IMPROVING QUALITY OF LIFE OF OLDER ADULTS LIVING IN A LONGTERM CARE FACILITY

by
Enino Nicolia Izu

PRACTICUM REPORT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SOCIAL WORK

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
April 2017

Abstract
Over half of the residents in long-term care have a diagnosis of dementia. Maintaining
a good quality of life is important, as there is no cure for dementia. Quality of life may be
used as a standard for caregiving and, as a framework for practice to enhance service
provision. The purpose of this four month practicum was, to explore quality of life as seen
and experienced by residents living with dementia in long-term care, factors that influence
quality of life, as well as the approaches used to improve quality of life.
This practicum report details my experiences in long-term care social work at Simon
Fraser Lodge in British Columbia. The practicum goals were set around professional
understanding of dementia and quality of life of older adults in a long term care facility.
While the focus of the practicum was on developing, improving, and understanding my role
in social work, it was also a medium for my developing ways of improving quality of life of
older adults. The medical and psychosocial models of disability were used as a basis for
understanding the practical experiences encountered in this practicum. This report and
practicum experience focused on personal growth as a social work student and ways of
improving quality of life of older adults living in Long-term care facilities.

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TABLE OF CONTENTS
ABSTRACT…………………………………………………………………………….…….ii
TABLE OF CONTENTS………………………………………………………..……….…..iii
DEDICATION…………………………………………………………………………...….vii
ACKNOWLEDGEMENT………………………………………………………...….….....viii
CHAPTER ONE: INTRODUCTION…….……………………….………….………….........1
Description of the practicum setting………………………………………………………….2
Simon Fraser Lodge…………………………………………………………………………..3
Learning Goals and Objectives……………………………………………………………….5
CHAPTER TWO: THEORETICAL ORIENTATION…………………..……..….……..6
Simon Fraser Lodge……………………………………………………………………..……7
Situating Myself in Simon Fraser Lodge…………………………………………….………..9
Practicum Learning Situation………………………………………………………………..10
Medical and Social Models of Disability………………………………….…….….…..….11
Medical Model…………………………………………………………………………….…11
Psychosocial Model…………………………………………………………………...……..12
CHAPTER 3: LITERATURE REVIEW......................................................................…...13
Older Adults……………...……………………………………………………….………….13
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Quality of Life Definition……………...………………………………………………….…15
Quality of Life……………………………………………………………………………….17
Long- Term Care. ………..……………………………………………………………….....17
Influences of Quality of Life for Older Adults…………………………..…….…………….18
The Seniors Policy Lens in Canada …………………………………………………………20
Components of Seniors Policy ………………………………………………………………20
Uses of Policy and Applications of Seniors Policy…………………………………………..21
Policy Direction in British Columbia………. ………………………………………..……...22
Current Policy Context…………………………………………………………….…..……..23
Cost……………………………………………………………………………………...........24
Senior’s policy Problem………………………………………………………...…………....25
CHAPTER FOUR: Learning Experiences from the Practicum………………………...........26
General Activities….................................................................................................................26
Admissions/ Discharge Planning and Referral…………………………………….…………27
Actively Participating in Interdisciplinary Team Meeting………………………...…………28
Grief and Loss Work with Residents and Family……………………………………………29
Assessment……………………………………………………….…………………………..30
Psych Educational and Education Work with Residents and Families………………………31
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Specific Goals……………………………………………………………………….……….32
Knowledge of Medical and Social Issues Faced by Social Workers in LTC……..………….32
Knowledge and Use of Community Resources..………………………………………….….32
Knowledge around Adult Guardianship, PGT, and Adult Protection………………..………33
Communication and Intervention Skill……...……………………………………………….34
Practicum as I Experienced It………………………………………………………………..35
Long Term Care (SFL) Social Work as I Experienced It…………………………...………..36
Physical Environment………………………………………………………………………..37
Outdoor Activities……………………………………………………………………………38
Recognition…………………………………………………………………………………..39
Relationships…………………………………………………………………………………40
Privacy………………………………………………………………………………………..40
Choice and Control…………………………………………………………………………...41
Spiritual Well-Being…………………………………………………………………………41
Chapter 5: Implications for Personal Professional Practice………………………………….43
Strategies for Change………………………………………………………………………...44
Develop Infrastructure with Attention to Unit Prices………………………………………..45
Develop Feedback Forms for Families………………………………………………………45
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Create More Supportive Environment……………………………………………………….45
Take Back the System………………………………………………………………………..45
Conclusion……………………………………………………………………….…………..46
References……........................................................................................................................47
Appendix: Learning contract, agency brochures………………………………………..……57

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Dedication
I dedicate this practicum report to God Almighty my creator, the Alpha and Omega, the First
and Last, Ancient of days, Lion of the tribe of Judah, my strong pillar, my source of
inspiration, wisdom, knowledge, and understanding. He has been the source of my strength
throughout this program and on His wings only have I soared. I also dedicate this practicum
report to my late sister; Teolanozuni Amamkwe Ituah, I remember you every day; my love
for you can never be quantified. Continue to rest in the arms of God Almighty.

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Acknowledgements
My greatest thanks go to all the members of my family, especially my husband Hyacinth, for
being there for me all through this process, who has been a constant source of support and
encouragement during the challenges of graduate school and life. I am truly thankful for
having you in my life. “I love you darling”! To my precious son Gianni, you came in the
middle of my Master’s Degree and I could never have asked for a more precious and
welcome "interruption". During such a short time you have taught me so much. I love you,
my handsome son!
To my parents (Mr. & Mrs. Amamkwe) words are not enough to express how much I love the
both of you. You taught me all I am today, for your prayers and continued love and care; I
say Thank you, and your labour of love will never be taken for granted.
To my eldest brother and family (Dr. &Mrs. Benjamin Onyenwosa), I say may the good Lord
continue to bless you and cause his good face to shine upon you for evermore. You saw me in
Nigeria and gave me another chance to live again, I am forever grateful for all you have done.
To my brother, sisters, nieces and nephews, Valentine, Ayo, Komi, Omanoreni, Blessing,
Benita, Benjamin, Jasmine, Billy, Ehinome, Donald, Denzel, Dakore, I say a big “Thank
you” God bless you all.
I will also like to express my deepest appreciation to my academic supervisor, Dr.
Nancy Jokinen, who has provided incredible support, advice and encouragement to me
throughout my Master’s degree; your wonderful words of encouragement and the push to
move on will never be forgotten. Leslie Webb, my agency supervisor, has been a wonderful
teacher, coach, mentor, and support during my practicum; her passion and experience in this
field as a social worker is one of the reasons I choose to work with the elderly. My special
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thanks also go to Dr. Glen Schmidt, who has taught me so much from scratch about social
work practice and academic writing.
I will like to say a big thank you to the residents of Simon Fraser lodge for trusting me
to assist them. They taught me a lot about human nature. I also owe a special thanks to all the
staff at Simon Fraser lodge that welcomed me, taught me a lot about various professions,
allowed me to shadow them and ask numerous questions, and never made me feel like a
student but treated me as a member of the professional team.
Finally, I thank my Pastor and Wife (Pastor & Mrs. Folorunsho) for their prayers,
words of motivation and words of comfort that came just in time. God bless you all.

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Chapter One: Introduction
Long term care (LTC) is provided or recommended for older people who are unable
to take care of themselves in their own home due to various health and social reasons. Quality
of life (QOL) is found to be an important and significant interpreter of mortality, choice,
physical dependence, and service utilization among older people (Ho et al., 2002). LTC
residents are more likely to experience a reduced QOL due to health issues or conditions,
changes in living environment, rigid daily routines, and different social interactions (Kane,
2003). In health and social services, the ideal goal is to promote a better QOL for older
adults (Holtkamp et al., 2000; Rönnberg, 1998; Wong et al., 2004).
QOL has become a general term and often spoken of in terms of a range of settings,
contexts, and environments. Its usage has become commonplace in day to day living because
it covers most aspects of life. QOL is a multidimensional concept, which cannot be
explained or expressed in medical terms alone and meaningful if measured in a holistic or allinclusive context. QOL contains both subjective and objective elements; therefore, it is of
great importance to put both into account or consideration when measuring the concept
(Kane, 2003). A good QOL is apparently a paramount and important goal for each longterm care (LTC) facility. QOL is specifically applicable for residents in LTC facilities who
may be considered one of the most vulnerable groups in society today given their age,
declining health, and levels of dependency.
Many older adults in LTC feel powerless or unable to criticize the level of care they
receive in LTC due to declining health, impairments, cognitive decline, or other various
conditions. Despite policies and regulations to ensure that good and minimum satisfactory
standards of care are followed, there is still evidence that the quality of long term care
services for older adults does not meet the expectations of their families, the public, and or

