attributes
which are
experienced
in different
ways by
different
people:
Enjoyment
Role
Attachment
Security
Control
AL influence on QoL of older adults
Does increased support in
AL deprive them of
important roles?
Does social and
recreational programming
offset role deficits and
increase enjoyment?
Do the rules and
regulations of ALs inhibit
control over decisionmaking or finances?
Do attachments to family
members suffer and are
these “replaced” with
attachments to staff/other
tenants?
Do physical environments
and staff in and around
ALs promote safety?
Mixed Methods Pilot Study
Three sites
• Targeted-SA; Targeted-Ch; Nontargeted
Environmental
Audits
• MEAP-PAF, POLIF, RESIF; SWEAT-R;
Behaviour Mapping Tool
Quality of Life
• 3 focus groups with residents (1 per
site); 6 interviews with staff (2 per
site)
Three sites - demographics
Numbers of tenants by sex
60
50
40
45
30
50
59
20
10
15
0
AL 1
AL 2
AL 3
male
female
no data
Three sites - language
Primary tenant languages by site
70
60
50
40
30
20
10
0
AL 1
AL 2
Punjabi
Hindi
Gujarati
Cant/Mand
AL 3
English
Spanish
Targeted sites - age
Age distribution of tenants at two targeted sites
85+
30
11
75-84
30
29
65-74
8
55-64
2
0
5
10
15
AL 3-no data
20
AL 2
AL 1
25
30
35
Targeted sites – tenant education
Education levels of tenants at two targeted sites
Bachelors+
10
12+
10
11
gr 9-12
20
< gr 8
50
9
0
10
20
AL 3-no data
30
AL 2
40
AL 1
50
60
Three sites – tenant ability
ADLs/IADLs with which tenants require assistance
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
AL 1
Shower
AL 2
Bed
Phone
Bathroom
Dressing
AL 3
Commn
Walking
Shopping
Targeted sites –activities in AL
Activities in which tenants participate on-site
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
AL 1
Daily TV
Music
AL 2
Newspaper
Games-sm gp
Games-lg gp
Walking
In-visits
Three sites – support staff
Support staff by AL site
25
20
15
10
5
0
AL 1
AL 2
ALWs/HCAs
AL 3
Nurses
Kitchen staff
ALW = Assisted Living Worker; HCA = Health Care Aides (same work)
Environmental Audits
18
Organizational environment
• policies, fees, rules, staffing, meals, activities
Physical environment
• Exterior: Built environment of the neighbourhood surrounding the residence
• Interior: Features and design of the residence
Social environment
• Interactions among residents and between residents and others (staff, visitors)
Organizational factors
19
Large number of
support staff
• 6 health care aids
• 2 practical nurses
• 5 kitchen staff
Low turn-over of
staff and tenants
• Most staff members have been with AL longer than a year
• 83% of tenants have lived here longer than 1 year
Rules and regulations
Scheduled
recreational activities
Opportunity for
tenant involvement
•
•
•
•
•
Appear moderately flexible
P.A. announcement 15 minutes before meal times
Scheduled mid-afternoon tea time
Assigned seating – dining room
Background music played during meal times
• Suggestions for activities taken from tenants
• Sometimes confusion with scheduling (e.g. cancellation of an
activity last minute)
• House meetings every second month
Physical features -neighbourhood
• Flat terrain
• Suburban
neighbourhood
Proximity to services
• Marked
crosswalk in
front of the
building
• Wide sidewalks
in good
condition
• Dim street
lighting in the
evening/at
night
Geography
Sidewalks and crossings
20
• No convenience
store
• Nearest bus
stop at the end
of the driveway
in front of the
building
• Distance to
shopping
Physical features-interior
21
Clean and tidy
spaces
Large corner
spaces with
seating
Quiet
Well-lit
Well-decorated
(daily and
seasonal)
Physical features-specific spaces
22
• Greatest traffic in
front of activity
and meal boards
• View of drive-way
from separate
waiting space
• Well-lit, somewhat
loud
Lobby
• Viewing gallery
above; high ceilings
• Seating four per
table
• View of driveway
and lobby
• Recreational and
social activity space
• Very open, well-lit
• Crowded during
exercise activities
• Kitchen for cooking
activities
Dining room
Multipurpose
room
Different Types of interactions
23
Low-level interaction
•
•
•
•
•
•
Head nod
Waving
Gesturing
Smiling at someone
Quick “hello”
Listening
High-level interaction
Other types of
interaction
• Conversation beyond
a short greeting
• Active participation in
an activity, e.g. “News
and Views”
• Physical engagement
with another, e.g.
hugging, patting on
the back
• Mumbling
• Cleaning
• Participating in an
individual activity, e.g.
