Site Selection Consistent with the comparison of difference design logic, two homes were purposefully selected from eight homes (where GPA program installation was to

begin in 2011) to provide maximum variation on organizational factors that may influence the installation and sustainability of a dementia-specific training program for staff in LTC homes. The two homes (Homes 6 and 7) that were selected for this study were in the same health region as the homes in the retrospective study (see Table 2.3). One LTC home was located in a small population centre, while the other LTC home was classified as being located in a rural area (Statistics Canada, 2017b). Differences in the two LTC homes were: (a) the owner-operator model (independently owned vs. owned and operated by the health region); (b) management and reporting structure (manager vs. an administrator and DOC); (c) the position of the GPA Coach (i.e., NAs versus a LPN and CNL); and (d) presence or absence of a CNL position (defined in Participant section in the retrospective study) in the home.

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A key difference in the two homes was the presence of a CNL within the health-region owned and operated homes (Table 2.3). Although not formally described as a facilitator, the role of the CNL encompassed many of the activities associated with facilitation. The presence of the CNL in the health region owned and operated home, and the fact that this person was one of the GPA Coaches (along with an LPN), provided a contrast to the independently owned home, which had no CNL and where the GPA Coaches were NAs. The homes were similar in the number of residents living in them and the distance away from the large urban centre (Table 2.3). GPA training for all staff began in each of these two homes on October 1, 2011. The prospective study was conducted over 15 months in these two rural LTC homes, from the GPA program training through the installation phase (Fixsen et al., 2005).

2.4.2.1.1 Home 6 Description. Home 6 is a 35 bed LTC home (built in the 1980s) in a small population centre (Table 2.3). The home is joined to the hospital and public health clinic by a large walkway and multi-purpose room. An individual may enter the LTC home from either the hospital side or through the LTC home front door. If a staff member or visitor enters via the hospital, they must walk through a hallway that opens up into the multi-purpose room. On both sides of the link way are double doors that are not secure or alarmed. The multi-purpose room is a large area where residents from the LTC home and the day program gather to visit, play games, and watch TV. There are many long tables for families to sit around and visit, and a piano if someone would like to play, a canary cage for residents to look at, and many shelves that hold plants. It is the sunniest room in the building. The multi-purpose room leads to a long hallway of resident rooms. At the end of this hallway is the nursing station. To the right and left of the nursing station there are two other long hallways that house ten residents per wing. The rooms are large, private, and sunny and residents do not have to share washrooms with each other. The hallways are large and roomy. Due to a limited amount of storage space, the staff must store equipment and laundry supplies in the hallway. On the left side of the nursing station is the dining room, the kitchen, the television room, and the staff lunch room. Directly in front of the nursing station is the staff charting room.

Around the corner from this room is the manager’s office (which she uses when she is working on the LTC home side of the building) and the front entry to the home. The manager splits her time between the LTC home and the hospital, so she has another office on the hospital side of the building that she uses when she is scheduled at the hospital. A full time RT is on staff

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Monday- Friday from 10:30 – 19:00 to provide residents with activities in the evenings. There is a large enclosed courtyard for the residents to spend time outdoors off the back of the building, and an outside enclosed space in front of the building where residents can go outside

(unsupervised) in all seasons (this area can be supervised from the dining room area). Staffing ratios of NAs (12 hour shifts) to residents during the day was 1:7 with a nurse on shift for 12 hours. At night time, there were two NAs and one nurse. The CNL works part time in the LTC home and part time in the hospital (two and a half days per week on each side of the building).

2.4.2.1.2 Home 7 Description. Home 7 is a 30 bed LTC home that is located on the outskirts of a rural town. The LTC home was built in the 1980s to meet the growing need of the aging population in the rural town. The entrance into the nursing home leads into a large foyer where residents have space to hang their jackets and take off their shoes. Ahead of the front doors is the nursing station and the administrator’s office. To the left of the front door is the TV room. This room houses six recliners which face the 42-inch television screen that is mounted on a table. The TV room is connected to the recreational area. There are floor to ceiling windows which cast light (and warmth) on those who are sitting directly in front of them. The recreation area is the part of the building where most of the residents are brought to participate in activities. The only furniture in this room is three long tables that run parallel to the windows. The

recreational room opens into the dining room and kitchen. There are six tables within the recreation room. Some of the tables have chairs for residents to sit in, while others are left open for residents in wheelchairs. This area is the nosiest in the entire building. The television is on most of the day and evening, and all of the residents tend to spend most of their time in this area.

The dining room overlooks a fenced in courtyard. Within this space, there is a gazebo and an open patio. Behind the nursing station is the medication room and three hallways of rooms (ten per hallway). At the top of one of the hallways is the tub room and down the other two wings are lounge areas where residents may go with their families to visit or watch TV. Directly to the right of the front door is the DOC’s office. Her office has windows that look out into the hallway and at the nursing station. On day shift, there are four NAs (working eight hour shifts) and one nurse who work 12 hour shifts. The staffing ratio during the day for nursing staff to residents was approximately 1:7. In the evening, there were two NAs and a nurse. At night, there were only two NAs in the building, and the RN was on call. A full time RT is employed Monday

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to Friday from 8:30- 16:30. She is responsible for coordinating and leading all the resident activities within the home. The administrator and the DOC are employed in part time positions.

Table 2.3

Comparison of Rural LTC Home Characteristics in the Prospective Study Rural LTC Home Ownership- Reporting Structure Formal Leadership Team and Employment Status Number of LTC Beds Position of GPA Coaches Clinical Nurse Leader Present in LTC Home Date of GPA Installation Staff on Day Shift (M-F)

Home 6 Health Region Owned and Operated (report to Health Region) Manager (F/T)

35 CNL and LPN Yes Oct-11 Nurse, NAs,

RT Manager and CNL split time between LTC home and hospital Home 7 Independently Owned (report to Board and Health Region) Administrator (P/T) DOC (P/T)

30 NAs No Oct-11 Nurse, NAs

Administrator, DOC, RT

Note. Director of Care = DOC. Clinical Nurse Leader = CNL. LPN = Licensed Practical Nurse. Nursing Aides = NAs. Recreation Therapist = RT. Direct Care Staff included CNL, Nurses, NAs, RTs, and GPA Coaches. Formal Leaders included Administrators, Managers, and Director of Care. F/T = Full Time. P/T = Part time.

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2.4.2.2 Participants. The prospective study focused on the experiences of staff in all