1

the residents in the facility (Organization for Economic Cooperation and Development
(OECD), 2005).
This practicum at Simon Fraser Lodge (SFL) was challenging yet a fulfilling
experience that opened my eyes to learn a lot about LTC, Canadian society, and myself in
general. I learned how to be an effective and productive social worker in order to enhance the
care that older adults with disability, dementia, or chronic health concerns receive in LTC
facility. Throughout my experience, work across departments was compared to gain an
understanding of how continuity of care for the resident is maintained. While the opportunity
to learn and contribute across several departments at SFL was an important part of this
practicum experience, the practicum was undertaken with a particular interest and focus on
QOL and disabilities and how residential care social workers view work with persons with
dementia and with seniors experiencing a range of disability issues. Gregorian (2005) uses
the term predictable chaos (p.5) to describe the day to day plan of social workers, while
Dhooper (1997) points out the importance of adaptation as a core social work quality.
Additionally, the practicum experience at SFL gave me insights on how family members
(e.g., spouse) are supported to cope with having their loved one in a residential facility, the
guilt of separation, and their continuing role in care as a family member.
Description of Practicum Setting
The practicum placement took place at Simon Fraser Lodge (SFL), a 130 bed
residential care facility in Prince George, British Columbia, Canada. This practicum started
on March 10, 2016 and continued until July 12, 2016; approximately 560 hours for four
months, Monday to Friday, 8.30am – 4.40pm
SFL is one of Northern Health’s contracted residential care facilities. The Northern
Health Authority (NHA) oversees all health care in BC from Quesnel north to the Yukon
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border, and from Haida Gwaii on the west coast to the Alberta border (Northern Health, n.d.).
Geographically, it is by far the largest health authority in the province. NHA has the highest
projected population growth rate of seniors anywhere in BC (Northern Health, 2010).
SFL is a modern care facility that specializes in dementia care and is working to
create a community wherein adults experiencing dementia and other disabilities have choices
about how they live, integrate, and contribute to the residential care facility community. My
practicum supervisor was an experienced social worker with a Master of Social Work degree.
SFL is a two-storey wood frame structure with residential character and appeal. It
was first built in the 1950s as a private hospital and later extended in 1992 with the addition
of a special care unit and again in 2000 to add a transitional care unit. Recently, in 2010, the
original private hospital was reconstructed and transformed SFL to a fully modern and wellappointed care environment (Northern Health, 2010).
SFL is a senior residential facility with 130 publicly subsidized beds. In SFL, there
are two types of accommodation: fully private rooms and private rooms with shared
bathrooms. The room furniture provided includes a night table, dresser, bed, lamp, and chair.
Residents are required to bring small personal items such as photos and mementos to beautify
and personalize their rooms (Northern Health, 2010).
In the facility, there are common areas for dining and recreation. There is a general
kitchen and laundry area that is accessed and used by staff only. The type of care services
offered range from complex care to specialized dementia care. Thirty one rooms are
designated dementia special care beds. Optional services (i.e., dentistry, chiropractic, and hair
salon) are available, if required, at a fee (Northern Health, 2010).
SFL specializes in dementia care and is known for providing exceptional care and a
home-like setting focusing on safety, quality, offering choice, staying connected to the
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community, cultural beliefs, and accountability. The overall SFL goal is to create a
community where adults with disabilities have choices on how they live, integrate and
contribute to the community within a residential care setting. The Lodge, as it is commonly
referred to, provides a safe, gentle-care environment that promotes personal health and
independence. Staff at SFL work closely with the families and a variety of community
networks to ensure relationships are supported and needs are met as best as possible. SFL
responds to the changing needs of many seniors. Their services include nursing recreational
and rehabilitative services, occupational therapy and physiotherapy, social work, dining
service, volunteer services, comfort fund, nutritional support, and long term care (Northern
Health, 2010).
The majority of the work during my placement took place in the social work unit,
which is responsible for


provision of, or referral, for mental health services;



advocating, and coordination of discharge planning;



provision of individual and family counselling;



documentation of resident’s psychosocial status;



information on community resources;



advocating with and for residents to ensure greater choice, quality of life, and quality of
care;



psychosocial assessments;



crisis intervention;



admission and discharge planning;



follow up with resident and family as needed;

4



and education related to illness including teaching coping and problem solving skills to
maintain or enhance psychosocial functioning;



as well as support to access funded supports and suitable placements.

Social work is also positioned to provide distinct systems perspectives in understanding the
family, SFL, and the community at large. At SFL, the social work department helps steer
complex systems to ensure services are identified and accessed. Furthermore, social workers
provide information relating to adult abuse, neglect, and crisis intervention as needed.
Learning Goals and Objectives
My overall goals for the placement were to:


increase knowledge, skills, and abilities to effectively practice social work with an olderaged population.



gain an understanding how continuity of care for a resident is maintained throughout the
facility and how care providers view, work, and contribute to the quality of life of adults
experiencing a range of disability issues living in their care.



gain an understanding about issues related to adult guardianship and adult protection.



gain an understanding about dementia and the unique care requirements within SFL.



become familiar with dementia and the associated challenges.

Becoming accustomed to this type of environment, along with all the learning that took place
was challenging at first but as I progressed in my practicum, I knew that SFL was the right
placement for me.
This report consists of five chapters. In this Chapter, I introduced the perceptions of
long term care (LTC) social work, practicum learning process, and description of practicum
setting. Chapter Two focuses on the theoretical orientation of SFL and my background as it

5

relates to LTC facility social work. Chapter Three provides a literature review on key aspects
including information on older adults, a brief description of the role social workers play in
LTC, and ethical challenges regularly faced in LTC facilities. Chapter Four includes learning
experiences, outlines my activities, and how I met the goals, and provides further information
on the experiences I gained from LTC social work. Chapter Five focuses on the implications
of social work practice as a social worker specific to LTC, and a conclusion of my practicum
experiences.

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CHAPTER TWO: Theoretical Orientation
This chapter features the theoretical orientation of the practicum setting and,
following that, how I positioned myself as it relates to the placement. According to Stephen
(2005), approximately one in six adults in British Columbia live with disability. In Canada as
a whole, 14.3% of the population was living with an activity-limiting disability according to
2006 statistics (Statistics Canada, 2010). This report only includes ‘‘adults and children
whose daily activities are limited by physical, mental, or other health related condition or
problem’’ (Statistics Canada, 2010, p.6). Despite the challenges of providing accurate
statistics, the Statistics Canada report made it clear that older adults are more likely to
experience an activity limiting disability. Because our population is aging, disability issues
will become increasingly important for social workers to consider. Llewellyn and Hogan
(2000) describe a number of models used in disability studies. Although they stated the
limitations of focusing on theoretical models, they recommend that models can help
understand information and ways of working or carrying out research.
Simon Fraser Lodge Orientation
Simon Fraser lodge (SFL), the practicum site, is one of Northern Health’s contracted
residential care facilities, and uses a medical model blended with psychosocial model. These
models influence how those working in the medical field along other professionals
conceptualize their work and relate with residents.
Medical Model
The medical model views disability in terms of ‘‘diagnosis and solution in medical
knowledge” (Barnes, Mercer, & Shakespeare, 1999, p.21). Since the medical profession deals
with people who are ill, the sick role has traditionally been given to people with disabilities,
even if they are only interacting with the medical profession to obtain proof of disability in
7

order to receive financial benefits (Quinn, 1995). Bracht (1990) points out that people with
chronic diseases or disabilities are not always in poor health, but will likely have episodes or
poor health during which time treatment is required. Under the medical model, the person
with a disability is seen as the victim of a tragedy, and in need of others to provide care
(Barnes et al., 1999). The medical model system acts in the role of relieving the individual or
family suffering caused by the disability (Hiranandani, 2005). Rehabilitation and cure are the
goals under this model, with professionals providing the expertise to ‘‘overcome, or at least
minimize, the negative concerns of the individuals disability’’ (Barnes et al., p.21).
Most health organizations employ the medical model. Mackelprang and Salsgiver
(2009) define this as involving a focus on pathology, and an emphasis on fixing the problem.
Beaulaurier and Taylor (2001) argue that medical therapy for people with disabilities became
much more noticeable after the Second World War, bringing social workers into close contact
with people who have disabilities. The goal of this work was to restore a person’s physical
functioning to the extent that a return to paid labour was possible, even if that meant “altering
patients in ways that made them more physically capable of dealing with an unaltered world’’
(Beaulaurier & Taylor, 2001, p. 71) While physical rehabilitation is an important part of the
medical care that people receive, if the focus remains on restoration or cure for too long, the
person may start to feel de-valued if the medical interventions are ultimately unsuccessful in
fixing the disease or disability (Beaulaurier & Taylor).
It is logical that doctors and residential care givers follow the medical model at times,
especially immediately after an accident or injury. Fook (1993) suggests that making
decisions for a person can be justified during a crisis, but as soon as the immediate situation
is dealt with, the individual’s opportunity to make choices must be restored and encouraged.
This includes decisions about medical care. Beaulaurier and Taylor (2001) point out that
social workers have an important role to play in helping people with disability take control
8

over their medical decisions as soon as possible, with the goal of ensuring they can do as
much as is possible or appropriate independently before they leave the hospital to their homes
or residential care facility.
Social workers must coexist, interact, and even work within systems influenced by, or
even dominated by, the medical model. Collaboration with the medical model is possible but
social workers must not lose their unique perspective (person-in-environment and holistic
approach) or they cease to function as a social worker (Beresford, 2004).
Psychosocial Model of Disability
The psychosocial model is a unique model of practice that looks at individuals in the
context of the collective effect that psychological factors and the surrounding social
environment have on their physical and mental wellness including their capability to
function. This approach is used in an extensive range of helping professions in health and
social care settings (Ruddy & House, 2005).
Psychosocial model aims and goals are to restore, maintain, and enhance the personal
and social functioning of residents by reducing complaints and improving functioning related
to mental disorders and/or social problems by addressing the different psychological and
social factors impeding the resident. It is also used as a method of improving the resident’s
quality of life through mobilizing strengths; supporting coping capacities; building selfesteem; changing or transforming dysfunctional patterns of thinking, feeling, and relating to
others; linking people to needed resources; and lessening environmental stressors.
Under this model, social workers strive to change societal barriers while also
providing advocacy, interventions, and educational needs to residents. Gregorian (2005)
suggests that the interaction between the medical and psychosocial models of disability is a