sewing, using the
computer,
praying/meditating
Levels of activity in different spaces
24
Dining room
Lobby
• Mostly low-level interactions
(greeting)
• High-level interactions in front of
activity and meal boards
• Mostly high-level interactions;
during period before meals are
served
• Low-level interactions during
and after meals (saying bye,
waving, gesturing)
Multipurpose room
• Greater occurrence of and
proportion of high-level
interactions; activities involve
active conversation and
participation
• High % no or low-level social
interaction observed during
crowded activities
Types of interactions by space (%)
25
120%
% of interactions
100%
Other interaction
80%
High-level
interaction
60%
40%
Low-level
interaction
20%
0%
Lobby
Dining Room Multipurpose Other Spaces
Room
Common Spaces
No social
interaction
Focus groups and staff i'vws
Environmental
audits
Open
comments
Brief summary
PPT for each
AL
Transcribed
discussion
QoL attribute
pointers &
environment
flipcharts
Focus groups
Pointer key words
Roles - sense of purpose
Relationship with family/friends
Relationship with spirituality or religion
Enjoyment/pleasure
Feelings of being safe
Control
E.g., Enjoyment/Pleasure
Qualitative data analysis
Tenant focus
group
transcriptions
(3)
Environmental
data
summaries
(1)
Focus group
flipchart
notes (3)
Nvivo
coding
sources
Staff
interview
transcriptions
(6)
Family relationships+ in AL
Female (AL3): I found that this [AL] is very helpful to my family because they
see the environment and understand it and appreciate the good features
and almost everything is good here. And they know that I’m safe, that I’m
cared for. They’ve gotten to know the staff, they have a good rapport and
they can come and visit me or take me out whenever they choose and I’m
not—and also, it benefits me in a number of ways. I’m not responsible or
holding my family responsible for me to get around or do the things that
older people can no longer do.
Male (AL3): I’m quite happy here and what happens is my daughter doesn’t
need to worry about me because I was living alone by myself and she was
very close to me so if something happened I could signal her and now here,
she knows that I’m—if something happens, I’m taken care of.
Family relationships+
Inexpensive meals for families (AL1)
Family room for private dining together (AL2)
• BUT “If there is only one family visiting, the staff doesn’t bother
opening the family room. They make that one family eat in the dining
hall. I really don’t like it when they do that. …They split up the family
so they can fit or they move the tenants in order to seat the family.”
Mass held in large room to include family members
(AL2)
Overnight guests allowed in suites (14 nights/yr)
• but limited by lack of guest room (AL 2&3)
Relationships challenged
Suites not
large enough
for bigger
family meals:
“…there’s 6 and my husband and I makes 8 and I was suggested to
use this room downstairs well, it’s not private. You know, you can’t
really have a family gathering. If the kids want to run around and
play and they’re making noise, it’s going to disturb the office, it’s
going to disturb everything so it’s not really appropriate” (AL3)
Location
precludes
“dropping in”:
I lived with my family and coming here and having them downtown,
a distance away, is quite a difference, you know. And getting used to
that. And experiencing sort of a loss because even though it’s a short
distance it’s still far enough away that I can’t get there by myself
(AL3)
Difficult to
host
friends/family
with special
dietary needs:
I tend to be going out with them more than I can reciprocate and
have them in” (AL 3)
Innovative dining room concept
We have very different cultures on those
three floors. You know, when it comes to
the dining room. Like, our floor, I’m on the
third floor. Everybody comes early, they
rush through eating, they tend not to visit.
Coffee time, they don’t stay in the [dining
room]. They come get their coffee and
take it to their rooms. You know they’re
much less sociable. So some of the people
who are social will go down to the second
floor now where they tend to gather in the
dining room for the coffee time And you
kind of develop from the culture when you
come in and join. You know, if everybody’s
leaving [the dining room], you leave too
(AL3).
Spiritual connection challenges
Inside physical environment:
• Tenants do not have access to a quiet room large enough to
hold mass for 15 people (own suites too small, multipurpose
room too distracting, noisy) (AL3)
Outside physical environment
• Access to a nearby chapel and church are inhibited by
uneven and steep sidewalks, and a short crossing light with
a button that’s off the sidewalk: “It’s very difficult. I took a
[wheel] chair out the other day for a test ride and I almost
fell out into the road trying to push the button” (AL3).
Crosswalk safety
AL2
AL1
• “Cars are parked along the
street. So when we press for
the pedestrian signals,
oncoming traffic can’t see if
there are actually people
crossing since the parked
cars block us. So cars keep
going because they can’t
see us. They see us only
when they’re very close to
the intersection.”
• T1: “There is no crosswalk
and we don’t feel safe
crossing.” T2: “There should
be one there because when
I go in this [wheel] chair, I
can’t cross there.” T3: “We
have to wait for some
decent man to stop so we
can cross the street.”
The safety-control trade-off
Rules and
regulations
and staff
support
designed to
enhance
safety also
inhibit tenants’
control over
day-to-day
decision
making
“Our feelings of being safe come from a “safety
bell” that we all have. We’re supposed to wear
it around our necks but I believe that no one here
today is wearing one” (AL2, also AL3).
Sign-out rules control and protect (all)
Medication assistance keeps them safe from
under-/over-dosing, but restricts their time - they
have to be in their rooms to receive it (AL 3).