9

continuous challenge for residential social workers, particularly regarding interdisciplinary
team meetings.
Situating Myself in Simon Fraser Lodge (SFL)
A disability lens (Llewellyn & Hogan, 2000) blended with a seniors’ policy lens
(Jansen 2011) was used to inform my understanding of differences between the medical and
social models of disability. I developed an awareness of the range of experiences older
people with disabilities have when interacting with social workers, and how social workers
utilize their skills to work with this population.
Quinn (1995) suggests that social workers who work with residents and family with
disabilities should consider accepting a structural framework that looks at solutions within
environments and systems first and individual lacks only if a problem persists. Bracht (1990)
points out the challenges that family members of the person with dementia may experience,
which include stress, caregiver concerns, guilt, and relationship problems.
Mailick (1990) differentiates between how a client and family react to the ‘‘crisis of
diagnosis’’ (p.108) and their adaptation to the longer term of dementia. During the first
phase, Mailick (1990) points out that the social worker must assist with expression of feeling,
access to information, information of resources, and acceptance of the diagnosis during the
initial stages. Social workers have a role to play in the early phase of diagnosis, as well as
when the illness changes over time.
Coming from another country and having a different view and understanding about
age related sickness, diseases, care, and disabilities aroused my interest to know what
amounts to the quality of life of older adults living in a Canadian residential care facility.
This practicum gave me that opportunity and also to be more culturally sensitive. In my home
country Nigeria, it is the responsibility of the children to take care of their parents when they
10

are old. It is seen as a curse for any child to put their parent in a residential care facility
regardless of their disability, old age, or health related situation. In my culture, when our
parents are getting old, it is seen as a time to give back for all their care and love towards you.
Most adults in my country, when asked about what amounts to their quality of life, respond
‘‘to live with my children when I am unable to take care of myself and to die in arms of their
children’’ (personal thoughts).
Various employment experiences have also allowed and given me the opportunity to
interact with the health care system and different funding agencies on behalf of and with
clients who have various disabilities. This experience ranged from writing notes to doctors
about issues that clients have had difficulty communicating directly to their doctors, to sitting
in during assessments for provincial disability benefits, and determining homes that suit
adults with disability. I have also had the opportunity to hear stories from family members of
adults with dementia, spinal cord injury, brain injury, and fetal alcohol spectrum disorder
(FASD) about their experiences in care facilities and rehabilitation including ongoing
challenges accessing appropriate care and having the kind of quality of life they desire. My
position as a person that has worked with adults with disabilities impacted how I worked
within the system and my practicum placement.
While it may not be obvious to the clients that I come into contact with, that I have
worked in this field, my knowledge of disability issues, quality of life, and oppression from a
personal perspective will inform how I perceive situations within community social work.
My learning and ability to perform community social work is impacted by my personal
experience. I have a unique position, having worked in the field with adults with disability.
This background gives me the ability to interact with people directly from a social worker
perspective and without the labels and stigma often put on people with disabilities, but with

11

the intimate knowledge of what it means to live with disability and struggles in attaining or
getting the quality of life desired.
My personal experience and culture coming from a different background stirred an
interest in exploring the quality of life of older adults with disabilities and how the psychosocial needs of the older adults receiving care are taken care of and addressed. I was
interested to know how I could use my social work understanding to work within the system
to aid communications between residents, professionals, the funding agency, and residential
care facilities to improve the experience and care that older-aged adults face on a day to day
basis. My previous work experience has allowed me to see different parts of our residential
care structures and how they operate, I was inquisitive to know how social workers stay true
to social work ethics while working within this system of care and how they cope while
dealing with adults with disability living in residential facilities that mainly deal and operate
on the medical model. I did this practicum having at the back of my mind how medical and
social models of disability are combined within social work practice, in particular concerning
older adults with disabilities, dementia, and chronic diseases.
Going for my placement, my intention was not to investigate or to judge the system,
but rather to learn, build my skills, recognise and understand how it works, and if there are
areas in the of level of care that could be improved to better assist the needs of older adults.
Practicum Learning Situations
There were a number of situations that impacted the knowledge I gained during the
practicum experience. Experience working with older adults with different disabilities,
diagnoses, and mental health issues were influenced by the referrals, presenting cases, and
waitlist during the time of the practicum. Shadowing my supervisor and other staff on
different cases and situations provided exposure to cases otherwise not possible. The four
12

months’ time frame of my practicum helped me to set goals that were realistic and could be
met within the timeframe and set hours for practicum. I worked with my practicum
supervisor, to set and review a realistic number of files, types of files, and activities
throughout the practicum that would work within the timeframe of my practicum.
In this chapter, identified the main theoretical orientations influencing the practicum.
The following chapter provides a literature review of key aspects related to older adults and
QOL.

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CHAPTER THREE: Literature Review
This chapter provides highlights from the literature pertaining to older adults
(demographics, disability, and other conditions including dementia), the medical and social
models of disability, residential care, and quality of life.
Older Adults
Older adults, defined as those aged 65 years and older, are the fastest growing part of
the Canadian population, consisting of 15.7% of the Canadian population as of July 1, 2014
(Canadian Broadcasting Corporation News, 2015). The population of older adults will
continue to rise and grow across Canada. By 2063, it is estimated that between 24 and 28
percent of Canada’s population will be aged 65 and older (Statistics Canada, 2013). In fact,
Statistics Canada reported that there are now more seniors aged 65 years and older in Canada
than children aged 14 years and younger (Canadian Broadcasting Corporation News, 2015).
This record rate of population aging has generated a significant policy problem for Canadian
provincial governments, who continue to struggle to find how to provide the most suitable,
best and cost-effective health care for older adults.
Research shows that throughout the developed world, not only are people living
longer, but they are doing so in better physical and cognitive health (Christensen et al., 2013).
While a high percentage of Canadian older adults report living in good health well past the
age of 65, more than 25% are restricted in their ability to do or carry out daily living activities
due to chronic or age-related health conditions (Canadian Institute for Health Information,
2011). Older adults are regular and frequent users of physician and acute care services
relative to other population segments, but these services are only part of the required care
range needed to support health throughout the aging process (Canadian Institute for Health
Information, 2011).
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Most adults over the age of 65 have at least one chronic health condition, and age is
the main determining risk factor for different diseases, including neurodegenerative
conditions such as dementia (Niccoli & Partridge, 2012). Many older adults suffer from
chronic health conditions such as dementia for which there is no cure and frequently require
long-term, non-physician care. Dementia is a progressive disease of the brain affecting
cognitive functioning, including deficits in memory, personality disorders, learning, impaired
reasoning, orientation, language, comprehension, and judgement (Feldman et al., 2008). The
risk of acquiring dementia increases exponentially with age and is assessed to double about
every five years after age 65. After age 85, the chances of developing dementia are nearly
50% (van der Flier & Scheltens, 2005). Furthermore, because of longer life spans and the
increasing population of older adults, it is predictable that both the occurrence and prevalence
of dementia will climb intensely as the Baby Boom generation progresses through old age. In
terms of incidence, the rate of new dementia cases in Canadians aged 65 and older is likely to
rise from 103,728 per year in 2008 to 257,811 in 2038. In terms of prevalence, in 2008 it was
estimated that there were 480,615 cases of dementia in Canada, representing 1.5% of the
population. By 2038, this number is likely to grow to over 1.1 million cases, signifying about
2.8% of the population. Based on recent policies and utilization rates, the increasing
incidence and occurrence of dementia are estimated to result in a tenfold increase in demand
for LTC services (Alzheimer Society of Canada, 2010). According to a report by the World
Health Organization (2012), dementia is rated as the second highest disease contributor to
years lived with a disability worldwide, contributing over 7.4 million years of dependence
and disability among sufferers.
The most prevalent symptoms people with early dementia may show are problems
recalling recent events, difficulty carrying out familiar tasks, learning new tasks, changes in
attitude or mood, character, behaviour, personality, impaired judgment, decreased social
15

relationships, reasoning, difficulty finding or choosing words, finishing thoughts, or
following directions, and although the chance of developing dementia increases with age,
dementia is not a normal part of aging (Wolfson, 2010). As is obvious by the high percentage
of different level of care days used for individuals with dementia, their unique care needs
cannot often be met in private homes particularly at advanced stages of the disease. Many
people with dementia may need around the clock supervision and care, which may not, for a
variety of social, personal, and financial/economic reasons, be provided by family members,
spouses, children, or informal carers.
Quality of Life (QOL)
There is a solid belief within the literature that QOL is fundamentally a multidimensional concept and concerns well-being (Gerritsen, Steverink, Ooms, & Ribbe, 2004;
Mozley et al., 2004). For the purpose of this practicum report, the World Health
Organization’s definition of QOL is used. This definition views QOL as "a person's insight or
perception of life in the culture and significant systems in which they live and in connection
to their values, morals, hopes, principles, hopes, standards, goals, and fears. It is a
comprehensive perception exaggerated in multifaceted ways by the individual’s mental
health, emotional or mental state, level of freedom or independence, social relationships, and
relationships noticeable to their surroundings" (WHOQOL Group, 1993, p. 153). The World
Health Organization Quality of Life Group went further to define QOL as ‘‘ individuals’
sensitivities of the positions in life in the setting of the culture and value systems in which
they live and in relation of their goals, hopes, values, expectations, and concerns’’ (Chan &
Pang, 2007, p. 16). It is important to note that QOL can be affected by social class, past
involvement, experience, gender, and age group (Gerritsen et al., 2004).

16

The WHO authors interpreted QOL as a self-appraisal of interrelated personal,
physical, and psychological aspects as well as the social environment. The process of
assessment includes weighting of these aspects by the chronically il1 older adult. Quality of
life (QOL) according to studies is found to be a significant judge of mortality, physical
dependence, and service utilisation among older people (Ho et al., 2002).
Quality of life (QOL) should be raised to an important and priority goal for LTC
rather than an afterthought to quality of care. “Quality of life” can be measured on either an
objective or subjective basis (Thappa & Rowland, 1989). Considerable research has been
dedicated to the definition of quality of life in residential care settings. These studies range
from surveys to face-to-face qualitative interview methods shown to assess the quality of life
characteristics from resident and staff points of view. Quality of life, as a multidimensional
concept, has been well defined and measured in a number of different ways; however, most
studies use a qualitative approach (Mozley et al., 2004).
There is an agreement that quality of life and the determinants that contribute to QOL
can be measured using objective indicators and subjective perceptions (Mozley et al., 2004).
Objective indicators include such factors as: adequate food, shelter, clothing, income, and
admittance to medical care (Hulsman & Chubbon, 1989). The residents cited less importance
on their physical functioning alone, suggesting that physical function was less significant if
their philosophical, emotional, and spiritual needs were satisfactorily met (Mozley et al.,
2004).
Long Term Residential Care
Residential care is provided for older adults who are incapable of living in their
homes due to health, financial, and social reasons. The standards for admission to residential
care facilities have been improved in such a way that only those with high level of complex
17

disability and those who are unable to provide consent on their own behalf are qualified for
public subsidies (Cohen, Tate, & Baumbusch, 2009). In 2012, the admission criteria were
reviewed and established that a client must have one or more of the following health or
disability issues to be eligible for a funded LTC bed: 1) severe behavioural problems on an
ongoing basis, 2) moderate to severe cognitive impairment, 3) physical dependence with
needs that require 24-hour nursing care, or 4) clinically complex multiple disabilities that
require dedicated skilled care from a variety of health professionals (British Columbia
Ombudsperson, 2012).
Recent studies reveal about half of the residential care residents in Canada have
dementia (Alzheimer's Association, 2008). This demographic will continue to increase with
the aging populace and with the subsequent increased number of seniors with dementia.
Residential care facilities will, therefore, be confronted with a dramatic increase in demands
to meet the needs related to residents with dementia. Kitwood (1997), among other experts in
dementia care (e.g, Dewing, 2004; Lyman, 1998; Sabat, 2006), condemns the traditional and
old model of dementia care in residential facilities in that it handles biomedical problems and
complications but does not address residents' psychosocial needs, wants, and improve their
quality of life.
The vast majority of older people receiving care in the residential facilities are cared
for in high quality, safe, and caring settings. There is, however, evidence to suggest that a
small percentage of seniors in residential homes live in inadequate physical environments and
experience a loss of personal freedom and choice. These concerns, in combination with
staffing issues, may lead to seniors living in residential care settings to be neglected and or
physically, psychologically, financially, or sexually abused (Goergen, 2004; Pillemer &
Moore 1989,). However, the full extent to which seniors in residential care experience neglect
and abuse is unknown.
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Influences on the Quality of Life of Older Adults
An individual’s physical and social environments have a substantial role to play in the
QOL. This is also true for residents of LTC facilities. LTC surroundings and locations can
directly and indirectly influence certain domains, e.g., comfort, meaningful activities, and
functional competence. Residents may also rely on the design and layout of the facility
setting for mobility to compensate for sensory losses or cognitive impairments (Parker et al.,
2004). Therefore, it could be said that the LTC setting or surroundings affect all aspects of
the residents’ QOL. A study by Kane et al. (2004) used resident reports of QOL to
differentiate between nursing homes and found that while resident characteristics clarified a
considerable amount of the variance between homes, there was a significant facility effect.
The study results found that nursing homes can affect various aspects of QOL including
choice, comfort, privacy, activity, food, relationships, security, spiritual well-being,
autonomy, and independence.
The design and layout of an LTC setting is also explicitly important for residents
suffering from dementia. In particular, persons with dementia benefit from home-like
environments, stimulation, easy access, and safe space (Parker et al., 2004). Other significant
principles important or relevant for residents of LTC with dementia are related to aesthetics,
appearance, way finding, safety, security, accessibility, functioning, and stimulation (Parker
et al., 2004). Additionally, gardening is an important part of the physical environment of an
LTC facility as it brings a change of activities for the residents as well as giving some
residents a feeling and sense of a homelike environment. It provides motivation and “diverse
sensory encouragement, including sound, color and fragrance” (Barnes and the Design in
Caring Environments Study Group, 2002). However, residents may be controlled or restricted
from accessing the therapeutic effects of a garden due to fear of the resident wandering out of
the facility and residents’ safety. This increases issues about the relationship between health
19

and safety and acceptable risk, and the importance of balancing issues and concerns for
health and safety with risk (Parker et al., 2004).
Certain domains of QOL can be influenced by personality traits more than others.
Kane (2003) found that spiritual wellbeing, security, and individuality had a strong
relationship with personality, while personality had little or no effect on factors such as
functional competency, autonomy or enjoyment. When specific personality behaviours such
as agreeableness and neuroticism were studied, the results showed that high levels of
agreeableness were associated with a high QOL. On the other hand, a lower QOL in domains
such as comfort, meaningful activity and autonomy was linked to neuroticism (Kane, 2003).
It has also been studied that social assessment and a positive attitude play substantial roles in
QOL assessments. Residents who make descending evaluations with people who are worse
off than them in some way report a better QOL (Beaumont & Kenealy, 2004). This finding
was supported by Bowling, Banister, Sutton, Evans, and Windsor (2002), who found that
individuals who were more positive, who made downward social evaluations, had higher selfefficacy and those who appraised themselves at a lower risk of undesirable health and life
situations were more likely to report a good QOL.
The Seniors Policy Lens in Canada
A senior policy lens is a fact-based methodology that is used to develop frameworks
aimed at enhancing and providing the medical and social services to the elderly. Mental
illness is common among older adults. Notably, this is attributed to complications that result
from old age. The elderly may require constant support to enable them to accomplish their
day-to-day goals. At advanced ages, seniors are not actively involved in economic activities
directly insinuating that their social lives and well-being are dedicated by policies in place
(Goldbloom & Bradley, 2012). It was on this basis that the seniors mental health policy lens
has been developed.
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Components of the Seniors Mental Health Policy Lens Toolkit
The seniors mental health policy lens is divided into four parts. The first part
describes the basis, which informed the development of the seniors policy plan. Particularly,
the core argument for these policy development notes that seniors are more susceptible to
mental and chronic diseases than the lower age groups. It is also worth noting that the
previous seniors policy was developed without considering the views of the elderly.
Obviously, this led to the gaps, in that it did not live to serve its intended purpose to benefit
seniors. The second part outlines the procedures to be followed in coming with the seniors
mental health policy lens and measuring its performance. The third part deals with the
provision of the policy with guidelines on how to implement it. The fourth section deals with
the interpretation of the seniors policy, which is achieved through the use of attachments
(David, 2007).
The recent development of a seniors policy lens is a milestone reached in addressing
the concerns of older adults. For many years, seniors have been neglected and side-lined
when it came to policy development and implementation. Evidently, this will go a long way
in ensuring that there are adequate policies in place to guarantee the seniors’ welfare
(MacCourt, 2008).
Uses and Applications of the Seniors Policy Lens
Seniors policy aims at investigating and coming up with the effect of current or
proposed legislation on the general well-being of the elderly. Furthermore, it sets out research
to develop and implement programs for elders that not only address the mental health of the
seniors but consider their general wellbeing (Kirby, 2008). The policy lens carries out an
examination of the application process in an effort to ensure that seniors receive quality and
timely service. Canada has made it mandatory for various stakeholders to recognise and