Accepting the need for “order”-AL2
“I feel that the freedom here is less. You can’t come and go as you wish.
And most of the times, the activities are pre-planned and they have an
allotted time. Everything is planned well.”
Set meal times at noon and 5pm
• “So if you sleep late, 5pm is too early for dinner. But we are okay with it. The staff rotation is
around meal times. They start their shift at 7pm so dinner is at 5pm in order for all the tables
and dishes to be cleaned before the next shift. So there is nothing we can do”
Assigned seating at mealtimes:
• “Some people forget where they sit or which rooms they live in. So it’s better to have
assigned seating.” “If it’s not assigned, the distribution of meals will be difficult.”
Resisting control – AL1
“Staff imposes “stuff” [rules and regulations] without explaining
why which sometime doesn't feel right, they have to explain it to
us what they are doing and why they are doing. Rules and
regulations are always nice but how they are implemented is the
issue. The staff should answer our question.”
“Power/lighting is included in resident monthly fee as per the
resident handbook, however residents have been charged
$15/month extra for hydro for the last 6 years…. We fought
and fought but nothing happened, no response.”
Financial control – AL1
Male: I remember that our sister here made a list of necessities and
needs that we have to see whether we can manage in $300 or
$350 left after paying our expenses here. So it was presented to
Director Fraser Health but he said ‘It’s your problem, I can't help it.’
Female: Like many of our medicines are not covered, we have to
buy them no matter what; with that ear, teeth and eye we have to
do it on our own so how do we manage in such small amount.
Sometimes I think that people who don't get financial help from
outside [family], they can't have a cup of coffee even, so this is a
major problem for us. If all the medication was covered then we
wouldn't face problems.
Enjoyment – different emphases
AL1:
AL2:
AL3:
• “Food is very good.
• “It's nutritious and delicious.”
• “we get different types of food, for example we get Indian, Italian, English,
Gujarati”
• “We have many programs here. For example, exercises, singing, bingo.”
• “We have festivities in the dining hall.”
• In their own rooms they play mahjong and watch TV.
• “We think we’re happy up on the 4th floor but I’m beginning to wonder if we’re as
happy as you people are [on the 2nd floor]. Now I know a couple of people up on
our floor who are always grumbling about the food or the staff or, you know, and
I’m sorry for them because they’re not very happy and it’s their own darn fault.”
Role loss
When people
are unable to
fulfill previous
roles in the
home, they
want or need
to move to AL:
• Well living at home is of course better, one
leaves home when there are problems; like
first my wife was sick for 12 years but I was
fine then she passed away and I got surgery
and now my arms don't work properly. I used
to make 100s of dollars at home, I was a
tailor. … Here, the staff looks after well
(AL1)
• I used to live with my daughters but I came
willingly here. They all used to go to work, no
one at the home …you have to see if you are
causing any problems for the kids because I
have many diseases and no one to look after
me at home. Here it's fine, they look after us
(AL1)
Aging as loss of purpose – AL 1
“This will be the last state of life … we cannot go back [home]. Our death
is right here … I see 14 or 15 people die here.”
“All the things you mention here, they don’t have as much meaning as when
we were younger.”
There is a conflict present that “people want to think the same way but
they have to accept that physically and mentally they are losing
themselves.”
“This part of life, you have to accept that you can’t do the things you used
to.”
Role shift
Adjustment to AL can be difficult for people whose
roles shift considerably as a result of the move
• “…we were just grandmas and taking care of the kids and that
kind of thing and moving into this place was like a shock and we
weren’t prepared to do it. You know, we weren’t really thinking we
were in that kind of situation where we needed that kind of care
and you know, feeling like a patient when you first moved in and
eventually it comes around and you begin to see the necessity and
the rest of it. But when you first move in and you’re in that situation,
everything is out of whack. The noise in the hallway is too loud, the
staff talking to some of the people who can’t hear is too loud, you
know, there’s a lot of stuff that goes on that you don’t really think
about, … having to ask to use the washer and dryer” (AL3).
Role Continuity
People are
able to
maintain
role
continuity
when they
know how to
keep
themselves
busy:
• “Sometimes I exercise in the morning,
and then I take some rest then do
some knitting or something for children
even if it's needed or not needed, just
to keep yourself busy” (AL1).
• Male: “I’m just about the same as
before [I moved here]. I’ve always
been busy. … I read sometimes, I
study some. I walk a lot.” [RA: “And
you participate in a lot of the activities
I noticed”]. Male: “Yes, the physical,
yes—the exercise” (AL3).
Tentative conclusions
All of the attributes of QoL in Grewal et al’s scheme
resonated with all groups
Environmental features of the AL clearly influenced
their capability to pursue the different attributes of
QoL:
•
•
•
•
Exterior physical – safetyOrganizational – safety+, control-, attachment+/-, enjoyment+
Interior physical – attachment+/AL overall (vs home) – attachment+/-, role
Thank you!
skoehn@providencehealth.bc.ca