21

consider the seniors’ mental health program operations. For example, it is a requirement that
all service providers must put in place systems that do not discriminate against the elderly.
The seniors policy lens acts as a reference in designing and developing new packages
and guidelines for the elderly. It is on the basis of this policy lens that review and revisions
of existing strategies for unlikely negative impacts on the elderly are made. Interestingly,
within the framework of the current strategies, weaknesses are established giving room for
developing holistic policies (Salokanga & Joukamaa, 2001). The policy ensures a basis for
comparing existing senior programs with the view of the elderly. Particularly, this is
necessary because some of the policies may have been developed without the seniors’ input.
It is through the current seniors policy lens that response to elderly needs is
referenced. The seniors policy lens in Canada is tasked with public education about the
mental disorders that are common among the elderly. It is important to remind policy makers
that seniors have contributed to the growth of this country in one way or the other, policy
makers should put in mind their well-being in all major activities to prevent side-lining them.
(Druick & Kotsopoulos, 2008).
Policy Directions in British Columbia
The BC government introduced two important policy changes to residential care in
2002. The process for creating a new LTC facility prior to regionalization involved the
government in providing funding and know-how to non-profit groups. However, critics note
that the request for proposal (RFP) method is both time and labour-consuming and, as such,
favours large private corporations or large, well-funded not-for-profits (Cohen, Tate, &
Baumbusch 2009).
A report by British Columbia’s Auditor General (2008) took the provincial
government’s leadership in the continuing care sector seriously. Auditor General John Doyle
also decided that the Ministry of Health was not “sufficiently satisfying its stewardship role
22

in making sure that the home and community care system has the capability to meet the needs
and wants of the population.” (P.4). Doyle was keen and pointed out that the Ministry is
obligated to better plan for future ability in all areas of home and community care, gather
more complete data for development purposes, and be clearer in their reporting of this data to
the public. Doyle’s report also highlighted the need to complement legislation covering LTC
facilities in BC (BC Auditor General, 2008). While, the majority of BC’s LTC facilities are
licensed under the Continuing Care and Assisted Living Act, about 29% of facilities are
licensed as private hospitals under the Hospital Act. There are significant but understated
changes among these two pieces of legislation. Facilities licensed under the Hospital Act are
not subject to random inspection and are not obliged to survey standardized incident
reporting protocols for LTC facilities. The Hospital Act also requires that all prescription and
non-prescription drugs be delivered at no extra cost to residents. While residents in facilities
licensed under the Continuing Care and Assisted Living Act take all or most prescription
medications covered by provincial pharma care, they are likely to pay for non-prescription
medications out of pocket (British Columbia Ombudsperson, 2012).
The report by the British Columbia Ombudsperson (2012) also raised alarm about this
inconsistency in the legislative framework, suggesting harmonization of the assistance and
safety accessible to all LTC residents. Among 176 approvals for BC’s home and community
care system, the Ombudsperson also proposed that the BC Ministry of Health create a reliable
process for determining the funding of LTC facilities and work with the Regional Health
Authority (RHA) to determine if the current budget for residential care is adequate to meet
population wants
In reply to the Auditor General and Ombudsperson’s reports, the BC government
released a report entitled Refining Care for BC Seniors: An Action Plan (Ombudsperson,
2012). There is indication that in some RHAs the emphasis has moved away from assisted
23

living and back to LTC, because of the policy legacies of the Continuing Care Renewal of
2001-2002 are revealed in the fact that in 2008, BC had the lowest number of residential care
beds (including LTC and assisted living) per 1000 adults aged 75 and older.
Current Policy Context
Today, extended health services such as LTC continue to be in something of a policy
vacuum (Jansen, 2011). While the federal government funds LTC indirectly through transfer
payments and directly through the administration of programs by the Department of Veterans
Affairs, no national criteria, principles, or high level coverage standards exist (Canadian
Healthcare Association, 2009; Jansen, 2011). Provincial LTC programs exist as a patchwork,
with substantial provincial differences in accessibility of services, public financing, eligibility
criteria, out-of-pocket payment, and data collection and reporting standards (Jansen, 2011).
While the over-all organization and administration of LTC services has continued
mostly unchanged, recent years have seen a significant change in the perception and care
needs of LTC residents. Some witnesses have noted that, in recent memory, some LTC
residents had only one to two easily managed chronic conditions, and that ensuring adequate
resident parking spaces was an issue of substantial concern facing LTC managers, concepts
that are basically strange with today’s resident population (Lieberman & Doupe, 2014;
Samuelsson, 2011). Delaying entry to LTC means that residents most often enter with
numerous chronic conditions and require great support or assistance with activities of daily
living such as feeding, toileting, social communication/ interaction, and mobility
(Samuelsson, 2011). LTC clients or residents on average have a shorter length of stay than in
the past, because they are mostly admitted closer to end of life.

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Costs
Fees charged to residents for publicly subsidized LTC are generally based on the cost
of room and board and not the costs of care required. At least from an administrative
standpoint, health care costs, such as the salaries of health professionals and limited medical
supplies, are funded through the provincial ministry or department responsible for LTC.
Residents are also most often expected to pay out-of-pocket for other expenses such as
clothing, eyeglasses, hearing aids, dental services, transportation, over-the counter
medications, dietary supplements, and any required co-payments for prescription drugs. In
many cases, personal hygiene and care items must be supplied or paid for by the resident. A
certain quota of the resident’s monthly income is frequently set aside and held in trust by the
facility to be used for these “extra” expenses, and low income, heavily subsidized residents
are given a small monthly “comfort allowance” in most provinces. Extra fees are sometimes
evaluated when private or semi-private rooms are requested (Canadian Institute of Health
Information, 2013b).
Maximum monthly rates for residents differ greatly across the country, fluctuating
from a low of $1674 in Ontario to a high of $3390 in New Brunswick. There are also
considerable differences in how resident capability to pay is considered; some provinces use
flat fee systems, others use income testing, and still others use combinations of income and
asset testing (Canadian Institute for Health Information, 2013b). The average monthly
income for married elderly couples (before taxes, but after transfers such as Old Age Security
in 2011 was $5317 (Statistics Canada, 2013), so the maximum fees represent a considerable
economic burden for those who require placement in LTC.
There are also ideological variances in the explanations of how rates are determined.
Some provinces, such as, Ontario, Nova Scotia, Alberta, and PEI, are careful to describe a

25

clear delineation between the accommodation rate paid by residents, and the health care rate
paid by the government. Other provinces, such as Newfoundland, Labrador, New Brunswick,
and Saskatchewan, do not: rather, they emphasize the total costs of running the facility.
Senior Policy Problem
Survey data has revealed that most seniors would prefer to live in the community for
as long as they are able (Bayer & Harper, 2000), and residential care rates represent
significantly higher cost to governments than home care or assisted living alternatives.
However, this goal has ignored the reality that there is a certain percentage of the older adult
population (i.e., the very frail, those with advanced dementia) for whom this may not be
possible.
Given the expected factors that are estimated to drive increased requests for LTC as
the demographic shift unfolds, provincial governments will need to observe and study how
best to provide QOL to seniors who need it while making an allowance for investment in
other parts of the continuing care continuum.
This chapter provided a review of the literature pertaining to older adults, quality of
life as well as LTC and policy directions. The next chapter discusses my practicum learning
experiences.

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CHAPTER FOUR: Learning Experiences from Practicum
The multifaceted nature of the LTC facility environment made it difficult to articulate
specific goals prior to entering the practicum. However, in the learning contract I predicted
and enunciated some general activities and specific goals in consultation with my practicum
supervisor. In this chapter, I provide a summary of what I did and what I learned over the
course of the practicum, linked to both general activities and specific goals.
General Activities
Shadowing
The first week of my practicum started with me shadowing my supervisor, nurses,
dietician, care aides, recreational supervisor in different departments. This included going to
interdisciplinary and family meetings, reading client assessments, and observing as my
supervisor went through the process of public guardian and trustee (PGT) referrals, and
helping the residents decide what resources they need. My supervisor got me involved
quickly. She had me complete tasks that helped me to better understand her job; these
included: writing up and updating chart notes after each encounter with clients or their family
members, sending referrals to the PGT, locating specific information in the charts, learning
how to fill out forms and gradually involving me in all day to day responsibilities performed
by LTC social workers.
I was able to spend time over the course of a month with nurses, care aids, and the
dietician under the supervision of my supervisor. Not only was the time of my practicum
interesting to me, but also it gave me the opportunity to see, learn, and experience another
part of social work. I was able to learn the way a LTC facility works and how the social
worker works together with other professionals to find solutions to challenging resident
problems. I also worked with a few nurses as they approached different residents for the
27

continuation of their care like administering medication and checking of blood pressure. I
also shadowed the whole process of their care from care aides and how each department
focused on a different aspect and task related to a resident; this helped me to develop my own
skills and style based on the workers I observed while on practicum.
Admissions, Discharge Planning and Referral
Admission and referral involves a wide range of activities including helping residents
understand and know the facility, providing tours around the facility, making referrals to
community resources, completing forms for those referrals, liaising with the hospital and
family members to ensure all the resident’s needs are and can be met, orientation to the
facility, and generally ensuring the resident and family members that they are safe and will be
given the best quality of life. To be effective, the social worker needs to be flexible because
plans change to fit and accommodate the resident’s changing physical and mental health
situation in getting used to a new home.
During the course of my practicum, I found that providing orientation for the resident
and family was important because it removes the fear and thought if this facility is the right
place for them or if the facility is like home to them. These are questions that sometimes run
through the mind of some spouses and their children. Sometimes it can be confusing for
people who have not experienced a move into a LTC facility before and the individual and
their family may need to hear information several times before they fully understand. Giving
information early in a resident’s stay was also important so that the resident and their family
could begin to think about what they wanted to do, and how to handle situations.
Discharge planning involves a wide range of activities, which include helping the
resident understand housing options, liaising with home support services, providing referrals
to community resources and or completing forms for those referrals, and liaising with other
28

social workers to ensure resident’s needs can be met upon discharge. Duffy and Healy (2011)
point out the importance of flexible discharge planning for older adults in particular, because
their physical and mental health can change significantly in a short time. I had this experience
with a resident that was admitted in the special care unit of the facility. This resident was very
violent before she was admitted to the facility, however within two months, there was a
significant improvement in her health and she demanded to return home to her husband. She
was then discharged after consulting with her family doctor.
As I progressed through the practicum I did lots of referrals to the PGT, Home and
Community Care for possible temporary rate reductions (TRR), and Community response
unit for some residents that needed counselling. Referrals to the PGT where made when the
social work department noticed and suspected mismanagement of a resident’s money. This
included mismanagement by their power of attorney or if a resident’s ability to manage their
money was questionable. The PGT is usually the last resort on the list after consulting with
resident’s family. Referrals to Home and Community Care were done when residents were
unable to pay their facility rent because they have other bills to pay outside the facility (e.g.,
medications, house insurance, hydro and so on). Referrals were made for a temporary rate
reduction through Home and Community Care to Northern Health. Sometimes residents were
approved for six months’ rent reduction and, if their situation remained the same, a renewal
of the TRR was applied for at the end of six months. Different referrals were done to meet
residents’ needs upon request.
Actively Participating in Interdisciplinary Team Meetings
Care conference meetings occurred once a week. The purpose was to ensure that team
members had the same up-to-date information on residents that included medical, emotional,
therapeutic relationship, and social issues. Additionally, care conferences were also held once

29

a year for each resident. For residents who were newly admitted to the facility, these
meetings provided an essential opportunity to share information. The meetings provided an
opportunity for doctors, pharmacists, recreational team, nurses, and social workers to share
information they had on each resident in other to give them their desired quality of life.
At first, it was difficult for me to participate in these meetings, partly because of
shyness and the fear of saying something wrong and I did not know the residents nor had
contact with them directly. This made me feel that I had less to contribute. As time went on,
however, my supervisor helped me to be actively involved with tasks and a case load of
different residents. As I worked independently with residents and their family members, I had
more to say and felt able to contribute in a positive way. This made me look forward to
attending care conferences because I had direct contact with the residents and their families.
Grief and Loss Work with Residents and Families
I had the opportunity to work with families regarding grief issues. For example, I
worked with a resident on grief issues following the death of his wife who had been in
hospice. The resident was able to talk to me and verbalized how he felt during this time.
This work was difficult but really interesting to me because, in some cases, it involved me
helping family members and spouses with counselling options when they were feeling guilty,
when they were finding it difficult to understand their loved one’s diagnosis, or had difficulty
leaving their parent or spouse in LTC. A number of families who had recently brought their
parent or spouse to the facility also needed counselling or closure. This work was challenging
for me because I have a different view and understanding about LTC coming from Africa and
how we take care of our parents when they are old and full of age. I was very careful to
ensure that I kept my own personal thoughts out of the discussions. It was very important for
me to respect where these residents and family members were at in the process of

30

understanding their diagnosis and I learned a lot from sitting with them and their families in
providing the needed support that they require in other for their parents or spouse to have a
good quality of life.
Assessment
Assessment is a crucial part of LTC social work because it provides the information
that social workers use to carry on with all other aspects of their work. It took time for me to
develop my skills to approach assessments with new residents in a relaxed manner that
permitted me to gather the required information without sounding and feeling like I was
scrutinizing the person. Shadowing my supervisor during this process helped me to become
comfortable in doing assessment on my own.
An assessment needs to be detailed and to cover a number of basic or required areas,
Common aspects of the assessment included: living situation before coming to the facility,
financial incapability, community resources, history of medical issues, formal and informal
support systems, recommendations, and care plan. The details of what was included during
the assessment process varied from department to department within the facility but the same
general topics or more were covered in all assessments. Social workers, however, were not
able to see all residents because of time constraints. Some typical indicators of the need for
social work follow-up included family dynamics (e.g. where children or spouse are having
the guilt of leaving their loved ones in LTC), lack of informal supports, power or attorney
(POA), need for substitute decision maker and health care decision maker.
My written assessments were fairly brief until my supervisor told me the importance
of writing in full details, keeping in mind that other people were going to read and make
decisions based on what I have written. I learned to put more information because I
recognized the importance of being able to read a fully- articulated assessment. In the later
31

part of my practicum, I developed the pattern to write any information thoroughly in order for
the next worker not to go through the stress of seeking information that was not written in the
assessment.
Psychoeducational and Education Work with Residents and Families
Some of the work I did during my placement involved providing information and
education. Sometimes it was to staff about residents’ social situations or to residents and their
families about the policies of the facility or their diagnosis. The level of care that some
residents need is sometimes confusing to families and some staff. I, therefore, spent a lot of
time outlining the services that are offered within the facility and available to residents and
their families especially around care. While I developed a level of comfort with the common
diagnoses people at the facility had and the different levels of care, my knowledge was not
enough to have adequate or in depth conversations about different situations with families or
residents. Some families wanted me to give them more details about their situation in the
facility, advice about treatment options for their loved ones and parents, in those situations, it
was helpful to explore ways of having the discussions with my supervisor. I found that
families often asked me for more specifics on their situations or for advice about treatment
options, which social workers are not qualified to give. This process helped me reinforce my
own learning and was a helpful way to improve more knowledge on what amounts to each
resident’s quality of life. I appreciated the educational part of the placement because it helped
me strengthen my own learning and was a tangible way of responding and assisting residents.
Specific Goals
Under the direction of my academic supervisor and practicum supervisor, I developed
specific goals for my practicum. While these were changed and improved during the process

32

of my practicum, this provided an opportunity for me to stay on track with my learning and to
keep track of my progress during my practicum placement.
Knowledge of Medical/Social Issues Faced by Social Workers in LTC
I attended different workshops offered by the organization during my practicum,
especially those associated to public guardian and trustee, conflict resolution, information
sessions, and social work team meetings. I was also able to expand my knowledge in
different areas by asking questions and listening during familiar discussions.
My goal was to develop an understanding of the following topics: dementia, quality of
life, PGT, and information on services offered by other LTC facilities. I paid close attention
during inter disciplinary meetings, care conferences and discussions with health
professionals, nurses and care aides, social workers in order to attain as much knowledge as I
could learn from them.
Knowledge and Use of Community Resources
I developed a good knowledge of community resources used by LTC social workers.
My initial goal was to meet and arrange tours with the following resources: hospice, two LTC
facilities, an adult day center, and a homeless shelter. I was able to visit hospice, homeless
shelter, a CLBC run senior home, and a private facility. These visits were very useful
because it gave me insight on how different facilities and older adults describe what amounts
to their QOL. I was particularly impressed with SFL and how they offer choices to residents
and their families, their positive approach on different levels of care, how families were
actively involved with residents, how they understand what amounts to each resident’s QOL,
and how they work together as a team to give each resident a good QOL.

33

Knowledge around Adult Guardianship, PGT and Adult Protection
I was able to review and attend workshops regarding adult guardianship, power of
attorney (POA), and public guardian and trustee (PGT). This area was a new experience for
me because I never knew social work was involved in the area of PGT and POA. I met with
the manager of PGT during one of his visits to SFL; I was able to ask a few questions about
PGT and their involvement regarding a particular resident whose case I was handling. The
following day I attended a workshop with my supervisor where PGT team members
explained to us their involvement and the referral process for older adults in LTC facilities. I
was impressed with the team work and their level of explanation and answers during this
workshop. My supervisor and I found this workshop very important because it helped solve
some of the questions we were having little or no answers to then. The workshop gave me a
better clarity and understanding as to when to make referrals to the PGT. I also had the
opportunity to go through some of the written legislation and copied most relevant sections in
order for me to review them as needed when the time arose. It is impossible to gain all
understanding, a complete knowledge of POA, referrals to PGT, and adult guardianship in a
duration of four months practicum but my supervisor was always present and gave me all the
opportunity to ask questions, she involved me in cases and situations that will give me a
better learning experience in the areas I seemed confused.
Communication and Intervention Skills
At first, I found it was really difficult for me to speak to residents on my own. I had a
conversation with my supervisor regarding the fear of not having the right answers to
questions asked by residents. My supervisor was encouraging and advised that I always meet
with her to discuss potential questions a resident might ask before meeting with the resident.
She also told me that I could tell the resident or their family member that I can ask or find out

34

about any questions they had if I was not sure of the answer. With time, my confidence grew
and the fear of saying something wrong gradually disappeared. I became more confident to
meet residents; knowing at the back of my mind that my answers could brighten up their day
and, in most cases or situations, my answers gave their family members a great relief
knowing that they had someone to talk to. Until the last week in my practicum, I continued to
shadow my supervisor on particularly complex cases or complex family dynamics; this gave
me the time and opportunity to familiarize myself with her ways of handling and working
through certain difficult procedures with residents and their families. My supervisor is a full
package of experience and her willingness to share with me gave my practicum a whole new
way and pattern of learning.
An important part of my practicum also involved meeting with residents
independently or with my supervisor to discuss and access what services were needed or area
that new residents were seeking answers about. Helping new residents settle in to the facility
comprised a lot of my practicum work. I read residents’ files and contacted their POA, if need
be, to make sure that residents’ files were up to date. After each meeting, or after having a
conversation with a resident and their family member, I wrote up my notes and also charted
on their file. At the end of each meeting with residents, I discussed the outcome of my
conversation with my supervisor. Sometimes during conversation with my supervisor, she
pointed out areas of concern that I should have raised and discussed with the resident. She
also made me aware of areas that I needed to follow up on. In all, this made me recognize
information that needs to be explored further. This practicum experience opened my eyes to
how important all information is and at what point information needs to be investigated,
considered, explored, and scrutinized with a critical eye.
As my practicum progressed, my supervisor increased my caseload although she was
available to talk to me whenever I needed help or at a crossroad to ensure that I was not
35

missing important aspects of a situation. Daily meetings with my supervisor were very
helpful because it gave me the confidence of having someone to talk to when I felt stressed in
situations or I needed to consider a suitable choice of options.
Practicum, As I Experienced It
Based on my work experience, some families do actively become involved at
mealtimes and special events like birthdays. For example, they provide bathing support,
emotional support, assist while feeding, pass on important information or knowledge of the
resident's preferences and habits, and bring in homemade treats and clothes for residents. It is
reasonable to think that family members will be more willing to partake in mealtime activities
if management and staff have a positive attitude and acknowledge the importance of their
involvement. Perhaps family members would visit more often if the facility environment is
more welcoming. Basically, family participation at birthdays, mealtimes, and social visits
plays a significant part in keeping residents feeling socially connected to their family
members at all times thereby removing any form of social detachment, loneliness, and feeling
from residents.
At the end of each day, I had planned as a part of my daily schedule to write my entire
document and do journaling. However, due to the nature of work at SFL, this was very hard
to do because it was hard to foretell what could happen on a daily basis. I planned time
during weekends at home to do my journaling. This helped me a lot because I found it to be
a time to reflect on the challenges and areas that I needed to improve or ask questions about. I
used this time to also deal with any stress from my day to day practice; I observed my own
growth in learning how to perform my social work duties within the LTC facility. I used
observation as a primary tool for gathering information while shadowing my supervisor and
asked questions when I felt lost during the course of my observation. I had additional

36

interactions with other professionals especially nurses, physiotherapists, occupational
therapists, dieticians, and the recreational team. The communication I had with other
professionals provided me with important opportunities to learn and understand the different
roles professionals have to improve the QOL of each resident in the facility. I gained this
experience by shadowing different professionals for few weeks, doing assessments with
them, reading their notes on residents’ charts and observing their work during interactions
with resident. This gave me a strong respect for the significant role they play.
My focus was on how I could improve my understanding and ability to perform tasks
as a social worker within the context of disability in LTC. My anticipation was to grow a
greater understanding of myself and skills as a social worker, the LTC setting provided me a
chance to assess my own work and growth while paying attention and learning from different
professionals on how to improve the QOL within a LTC facility.
LTC Facility (SFL) Social Work as I Experienced It
LTC facility social work is comprised of different activities. Everyday brought
something new, although certain situations recurred on a daily basis. Each unit had different
activities or schedules planned monthly; they usually had care conferences every week where
members of the interdisciplinary team meet to discuss a new resident or old resident on their
care, social issues, emotional issues and medical issues. These meetings provided
opportunities to know the level of care each resident received to ensure holistic care and
planning is carried out for each resident.
During the course of my practicum, I experienced some situations that challenged me.
Each one provided an opportunity to learn from the circumstance and develop my own skills
in managing difficult requests or situations. For example, the first situation involved a
resident that that was deemed incompetent and was diagnosed with dementia, her being
37

violent and agitated made it challenging for her husband to provide adequate care at home yet
her husband was unwilling to make the decision for her to go into a LTC facility. When her
husband finally agreed to admit her into a LTC facility, I observed that the relationship
between her husband and her children was complicated and I spent a lot of time phoning and
having individual discussions and meetings with various family members. Some of the
challenges I faced were gathering information from everyone involved, trying to contact the
POA. When there are complex family dynamics, it can be difficult to know whom to talk to
in the family because every member of the family wants to make decisions and see things go
their own way.
Another situation involved a resident that was diagnosed with dementia whose
physical limitations made it challenging for her husband to take care of her. Her husband also
had a brain injury. She was behind in the payment of rent at SFL due to credit card debt. I
contacted her husband about the payment and a possible TRR; he declined and said he would
be going to the bank to make sure he gets money before his wife’s creditors take the money
out of her bank account. I discussed this situation with my supervisor and she had a meeting
with the resident’s husband. Coordinating the process took significant time; I was able to
observe this process in action while shadowing my supervisor and I learned a lot about the
importance of consulting with my supervisor when faced with a challenging situation.
As I progressed in my practicum, I found that these uncommon or difficult situations
are in fact common in the LTC environment. Yet, that was the first time that I have ever
experienced it and worked through it with the help of my supervisor. It was an important case
to learn and I appreciated the opportunity to develop my social work skills.
Physical environment. SFL is a very busy place that I looked forward to going to
every morning when I woke up. There were always a lot of visitors and staff moving from

38

one unit to another, meal carts, residents, wheelchairs, rooms were constantly changed
depending on resident’s needs, new admissions, and cleaning carts, bingos and the fiddlers
playing every Thursday morning. I always listened to the fiddlers play because it was a time
for me to release and get a breath of new energy. It gave me so much joy seeing residents
smile, dance with one another, and care for each another. Whenever I missed a day at the
facility, I felt I had lost a lot because I constantly had this reminder at the back of my mind
that my presence could console or answer a very important question to improve the QOL of a
resident.
Outdoor activities. Outdoor activities help and encourage residents to mix with
other residents and people outside the facility and were seen by residents as significant for
knowing what was going on in the community or around the facility. It was the more able
residents in the facility that were involved in these activities if they so wished. Sometimes it
depends on the mood and willingness of the resident that determines the type of activity to be
done on different days. Some activities that were carried out within the facility were made
easy because of the security system used within the facility. Facilities had to safeguard the
surrounding of residents as in all facilities, there were some residents who were confused and
had inclination to wander around. Facilities, therefore, had to have a device or security
system to make sure residents who were a concern or residents who have tendency to wander
could not leave the facility unnoticed. Many facilities had a security keypad system, which
could only be operated by staff and sometimes-family members have the codes to the unit
where their parents are. Many residents that are more able who require leaving the facility for
a walk or visits could not do so without a staff member helping or facilitating their exit and
re-entry into the facility. Substantial planning had, therefore, to be done before leaving the
facility especially when residents are leaving with their children or spouse. SFL had, with the
permission of residents’ relatives, to put an electronic tagging system around the wrist of
39

residents that had the tendency to wander around. The electronic tag would set off an alarm if
they tried to leave the facility.
Recognition of people. Due to large number of staff, family members, the
recognition of individual residents was a great challenge for me at SFL. I tried to remember
residents’ names; my supervisor helped me with this by calling staff by their names,
introducing me to residents and by calling residents by name whenever she met them.
Gradually I was able to recognize and remember names of residents and staff. Additionally, it
was difficult for me to call residents by name because in my culture addressing your seniors
by their names was regarded as a sign of disrespect and lack of parental training. We
addressed our seniors by saying Ma or Sir and kneeling down when talking to them; this
process showed that you were trained properly by your parents and that you also wanted to
live long. I did not tell my supervisor this because I was also uncomfortable calling her by
name. When time went on, however, I managed to put my personal beliefs and habits aside. I
was able to recognize residents by their faces and called residents by name and came to terms
that I cannot hide behind this as an excuse when pursing my career as a social worker. Doing
my practicum in a LTC environment built my courage and self-confidence because it gave
me the opportunity to think outside the box before making any judgement or decision.
Relationships. As easy and simple as it may sound; nurtured relationships improve
QOL. Regular visits of children, spouse, family friends or neighbors mean a lot to older
adults. The sense of guilt and feelings of rejection gradually blow away when residents have
frequent visitors and this is something I observed daily in SFL. SFL encouraged and
respected family relationships.
Privacy. Privacy in SFL is well respected because it gives residents a sense of
respect and control to be alone when they wish, to be together in private with others

40

residents when they also wish. According to Westin (1967) in a seminal work, four aspects
of privacy are: solitude, intimacy, anonymity, and reserve. Furthermore, he recommends
four reasons why these types of privacy are needed: to exercise self-sufficiency and maintain
individuality; to attain emotional and open release particularly important during times of
loss, shock, or sorrow; to conduct self-evaluation, which compels private information
managing and reflection; and to achieve limited and protected communication. Pastalan
(1970) also supports the importance of privacy and its purpose in LTC, he stated that LTC
environment and rooms should be designed in such a way that each older adult realizes such
privacy, which is obviously more easily achieved in residential settings with private rooms
and baths (Kane, Baker, Salmon, & Veazie, 1998).
Choice and control. Quality of life in residential care homes is a multifaceted issue
that may be determined by a senior’s independence, choice, control, individuality, and
autonomy, in the residential care facility where they are residing. Environmental adaptation
seems to be a way to develop the quality of life of residential care home for older adults with
disability.
Opportunities to choose, especially from among different options, can meaningfully
influence a resident’s sense of well-being. Improving personal control in everyday life and
giving personal responsibility enabling choices that empowers residents. With future choice
and control improvements guaranteed for older adults, meaningful change will take place in
the provision of accommodated care for older adults
LTC residential providers must become active and proactive in anticipation of
improvements modifications, by changing new organizational models and methods of service
delivery to boost uncertain resources and maintain quality of life and of care for older adults.

41

Spiritual well-being. Finally, though indefinable and related to both psychological
and social well-being, spiritual well-being cannot be ignored as a domain of QOL (Olson &
Kane, 2000). Religious and spiritual activities help to reframe stressful happenings in a way
that inspires the resident naturally to deal with life stressors. Spirituality can also encourage a
resident toward the use of effective coping tactics. Moreover, these ideas, however poorly
measured, have been connected with health outcomes.
This chapter provided a review of my practicum learning experiences. The next
chapter discusses Implications for Professional Practice and Conclusion

42

CHAPTER FIVE: Implications for Professional Practice and Conclusion
The goal and expectancy of all professional staff in a LTC facility is to provide the
best care for residents under often-chaotic conditions. Each professional group working with
a given resident has a different role or perspective on what care should look like. Therefore, I
focused my thoughts and observations on practice implications for social work within LTC,
using social work values and ethics as a guide.
The amount of support and advocacy social workers do to ensure residents are well
cared for and given what they need exceeded my expectation. Social workers engage in a
range of activities from advocacy to charting any changes to alert other staff on important
aspects of a resident’s care. Although advocacy is already part of the social work job
description, some residents and family that I spoke with needed some form of advocacy in
order to have good QOL. Social workers practising in LTC facilities must continue to lobby,
work with other professionals, and advocate for policy change to provide inclusiveness to
those in LTC.
The core values of social work must be displayed at all times and residents’ QOL
must be the main focus at all times. Social workers have an important role in supporting
residents facing life-changing or challenging situations and working with residents whose
rights may be undermined through abuse and neglect. I encourage social workers
participating in multi-disciplinary team meetings to continue to contribute from a holistic
view, with a perspective of the whole person, rather than to focus only on symptoms,
situation, or circumstances. Social workers should put residents first, ensuring that their needs
are met in ways and situations residents choose, and not according to how professionals
believe things should be achieved, because social workers are in good position to support
better resident’s endings and QOL.

43

One of the current roles for social workers is also to help residents find resources and
identify areas of main concern. Social workers need to manage resources well and efficiently
in such a way that will sustain or maintain a focus on achieving the chosen outcome of
residents using or accessing these resources. When resources are made available, residents
will have the guarantee and be assured that they can exercise choice and control over the way
that services are provided.
Residents who are in LTC facilities who use social care and support services
recognize the limits and boundaries social workers can face when working within the
controlled rules and resources of an organizations (Beresford, 2004). Most times
organizational and budget issues have a strong impact on a resident’s relationship with social
workers. It is important that policy makers are open and transparent about changeable
decisions, putting older adults into consideration.
Strategies for Change
Develop Infrastructure
New infrastructures must be encouraged including changing policies, professional
roles, organizational boundaries, and funding to increase staff levels (i.e., more nurses, care
aides, and social workers). Change is also needed in relation to how government can best
exercise their roles: paying for care for older adults with low incomes, and defining the nature
of care through licensing rules. If policies, training, and care are changed from the policy
makers or governing body, we will reach a point when the controversies and questions
surrounding QOL in LTC will be minimized and possibly be a thing of the past.

44

Develop Feedback Forms for Families
Feedback and information is needed at the macro level to describe the work of
provider organizations as well as at the micro level of the resident in LTC. Providers also
need to learn and train their staff on how to improve QOL, discuss concerns with residents
and their family, and use that information to improve services that are been rendered to
residents and their family. Feedback collected across different facilities can be used to
measure and compare progress in QOL either within nursing homes or across other LTC
settings.
Create More Supportive Environments
What is needed is better access to specialized equipment such as eating systems,
hands free drinking equipment, slip resistant tray liners,. Supportive environments also
include wheel chair accessible walkways, rails and entries for residents, and maximizing the
sense of privacy that many older adults see as a big part of a good QOL.
Take Back the System
LTC for older adults needs to be viewed in new and different ways. consideration and
focus should be on the hopes and fears of all older adults and include the perspectives of
family members as well as service personnel (e.g., social workers, nurses, aides, doctors), and
policy makers.. Consideration and discussion is needed about the conditions under which
older people could better be treated and given choices, security, privacy, relationships, and
meaningful activity. All individuals involved in these discussions and decisions should keep
in mind the overall goal of a good QOL for older people and, in particular, for people with
dementia. LTC providers should begin their discussions by considering how residents with
physical and cognitive disability would want to live in their old age. In all ways, we must
45

keep our focus on QOL and how we can better improve the lives of older adults living in
LTC.
Conclusion
QOL in LTC facility is an important topic that is enhanced by the seniors’
independence, choice, individuality, and autonomy. Promoting the QOL of seniors requires
multi-disciplinary input and effort to promote the general model of LTC delivery. An actual
model would target promoting independence, choice making and privacy in individual care
and living environment reducing power struggle relationship between residents and formal
caregivers, enabling participation in decision making, and improving family involvement and
interaction.
It is important for LTC facility managers to develop methods to reassure social
relationships, such as cultural, outdoor and leisure activities, as well as physical exercise,
among the LTC residents, Beresford (2004) supports the thought that social separation is
connected to aggravate mental and physical health. Loneliness may be identified among LTC
residents and those living in the community, subject to the living conditions they are in. It is
also known that group activities greatly contribute to residents' independence. There is also
need for proper training of those involved with residents in LTC, so that staff may develop
strategies significant in providing support, reassurance and encouragement in the adaptation,
adjustment and maintenance of QOL to residents (Gerritsen et al., 2004).
The practicum placement at SFL was a valuable learning experience giving the
opportunity to develop strong social work skills for use in a residential care facility and
caring for older adults in general. The focus on older adults is timely and relevant because of

46

the increasing challenges of delivering health care services to clients and an aging population
in a climate of financial limitations and controls.

47

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Appendix: Learning Goals and Activities
For this practicum my focus will be on gaining comprehensive knowledge and
performing social work duties within a residential care facility setting. In discussion with the
proposed practicum supervisor, the practicum will include activities such as:
1. Shadowing and working with an experienced social worker in several departments and
progressively taking on more responsibilities
2. Actively participating in multi- disciplinary team meetings
3. Grief and loss work with clients and families
4. Assessments
5. Psychoeducational and education work with clients and families
6. Discharge planning and referral
7. Developing familiarity with dementia and the associated challenges.
Time will also be set out in my schedule to allow for documentation and journaling at
the end of each working day. Personal observation and reflections will be written as part of
my learning, but information that could identify clients or workers will not be included to
protect the identity of those in SFL. This is an effective method for documenting practicum
experiences and reflecting on practicum learning (Bhandari, 2011). Observation will be the
primary focus of information gathering, and any questions I have will be written down and
discussed with my supervisor. My main purpose and focus will be on developing my
understanding and skills to execute the responsibilities of health care social workers.
In close consultation with my practicum supervisor, and under the general direction of my
academic supervisor my specific goals will be:

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Specific Goals
1. To develop an increased knowledge and understanding of a range of SFL policies,
procedures, services, and programs and the health professionals employed within the
facility.
Activities


Read and become familiar with the use of pertinent policies and procedures



Attend multi- team meetings



Arrange to meet with representatives of as many of the following programs/
services as available: physiotherapy, occupational therapy; nutrition; mental health
services; home and community care services; elderly services.

2. Develop knowledge and use of community resources
Activities


Meet with and become familiar with various community resources (e.g. Prince
George Council of seniors, Hospice House, and Rainbow Adult day centre.



Independently assess community resources that are available to a client and refer
effectively to ensure successful use of resources.

3. Increase my knowledge about adult guardianship and adult protection
Activities


Review pertinent legislation and policies regarding adult protection and guardianship



Recognize and effectively manage issues related to guardianship and protection



Gain an understanding how continuity of care for a resident is maintained throughout
the facility and how providers view care, work, and contribute to the quality of life of
adults experiencing a range of disability issues living in their care.
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4. Enhance my communication and intervention skills
Activities


Shadow my supervisor for the first 2-3 weeks to learn skills specific to working with
clients and their families



Meet with clients either independently or with my supervisor to assess and establish
what services are needed to make them have the type of quality of life they desire.



Complete documentation as required on each client which will be reviewed and cosigned by my supervisor.



Progressively take on more responsibility for managing case load independently
throughout the practicum. This will be done with ongoing consultation and
supervision from my supervisor.

5

Develop an increased knowledge of medical terminology used at SFL
Activities


Become familiar with regularly used terms used by medical and systemic terminology
encountered during the practicum, which will include an understanding of how to
communicate these concepts to clients and families



I will develop my understanding of how the medical model and social models of
disability are understood and used in daily social work practice at SFL.



To gain an understanding about dementia and the unique care requirements within
SFL.

6 Develop knowledge about common social and medical issues faced by SFL social workers
Activities


Attend workshops on dementia and palliative care



Attend Alzheimer’s society meetings and workshops
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7 Gain an understanding of how the social model and medical models of disability are
understood and used in daily social work practice.
8.

Become familiar with dementia and the associated challenges.

Activities


Gain an understanding of sun downing



Gain an understanding about the different stages of Dementia



Gain an understanding in different behaviours associated with dementia

9 Engage client families in psychoeducational activities.
Activities


Shadow my supervisor and develop my communicating skill on working with clients
and families



Provide information about community resources,



Counselling interventions as needed that is proactive as well as crisis oriented, and
conducting assessments.

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